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Inequality in Immunization 2024

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A special issue of Vaccines (ISSN 2076-393X).

Deadline for manuscript submissions: 30 April 2024 | Viewed by 6926

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Special Issue Editors

Dr. Ahmad Reza Hosseinpoor

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Guest Editor

Department of Data and Analytics, World Health Organization, 20 Avenue Appia, 1211 Geneva, Switzerland
Interests: health inequality; monitoring; immunization
Special Issues, Collections and Topics in MDPI journals

Dr. Devaki Nambiar

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Department of Data and Analytics, World Health Organization, 20 Avenue Appia, 1211 Geneva, Switzerland
Interests: health systems; inequalities; social determinants of health
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Dr. Nicole Bergen

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Department of Data and Analytics, World Health Organization, 20 Avenue Appia, 1211 Geneva, Switzerland
Interests: health inequalities; immunization; health policy

Dr. M. Carolina Danovaro

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Immunization Analysis & Insights (IAI), World Health Organization, 20 Avenue Appia, 1211 Geneva, Switzerland
Interests: immunization; vaccine delivery
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Dr. Hope L. Johnson

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GAVI, The Vaccine Alliance, Geneva, Switzerland
Interests: immunization; monitoring evaluation and learning

Dr. Ciara Sugerman

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Global Immunization Division, US Centers for Disease Control and Prevention, 1600 Clifton Road, Atlanta, GA 30329, USA
Interests: immunization system strengthening, evidence base for strengthening immunization service delivery, life course approach

Special Issue Information

Dear Colleagues,

Inequalities persist in the coverage of immunization globally and across the life course. Evidence has revealed gaps or gradients in childhood and adult immunization within and across countries, and with respect to dimensions of inequality such as sex, gender, socio-economic status, place of residence and more. Yet, our understandings of patterns of inequalities in immunization remain incomplete. The year 2024 marks 50 years of the Expanded Programme on Immunization (EPI). The EPI has galvanized national and global collaboration and helped set up essential infrastructure and standardized processes to universalize access to immunization. In this Special Issue, we place emphasis on research and review articles that deepen our understanding of immunization inequalities as well as highlight entry points or modalities to reduce them. We encourage submissions that apply rigorous and innovative methodological approaches, including multilevel modeling, compound and/or intersectional vulnerabilities or disadvantages, and geospatial approaches, as well as statistical and computational innovations in understanding and summarizing inequalities in immunization.

Dr. Ahmad Reza Hosseinpoor
Dr. Devaki Nambiar
Dr. Nicole Bergen
Dr. M. Carolina Danovaro
Dr. Hope L. Johnson
Dr. Ciara Sugerman
Guest Editors

Manuscript Submission Information

Manuscripts should be submitted online at www.mdpi.com by registering and logging in to this website. Once you are registered, click here to go to the submission form. Manuscripts can be submitted until the deadline. All submissions that pass pre-check are peer-reviewed. Accepted papers will be published continuously in the journal (as soon as accepted) and will be listed together on the special issue website. Research articles, review articles as well as short communications are invited. For planned papers, a title and short abstract (about 100 words) can be sent to the Editorial Office for announcement on this website.

Submitted manuscripts should not have been published previously, nor be under consideration for publication elsewhere (except conference proceedings papers). All manuscripts are thoroughly refereed through a single-blind peer-review process. A guide for authors and other relevant information for submission of manuscripts is available on the Instructions for Authors page. Vaccines is an international peer-reviewed open access monthly journal published by MDPI.

Please visit the Instructions for Authors page before submitting a manuscript. The Article Processing Charge (APC) for publication in this open access journal is 2700 CHF (Swiss Francs). Submitted papers should be well formatted and use good English. Authors may use MDPI's English editing service prior to publication or during author revisions.

Keywords

health inequalities
immunization
life course
methodology

Published Papers (6 papers)

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19 pages, 246 KiB

Open AccessArticle

Enhancing COVID-19 Vaccine Uptake among Tribal Communities: A Case Study on Program Implementation Experiences from Jharkhand and Chhattisgarh States, India

by Ankita Meghani, Manjula Sharma, Tanya Singh, Sourav Ghosh Dastidar, Veena Dhawan, Natasha Kanagat, Anil Gupta, Anumegha Bhatnagar, Kapil Singh, Jessica C. Shearer and Gopal Krishna Soni

Vaccines 2024, 12(5), 463; https://doi.org/10.3390/vaccines12050463 - 26 Apr 2024

