Inequalities In Vaccination Coverage Research Articles

Vaccine Supply Chains in Resource-Limited Settings: Mitigating Rainy Season Disruptions

Immunization is widely recognized as one of the most successful and cost-effective health interventions, preventing two to three million deaths from vaccine-preventable diseases each year. Although progress has been made in recent years, substantial operational challenges persist in resource-limited settings with frequent stock-outs contributing to sub-optimal immunization coverage and inequality in vaccine access. In this paper, we investigate the role of rainy season induced supply chain disruptions on vaccination coverage and inequalities. We develop a modeling framework combining spatial modeling — to predict flood disruptions in road networks — and a discrete-event simulation of a multi-tiered vaccine supply chain (VSC). Our models are fitted and validated using data from the Malagasy VSC network. Our baseline simulation predicts the national vaccination coverage with good accuracy and suggests that 67% of regions with low reported immunization coverage are affected by rainy season disruptions or operational inefficiencies, causing significant geographical inequalities in vaccine access. We investigate various mitigation strategies to increase the resiliency of VSCs and find that by strategically placing buffer inventory at targeted facilities prior to the rainy season the proportion of children receiving all basic vaccines in these areas is increased by 7% and the geographical inequality in vaccination coverage is reduced by 11%. By also increasing the replenishment frequency from every third month to every month, the national vaccination coverage improves by 37%. Our results contribute to achieving the UN Sustainable Development Goals (SDGs) by providing actionable insights for improving vaccination coverage (SDG 3) and investigating the resiliency of the VSC to increased flooding due to climate change (SDG 13).

Inequalities in vaccination coverage and differences in follow-up procedures for asylum-seeking children arriving in Wales, UK.

The European Vaccine Action Plan 2015-2020 highlights the importance of reducing inequities and monitoring performance in underserved groups including migrants. However, there are limited data from European countries and policies for catch-up vary by country. Vaccination coverage in accompanied asylum-seeking children aged 5 to 16 years in two dispersal areas of Wales is presented alongside the coverage in the local population. Coverage data for asylum-seeking children were collated locally using asylum seeker nurse records whilst coverage in the local population was calculated using data from the National Community Child Health Database, a repository of data from all local Child Health Systems in Wales. The processes for following up outstanding vaccinations were also collected using a face-to-face questionnaire distributed to lead asylum seeker nurses in each area. As at the date of assessment, 45.6% (67/147) of children dispersed to area one had received all recommended immunisations compared with 62.2% (150/241) dispersed to area two, OR 0.51 (95% CI 0.33-0.79). At both sites the odds of being vaccinated against key vaccine preventable infections were around three times lower if you were an asylum-seeking child, compared with the local population. Similar procedures were in place for new asylum seekers in both dispersal areas. Area one had less resource to follow up missing immunisations, and children did not receive an initial health assessment unlike area two. Verbal history was accepted in area one but not in area two, despite area two having higher vaccine uptake.Conclusion: Asylum-seeking children have low rates of vaccine uptake compared with the general population, although uptake differs depending on dispersal area. Inequalities in vaccination services, such as resource and strategies to improve uptake, need to be considered.What is Known:• The European Vaccine Action Plan 2015-2020 highlights the importance of reducing inequities and monitoring performance in underserved groups including migrants.• Limited data from European countries suggest inequalities in uptake of immunisations in migrants compared with the local population. Policies for catching up immunisations vary by country.What is New:• Despite national policy for vaccination of migrants with missing or incomplete vaccination history in Wales, this work suggests vaccination coverage in asylum-seeking children is not equitable with the local population.• Vaccination coverage in asylum-seeking children dispersed to different areas of Wales also varies, and this may be associated with differences in local catch-up strategies and the ability to follow national policy. Resource and strategies to maintain engagement with health services play an important role in increasing vaccine uptake in underserved groups.

Decomposing socioeconomic inequality in child vaccination in the Gambia, the Kyrgyz Republic and Namibia

