VoICE : Search Immunization Evidence

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The VoICE tool is a compendium of the many direct and downstream impacts of vaccine-preventable disease and immunization. The database contains summary explanations of the link between immunization and each impact, as well as sources of evidence for each link. You can browse the VoICE tool by topic, or use the filters to find results based on topic, disease or vaccine, location and published year.

34 Key Concepts, 38 Sources
Key Concept

Key Evidence: Malnutrition is a leading contributor to morbidity and mortality during humanitarian emergencies, and a cyclical relationship exists between malnutrition and infectious diseases. Universal immunization programs have been shown to improve the height and weight measurement markers associated with malnutrition.

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Key Concept

Key Evidence: Children in the poorest 20% of households in Laos have a 4-5 times greater risk of dying from rotavirus than the richest 20%. Consequently, rotavirus vaccination was almost five times more cost-effective in the lowest income groups in the Central Region than in the richest households in the wealthier North region. Thus, rotavirus vaccination has a greater potential for health gains and greater cost-effectiveness among marginalized populations.

From the VoICE Editors: Note that these gains are dependent on improving vaccination coverage, access to health care and environmental health in these populations.

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Key Concept

Key Evidence: A study modeling the relationship between disease and poverty in Ethiopia found that among the top 20 causes of death in Ethiopia, diarrhea and lower respiratory infections (LRIs) are the top two drivers of medical impoverishment. It is estimated that in 2013, out-of-pocket direct medical costs for diarrheal disease drove an estimated 164,000 households below the poverty line (representing 47% of all the diarrhea cases), and LRIs led to an estimated 59,000 cases of poverty (17% of LRI cases). Of the top 10 health-associated drivers of poverty, four are at least partially vaccine-preventable (1. Diarrhea, 2. LRI, 4. TB. 10. Pertussis).

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Key Evidence: Costs for treatment for rotavirus at a large urban hospital in Malaysia led one third of families to experience catastrophic health expenditures (CHC). When direct and indirect costs of treating rotavirus were considered, almost 9 in 10 families spent more than 10% of their monthly household income on treating rotavirus. In addition, 6% of families were pushed into poverty after paying for treatment.

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Key Concept

Key Evidence: An analysis of the association between undernutrition and mortality in young children revealed that in 60% of deaths due to diarrhea, 52% of deaths due to pneumonia, 45% of deaths due to measles and 57% of deaths attributable to malaria, undernutrition was a contributing factor.

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Key Concept

Key Evidence: A comprehensive review of the economics of cholera and cholera prevention concluded that vaccination using oral cholera vaccines can be cost-effective, especially when herd effects are taken into account and when vaccination is administered to populations and age groups with high incidence rates (e.g., children) and to areas with high cholera case fatality rates.

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Key Evidence: A study using local epidemiological and economic data found that vaccinating children 1-14 years old in high-risk slum areas in Dhaka, Bangladesh using a locally-produced oral cholera vaccine provided through periodic campaigns would be a highly cost-effective means of controlling endemic cholera — reducing cholera incidence in the entire population by 45% over 10 years and costing US$440-635 per DALY averted. Vaccinating all persons aged one and above would reduce incidence much further (by 91%) but would be less cost-effective.

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Key Concept

Key Evidence: A two-dose schedule of rotavirus vaccine was estimated to be cost-effective in Somalia, where more than 20 years of civil conflict have significantly damaged the health system and vaccine coverage is exceedingly low. Researchers estimate that in 2012, routine use of rotavirus vaccine, even at low coverage rates, would have averted nearly 25% of deaths due to rotavirus diarrhea in Somali children under one year of age.

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Key Evidence: Children under 5 years of age bear the greatest burden of indirect conflict-associated mortality (indirect mortality results from disruption of health services including immunization, food insecurity, and high risk living conditions such as those found in refugee camps). The leading causes of child death in these circumstances include respiratory infections, diarrhea, measles, malaria, and malnutrition.

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Key Evidence: Respiratory infections and diarrhea are the leading causes of death during humanitarian emergencies according to a 2016 review of vaccine-preventable diseases and the use of immunizations during complex humanitarian emergencies.

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Key Concept

Key Evidence: In a UK cost-effectiveness analysis, which takes into account herd effect, the budget impact analysis demonstrated that the introduction of a rotavirus vaccine (RVV) program could pay back between 58-96% of the cost outlay for the program within the first 4 years.

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Key Evidence: In an economic evaluation of vaccination against rotavirus conducted in Italy, it was shown that as early as the second year after rotavirus vaccine introduction, the vaccine cost would be more than offset by savings from prevention of disease cases and hospitalizations.