Viewed by 249

Abstract

Tribal populations in India have health care challenges marked by limited access due to geographical distance, historical isolation, cultural differences, and low social stratification, and that result in weaker health indicators compared to the general population. During the pandemic, Tribal districts consistently reported lower COVID-19 vaccination coverage than non-Tribal districts. We assessed the MOMENTUM Routine Immunization Transformation and Equity (the project) strategy, which aimed to increase access to and uptake of COVID-19 vaccines among Tribal populations in Chhattisgarh and Jharkhand using the reach, effectiveness, adoption, implementation, and maintenance framework. We designed a qualitative explanatory case study and conducted 90 focus group discussions and in-depth interviews with Tribal populations, community-based nongovernmental organizations that worked with district health authorities to implement the interventions, and other stakeholders such as government and community groups. The active involvement of community leaders, targeted counseling, community gatherings, and door-to-door visits appeared to increase vaccine awareness and assuage concerns about its safety and efficacy. Key adaptations such as conducting evening vaccine awareness activities, holding vaccine sessions at flexible times and sites, and modifying messaging for booster doses appeared to encourage vaccine uptake among Tribal populations. While we used project resources to mitigate financial and supply constraints where they arose, sustaining long-term uptake of project interventions appears dependent on continued funding and ongoing political support. Full article

(This article belongs to the Special Issue Inequality in Immunization 2024)

10 pages, 1420 KiB

Open AccessArticle

The Impact of the Coronavirus Pandemic on Vaccination Coverage in Latin America and the Caribbean

by Ignacio E. Castro-Aguirre, Dan Alvarez, Marcela Contreras, Silas P. Trumbo, Oscar J. Mujica, Daniel Salas Peraza and Martha Velandia-González

Vaccines 2024, 12(5), 458; https://doi.org/10.3390/vaccines12050458 - 25 Apr 2024

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Abstract

Background: Routine vaccination coverage in Latin America and the Caribbean declined prior to and during the coronavirus pandemic. We assessed the pandemic’s impact on national coverage levels and analyzed whether financial and inequality indicators, immunization policies, and pandemic policies were associated with changes in national and regional coverage levels. Methodology: We compared first- and third-dose coverage of diphtheria–pertussis–tetanus-containing vaccine (DTPcv) with predicted coverages using time series forecast modeling for 39 LAC countries and territories. Data were from the PAHO/WHO/UNICEF Joint Reporting Form. A secondary analysis of factors hypothesized to affect coverages during the pandemic was also performed. Results: In total, 31 of 39 countries and territories (79%) had greater-than-predicted declines in DTPcv1 and DTPcv3 coverage during the pandemic, with 9 and 12 of these, respectively, falling outside the 95% confidence interval. Within-country income inequality (i.e., Gini coefficient) was associated with significant declines in DTPcv1 coverage, and cross-country income inequality was associated with declines in DTPcv1 and DTPcv3 coverages. Observed absolute and relative inequality gaps in DTPcv1 and DTPcv3 coverage between extreme country quintiles of income inequality (i.e., Q1 vs. Q5) were accentuated in 2021, as compared with the 2019 observed and 2021 predicted values. We also observed a trend between school closures and greater-than-predicted declines in DTPcv3 coverage that approached statistical significance (p = 0.06). Conclusion: The pandemic exposed vaccination inequities in LAC and significantly impacted coverage levels in many countries. New strategies are needed to reattain high coverage levels. Full article

(This article belongs to the Special Issue Inequality in Immunization 2024)

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25 pages, 3170 KiB

Open AccessArticle

Comparison of Wealth-Related Inequality in Tetanus Vaccination Coverage before and during Pregnancy: A Cross-Sectional Analysis of 72 Low- and Middle-Income Countries

by Nicole E. Johns, Cauane Blumenberg, Katherine Kirkby, Adrien Allorant, Francine Dos Santos Costa, M. Carolina Danovaro-Holliday, Carrie Lyons, Nasir Yusuf, Aluísio J. D. Barros and Ahmad Reza Hosseinpoor

Vaccines 2024, 12(4), 431; https://doi.org/10.3390/vaccines12040431 - 17 Apr 2024

