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.

90 Key Concepts, 100 Sources
Key Concept

Key Evidence: An outreach strategy in Kenya to vaccinate children against measles in hard-to-reach areas (e.g., beyond 5 km from a vaccination post) would be highly cost-effective, despite the higher cost per child to reach these children. The estimated cost per DALY averted ranged from US$122 (if 50% of these children receive the first dose and one-half of them the second dose) to US$274 (if 100% receive the first dose) — considerably less than the country’s GDP per capita of US$1,865 used as the threshold of cost-effectiveness.

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Key Concept

Key Evidence: In contrast to non-Somalis, family wealth did not significantly affect the likelihood of being fully vaccinated among Somali refugee children living in Kenya. This may point to systemic barriers to vaccination that cut across all socio-economic levels of the Somali refugee population.

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Key Evidence: An analysis of survey data in Latin America and Caribbean countries found that DPT3 coverage rates among indigenous children were significantly lower than in children of European or mixed ethnicity in three out of 14 countries, while significant inequities between these groups in coverage of maternal health services, such as antenatal care and delivery by a skilled birth attendant, existed in most of the countries. The greater equity in access to childhood vaccination by ethnic group may be because vaccinations are often delivered in the communities through immunization campaigns, whereas maternal health services require accessing health facilities, which may incur user fees and transportation costs.

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Key Concept

Key Evidence: In India, inequities in vaccination coverage exist between states, within states, and in urban vs. rural settings. 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 Evidence: Full immunization coverage, within the Democratic Republic of Congo, varies drastically by region. In the province with the lowest coverage, approximately 5% of children were fully immunized, while in the province with highest coverage, over 70% of children were fully immunized.

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Key Evidence: 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 Concept

Key Evidence: Vaccinating children against rotavirus in Bangladesh would prevent more than 50,000 outpatient visits and 40,000 hospitalizations in children under five each year, and reduce treatment costs by US$5.8 million over 2 years — nearly all (96%) from fewer hospitalizations. Since this study didn’t take herd effects into account, the actual impact would likely be greater.

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Key Evidence: 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 Evidence: Researchers estimate that vaccinating against 10 diseases in the world’s 94 poorest countries between 2011-2020 will avert US$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 US$544 billion of the treatment costs averted.

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Key Concept

Key Evidence: Vaccinating children against rotavirus in Bangladesh would prevent more than 50,000 outpatient visits and 40,000 hospitalizations in children under five each year, and reduce treatment costs by US$5.8 million over 2 years — nearly all (96%) from fewer hospitalizations. Since this study didn’t take herd effects into account, the actual impact would likely be greater.

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Key Concept

Key Evidence: An analysis of the impact of rotavirus vaccine in 25 countries found that the rates of vaccination in all countries were highest and risk mortality lowest in the top two wealth quintile’s coverage. Countries differed in the relative inequities in these two underlying variables. Cost per DALYs averted in substantially greater in the higher quintiles. In all countries, the greatest potential vaccine benefit was in the poorest quintiles; however, reduced vaccination coverage lowered the projected vaccine benefit.

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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 Evidence: A study looking at the impact of pneumococcal vaccine introduction and scaling up pneumonia treatment in Ethiopia found that 30-40% of all deaths averted by these interventions would be expected to occur in the poorest wealth quintile. The greatest resulting financial risk protection would also be concentrated among the bottom income quintile.

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Key Evidence: 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 Concept

Key Evidence: A study in Kenya estimated that the failure to vaccinate the 21% of children considered hard-to-reach (living beyond a 5 km radius of a vaccination post) against measles would result — over 4 years — in more than 1,400 measles cases, 257 deaths, and cost nearly US$10 million, mainly in productivity losses from caretakers missing work.

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Key Concept

Key Evidence: Meningococcal meningitis epidemics in Burkina Faso “… disrupted all health services from national to operational levels,…” according to a 2011 study. Impacts included a shortage of available hospital beds and medicines, a reduction or delay in routine lab analyses for other diseases, longer wait times, and an increase in misdiagnoses by overtaxed health workers.