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Key Concept

Key Evidence: Those who experienced more frequent or longer episodes of diarrhea as an infant were more likely to have metabolic syndrome as adults. A longitudinal study in Guatemala found that diarrhea episodes in early infancy are associated with chronic health issues later in life. Each 1% increase in diarrhea burden in children 0-6 months was associated with a 3% increased prevalence in high blood pressure in adulthood. Similarly, a 1% increase in diarrhea burden in older infants 6-12 months was associated with a 4% increased prevalence in elevated waist circumference in adulthood.

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Key Concept

Key Evidence: A study of children under 5 years of age in Dhaka, Bangladesh found that severely malnourished children were nearly 8 times more likely to suffer death from diarrhea than those who were not severely malnourished.

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Key Concept

Key Evidence: A pooled analysis of nine studies assessing the effects of diarrhea on stunting prior to the age of 24 months showed that the odds of stunting were significantly increased with each diarrheal episode. Each day of diarrhea prior to attaining 24 months of age also contributed to the risk of stunting. For each five episodes of diarrhea, the odds of stunting increased by 13%. In addition, once a child becomes stunted, only 6% of those stunted at 6 months of age recovered by 24 months of age.

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Key Evidence: A review of gut infections and effects on physical growth and development found that for children living in impoverished areas of the world, episodes of diarrhea during the first two years of life not only negatively affected their physical growth, but could result in a 10 points lower IQ than average by age 7.

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Key Concept

Key Evidence: Children hospitalized with rotavirus in Norway were absent from daycare for 6.3 days, on average, and 73% of their parents missed work — for a mean of almost 6 days. These data, which can be used in economic evaluations of rotavirus vaccination, show that work absenteeism resulting from having a child hospitalized with rotavirus poses a considerable economic burden on society.

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Key Concept

Key Evidence: In a modeled analysis of the economic impact of vaccine use in the world’s 72 poorest countries, for countries included in the analyses from the African region, scaling up coverage of the Rotavirus (RVV) vaccine to 90% was projected to result in more than US$900 million in treatment costs averted.

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Key Concept

Key Evidence: In India, a multi-strategy community intervention, the National Rural Health Mission (NRHM) was successful in reducing disparities between pregnant women who had an institutional delivery in urban and rural areas. Geographic inequities reduced from 22% to 7.6% and socioeconomic disparities declined from 48.2% to 13%. Post the NRHM period, the difference between the number of children with full vaccination i.e., Bacillus Calmette Guerin (BCG) vaccine for tuberculosis, 3 doses of Diphtheria Pertussis and Tetanus vaccine (DTP), 3 doses of Oral Polio Vaccine (OPV), and measles vaccine, in urban and rural areas was observed to be non-significant.

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Key Concept

Key Evidence: Through use of local Maternal Child Health (MCH) incentives, along with the use of locally appointed Health Activists, India’s National Rural Health Mission (NRHM) multiple-strategy community intervention program was able to achieve household level improvements in all of the following indicators for women and children over the 7 year program:
– the proportion of pregnant women having 3 or more ante-natal check-ups (from 43% to 74.5%)
– receiving at least one Tetanus Toxoid injection (from 83.5% to 93.6%)
– institutional deliveries (from 35.7% to 77%)
– post-natal check-ups within 2 weeks of delivery (from 49% to 67.2%) and,
– children who received ORS for diarrhea from (32.3% to 44.8%).

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Key Concept

Key Evidence: Costs for treatment for rotavirus at a large urban hospital in Malaysia led one third of families to experience catastrophic health expenditures (CHC). When direct and indirect costs of treating rotavirus were considered, almost 9 in 10 families spent more than 10% of their monthly household income on treating rotavirus. In addition, 6% of families were pushed into poverty after paying for treatment.

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Key Evidence: Children with rotavirus experience longer hospital stays than children with non-rotavirus diarrhea. In a study looking at the direct and indirect costs of treating rotavirus in Malaysia, rotavirus hospitalizations cost families 26% of their average total monthly household income, which was significantly higher than the cost for non-rotavirus diarrhea hospitalizations.

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Key Concept

Key Evidence: In Malawi, in 17% of cases where children were admitted to the hospital, and in 9% of cases where children were treated as outpatients for diarrhea, household costs associated with treating that episode, exceeded monthly income in a significant number of cases. The costs were significant enough to push families from each income level below the national poverty line for the month in which the illness occurred.

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Key Concept

Key Evidence: A study of a cholera outbreak in Peru in 1991-92 estimates that the national economy conservatively suffered more than US$50 million in economic losses due to reduced tourism revenue, reduced revenue on export of goods and lower domestic consumption as a result of the outbreak of cholera.

