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.

35 Key Ideas, 25 Sources
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

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 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 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

A study in a population of urban poor in Delhi, India, which examined household and neighborhood-level determinants of childhood immunization, found that less than half of children between 1 and 3.5 years of age received complete immunization as recommended. This was significantly lower than the overall state-level average of 70% immunization coverage.

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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 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

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

Among families participating in a study in Western Cape, South Africa, 35% of mothers who were previously employed stopped working to care for children who had survived tuberculosis meningitis with permanent disabilities. 19% of families reported experiencing financial loss as a result of caring for these disabled children.

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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

Among families participating in a study in Western Cape, South Africa, 35% of mothers who were previously employed stopped working to care for children who had survived tuberculosis meningitis resulting in permanent disabilities. 19% of families reported experiencing financial loss as a result of caring for these disabled children.

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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

Among children participating in a study in Western Cape, South Africa who were well enough to attend school after surviving tuberculous meningitis, more than half (53%) had failed a school grade at least once.

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Key Idea

A study conducted in the urban poor in Delhi, India examining household and neighborhood-level determinants of childhood immunization found that the odds of complete vaccination in children were higher if the mother was literate (1.6x), if the child was born within the city limits (2.7x), born in a health facility (1.5x), and if they belonged to the wealthiest 20% of families sampled from this poor urban area (2.5x).

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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 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

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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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

A study conducted in the urban poor in Delhi, India found that the odds of complete vaccination were lower in female children than in male children. The female:male complete immunization coverage ratio showed only 78 females received complete immunizations per every 100 males immunized. The authors note that this gender inequity effect in immunization has not changed in many Indian states despite increasing overall vaccine coverage rates.

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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.

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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

A study conducted in the urban poor in Delhi, India examining household and neighborhood-level determinates of childhood immunization found that the odds of complete vaccination in children were higher if the mother was literate (1.6), if the child was born within the city limits (2.7), born in a health facility (1.5), and if they belonged to the wealthiest 20% of families sampled from this poor urban area (2.5).

View Source >

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

2 of the 18 drug-resistant threats to US health security identified in a 2013 CDC report are potentially vaccine-preventable.

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Key Idea

The US CDC identifies the use of vaccines as one of the 4 critical steps for controlling the spread of antibiotic resistance.

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Key Idea

TB and pneumococcal infections are two of 18 drug-resistant threats to US health security identified by the CDC in 2013 and are potentially vaccine-preventable. Most antibiotic resistant TB infections in the US occur in people born outside the US.

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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

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

The US CDC estimates that antibiotic resistant pneumococcal infections in the US add $96 million to the costs of treatment each year.

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