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Key Evidence: Fear of Ebola during the 2014-2016 epidemic in 3 West African countries had a major impact on the health sector in neighboring Nigeria, where hospitals reported sharp decreases in patient volume resulting in major financial losses. Some hospitals also turned away febrile patients to prevent being associated with Ebola while staff in other hospitals abandoned their posts.

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Key Evidence: A 2015 study projected that the crippling of immunization programs resulting from the 2014 Ebola epidemic in Guinea, Liberia, and Sierra Leone could double the number of people at risk of a measles outbreak, and could cause up to 16,000 measles deaths, surpassing the number of deaths caused by Ebola itself.

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Key Concept

Key Evidence: A large meningococcal meningitis epidemic in Burkina Faso cost the health system an estimated US$7.1 million, representing nearly 2% of the country’s entire annual health budget.

From the VoICE editors: In this study of a 2007 outbreak, 86% of the health system cost covered a reactive vaccination campaign using older polysaccharide vaccines. Routine vaccination with new, conjugate vaccines are expected to prevent or limit future outbreaks and thus reduce these costs.

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Key Concept

Key Evidence: A study found that children of poor labor migrants living in Delhi, India are much less likely to be fully vaccinated than the general population and thus are at greater risk of vaccine-preventable diseases. Only 31% – 53% of children from migrant families were fully immunized (against 7 diseases) by 12 months of age, compared to 72% in the overall population of Delhi — with recent migrants having the lowest rates. There is therefore a need to focus on the delivery of health services to migrants.

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Key Evidence: Somali refugee children in Kenya were nearly 60 times more likely than children of the main ethnic group in the study (Kikuyu) to not have received any childhood immunization and more than twice as likely to have not completed their vaccinations. Although Somali children made up less than 8% of the sample, they accounted for nearly half of all non-vaccinated children.

From the VoICE Editors: This study used data from Kenya’s Demographic and Health Survey data.

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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 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: Across many South Asian and sub-Saharan African countries, children of mothers who received no formal education were nearly 3 times as likely to die before reaching age 5 as those born to mothers with some secondary education.

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Key Concept

Key Evidence: The expertise and assets gained through efforts to eradicate polio at least partially explain the improvement between 2013 and 2015 in vaccination coverage of DPT3 in six out of ten “focus” countries of the Polio Eradication Endgame strategic plan. This includes substantial increases in vaccination rates in India, Nigeria, and Ethiopia, which, combined, reduced the number of children not fully vaccinated with DPT by 2 million in 2 years.

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Key Concept

Key Evidence: 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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Key Concept

Key Evidence: Kenyan children born outside of a health facility with the aid of a traditional birth attendant were around 80% more likely to be non-vaccinated or under-vaccinated than children born in a government health facility.

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Key Evidence: Children in Pakistan born to women who had 3 or 4 antenatal care (ANC) visits were 40-60% more likely to receive all required vaccines on time than children whose mothers made only 1 or 2 ANC visits.

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Key Evidence: The likelihood of a child 12-23 months of age in Myanmar having completed their vaccinations was more than 3 times greater if his or her mother had received tetanus vaccination during pregnancy, and almost 2 times greater if she made at least 4 antenatal care visits than mothers who hadn’t, after other factors, such as parents’ educational level, household income, residence (rural vs. urban) and mother’s age, were controlled for.

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Key Evidence: Use of recommended maternal health care services — defined as at least 4 antenatal care visits, having a skilled attendant at birth, and delivery in a health facility — was a predictor of timely vaccination of mothers’ infants in a study conducted in Ghana. Compared to children whose mothers received one or two of these services, infants born to mothers who received all three interventions were roughly 30% more likely to be fully vaccinated by 12-23 months of age, while children whose mothers received none of these services were only about half as likely to be fully vaccinated. Investing in maternal health, which creates familiarity with the health system and increases mothers’ knowledge about disease prevention, can improve the health of both the mother and her children beyond infancy.