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Key Concept

Key Evidence: A study of the economic burden of cholera in Africa found that 110,837 cases of cholera reported in 2007 resulted in an economic loss of $43.3 million, $60 million and $72.7 million US dollars, assuming life expectancies of 40, 53 and 73 years respectively.

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Key Concept

Key Evidence: A large longitudinal study in the Philippines found that children suffering bouts of diarrhea and respiratory infections were at a significantly increased risk of physical stunting which is associated with “poor functional outcomes such as impaired cognitive development.”

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Key Evidence: A study looking at the long term cognitive deficits faced by children in an urban Brazilian shantytown with high incidence of diarrhea in the first two years of life showed that this cohort scored significantly lower on 3/5 types of test measuring cognitive function at ages 6-10 compared to children who did not suffer recurrent bouts of early childhood diarrhea. In particular, the children who suffered from persistent early childhood diarrhea scored lower on tests assessing nonverbal intelligence (TONI) and IQ through assessing ability to match symbols to numbers (WISC-III Coding task) and short-term memory (WISC-III digit scan).

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Key Concept

Key Evidence: In a study of children in a Brazilian shantytown, researchers found that the greater the number of episodes of persistent diarrhea before age two, the more delayed a child was in terms of school readiness. Overall, each episode of diarrhea delayed a child’s starting school by 0.7 months. Likewise, 6-10 years later, increasing episodes of diarrhea before age two predicted delays in age-appropriate educational attainment.

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Key Concept

Key Evidence: Children in slum settings have higher burdens of vaccine-preventable disease (one study found children in slums in Manila, Philippines were 9 times more likely to have tuberculosis than other urban children) and lower rates of immunization (a study in Niger found 35% coverage in slums vs. 86% in non-slum urban areas).

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Key Concept

Key Evidence: A study of children under 5 years of age in Dhaka, Bangladesh found that severely malnourished children were nearly 8 times more likely to suffer death from diarrhea than those who were not severely malnourished.

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Key Evidence: A study of Kenyan children under 5 years of age found that immunization with polio, BCG, DPT, and measles to be protective against stunting in young children (27% less likely to be stunted than unimmunized children under age 2 years). In addition, children with diarrhea and cough in the 2 weeks prior to the survey were 80-90% more likely to be underweight or to suffer from wasting.

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Key Evidence: An analysis of the association between undernutrition and mortality in young children revealed that in 60% of deaths due to diarrhea, 52% of deaths due to pneumonia, 45% of deaths due to measles and 57% of deaths attributable to malaria, undernutrition was a contributing factor.

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Key Concept

Key Evidence: An analysis of the association between undernutrition and mortality in young children revealed that in 60% of deaths due to diarrhea, 52% of deaths due to pneumonia, 45% of deaths due to measles and 57% of deaths attributable to malaria, undernutrition was a contributing factor.

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Key Concept

Key Evidence: A group of experts evaluated a number of maternal, neonatal, and child health interventions for equity across wealth quintiles using data from 1990-2006. Immunization was found to have the narrowest differences in coverage of services between the poorest and wealthiest children. In other words, of the interventions evaluated, immunization was the most equitable across income groups.

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Key Concept

Key Evidence: A group of experts evaluated a number of maternal, neonatal, and child health interventions for equity across wealth quintiles using data from 1990-2006. Immunization was found to have the narrowest differences in coverage of services between the poorest and wealthiest children (28% higher coverage in the highest wealth quintile compared to the lowest). By contrast, indicators of treatment coverage for children sick with diarrhea and pneumonia were nearly 60% higher in the highest wealth quintile compared to the poorest. This means that poor children are at a much greater disadvantage with respect to receiving treatment for pneumonia and diarrhea than they are for receiving vaccines to prevent these infections.

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Key Concept

Key Evidence: A study in Kenya revealed that immunization with polio, BCG, DPT and measles had protective effects with respect to stunting in children under 5 years of age. In children under the age of 2 years, immunized children were 27% less likely to experience stunting when compared to unimmunized children. Additionally, children who suffered from cough or diarrhea in the 2 weeks prior to the study showed an 80-90% higher probability of being underweight or experiencing wasting.

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Key Concept

Key Evidence: Several countries have seen a significant decrease in the number of rotavirus-related hospital admissions in rotavirus unvaccinated children ages 2-5 years who were not age eligible to receive the vaccine post introduction. The US had a 41-92% decrease, Australia had a 30-70% decrease, Belgium had a 20-64% decrease, Austria had a 35% reduction and El Salvador had a 41-81% decrease. In addition, there was a reduction in hospitalizations due to gastroenteritis of any cause by 17-51% in the US and 40% in Australia.

