CSU 108/2010: VACCINATION AND EQUITY

Monday, 25th of October 2010

CSU 108/2010: VACCINATION AND EQUITY

This update will not cover the range of vaccines available. The American child is likely to get vaccination against a dozen or so diseases; the African or Asian child will typically get vaccines against 8 or 9. The high cost of new vaccines is a well known impediment to early introduction of new vaccines in poor countries.

Can we address the equity issues in terms of coverage with existing vaccines? Would it be fair to say that

1) Routine immunization services are as equitable or inequitable as the health services of which they form a part (see items 2 and 3).

2) Mass campaigns and Child Health Days are, if well run, inherently equitable (see item 4).

Food for thought.

1) MONITORING EQUITY ACROSS COUNTRIES

This review is interesting from the methodological standpoint. Use of data from successive DHS and MICS surveys is one way to track trends in disparity reduction. Full text is at http://www.scielosp.org/pdf/bwho/v83n5/v83n5a16.pdf

Monitoring equity in immunization coverage

Surveillance de l'équité en matière de couverture vaccinale

Vigilancia de la equidad en la cobertura de inmunización

Enrique Delamonica^I,¹; Alberto Minujin^II; Jama Gulaid^II

^IProgramme Officer, Policy Analysis, UNICEF, Division of Policy and Planning, 3 United Nations Plaza, New York, NY 10017, USA (email: edelamonica@unicef.org)
^IISenior Policy Adviser, UNICEF, New York, NY, USA

ABSTRACT

This paper analyses trends in coverage of three doses of diphtheria–pertussis–tetanus vaccine (DPT3) by wealth groups in selected countries. It discusses the depth of disparities in coverage by wealth and changes during the 1990s. Complete assessment of equity in income and its trends have been discussed in other papers, however issues related to children's well-being have often been brushed aside because the comparable data needed to fully understand and rectify inequalities is lacking.
A focal point of this paper pertains to gathering any and all information recorded about the immunization of children and then transcribing these data so that it is applicable to all countries. We analyse the technical difficulties and methodological solutions that would enable comparisons to be made between various measures of inequity taken from different surveys at two or three points in time among a variety of subpopulations in order to obtain disaggregated data.
This paper argues for a simultaneous analysis of changes in averages and disparities in immunization coverage along variables of interest, such as wealth, gender and place of residence in order to achieve a better understanding of trends. We also focus on measurement issues and describe trends in immunization by wealth. We conclude with a brief discussion of issues related to monitoring equitable outcomes and offer suggestions for further research. In addition, the paper presents some lessons that can be drawn about monitoring and policies. We hope that this analysis of patterns of disparities will help policy-makers in devising, proposing and executing efficient policies and interventions.

Keywords: Immunization programs/economics/organization and administration; Diphtheria-tetanus-pertussis vaccine/administration and dosage; Social justice: Socioeconomic factors; Delivery of health care; Health surveys; Child; Cross-cultural comparison (source: MeSH, NLM).

RÉSUMÉ

Le présent article analyse les tendances par groupes de revenus de la couverture obtenue avec le vaccin combiné diphtérie/coqueluche/tétanos (DPT3) en trois doses, dans un certain nombre de pays. Il débat de l'ampleur des disparités de la couverture en fonction du niveau de richesse et des changements intervenus pendant les années 1990. L'évaluation complète des inégalités en termes de revenus et les tendances suivies par ces inégalités ont déjà été examinées dans d'autres articles, cependant les questions relatives au bien-être des enfants sont souvent écartées en raison du manque de données comparables nécessaires à la parfaite compréhension et à la rectification des inégalités.
L'article se focalise sur la collecte de toutes les informations enregistrées au sujet de la vaccination des enfants et sur la transcription de ces données de manière à les rendre applicables à tous les pays. Il analyse les difficultés techniques et les solutions méthodologiques qui permettraient des comparaisons à deux ou trois instants entre diverses mesures de l'inéquité, tirées de différentes études parmi diverses sous-populations, en vue d'obtenir des données désagrégées.
Le présent article argumente en faveur d'une analyse simultanée des variations des moyennes et des disparités de la couverture vaccinale en fonction de paramètres intéressants, tels que la richesse, le sexe et le lieu de résidence, dans le but de parvenir à une meilleure compréhension des tendances. Il se concentre également sur les problèmes de mesure et décrit les tendances de la vaccination par niveau de revenus. Il conclut par une brève discussion des questions liées à la surveillance de l'équitabilité des résultats et formule des propositions de recherches ultérieures. Il présente en outre certaines des leçons pouvant être tirées à propos de la surveillance et des politiques. Les auteurs espèrent que cette analyse des schémas de disparité aidera les décideurs dans la conception, la formulation et la mise en œuvre de politiques et d'interventions efficaces.