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Key Evidence: Ethiopian mothers use of any of three maternal health services — antenatal care, delivery services, or tetanus vaccination — significantly increased the likelihood of their children being fully immunized by 12-23 months of age. Therefore, national immunization initiatives should concentrate on improving access of pregnant women to these key maternal health services.

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Key Concept

Key Evidence: A 2006-07 meningococcal meningitis epidemic in Burkina Faso cost households an average of US$90 for each case of meningitis that occurred. These costs — representing nearly 2.5 months of the average per capita income for that year — included direct and indirect costs of treatment and lost income to caretakers.

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Key Concept

Key Evidence: In a study of nearly 40,000 recipients of PCV7 and control subjects in northern California, there was a 5.4% reduction in the number of antibiotic prescriptions and a 12.6% reduction in the use of “second-line antibiotics” among children who received the pneumococcal conjugate vaccine. Between the time the first dose was administered and the age of 3.5 years, use of the vaccine prevented 35 antibiotic prescriptions per 100 fully vaccinated children.

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Key Concept

Key Evidence: Somali refugee children in Kenya were nearly 60 times more likely than children of the main ethnic group in the study (Kikuyu) to not have received any childhood immunization and more than twice as likely to have not completed their vaccinations. Although Somali children made up less than 8% of the sample, they accounted for nearly half of all non-vaccinated children.

From the VoICE Editors: This study used data from Kenya’s Demographic and Health Survey data.

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Key Concept

Key Evidence: The introduction of PCV-10, along with a “catch-up” campaign for 1-4 year olds, led to dramatic reductions in the rates of pneumococcal pneumonia in adults (≥18 years old) in a rural area of Kenya with high rates of both adult pneumococcal pneumonia and HIV. Over five years following the vaccine introduction, the incidence rates among adults were 47-94% lower each year than in the pre-vaccine period, with similar declines for HIV-infected and HIV-uninfected adults.

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Key Concept

Key Evidence: Communities with higher rates of health services utilization, particularly institutional childbirth, were more likely to have higher immunization coverage rates.

From the VoICE editors: This data, from a study in the Democratic Republic of Congo, had an adjusted odds ratio of 2.36.

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Key Evidence: Missed opportunities for vaccination i.e. percentage of children who failed to attain full immunization coverage (FIC) among those receiving one or more other health interventions were assessed through a study of 14 geographically diverse countries. In children with a vaccination rate below 70%, FIC was observed to be lowest in children born to mothers who failed to attend antenatal care across countries. The largest difference in FIC (54%) was observed in Côte d’Ivoire comparing children born to mothers who attended four or more ANC visits compared to no ANC visits. The presence of skilled birth attendant (SBA) was linked to higher rates of FIC with a 36% lower FIC in children born without a SBA in Nigeria. Post-natal care (PNC) acted as a factor contributing to 31% increase in FIC in the children who received PNC in Ethiopia. Vitamin A supplementation and sleeping under an insecticide treated bed net (ITN) were also positively linked to increase in FIC in the Democratic Republic of Congo and Haiti respectively.

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Key Concept

Key Evidence: An analysis conducted in areas of Ethiopia with high proportions of refugees found that high measles vaccination coverage was linked to lower rates of acute malnutrition (wasting) in children under five. For each percentage point increase in measles vaccination coverage, there was a 0.65% decrease in the rate of acute malnutrition in these areas.

From the VoICE Editors: The analysis was conducted on data from more than 150 nutrition surveys.

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Key Concept

Key Evidence: An analysis conducted in areas of Ethiopia with high proportions of refugees found that high measles vaccination coverage was linked to lower rates of acute malnutrition (wasting) in children under five. For each percentage point increase in measles vaccination coverage, there was a 0.65% decrease in the rate of acute malnutrition in these areas.

From the VoICE Editors: The analysis was conducted on data from more than 150 nutrition surveys.

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Key Concept

Key Evidence: Findings of a systematic review evaluating the relationship between pneumonia and malnourishment found that severely malnourished children in developing countries had 2.5 to 15 times the risk of death. For children with moderate malnutrition, the risk of death ranged from 1.2 to 36.