Viewed by 355

Abstract

Immunization of pregnant women against tetanus is a key strategy for reducing tetanus morbidity and mortality while also achieving the goal of maternal and neonatal tetanus elimination. Despite substantial progress in improving newborn protection from tetanus at birth through maternal immunization, umbilical cord practices and sterilized and safe deliveries, inequitable gaps in protection remain. Notably, an infant’s tetanus protection at birth is comprised of immunization received by the mother during and before the pregnancy (e.g., through childhood vaccination, booster doses, mass vaccination campaigns, or during prior pregnancies). In this work, we examine wealth-related inequalities in maternal tetanus toxoid containing vaccination coverage before pregnancy, during pregnancy, and at birth for 72 low- and middle-income countries with a recent Demographic and Health Survey or Multiple Indicator Cluster Survey (between 2013 and 2022). We summarize coverage levels and absolute and relative inequalities at each time point; compare the relative contributions of inequalities before and during pregnancy to inequalities at birth; and examine associations between inequalities and coverage levels. We present the findings for countries individually and on aggregate, by World Bank country income grouping, as well as by maternal and neonatal tetanus elimination status, finding that most of the inequality in tetanus immunization coverage at birth is introduced during pregnancy. Inequalities in coverage during pregnancy are most pronounced in low- and lower-middle-income countries, and even more so in countries which have not achieved maternal and neonatal tetanus elimination. These findings suggest that pregnancy is a key time of opportunity for equity-oriented interventions to improve maternal tetanus immunization coverage. Full article

(This article belongs to the Special Issue Inequality in Immunization 2024)

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10 pages, 1975 KiB

Open AccessArticle

Analyzing Subnational Immunization Coverage to Catch up and Reach the Unreached in Seven High-Priority Countries in the Eastern Mediterranean Region, 2019–2021

by Kamal Fahmy, Quamrul Hasan, Md Sharifuzzaman and Yvan Hutin

Vaccines 2024, 12(3), 285; https://doi.org/10.3390/vaccines12030285 - 08 Mar 2024

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Abstract

Yearly national immunization coverage reporting does not measure performance at the subnational level throughout the year and conceals inequalities within countries. We analyzed subnational immunization coverage from seven high-priority countries in our region. We analyzed subnational, monthly immunization data from seven high-priority countries. Five were Gavi eligible (i.e., Afghanistan, Pakistan, Somalia, Syria, and Yemen); these are countries that according to their low income are eligible for support from the Global Alliance on Vaccine and Immunization, while Iraq and Jordan were included because of a recent decrease in immunization coverage and contribution to the regional number of under and unimmunized children. DTP3 coverage, which is considered as the main indicator for the routine immunization coverage as the essential component of the immunization program performance, varied monthly in 2019–2021 before reaching pre-pandemic coverage in the last two months of 2021. Somalia and Yemen had a net gain in DTP3 coverage at the end of 2021, as improvement in 2021 exceeded the regression in 2020. In Pakistan and Iraq, DTP3 improvement in 2021 equaled the 2020 regression. In Afghanistan, Syria and Jordan, the regression in DTP3 coverage continued in 2020 and 2021. The number of districts with at least 6000 zero-dose children improved moderately in Afghanistan and substantially in Somalia throughout the follow-up period. In Pakistan, the geographical distribution differed between 2020 and 2021.Of the three countries with the highest number of zero-dose children, DTP1 coverage reached 109% in Q4 of 2020 after a sharp drop to 69% in Q2 of 2020. However, in Pakistan, the number of zero-dose children decreased to 1/10 of its burden in Q4 of 2021. In Afghanistan, the number of zero-dose children more than a doubled. Among the even countries, adaptation of immunization service to the pandemic varied, depending on the agility of the health system and the performance of the components of the expanded program on immunization. We recommended monitoring administrative monthly immunization coverage data at the subnational level to detect low-performing districts, plan catchup, identify bottlenecks towards reaching unvaccinated children and customize strategies to improve the coverage in districts with zero-dose children throughout the year and monitor progress. Full article

(This article belongs to the Special Issue Inequality in Immunization 2024)

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20 pages, 11085 KiB

Open AccessArticle

Geospatial Analyses of Recent Household Surveys to Assess Changes in the Distribution of Zero-Dose Children and Their Associated Factors before and during the COVID-19 Pandemic in Nigeria

by Justice Moses K. Aheto, Iyanuloluwa Deborah Olowe, Ho Man Theophilus Chan, Adachi Ekeh, Boubacar Dieng, Biyi Fafunmi, Hamidreza Setayesh, Brian Atuhaire, Jessica Crawford, Andrew J. Tatem and Chigozie Edson Utazi

Vaccines 2023, 11(12), 1830; https://doi.org/10.3390/vaccines11121830 - 08 Dec 2023