From the VoICE Editors: This data is from a review article of multiple studies that evaluated the benefits of rotavirus vaccine following vaccine introduction.

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Key Evidence: In Nagoya, Japan, hospitalizations due to rotavirus (RV) decreased sharply in children 2-4 years of age once the percent of infants vaccinated against RV climbed to around 80%. Few of these older children had likely received the vaccine, suggesting that they were protected as a result of herd immunity.

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Key Concept

Key Evidence: Multiple studies show that

  1. Diarrhea and pneumonia impair children’s growth and that underlying malnutrition is a major risk factor for these conditions.
  2. “Episodes of diarrhea may predispose to pneumonia in undernourished children” and
  3. Immunization against influenza (in mothers) and Streptococcus pneumoniae may improve infant growth. In addition, new studies from Bangladesh, Colombia, Ghana, and Israel further support the paradigm that malnutrition is a key risk factor for diarrhea and pneumonia.

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Key Concept

Key Evidence: A large longitudinal study in the Philippines found that children suffering bouts of diarrhea and respiratory infections were at a significantly increased risk of physical stunting which is associated with “poor functional outcomes such as impaired cognitive development.”

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Key Evidence: A prospective case-control study conducted in several developing countries found that children with moderate-to-severe diarrhea grew significantly less in length in the two months following their episode compared to age- and gender-matched controls.

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Key Evidence: A study of Kenyan children under 5 years of age found that children with diarrhea and cough in the 2 weeks prior to the survey were 80-90% more likely to be underweight or to suffer from wasting.

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Key Concept

Key Evidence: In a recent review of data from developing countries, researchers found that episodes of diarrhea may predispose undernourished children to pneumonia.

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Key Concept

Key Evidence: In Rwanda, the number of hospital admissions for diarrhea and rotavirus fell substantially after rotavirus vaccine (RVV) introduction, including among older children age-ineligible for vaccination. This suggests indirect protection through reduced transmission of rotavirus. Two years after RVV introduction, the country had nearly 400 fewer hospital admissions for diarrhea among young children.

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Key Evidence: A meta-analysis of studies measuring the impact of rotavirus vaccine (RVV) on severe gastroenteritis morbidity and mortality, found a 22% herd immunity effect for severe rotavirus gastroenteritis in children less than one year of age in US and El Salvador.  In Latin America, severe gastroenteritis due to any cause was reduced by 25%.

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Key Concept

Key Evidence: Children in slums suffer from higher rates of diarrheal and respiratory illness, malnutrition, and have lower vaccination rates. Mothers residing in slums are more poorly educated and less likely to receive antenatal care and skilled birth assistance.

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Key Concept

Key Evidence: This paper presents the first cost-benefit comparison of improved water supply investments and cholera vaccination programs. The study results showed that improved water supply interventions combined with targeted cholera vaccination programs are much more likely to yield attractive cost-benefit ratio outcomes than a community-based vaccination program alone.

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Key Concept

Key Evidence: Two years after rotavirus vaccine introduction in Rwanda, the country saw nearly 400 fewer hospital admissions for diarrhea among young children at 24 district hospitals.

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Key Evidence: A review of evaluations of rotavirus vaccine impact on hospitalizations and all-cause acute gastroenteritis (AGE) across multiple countries showed that during the first decade since vaccine licensure, a 32% median reduction in hospitalizations due to AGE were observed in children under a year of age. In children younger than 5 years of age a 38% median reduction was noted. Additionally, laboratory confirmed cases of rotavirus-related hospitalization dropped by 80% and 67% in children under 1 year and 5 years of age respectively. The vaccine introduction also lead to a 46% decrease of AGE in children under 5 years of age in a high mortality setting.

From the VoICE Editors: These observations were evaluated using standardized, evidence- based PRISMA guideline.

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Key Evidence: A study in four hospitals in Botswana found that over a two-year period following the introduction of rotavirus vaccine, hospitalizations from all causes of diarrhea fell by one-third in infants (0-11 months old), and by nearly one-quarter in all children under five years of age. Ninety percent of infants 4-11 months old in the study population received at least one dose of the vaccine, and 75% received both doses during this period. The vaccine’s impact was most apparent during the rotavirus season when the average number of hospitalizations from diarrhea fell 43% among infants and by one-third among all children under five.

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Key Evidence: In a Bangladeshi study, pneumonia and acute diarrhea were the first and third most common reasons for childhood hospital admission with over half (54%) of the acute diarrhea admissions caused by rotavirus. One in four children taken to this large pediatric hospital were refused admission because all beds were occupied. Vaccination could have prevented children with rotavirus from requiring essential hospital resources when one in four children refused admission had symptoms of pneumonia.

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