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.

50 Key Ideas, 33 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 of measles vaccine in Bangladesh found that children from the poorest quintile were more than twice as likely to die as those from the least quintile in the absence of measles vaccination. The difference in mortality between unvaccinated and vaccinated was statistically significant (p<0.10) and robust across alternative measures of socioeconomic status.

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Key Idea

During the conflict in Yemen, efforts spearheaded by WHO, with coordination among partners and effective use of resources, especially GAVI, resulted in continued high pentavalent vaccine coverage decreasing only 3% from 2010 to 2015. Yemen also remained polio-free through 2015 and smoothly introduced two new vaccines (MR and IPV).

During the humanitarian crisis in the Syrian Arab Republic, the constant support from WHO, UNICEF and local NGOs resulted in immunizations against VPDs reaching over 90% of children.

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Key Idea

The detection of H1N1 influenza virus in Mexico in 2009, and subsequently throughout other countries in the Americas, benefited from the laboratory experience with measles and rubella in the region…. [leading to] the rapid detection of and response to what eventually became a novel pandemic virus.

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Key Idea

An analysis of undernutrition and mortality in young children found that among the principal causes of death, 60.7% of deaths as a result of diarrhea, 52.3% of deaths as a result of pneumonia, 44.8% of deaths as a result of measles, and 57.3% of deaths as a result of malaria are attributable to undernutrition.

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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

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

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

In an analysis of statewide survey data collected in Bihar, India, researchers reported that female newborns had significantly lower odds of receiving care if ill compared to male newborns (80.6% vs. 89.1%) and lower odds of having a postnatal check up visit within a month of birth (5.4% vs. 7.3%). This gender inequity is more pronounced among families at lower wealth levels and those with higher numbers of siblings.

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A study that examined the gender-gap in immunization coverage in a rural area of Bangladesh showed that poverty, low maternal education, and second or higher birth order had a stronger negative effect on the likelihood of full immunization coverage for girls compared to boys. In other words, girls from households in this area that were below the poverty line were 11% less likely to be fully immunized than boys from households below the poverty line. Girls were also 6% less likely than boys to be fully vaccinated if their mothers did not attend high school, and 5% less likely than boys to be vaccinated if they were not the first born child in the family.

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Key Idea

In urban residents in the Democratic Republic of Congo, chronically malnourished children were less likely to have received two doses of measles-containing vaccine, compared to healthy children (OR=0.4).

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Key Idea

It is estimated that under current vaccine coverage trends in 41 Gavi-eligible countries, enhanced Gavi funding would help to avoid out-of-pocket health expenditures in an amount that surpasses $4.5 billion attributable to measles, $168 million attributable to severe pneumococcal disease and $200 million attributable to severe rotavirus.

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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

In 41 GAVI-eligible countries it is estimated that, in the absence of measles vaccination, the occurence of Medical Impoverishment (MI) or households falling below the poverty line due to medical expenditures to manage measles disease would be 5.3 million. With current coverage rates, 700 thousand housholds would suffer MI. If Gavi support afforded enhanced coverage, the estimate of households suffering MI would decrease to 500 thousand.

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Key Idea

In 41 GAVI-eligible countries, it is estimated that without any rotavirus vaccine (RVV) coverage, an estimated 2.2 million Catastrophic Health Costs (CHC) cases and 600,000 Medical Impoverishment (MI) cases would occur due to rotavirus gastroenteritis. Unfortunately these figures would not significantly decrease under the current immunization forecasts because very few countries have introduced the RVV. However, with the introduction of RVV the number of CHC cases would drop to 1.3 million and MI cases to 400,000, representing a 40% reduction.

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Key Idea

In a financial risk model analysis of 41 Gavi-eligible countries, the burden of Catastrophic Health Costs (CHC) and Medical Impoverishment (MI) would be greatest in the lowest income populations. With expanded vaccine coverage, the share of prevented cases of measles, pneumococcal disease and rotavirus, in relation to the total number of cases prevented, would be larger in the lowest income populations thereby providing a larger financial risk protection (FRP) to these populations.