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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: In 41 Gavi-eligible countries it is estimated that, in the absence of measles vaccination, the occurrence 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 households 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 Concept

Key Evidence: 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 US$4.5 billion attributable to measles, US$168 million attributable to severe pneumococcal disease, and US$200 million attributable to severe rotavirus.

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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 Concept

Key Evidence: In households with seven or more members, the odds of a child receiving full immunization coverage were roughly 20% lower than in households with only three members, even after accounting for the effect of wealth quintile, religion, and population density.

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Key Evidence: Children of Bangladeshi mothers younger than 34 years were more than three times as likely to have incomplete vaccination compared to children of mothers older than 35 years.

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Key Evidence: Children who were born as the fourth or fifth child in their household were more than twice as likely to be incompletely vaccinated with BCG, measles vaccine, and pentavalent vaccine than those who were born as the second or third child in their household.

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Key Evidence: 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 authors 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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Key Concept

Key Evidence: 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.

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Key Concept

Key Evidence: A study found that children of poor labor migrants living in Delhi, India are much less likely to be fully vaccinated than the general population and thus are at greater risk of vaccine-preventable diseases. Only 31% – 53% of children from migrant families were fully immunized (against 7 diseases) by 12 months of age, compared to 72% in the overall population of Delhi — with recent migrants having the lowest rates. There is therefore a need to focus on the delivery of health services to migrants.

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Key Evidence: 69% of children under five with severe acute respiratory infections (ARI) from families recently relocated to urban Bangladesh visited a qualified medical provider as compared to 82% of children from households that have lived there for at least two years. After adjusting for wealth and other socioeconomic factors, recent migrants were still 11% less likely to seek treatment for ARI from qualified providers than longer-term residents, indicating the need for targeted efforts aimed towards children in high turnover communities and to link these households with existing health services.

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Key Evidence: According to a systematic review and meta-analysis, children who are rural-urban migrants in China, India and Nigeria were less likely to be fully-immunized by the age of one year than non-migrant urban residents and the general population. These inequities in vaccination rates — often concealed in national averages — call for special efforts to improve immunization rates in this rapidly growing sub-population to reduce both health inequities and the risk of infectious disease outbreaks in the wider society.

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Key Concept

Key Evidence: Children of unemployed mothers in Bangladesh were 1.5 times as likely to have incomplete vaccination status compared to children of employed mothers. Maternal unemployment was also significantly linked to delays in BCG and measles vaccinations.

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Key Evidence: Children of divorced mothers were three times less likely to be fully immunized than mothers cohabitating with a partner. In addition, it was found that children of mothers who work part time were approximately 2.3 times less likely to be fully immunized than mothers who work full time.

From the VoICE Editors: This study, conducted in Ghana, used Chi-Squared analysis to determine adjusted odds ratios. Multivariable analysis was not conducted.

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Key Concept

Key Evidence: The evidence on cholera disease dynamics suggests that significant herd protection can result from a relatively small number of immunizations, particularly in endemic areas where there is some natural immunity among the population.

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Key Concept

Key Evidence: A multi-site study of cholera vaccination programs found that the vaccine was cost-effective in school- and community-based vaccination programs for children in India, Mozambique, and Indonesia.

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Key Evidence: Assuming 90% coverage, a 9-valent PCV (PCV9) program in The Gambia would prevent approximately 630 hospitalizations, 40 deaths, and 1000 DALYs, for the birth cohort over the first 5 years of life. The estimated cost would be $670 per DALY averted in The Gambia.

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Key Concept

Key Evidence: A study looking at the impact of pneumococcal vaccine introduction and scaling up pneumonia treatment in Ethiopia found that 30-40% of all deaths averted by these interventions would be expected to occur in the poorest wealth quintile. The greatest resulting financial risk protection would also be concentrated among the bottom income quintile.