Mots clés: Programmes de vaccination/économie/organisation et administration; Vaccin diphtérie-tétanos-coqueluche/administration et posologie; Justice sociale; Facteur socioéconomique; Délivrance soins; Enquête santé; Enfant; Comparaison transculturelle (source: MeSH, INSERM).

RESUMEN

En el presente artículo se analizan las tendencias de la cobertura con tres dosis de la vacuna contra la difteria-tétanos-tos ferina (DPT3) según los grupos sociales por nivel de riqueza. Se examinan la magnitud de las disparidades en la cobertura según la riqueza y los cambios registrados en ese sentido durante los años noventa. Si bien en otros artículos se ha hecho ya una evaluación exhaustiva de la equidad de ingresos y de sus tendencias, los aspectos relacionados con el bienestar de los niños se han dejado a menudo de lado por falta de los datos comparables necesarios para comprender y corregir plenamente las desigualdades.
Un elemento fundamental de este artículo es la recopilación de cualquier tipo de información registrada acerca de la inmunización de los niños y la posterior traducción de esos datos para poder aplicarlos a todos los países. Analizamos las dificultades técnicas y las soluciones metodológicas que permitirían comparar diversas medidas de la inequidad extraídas de distintos estudios en dos o tres puntos temporales entre diversas subpoblaciones a fin de obtener datos desglosados.
En este artículo se aboga por analizar simultáneamente los cambios de los promedios y las diferencias de la cobertura vacunal en función de variables de interés como, por ejemplo, la riqueza, el género y el lugar de residencia, a fin de comprender mejor las tendencias. Abordamos también diversos aspectos relacionados con la medición y describimos las tendencias de la inmunización en función de la riqueza. Para finalizar, analizamos brevemente algunas cuestiones relacionadas con el monitoreo de los resultados de equidad y sugerimos nuevas investigaciones. Además, el artículo presenta algunas lecciones que cabe extraer acerca del monitoreo y las políticas. Esperamos que este análisis de las pautas de las disparidades ayude a los formuladores de políticas a idear, proponer y ejecutar políticas e intervenciones eficientes.

Palabras clave: Programas de inmunización/economía/organización y administración; Vacuna difteria-tétanos-pertussis/administración y dosificación; Justicia social; Factores socioeconómicos; Prestación de atención de salud; Encuestas epidemiológicas; Niño; Comparación transcultural (fuente: DeCS, BIREME).

2) VACCINATION AND EQUITY, COASTAL KENYA

Full text is at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2920577/?tool=pubmed

Good reading.

Spatial and socio-demographic predictors of time-to-immunization in a rural area in Kenya: Is equity attainable?

Jennifer C. Moïsi,^abJonathan Kabuka,^b Dorah Mitingi,^b Orin S. Levine,^a and J. Anthony G. Scott^bc

^aDepartment of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA

^bKEMRI/Wellcome Trust Research Programme, Kilifi, Kenya

^cNuffield Department of Clinical Medicine, John Radcliffe Hospital, Oxford, UK

Jennifer C. Moïsi: jmoisi@jhsph.edu

Corresponding author at: 615N. Wolfe St, E8539, Baltimore, MD, USA. Tel.: +1 254 711 574 644. Email: jmoisi@jhsph.edu

Received April 2, 2010; Revised May 5, 2010; Accepted June 2, 2010.

This document may be redistributed and reused, subject to certain conditions.

This document was posted here by permission of the publisher. At the time of the deposit, it included all changes made during peer review, copy editing, and publishing. The U. S. National Library of Medicine is responsible for all links within the document and for incorporating any publisher-supplied amendments or retractions issued subsequently. The published journal article, guaranteed to be such by Elsevier, is available for free, on ScienceDirect, at: http://dx.crossref.org/10.1016/j.vaccine.2010.06.011

Abstract

We conducted a vaccine coverage survey in Kilifi District, Kenya in order to identify predictors of childhood immunization. We calculated travel time to vaccine clinics and examined its relationship to immunization coverage and timeliness among the 2169 enrolled children (median age: 12.5 months). 86% had vaccine cards available, >95% had received three doses of DTP-HepB-Hib and polio vaccines and 88% of measles. Travel time did not affect vaccination coverage or timeliness. The Kenyan EPI reaches nearly all children in Kilifi and delays in vaccination are few, suggesting that vaccines will have maximal impact on child morbidity and mortality.