Extant work suggested pro-rich distribution of vaccination coverage in low- and middle-income countries (LMICs). However, the current literature also suggested pro-poor distribution of vaccination in some countries, including the Gambia, the Kyrgyz Republic and Namibia. This study aimed to explain socioeconomic inequalities in the completion rate of the four-core vaccines (i.e., Bacille Calmette-Guérin [BCG], diphtheria-tetanus-pertussis [DTP, 3 doses], Polio [3 doses] and Measles vaccines) in the three aforementioned countries. We used the most recent available Demographic Health Surveys (DHS) to measure vaccination completion rates among children (aged 0–59 months, n = 16,752) in the three countries. The normalized concentration index (Cn) was used to quantify and decompose socioeconomic inequalities in vaccination coverage in each country. The negative values of the Cn index suggested that children belong to lower socioeconomic status groups were more likely to be immunized than their higher socioeconomic status counterparts in the Gambia (Cn = −0.101, 95% confidence interval [CI]: −0.128 to −0.074), the Kyrgyz Republic (Cn = −0.097, 95% CI: −0.13 to −0.063) and Namibia (Cn = −0.161, 95% CI: −0.199 to −0.124). The decomposition analysis of the Cn suggested that the difference in child vaccination completion rates between rural and urban areas was the main factor contributing to the concentration of child vaccination among the poor in the Gambia and Namibia. The concentration of child vaccination among the poor in the Kyrgyz Republic was chiefly determined by household wealth. These results suggest that there should be strategies to improve child immunization uptake among urban children in the Gambia and Namibia. Since household wealth was the main factor contributing to the observed pro-poor distribution of child vaccination in the Kyrgyz Republic, further studies are required to understand the reasons for lower vaccination rate among the wealthy children in order to implement the most effective strategies to increase child vaccination uptake.

Social inequities in vaccination coverage among infants and pre-school children in Europe and Australia \u2013 a systematic review

BackgroundHerd immunity levels of vaccine uptake are still not reached in some high-income countries, usually in countries with persisting social inequities in uptake. Previous studies have focused on factors within one health care system. This study takes a broader health care systems approach by reviewing the socioeconomic distribution of vaccination coverage on the national level in light of structural and organizational differences of primary care for children.MethodsA systematic literature review of socio-economic patterns of uptake of Measles-Mumps-Rubella (MMR) and/or Diphteria-Tetanus-Pertusis (DTP) in population based studies of children 0–5 years of age living in the 30 European Economic Area (EEA) or European Free Trade Association (EFTA) countries and Australia, was carried out using the PRISMA guidelines. The health care system in the countries in the study were categorized by degree of freedom of the primary care provider (hierarchical or non-hierarchical) and whether preventive services were provided in a separate organization (well-baby clinics).ResultsThe review identified 15 studies from 10 European countries and Australia that fulfilled the criteria. Although the heterogeneity of the socio-economic indicators did not allow for a conclusive meta-analysis, the study pointed towards lower levels of inequities in primary care models with well-baby clinics. In non-hierarchical primary care organizations that also lacked well-baby clinics, socioeconomic gaps in uptake were often found to be large.ConclusionThis review indicates that structural and organizational aspects of health care systems for young children are important for equity in vaccine uptake.

Socioeconomic inequalities in child vaccination in low/middle-income countries: what accounts for the differences?

BackgroundSocioeconomic inequalities in child vaccination continue to be a global public health concern. This study aimed to measure and identify factors associated with socioeconomic inequalities in full immunisation coverage against...

Monitoring equity in vaccination coverage: A systematic analysis of demographic and health surveys from 45 Gavi-supported countries

Objectives(1) To conduct a systematic analysis of inequalities in childhood vaccination coverage in Gavi-supported countries; (2) to comparatively assess alternative measurement approaches and how they may affect cross-country comparisons of the level of inequalities. MethodsUsing the most recent Demographic and Health Surveys (2005–2014) in 45 Gavi-supported countries, we measured inequalities in vaccination coverage across seven dimensions of social stratification and of vulnerability to poor health outcomes. We quantified inequalities using pairwise comparisons (risk differences and ratios) and whole spectrum measures (slope and relative indices of inequality). To contrast measurement approaches, we pooled the estimates using random-effects meta-analyses, ranked countries by the magnitude of inequality and compared agreement in country ranks. ResultsAt the aggregate level, maternal education, multidimensional poverty, and wealth index poverty were the dimensions associated with the largest inequalities. In 36 out of 45 countries, inequalities were substantial, with a difference in coverage of 10 percentage points or more between the top and bottom of at least one of these social dimensions. Important inequalities by child sex, child malnutrition and urban/rural residence were also found in a smaller set of countries. The magnitude of inequality and ranking of countries differed across dimension and depending on the measure used. Pairwise comparisons could not be estimated in certain countries. The slope and relative indices of inequality were estimated in all countries and produced more stable country rankings, and should thus facilitate more reliable international comparisons. ConclusionsInequalities in vaccination coverage persist in a large majority of Gavi-supported countries. Inequalities should be monitored across multiple dimensions of vulnerability. Using whole spectrum measures to quantify inequality across multiple ordered social groups has important advantages. We illustrate these findings using an equity dashboard designed to support decision-making in the Sustainable Development Goals period.

An equity dashboard to monitor vaccination coverage.