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Key Evidence: 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 Concept

Key Evidence: A study in Bangladesh found that families are heavily borrowing or losing assets to be able to bear the cost of pneumonia in their children <5 years of age.

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Key Evidence: Three studies in Bangladesh and India found that the direct medical costs for children hospitalized with pneumonia were 27% to 116% of the average monthly income of households. And, while these costs represent a major portion of a family’s monthly income, they don’t include non-medical costs, such as transport and food costs, nor the lost wages of family members who miss work to care for the child.

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Key Evidence: During a meningococcal meningitis epidemic in Burkina Faso, households spent, on average, US$90 for treatment and other direct costs for family members with the disease. These costs, the equivalent of one third of the country’s annual GDP per capita, were in addition to the loss of income and assets from family members caring for patients.

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Key Evidence: In a 2002 study from Cambodia, households with a dengue patient had to borrow money at high interest rates and lose productive assets (land) to repay debts linked to healthcare costs. Public healthcare cost significantly less than private healthcare but was either not present where people lived or did not have a good reputation.

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Key Evidence: 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. The number of 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 Concept

Key Evidence: In rural Malawi, even though medical care for cholera is free-of-charge in the public sector, more than half of families had to borrow money or sell livestock or other assets to compensate for the lost wages of patients or caregivers and other costs (such as for food and transportation) incurred as a result of an episode of cholera.

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Key Concept

Key Evidence: In a global review of the costs of treating childhood pneumonia, the average costs of a hospitalized case of pneumonia in children under five years of age was US$243 in primary or secondary hospitals in low- and middle-income countries (ranging from US$40 – US$563) and US$559 in tertiary hospitals (ranging from US$20 – US$1,474). In high-income countries, the cost of hospitalized cases averaged US$2,800 in primary or secondary hospitals and more than US$7,000 in tertiary hospitals. Note that in most of these studies, only direct medical costs were included and thus total costs – including non-medical costs and lost wages – would be considerably higher.

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Key Evidence: In rural Malawi, where medical care for cholera is free-of-charge, cholera still cost households, on average, US$66 in lost wages of the patient or caregiver and direct, non-medical costs, such as food and transportation. The direct cost to health facilities was $60 per case, twice as much as the 2016 per capita health budget for Malawi that year.

From the VoICE editors: Data on per capita health expenditures by country can be found in the WHO Health Expenditures database here: http://apps.who.int/nha/database/Select/Indicators/en

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Key Concept

Key Evidence: 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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Key Concept

Key Evidence: During the 2014-2016 Ebola epidemic in 3 West African countries, fear of the disease in neighboring Nigeria and misperceptions on how disease spreads negatively affected many sectors of the economy – retail, hospitality, airline industries, and certain agricultural sectors.

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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: 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 Concept

Key Evidence: A recent study estimated that, during the decade from 2011-2020, every US$1 invested in immunization programs in the world’s 73 poorest countries would yield a US$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 US$44 per US$1 invested.

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Key Concept

Key Evidence: In The Gambia, 58% of children who survived pneumococcal meningitis had long lasting negative health outcomes. Half had major disabilities such as mental retardation, hearing loss, motor abnormalities, and seizures.

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Key Evidence: In a systematic literature review of studies in Africa, it was found that 25% of children who survived pneumococcal or Hib meningitis had neuropsychological deficits.

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Key Concept

Key Evidence: In India, inequities in vaccination coverage exist between states, within states, and in urban vs. rural settings. 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 Evidence: Wealth and mother’s education are significant predictors of vaccination rates in both urban and rural settings. However, low paternal education, lack of antenatal care, and home births were significantly associated with low vaccination rates only in rural settings. This suggests the need for tailored vaccine programs.

From the VoICE Editors: This study compared the significance of risk factors for low vaccination rates in rural versus urban settings in Tanzania.

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Key Evidence: In a large survey in Pakistan, children were about 30% more likely to receive all the national immunization program vaccinations on time if either their mother or father had a secondary school or higher level of education than those whose mothers or fathers had no formal education.

