Abstract
Measles vaccination is estimated to have averted 13·8 million deaths between 2000 and 2012. Persisting heterogeneity in coverage is a major contributor to continued measles mortality, and a barrier to measles elimination and introduction of rubella-containing vaccine. Our objective is to identify determinants of inequities in coverage, and how vaccine delivery must change to achieve elimination goals, which is a focus of the WHO Decade of Vaccines. We combined estimates of travel time to the nearest urban centre (⩾50 000 people) with vaccination data from Demographic Health Surveys to assess how remoteness affects coverage in 26 African countries. Building on a statistical mapping of coverage against age and geographical isolation, we quantified how modifying the rate and age range of vaccine delivery affects national coverage. Our scenario analysis considers increasing the rate of delivery of routine vaccination, increasing the target age range of routine vaccination, and enhanced delivery to remote areas. Geographical isolation plays a key role in defining vaccine inequity, with greater inequity in countries with lower measles vaccine coverage. Eliminating geographical inequities alone will not achieve thresholds for herd immunity, indicating that changes in delivery rate or age range of routine vaccination will be required. Measles vaccine coverage remains far below targets for herd immunity in many countries on the African continent and is likely to be inadequate for achieving rubella elimination. The impact of strategies such as increasing the upper age range eligible for routine vaccination should be considered.
Highlights
Vaccination has proved one of the most successful public health interventions, resulting in substantial mortality and morbidity reductions worldwide [1, 2]
We show that geographical isolation plays a key role in shaping vaccination inequity across a range of countries in Africa and explore how modalities for enhancing vaccination coverage will impact geographical inequity
Age, and approximate geographical longitudes and latitudes of residence for children aged 9–59 months were obtained from Demographic Health Surveys (DHS) on the African continent occurring during or after 2000 [33]
Summary
Vaccination has proved one of the most successful public health interventions, resulting in substantial mortality and morbidity reductions worldwide [1, 2]. Despite major successes in ramping up vaccination [5], significant outbreaks occurred across the African continent between 2009 and 2011 [6]; and many individuals remain at risk. Both low coverage of routine vaccination programmes, and suboptimal implementation of the catch-up or follow-up campaigns designed to reach susceptible children (Supplementary Immunization Activities, or SIAs) who had accumulated over the previous years of low routine coverage [7] contribute to this. The impact of inequities in vaccination rates, and the resulting heterogeneity in the population landscape of immunity on the measles endgame, is a key public health question. We show that geographical isolation plays a key role in shaping vaccination inequity across a range of countries in Africa and explore how modalities for enhancing vaccination coverage will impact geographical inequity
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