Equity monitoring is a priority for Gavi, the Vaccine Alliance, and for those implementing The 2030 agenda for sustainable development. For its new phase of operations, Gavi reassessed its approach to monitoring equity in vaccination coverage. To help inform this effort, we made a systematic analysis of inequalities in vaccination coverage across 45 Gavi-supported countries and compared results from different measurement approaches. Based on our findings, we formulated recommendations for Gavi’s equity monitoring approach. The approach involved defining the vulnerable populations, choosing appropriate measures to quantify inequalities, and defining equity benchmarks that reflect the ambitions of the sustainable development agenda. In this article, we explain the rationale for the recommendations and for the development of an improved equity monitoring tool. Gavi’s previous approach to measuring equity was the difference in vaccination coverage between a country’s richest and poorest wealth quintiles. In addition to the wealth index, we recommend monitoring other dimensions of vulnerability (maternal education, place of residence, child sex and the multidimensional poverty index). For dimensions with multiple subgroups, measures of inequality that consider information on all subgroups should be used. We also recommend that both absolute and relative measures of inequality be tracked over time. Finally, we propose that equity benchmarks target complete elimination of inequalities. To facilitate equity monitoring, we recommend the use of a data display tool – the equity dashboard – to support decision-making in the sustainable development period. We highlight its key advantages using data from Côte d’Ivoire and Haiti.

Equity measurement in the post-2015: a systematic analysis of inequalities in vaccination coverage in GAVI-supported countries

Equity measurement in the post-2015: a systematic analysis of inequalities in vaccination coverage in GAVI-supported countries

Inequalities in vaccination coverage for young females whose parents are informal caregivers

Inequalities in vaccination coverage for young females whose parents are informal caregivers

Inequity in childhood immunization in India: A systematic review

Despite a reduction in disease burden of vaccine preventable diseases through childhood immunization, considerable progress needs to be made in terms of ensuring efficiency and equity of vaccination coverage. To conduct a systematic review to identify and explore factors associated with inequities in routine vaccination of children in India. Publications reporting vaccination inequity were retrieved through a systematic search of Medline and websites of the WHO, UNICEF and demographic health surveys in India. No restrictions were applied in terms of study designs. The primary outcome measure was complete vaccination or immunization defined as per the standard WHO definition. There were three nationwide data sets viz. the three National Family Health Surveys (NFHS), a research study conducted by the Indian Council of Medical Research (ICMR) and a UNICEF coverage evaluation survey. In addition, several publications representing different population groups or geographic regions were available. A small number of publications were reanalyses of data from the NFHS series. There is considerable inequity in vaccination coverage in different states. Within states, traditionally poor performing states have greater inequities, although there are significant inequities even within better performing states. There are significant inequities in childhood vaccination based on various factors related to individual (gender, birth order), family (area of residence, wealth, parental education), demography (religion, caste), and the society (access to health-care, community literacy level) characteristics. Girls fare uniformly worse than boys and higher birth order infants have lower vaccination coverage. Urban infants have higher coverage than rural infants and those living in urban slums. There is an almost direct relationship between household wealth and vaccination rates. The vaccination rates are lower among infants with mothers having no or low literacy, and families with insufficient empowerment of women. Paternal literacy has an inconsistent positive relationship with infant vaccination. There is a relationship between religion and caste and childhood vaccination. Access to health services and other infrastructure, is associated with better vaccination coverage of infants. The precise impact of specific risk factors operating singly or in combination cannot be calculated from this systematic review. This systematic review identifies and explores factors associated with inequity in childhood immunization in India; and provides information for urgent action to redress the imbalances.

Tetanus complicating snakebite in northern Nigeria:: clinical presentation and public health implications

Background: There is inequality in vaccination coverage, and adult farmers in tropical rural communities could have missed tetanus toxoid as campaigns target children. Snakebite is not uncommon and partly because of lack of effective antivenom, management in inaccessible areas could be complicated with tetanus in unimmunized victims. Patients and results: Four snakebite victims who developed tetanus were seen in northern Nigeria. Three were bitten while farming and patients took 10–25 days before presenting to hospital. All patients had incised bite sites and applied local medicinal herbs and in one case, a black ‘snake’ stone. Bites were by the cobra ( Naja nigricollis) and carpet viper ( Echis ocellatus) in the extremities and victims had swollen limbs and bleeding with incoagulable blood. Three of the patients were given anti-tetanus serum (ATS) after development of tetanus symptoms in a primary facility and only one recalled receipt of one dose of tetanus toxoid prior to bite. Patients had trismus, rigidity, backache, spasms and one had autonomic dysfunction and was managed with antispasmodics, ATS, wound care, antibiotics and supportive measures. Two patients with envenoming and severe tetanus received antivenom, but died. One of the two surviving patients developed osteomyelitis with prolonged hospital stay, while the other recovered with residual disability. Conclusion: Tetanus could follow snakebite in inaccessible rural agricultural communities with inadequate health care provision. Clinical presentation is typical but late and is confounded by snakebite complications leading to considerable morbidity and mortality. The cases highlight the triple problems of inadequacy, inaccessibility and inequality in health care and calls for measures aimed at improvement.