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.

31 Key Ideas, 24 Sources
Key Idea

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 Idea

A study looking at the relationship between gender roles and full immunization coverage of children in Nigeria found that children of mothers who did not have decision-making autonomy were half as likely to be fully immunized than mothers with autonomy. To further assess the roles of gender and relationship power, children were nearly twice as likely to be fully vaccinated in households where only the mother contributed to household earnings compared to children whose parents contributed equally.

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Key Idea

In Tanzania, poverty was found to have a negative effect on receiving vaccines on time (at the recommended age). Children in the wealthiest quintile experienced 19% fewer delays for BCG vaccination, 23% fewer delays for the third dose of DTP vaccination, and 31% fewer delays for the first dose of measles-containing vaccine, compared to children of the poorest quintile.

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Key Idea

Children in Tanzania living 5 km or greater distance from the nearest healthcare facility were less likely to be immunized than children living less than 5 km from facilities. Compared to children living close a health facility, children far from a health facility had almost three times the risk of missing out on BCG, 84% higher risk of missing the third dose of DTP, and 48% higher for missing the first dose of measles-containing vaccine. Of children who did receive BCG, those living more than 5 km from facilities had a 26% more likely to received BCG vaccine late than children close to the facility.

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Key Idea

The 2008 Nigerian Demographic Health Survey data suggest that children in communities with high unemployment were 1/3 as likely to be fully immunized than children in communities with a medium level of unemployment.

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Key Idea

Inequity in vaccination coverage in India was found between states, within states, in urban vs. rural. Lower parental education resulted in lower coverage, girls had lower coverage than boys and infants born to families with a large number of children also had lower coverage than others. A direct relationship between household wealth and coverage was also found.

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Key Idea

An analysis of under-5 mortality rates (U5MR) in India’s 35 states and union territories and 640 districts was conducted in order to estimate excess female mortality. When comparing India’s census data to data from 46 countries without gender bias, researchers found that more than 90% of districts had excess female mortality. The four largest states in northern India accounted for two-thirds of India’s total number. In more than 10% of northern Indian districts, excess U5MR exceeded 30 per 1000 live births, showing that geography is also a key factor in infant and child death among girls. Low economic development, gender inequity, and high fertility were the main predictors of excess female mortality.

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Key Idea

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 Idea

After instituting a multiple-strategy community intervention program in India, for pregnant women who had an institutional delivery, the geographic and socioeconomic inequities between those in urban and rural areas declined from 22% to 7.6%, and disparities between the rich and poor declined from 48.2% to 13%.

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Key Idea

In the mid-1980s, the Indian government examined the effect of their universal immunization program on child mortality and educational attainment. Results indicate that exposure to the program reduced infant mortality by 0.4 percentage points and under five child mortality by 0.5 percentage points. These effects on mortality account for approximately one-fifth of the decline in infant and under five child mortality rates between 1985-1990. The effects are more pronounced in rural areas, for poor people, and for members of historically disadvantaged groups.

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In a study of immunization in the Philippines, children vaccinated against 6 diseases performed significantly better on verbal reasoning, math and language tests than those who were unvaccinated. (note: Researchers did not find an association with physical growth.)

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Key Idea

Models based on demographic data from Ghana suggest that immunization would eliminate the childhood mortality risk associated with living in poverty and greatly diminish the increased risk of mortality borne by children whose parents have low levels of education.

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Key Idea

Vaccination of children in the Philippines against 6 diseases was found to significantly increase IQ and language scores (compared to children receiving no vaccinations) and was estimated to have a 21% rate of return.

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Key Idea

Nigerian Demographic Health Survey data suggests that community literacy influences immunization status. Children in communities with low levels of illiteracy were 82% less likely to be fully immunized than children in communities with medium levels of illiteracy.

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A study conducted in Eastern Uganda found that Ugandan children whose mothers had some secondary schooling were 50% more likely to have received scheduled vaccinations by 6 months of age than children whose mothers had attended school only through primary level. This effect became more pronounced with delivery of the later doses of each vaccine (OPV2, 3 & DPT-HB-Hib 2,3).

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Key Idea

A study looking at WHO data from member states shows that globally, coverage of the third dose of DTP is 26% higher among children born to mothers with some secondary education compared to mothers with no education.

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Researchers looking at vaccination coverage in 45 low- and middle-income countries found that maternal education is a strong predictor of vaccine coverage. Children of the least educated mothers are 55% less likely to have received measles containting vaccine and three doses of DTP vaccine than children of the most educated mothers.

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Key Idea

Across multiple studies reviewed, the effect of measles vaccine appears to be more beneficial to girls than to boys.

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Key Idea

An impact evaluation for a women’s empowerment program in India found that the children of mothers who participated the empowerment program were significantly more likely to be vaccinated against DTP, measles, and tuberculosis than children of mothers not involved in the program. This study also found that the women’s empowerment program had positive spillover effects: In villages where the program occurred, children of mothers not in the program (non-participants) were 9 to 32% more likely to be immunized against measles than in villages where the program did not occur (controls). Overall, measles vaccine coverage was nearly 25% higher in the program villages compared to the control villages.

