Abstract
BackgroundChildren unreached by vaccination are at higher risk of poor health outcomes and India accounts for nearly a quarter of unvaccinated children worldwide. The objective of this study was to investigate compositional and contextual determinants of non-receipt of childhood vaccines in India using multilevel modelling.Methods and FindingsWe studied characteristics of unvaccinated children using the District Level Health and Facility Survey 3, a nationally representative probability sample containing 65 617 children aged 12–23 months from 34 Indian states and territories. We developed four-level Bayesian binomial regression models to examine the determinants of non-vaccination. The analysis considered two outcomes: completely unvaccinated (CUV) children who had not received any of the eight vaccine doses recommended by India’s Universal Immunization Programme, and children who had not received any dose from routine immunisation services (no RI). The no RI category includes CUV children and those who received only polio doses administered via mass campaigns. Overall, 4.83% (95% CI: 4.62–5.06) of children were CUV while 12.01% (11.68–12.35) had received no RI. Individual compositional factors strongly associated with CUV were: non-receipt of tetanus immunisation for mothers during pregnancy (OR = 3.65 [95% CrI: 3.30–4.02]), poorest household wealth index (OR = 2.44 [1.81–3.22] no maternal schooling (OR = 2.43 [1.41–4.05]) and no paternal schooling (OR = 1.83 [1.30–2.48]). In rural settings, the influence of maternal illiteracy disappeared whereas the role of household wealth index was reinforced. Factors associated with no RI were similar to those for CUV, but effect sizes for individual compositional factors were generally larger. Low maternal education was the strongest risk factor associated with no RI in all models. All multilevel models found significant variability at community, district, and state levels net of compositional factors.ConclusionNon-vaccination in India is strongly related to compositional characteristics and is geographically distinct. Tailored strategies are required to overcome current barriers to immunisation.
Highlights
Vaccination is a key strategy for reducing child mortality [1,2]
In keeping with the definition in standard use in India, full immunisation is defined as a child 12–23 months of age receiving all of the following vaccines: a dose of Bacille Calmette-Guerin vaccine (BCG) vaccine at birth; three doses of DPT vaccine at 6, 10 and 14 weeks of age; at least three doses of oral poliovirus vaccine (OPV) at 6, 10 and 14 weeks of age; and one dose measles-containing vaccine (MCV) at 9 months of age
Of 65 617 children aged from 12 to 23 months, 3173 (4.83%, [95% Confidence Intervals (CI): 4.62–5.06]) were completely unvaccinated (CUV) and failed to receive any of the eight recommended vaccine doses while 7883 (12.01%, [95% CI: 11.68–12.35]) did not receive any vaccine dose through routine services (No-RI)
Summary
Vaccination is a key strategy for reducing child mortality [1,2]. In 1974, the World Health Organization (WHO) established the Expanded Programme on Immunization (EPI) to ensure that all children had access to six basic vaccines: Bacille Calmette-Guerin vaccine (BCG), diphtheria-tetanus-pertussis vaccine (DTP), oral poliovirus vaccine (OPV), and measles-containing vaccine (MCV) [3]. A recent report suggests that vaccination against four diseases targeted by the EPI - diphtheria, tetanus, pertussis and measles averts an estimated 2 to 3 million deaths every year [4,5]. Despite this success, 22.6 million infants remained unvaccinated (defined as non-receipt of DTP1)-or under-vaccinated (defined as nonreceipt of DTP3) worldwide in 2012 [6]. According to the Child Health Epidemiology Reference Group (CHERG), of the estimated 8.8 million deaths of children under 5 years of age worldwide in 2008, 1.5 million (17%) were due to vaccine preventable diseases (VPDs) [7,8]. The objective of this study was to investigate compositional and contextual determinants of non-receipt of childhood vaccines in India using multilevel modelling
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