3) VACCINATION AND EQUITY IN RURAL PAKISTAN

Full text is at http://www.biomedcentral.com/1472-698X/9/S1/S7

Equity and vaccine uptake: a cross-sectional study of measles vaccination in Lasbela District, Pakistan

Steven Mitchell¹ , Neil Andersson² , Noor Mohammad Ansari³ , Khalid Omer³ , José Legorreta Soberanis² and Anne Cockcroft³

¹CIETcanada, 1 Stewart Street, Ottawa, Ontario, Canada

²Centro de Investigación de Enfermedades Tropicales (CIET), Universidad Autónoma de Guerrero, Acapulco, México

³CIET in Pakistan, House 226, Block 18, Gulshan-e-Iqbal, Karachi, Pakistan

author email corresponding author email

BMC International Health and Human Rights 2009, 9(Suppl 1):S7doi:10.1186/1472-698X-9-S1-S7


Published:	14 October 2009

Abstract

Background

Achieving equity means increased uptake of health services for those who need it most. But the poorest families continue to have the poorest service. In Pakistan, large numbers of children do not access vaccination against measles despite the national government's effort to achieve universal coverage.

Methods

A cross-sectional study of a random sample of 23 rural and 9 urban communities in the Lasbela district of south Pakistan, explored knowledge, attitudes and discussion around measles vaccination. Several socioeconomic variables allowed examination of the role of inequities in vaccination uptake; 2479 mothers provided information about 4007 children aged 10 to 59 months. A Mantel-Haenszel stratification analysis, with and without adjustment for clustering, clarified determinants of measles vaccination in urban and rural areas.

Results

A high proportion of mothers had appropriate knowledge of and positive attitudes to vaccination; many discussed vaccination, but only one half of children aged 10-59 months accessed vaccination. In urban areas, having an educated mother, discussing vaccinations, having correct knowledge about vaccinations, living in a community with a government vaccination facility within 5 km, and living in houses with better roofs were associated with vaccination uptake after adjusting for the effect of each of these variables and for clustering; maternal education was an equity factor even among those with good access. In rural areas, the combination of roof quality and access (vaccination post within 5 km) along with discussion about vaccines and knowledge about vaccines had an effect on uptake.

Conclusion

Stagnating rates of vaccination coverage may be related to increasing inequities. A hopeful finding is that discussion about vaccines and knowledge about vaccines had a positive effect that was independent of the negative effect of inequity - in both urban and rural areas. At least as a short term strategy, there seems to be reason to expect an intervention increasing knowledge and discussion about vaccination in this district might increase uptake.

4) VACCINATION CAMPAIGNS AND EQUITY IN KENYA

From chapter 5 of Attacking Inequality, this study of equity in Kenya looks at coverage across quintiles.

The following excludes graphics; for text and graphics, consult the full text at

http://siteresources.worldbank.org/INTPAH/Resources/Publications/YazbeckAttackingInequality.pdf

Excerpt:

Despite criticisms, African governments have not been deterred from

pushing ahead with immunization campaigns. Between 2001 and 2006,

42 African countries mounted catch-up measles campaigns and at least one

follow-up measles campaign each, reaching over 300 million children. In

2007, 16 countries were implementing measles campaigns seeking to reach

nearly 40 million more children. In 2005, 21 countries in the region mounted

similar campaigns against polio.

On average, the measles campaigns reached nearly 95 percent of the children

they targeted in the 19 countries with adequate data. By doing so, the

campaigns can presumably claim credit for at least part, perhaps a majority,

of the 90 percent decline in measles deaths reported in these countries

between 2000 and 2006.

But such overall figures do not speak directly to the impact of campaigns

on health equity. For that, one must look further, at the social and economic

distribution of the children whom the campaigns reached. In this regard,

the experience of measles campaigns in Kenya, where the distribution issue

has been directly examined, is instructive.

In June 2002, Kenya’s health ministry organized an initial nationwide

catch-up campaign that sought to provide measles immunization and vitamin

A supplementation to 13.5 million children. Shortly thereafter, the ministry

undertook a large-scale household survey, also covering all parts of the

country, to assess the campaign’s results. The survey focused on determining

whether children in the households covered had been covered through

regular immunization activities or the campaign, drawing primarily on documentation

provided to mothers at the time of immunization, supplemented

by mothers’ recall. The survey questionnaire also included enough

information about household characteristics to permit an assessment of its

assets or wealth, thereby permitting a comparison of the immunization

experience among children living at different economic levels.