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An analysis of data from the 2011 Ethiopian Demographic and Health Survey investigated the relationship between individual- and community-levels of women’s autonomy and children’s immunization status. The results show that community-level autonomy is associated with an increased number of children’s immunizations above and beyond that of individual-level women’s autonomy. These results indicate that empowering women within households not only improves the individual mother’s children’s health, but also serves to improve the lives of other children within the community.

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A systematic review of studies from countries in Africa and Southeast Asia investigated the relationship between a woman’s “Agency” (defined as the woman’s ability to state her goals and to act upon them with motivation and purpose) and childhood immunizations in lower-income settings. The review found a general pattern among studies in which higher agency among mothers was associated with higher odds of childhood immunizations. Empowering women in these settings show promise as a means to improve child health.

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Key Idea

Inequity in vaccination coverage in India was found between states, within states, and in urban vs. rural. Lower parental education resulted in lower coverage, girls had lower coverage than boys and infants born to families with a large number of children also had lower coverage than others. A direct relationship between household wealth and coverage was also found.

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Key Idea

In an analysis of immunization coverage in 45 low- and lower-middle income Gavi-eligible countries, researchers found that overall, maternal and paternal education were two of the most significant drivers of coverage inequities in these countries. Pooling the data from all countries, the authors found that “children of the most educated mothers are 1.45 times more likle to have received DTP3 than children of the least educated mothers.” The same held true for measles vaccines with a 1.45-fold likelihood of vaccination in children of the most educated mothers.

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Key Idea

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 Idea

In the mid-1980s, the Indian government embarked on one of the largest childhood immunization programs-called Universal Immunization Program (UIP)-in order to reduce the high mortality and morbidity among children. Results indicate that exposure to the program reduced infant mortality by 0.4 percentage points and under five child mortality by 0.5 percentage points. These effects on mortality are sizable{they account for approximately one-fifth of the decline in infant and under five child mortality rates between 1985- 1990. The effects are more pronounced in rural areas, for poor people, and for members of historically disadvantaged groups. The 0.5 percentage point reduction each year over 5 years (from 15% under 5 mortality in 1985 to 12.3% in 1990), represents an 18% reduction overall in under 5 mortality.

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Models based on demographic data from Ghana suggest that immunization would eliminate the childhood mortality risk associated with living in poverty and greatly diminish the increased risk of mortality borne by children whose parents have low levels of education.

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Key Idea

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 Idea

A package of 5 vaccines was delivered and it was found that children from poorer households benefited more in terms of health outcomes from immunization than did those from relatively wealthier households. Results suggest that most of the risk of dying before age five can be eliminated with full immunization in the severely health-deprived setting.

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Key Idea

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 Idea

Globally, coverage of the third dose of DTP is 15% higher among children in the highest compared to lowest wealth quintile. However, this masks differences of up to 64% in the most inequitable countries (Nigeria).

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Inequity in vaccination coverage in India was found between states, within states, and in urban vs. rural. Lower parental education resulted in lower coverage, girls had lower coverage than boys and infants born to families with a large number of children also had lower coverage than others. A direct relationship between household wealth and coverage was also found.

View Source >

In Tanzania, poverty was found to have a negative effect on receiving vaccines on time (at the recommended age). Children in the wealthiest quintile experienced 19% fewer delays for BCG vaccination, 23% fewer delays for the third dose of DTP vaccination, and 31% fewer delays for the first dose of measles-containing vaccine, compared to children of the poorest quintile.

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Key Idea

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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A package of 5 vaccines was delivered and it was found that children from poorer households benefited more in terms of health outcomes from immunization than did those from relatively wealthier households. Results suggest that most of the risk of dying before age five can be eliminated with full immunization in the severely health-deprived setting.

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Key Idea

In a 2014 review of the non-specific effects of measles vaccines, among others, the WHO Strategic Advisory Group of Experts indicated that some studies of measles vaccine were suggestive (but not conclusive) of a beneficial effect of measles vaccine on mortality beyond the expected direct effect of the vaccine against measles.

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Key Idea

Data from India’s National Family Health Survey-3 was modeled to determine the contributing factors to height, weight and haemoglobin concentration of over 25,000 children. Results showed that, despite the average child receiving only 1.95 doses of DPT and 2.43 doses of polio vaccinations, and the fact that 45% of children were unimmunized against measles, children’s vaccinations were a statistically significant positive predictor for children’s height, weight and haemoglobin level.

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Universal Immunization Programs (UIP) increased the average age-appropriate height and weight of 4 year old children in a study in India. The magnitude of effect suggests that, on average, UIP reduced the height deficit of these children by 22–25% and their weight deficit by 15%.

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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 Idea

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 Idea

Children [in slums] suffer from higher rates of diarrhoeal 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 Idea

A recent review looks at evidence linking vaccinations in early infancy to childhood development services. BCG and DPT have the highest coverage of any vaccines worldwide and are typically administered within 6 weeks of birth. This timing offers the opportunity to deliver a range of early childhood development interventions such as newborn hearing screening, sickle cell screening, treatment and surveillance, maternal education around key newborn care issues such as jaundice, and tracking early signs of poor growth and nutrition.

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Key Idea

Globally, coverage of the third dose of DTP is 8% higher among urban dwellers compared to children raised in a rural environment.

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