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Key Idea

In 41 GAVI-eligible countries it is estimated that, in the absence of any measles vaccine use, approximately 18.9 million households would have Catastrophic Health Costs (CHC) attributable to measles. CHC decreases to 3.4 million households in these countries if the current vaccine coverage forecasts is unchanged and decreases to 2.6 million cases if coverage was enhanced with Gavi support. Overall, optimizing vaccine coverage for measles can reduce by approximately 90% the incidence of CHC due to measles disease.

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Key Idea

Researchers estimate that vaccinating against 10 diseases in the world’s 94 poorest countries between 2011-2020 will avert $586 Billion in costs of illness (including treatment costs, transportation costs, lost caretaker wages and productivity losses due to death and disability). The 73 Gavi-supported countries account for $544 billion of the treatment costs averted.

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Key Idea

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

For every 6 children vaccinated with measles vaccine in a poor, largely rural community in South Africa, one additional grade of schooling was achieved.

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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

“It is estimated that in 41 GAVI-eligible countries, approximately 6.6 million households would suffer Catastrophic Health Costs (CHC) in the absence of pneumococcal vaccine coverage. Due to the current absence of a pneumococcal immunization plan in many of these countries, the number of CHC cases would only decrease slightly to 6.4 million with current immunization programs. If pneumococcal vaccine programs would be implemented or expanded with Gavi support, the number of households experiencing CHC would decrease to 4.6 million – a decrease of approximately 30%.
Similarly, the estimates of medical impoverishment without vaccine coverage in this model showed that pneumococcal disease would cause 800,000 households to fall under the poverty line. “

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Key Idea

A recent study estimated that, during the decade from 2011-2020, every $1 invested in immunization programs in the world’s 73 poorest countries would yield a $16 return on investment. Using an approach accounting for additional societal benefits of vaccination (the “full income approach”, which quantifies the value that people place on living longer and healthier lives), researchers estimated the return could be as high as $44 per $1 invested.

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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

For every 6 children vaccinated with measles vaccine in a poor, largely rural community in South Africa, one additional grade of schooling was achieved.

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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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Key Idea

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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A study that examined the gender-gap in immunization coverage in a rural area of Bangladesh showed that poverty, low maternal education, and second or higher birth order had a stronger negative effect on the likelihood of full immunization coverage for girls compared to boys. In other words, girls from households in this area that were below the poverty line were 11% less likely to be fully immunized than boys from households below the poverty line. Girls were also 6% less likely than boys to be fully vaccinated if their mothers did not attend high school, and 5% less likely than boys to be vaccinated if they were not the first born child in the family.

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Key Idea

A review of measles vaccination data found that female children experience substantially higher mortality risks from measles relative to male children, and greater reductions in mortality with vaccination. In essence, vaccinating female children against measles provides them with the same survival chances as unvaccinated male children.

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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

A multiple-strategy community intervention program of the National Rural Health Mission (NRHM) in India, designed to reduce maternal and child health (MCH) inequalities was implemented between 2005 and 2012. The gender gap in immunization coverage swung from significantly favoring boys before the intervention to a slight advantage for girls by the end of the intervention. Specifically the coverage differentials changed as follows: for full immunization (5.7% to -0.6%), for BCG immunization (1.9 to -0.9 points), for oral polio vaccine (4% to 0%) and for measles vaccine (4.2% to 0.1%).

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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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In a systematic review of qualitative research from low- and middle-income countries, women’s low social status was shown to be a barrier to their children accessing vaccinations. Specific barriers included access to education, income, resource allocation and autonomous decision-making related to time. The author’s suggest that expanding the responsibility for children’s health to both parents (mothers and fathers) may be one important element in removing persistent barriers to immunization often faced by mothers.

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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

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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An analysis of undernutrition and mortality in young children found that among the principal causes of death, 60.7% of deaths as a result of diarrhea, 52.3% of deaths as a result of pneumonia, 44.8% of deaths as a result of measles, and 57.3% of deaths as a result of malaria are attributable to undernutrition.

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Key Idea

A study of the impact of measles vaccine in Bangladesh found that unvaccinated children in the poorest quintile were more than twice as likely to die as those from the least poor quintile. In addition, vaccination reduced socioeconomic status-related mortality differentials

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Key Idea

Measles vaccine in Bangladesh: Unvaccinated children in the poorest quintile were more than twice as likely to die as those from the least poor quintile. In addition vaccination reduced socioeconomic status-related mortality differentials.

