Abstract
Objectives:In many countries, measles disproportionately affects poorer households. To achieve equitable delivery, national immunization programs can use 2 main delivery platforms: routine immunization and supplementary immunization activities (SIAs). The objective of this article is to use data concerning measles vaccination coverage delivered via routine and SIA strategies to make inferences about the associated equity impact.Methods:We relied on Demographic and Health Survey and Multiple Indicator Cluster Surveys multi-country survey data to conduct a comparative analysis of routine and SIA measles vaccination status of children by wealth quintile. We estimated the value of the angle, θ, for the ratio of the difference between coverage levels of adjacent wealth quintiles by using the arc-tangent formula. For each country/year observation, we averaged the θ estimates into one summary measurement, defined as the “equity impact number.”Results:Across 20 countries, the equity impact number summarized across wealth quintiles was greater (and hence less equitable) for routine delivery than for SIAs in the survey rounds (years) during, before, and after an SIA about 65% of the time. The equity impact numbers for routine measles vaccination averaged across wealth quintiles were usually greater than for SIA measles vaccination across country-year observations.Conclusions:This analysis examined how different measles vaccine delivery platforms can affect equity. It can serve to elucidate the impact of immunization and public health programs in terms of comparing horizontal to vertical delivery efforts and in reducing health inequalities in global and country-level decision-making.
Highlights
Underlying differences in the social determinants of health create systematic differences in health among groups in society.[1]
The analysis focused on low- and middle-income countries (LMICs) for which years and dates of measles supplementary immunization activities (SIAs) were available from the World Health Organization (WHO).[25]
According to an independent 2-sample t test, the MCV1 q for the same survey round as the SIA was greater than the SIA q (P, .001), the MCV1 q for the previous survey round to the SIA was greater than the SIA q (P = .011), and the MCV1 q for the subsequent survey round to the SIA was greater than the SIA q (P, .001)
Summary
Underlying differences in the social determinants of health create systematic differences in health among groups in society.[1] In particular, health largely improves with increasing income[2,3,4] for many reasons including differential access to health services according to the opportunities afforded by wealth, especially in low- and middle-income countries (LMICs).[5,6] Without considering whom an intervention will reach and who can benefit most from the intervention, delivering public health programs and technologies to mitigate disease burden can further exacerbate these inequalities, as seen with unequal ownership of insecticidetreated nets for malaria control, for example.[7] evidence shows that inequalities in under-5 mortality in LMICs are decreasing, large disparities still persist and highlight the need to prioritize inequality reduction and equity in decision-making at the global and national levels.[8] Despite previous progress toward measles elimination and control efforts, the measles incidence has increased in 5 of 6 World Health Organization (WHO) regions since 2016, with reported cases increasing by 45% in LMICs receiving vaccination support from Gavi, the Vaccine Alliance.[9] The burden of measles mortality is highest among vulnerable populations, including younger children (less than 5 years of age) and low-income countries, in sub-Saharan Africa.[10,11]
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