Viewed by 1921

Abstract

The persistence of geographic inequities in vaccination coverage often evidences the presence of zero-dose and missed communities and their vulnerabilities to vaccine-preventable diseases. These inequities were exacerbated in many places during the coronavirus disease 2019 (COVID-19) pandemic, due to severe disruptions to vaccination services. Understanding changes in zero-dose prevalence and its associated risk factors in the context of the COVID-19 pandemic is, therefore, critical to designing effective strategies to reach vulnerable populations. Using data from nationally representative household surveys conducted before the COVID-19 pandemic, in 2018, and during the pandemic, in 2021, in Nigeria, we fitted Bayesian geostatistical models to map the distribution of three vaccination coverage indicators: receipt of the first dose of diphtheria-tetanus-pertussis-containing vaccine (DTP1), the first dose of measles-containing vaccine (MCV1), and any of the four basic vaccines (bacilli Calmette-Guerin (BCG), oral polio vaccine (OPV0), DTP1, and MCV1), and the corresponding zero-dose estimates independently at a 1 × 1 km resolution and the district level during both time periods. We also explored changes in the factors associated with non-vaccination at the national and regional levels using multilevel logistic regression models. Our results revealed no increases in zero-dose prevalence due to the pandemic at the national level, although considerable increases were observed in a few districts. We found substantial subnational heterogeneities in vaccination coverage and zero-dose prevalence both before and during the pandemic, showing broadly similar patterns in both time periods. Areas with relatively higher zero-dose prevalence occurred mostly in the north and a few places in the south in both time periods. We also found consistent areas of low coverage and high zero-dose prevalence using all three zero-dose indicators, revealing the areas in greatest need. At the national level, risk factors related to socioeconomic/demographic status (e.g., maternal education), maternal access to and utilization of health services, and remoteness were strongly associated with the odds of being zero dose in both time periods, while those related to communication were mostly relevant before the pandemic. These associations were also supported at the regional level, but we additionally identified risk factors specific to zero-dose children in each region; for example, communication and cross-border migration in the northwest. Our findings can help guide tailored strategies to reduce zero-dose prevalence and boost coverage levels in Nigeria. Full article

(This article belongs to the Special Issue Inequality in Immunization 2024)

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11 pages, 242 KiB

Open AccessPerspective

Measuring Zero-Dose Children: Reflections on Age Cohort Flexibilities for Targeted Immunization Surveys at the Local Level

by Gustavo C. Corrêa, Md. Jasim Uddin, Tasnuva Wahed, Elizabeth Oliveras, Christopher Morgan, Moses R. Kamya, Patience Kabatangare, Faith Namugaya, Dorothy Leab, Didier Adjakidje, Patrick Nguku, Adam Attahiru, Jenny Sequeira, Nancy Vollmer and Heidi W. Reynolds

Vaccines 2024, 12(2), 195; https://doi.org/10.3390/vaccines12020195 - 14 Feb 2024

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Abstract

Zero-dose (ZD) children is a critical objective in global health, and it is at the heart of the Immunization Agenda 2030 (IA2030) strategy. Coverage for the first dose of diphtheria–tetanus–pertussis (DTP1)-containing vaccine is the global operational indicator used to estimate ZD children. When surveys are used, DTP1 coverage estimates usually rely on information reported from caregivers of children aged 12–23 months. It is important to have a global definition of ZD children, but learning and operational needs at a country level may require different ZD measurement approaches. This article summarizes a recent workshop discussion on ZD measurement for targeted surveys at local levels related to flexibilities in age cohorts of inclusion from the ZD learning Hub (ZDLH) initiative—a learning initiative involving 5 consortia of 14 different organizations across 4 countries—Bangladesh, Mali, Nigeria, and Uganda—and a global learning partner. Those considerations may include the need to generate insights on immunization timeliness and on catch-up activities, made particularly relevant in the post-pandemic context; the need to compare results across different age cohort years to better identify systematically missed communities and validate programmatic priorities, and also generate insights on changes under dynamic contexts such as the introduction of a new ZD intervention or for recovering from the impact of health system shocks. Some practical considerations such as the potential need for a larger sample size when including comparisons across multiple cohort years but a potential reduction in the need for household visits to find eligible children, an increase in recall bias when older age groups are included and a reduction in recall bias for the first year of life, and a potential reduction in sample size needs and time needed to detect impact when the first year of life is included. Finally, the inclusion of the first year of life cohort in the survey may be particularly relevant and improve the utility of evidence for decision-making and enable its use in rapid learning cycles, as insights will be generated for the population being currently targeted by the program. For some of those reasons, the ZDLH initiative decided to align on a recommendation to include the age cohort from 18 weeks to 23 months, with enough power to enable disaggregation of key results across the two different cohort years. We argue that flexibilities with the age cohort for inclusion in targeted surveys at the local level may be an important principle to be considered. More research is needed to better understand in which contexts improvements in timeliness of DTP1 in the first year of life will translate to improvements in ZD results in the age cohort of 12–23 months as defined by the global DTP1 indicator. Full article

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