Overall, the campaign raised Kenya’s measles immunization rate among

children ages 9–23 months from 77 percent to 90 percent. As shown in

table 12.1, the increases were largest in the lowest economic groups, regardless

of whether the changes were measured in absolute or relative terms.

Among children in the poorest 20 percent of households, for example,

coverage increased by 32 percent or 21 percentage points, compared with a

(statistically insignificant) decline of 2 percent or 2 percentage points among

children in the best-off 20 percent of households.

To be sure, many of the children immunized through the campaign

already had a significant degree of protection through vaccinations they

had previously received through regular health services. (Measles campaigns

typically seek to immunize all children in the areas in which they

operate, regardless of the children’s previous immunization status.

Although one dose of vaccine administered correctly at the optimal age provides

85 percent protection, the immunization fails to protect adequately

in 15 percent of cases under even the best of circumstances—and circumstances

in low-income country programs are rarely the best.) While these

children received a potentially significant degree of extra protection, the

greatest benefits accrued to children who had not previously received a

measles immunization.

The distribution of coverage among these previously unprotected children

also favored the poor. As can be seen from figure 12.1, almost 17 percent

of immunized children in the poorest quintile of households had not

been previously covered. This figure declines steadily across income classes,

reaching a level of under 4 percent for children in the wealthiest quintile of

households.

One reason for this pro-poor distribution of benefits appears to have

been the lowered costs to families of obtaining immunizations for their children.

While the estimated per-immunization cost to the government and

participating donors was about the same (around US$0.90) for both the routine

program and the catch-up campaign, bringing immunizations closer to

families greatly reduced expenses for transportation and the time they had

to take off from work. As a result, the average per-family cost of an immunization

was only US$0.11 for vaccinations provided through the campaign,

compared with US$0.86 for those made available through regular services.

How typical are these Kenyan results? There is no way to know for certain;

but there is also no obvious reason to consider Kenya’s regular immunization

program and campaign, or the setting in which they occurred,

notably different from those of the many other African countries that have

also tried measles campaigns. Further suggestive evidence comes from careful

studies in Ghana and Zambia showing that treated bed nets distributed

through measles campaigns effectively reached even the poorest population

groups, implying that the immunizations did so as well.

Afurther, general consideration is the likelihood that, in situations when

the coverage before an SIA campaign is already high, unimmunized children

will be disproportionately poor—as was the case in Kenya. This makes

it difficult to significantly increase overall coverage without effective outreach

to disadvantaged groups.

To the extent that such considerations and evidence are valid, the Kenya

outcome would seem adequate to support a working hypothesis that the

benefits of measles campaigns, and perhaps polio campaigns as well, undertaken

elsewhere in Sub-Saharan Africa are likely to benefit primarily the

poor. This appears especially likely in countries where a reasonably high

level of overall coverage had been achieved before the campaigns’ initiation.

Of course, this is not to deny the possible shortcomings of campaigns

that critics have noted, as reported above. But it does point to a potentially

significant advantage of the campaign approach that deserves consideration

in any overall assessment of the approach’s potential.

5) Ghana and Zambia: Achieving Equity in the Distribution of Insecticide-Treated Bednets through Links with Measles Vaccination Campaigns

http://siteresources.worldbank.org/INTPAH/Resources/Reaching-the-Poor/Ch4.pdf

From the discussion:

These findings suggest that integration of ITN delivery into measles vaccination

campaigns achieves unprecedented levels of ITN ownership and equity

at very low cost. In the study populations, the poorest families’ ITN ownership

rates were comparable to or exceeded those among the least poor. The

increase in the equity ratio of ITN ownership in the poorest households compared

with the least poor was substantial, rising from 0.29 to 1.01 in Ghana

and from 0.32 to 0.88 in Zambia. Expressed as a difference rather than a rate,

coverage among the poorest households in Ghana increased by 89.6 percentage

points compared with 82.7 percentage points for the least poor. In Zambia

the increase was 67.9 percentage points for the poorest and 57.6

percentage points for the least poor. This approach to ITN distribution

resulted in a larger coverage increase among the poorest in both relative and

absolute terms while ensuring high coverage levels for all wealth groups.

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