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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 study of measles vaccine in Bangladesh found that children from the poorest quintile were more than twice as likely to die as those from the least quintile in the absence of measles vaccination. The difference in mortality between unvaccinated and vaccinated was statistically significant (p<0.10) and robust across alternative measures of socioeconomic status.

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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

In a systematic review of qualitative research from low- and middle-income countries, women’s low social status was shown to be a barrier to their children accessing vaccinations. Specific barriers included access to education, income, resource allocation and autonomous decision-making related to time. The author’s suggest that expanding the responsibility for children’s health to both parents (mothers and fathers) may be one important element in removing persistent barriers to immunization often faced by mothers.

View Source >

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.

View Source >

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

Researchers investigating the causes of a measles outbreak in Burkina Faso that occurred despite a recent mass vaccination campaign, found that migration to and from Cote d’Ivoire was a major risk factor for children. Unvaccinated children who developed measles were 8.5x more likely to have recently traveled to Cote d’Ivoire than unvaccinated children who had not traveled across the border. Children returning to Burkina Faso after a period of time in Cote d’Ivoire were less likely to have been vaccinated due to low routine coverage of measles vaccines in Cote d’Ivoire. Conversely, unvaccinated children from Burkina Faso who traveled to Cote d’Ivoire and returned were more likely to be exposed to measles and thus had a higher rate of disease than children who never visited Cote d’Ivoire.

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Large measles outbreaks occurred in Lebanon and Jordan, following an influx of Syrian refuges migrating to escape conflict. In Lebanon, the measles incidence increased 200-fold in one year following high migration. There were 2.1 measles cases per million population in Lebanon in 2012; this increased to 411 cases in 2013.

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Key Idea

In 2013 nearly all of the 175 cases of measles in the US could be traced back to international importations.

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Key Idea

In a study of data from England & Wales, Denmark and the US, it was shown that measles infection suppresses the immune system for up to 3 years after infection, increasing the risk of death due other childhood infections during that time. This means that prevention of measles significantly impacts overall health during critical childhood years.

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An analysis in India suggested that children aged 12–59 months who did not receive measles vaccination in infancy were three times more likely to die than those vaccinated against measles. Children from lower caste households who were not vaccinated in infancy had the highest risk of mortality (odds ratio, 8.9). A 27% increase in child mortality was attributable to failure to vaccinate against measles in the study population. Measles vaccine seems to have a non-specific reducing effect on overall child mortality in this population. If true, children in lower castes may reap the greatest gains in survival.

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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

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.

View Source >

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

In a study of data from England & Wales, Denmark and the US, it was shown that measles infection suppresses the immune system for up to 3 years after infection, increasing the risk of death due to other childhood infections during that time. This means that prevention of measles significantly impacts overall health during critical childhood years.

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Key Idea

Mothers infected with rubella virus during the first trimester of pregnancy can give birth to children with permanent disabilities such as intellectual impairment, autism, blindness, deafness and cardiac defects. The infection is completely preventable if mothers are vaccinated before pregnancy.

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Key Idea

In the Americas, a platform built to secure polio eradication has been expanded to help track, control, prevent and monitor immunization impact for measles and rubella. In India, highly trained polio health workers have become the basis for a trained workforce working towards the elimination of measles and rubella and helping ensure India’s certification by WHO for having eliminated maternal and neonatal tetanus.

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Key Idea

The American Academy of Pediatrics and the International Pediatric Association were included as partners in the measles and rubella elimination initiative, allowing for more direct collaboration around the interactions of primary health and immunization services and concerns.

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Key Idea

The detection of H1N1 influenza virus in Mexico in 2009, and subsequently throughout other countries in the Americas, benefited from the laboratory experience with measles and rubella in the region…. [leading to] the rapid detection of and response to what eventually became a novel pandemic virus.

View Source >

Key Idea

Among the principal causes of death in young children, 60.7% of deaths as a result of diarrhea, 52.3% of deaths as a result of pneumonia, 44.8% of deaths as a result of measles, and 57.3% of deaths as a result of malaria are attributable to under nutrition.

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