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Key Evidence: Children of mothers with secondary education or higher were significantly more likely to be fully immunized than children of mothers with lower levels of educational attainment.

From the VoICE editors: Data was collected in the Democratic Republic of Congo from a cross-sectional survey (the Demographic and Health Survey) and analyzed in the aggregate. However, the authors note high variation in coverage across localities. 

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Key Evidence: 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 Concept

Key Evidence: Maternal education benefits immunization rates of all community members, not only mothers’ own children. In Nigeria, children’s odds of being fully immunized improved by 1.06 times for every additional year of education the mothers received. Children’s odds of being fully immunized increased by 1.2 times for each additional year of maternal education in the community.

From the VoICE Editors: The authors controlled for factors including maternal employment, average household wealth, whether the child was born in a hospital, urban status of communities, and geographic location of communities.

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Key Evidence: 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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Key Evidence: Data from the Kenya Demographic and Health Survey show that women with a primary school education were 2 to 5 times more likely to have their infants vaccinated (depending on the vaccine) and women with a secondary school education were 2.5 to 9 times more likely to have their infants vaccinated than mothers with less than a primary education or no education [after adjusting for wealth, age, religion and other variables]. Targeted communications activities to sensitize less educated women on the value of vaccination could be a short-term measure to close this gap.

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Key Evidence: 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 containing vaccine and three doses of DTP vaccine than children of the most educated mothers.

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Key Concept

Key Evidence: 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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Key Concept

Key Evidence: 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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Key Evidence: 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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Key Evidence: 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 authors 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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Key Concept

Key Evidence: In India, inequities in vaccination coverage exist between states, within states, and in urban vs. rural settings. 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 Evidence: A study looking at DHS data from 67 countries found that, globally, girls and boys had the same likelihood of being vaccinated. In some countries where there is known gender inequity and son preference, girls were more likely to not be vaccinated.

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Key Evidence: 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 Concept

Key Evidence: An ecological study designed to investigate the association between child mortality rates and gender inequality using the United Nations Development Programme’s Gender Inequality Index (GII), showed that low- and middle-income countries have significantly higher gender inequality and under-5 mortality rates than high-income countries. Greater gender inequality was significantly correlated with lower immunization coverage and higher neonatal, infant, and under-5 mortality.

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Key Evidence: To better understand the drivers of vaccination coverage and equity, a 2017 study examined the country-level factors influencing vaccination coverage in 45 low- and lower-middle income Gavi-supported nations. Countries with the least gender equality – as measured by reproductive health, women-held parliamentary seats, educational attainment, and other factors – also had lower rates of vaccine coverage.

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Key Concept

Key Evidence: 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 likely 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 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: Human Papillomavirus (HPV) infections are more prevalent and persistent in HIV-infected individuals — HPV prevalence rates of 76% in HIV-infected women compared to the 46% prevalence rate in HIV-uninfected women. Cervical prevalence rates are also higher in HIV-infected women — between 48-73% in case compared to 28% in HIV-uninfected women. Additionally, HPV infections and HPV-associated diseases appear to exert a disproportionately higher burden of disease in HIV-infected women as opposed to HIV-uninfected women.

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Key Evidence: Prior to the introduction of PCV, adults with HIV in a rural area of Kenya were nearly five times more likely to have pneumococcal pneumonia than non-infected adults, and the majority of cases with bacteremia (blood infection) occurred in HIV positive individuals.

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Key Evidence: A small hospital-based study in India found that 6 month old infants born to HIV-infected women were 11 times more likely to lack measles antibodies than 6 month olds not exposed to HIV whether or not the exposed infants were themselves infected with HIV. The lack of antibodies in most HIV-exposed infants — making them more vulnerable to measles — may be due to lower levels of measles antibodies in HIV-infected mothers or to poorer transfer of antibodies to the fetus across the placenta.

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Key Concept

Key Evidence: The Indian government childhood immunization program, UIP, designed in the 1980s to reduce the high mortality and morbidity in children, resulted in reduced infant mortality by 0.4% percentage points and under-5 mortality by 0.5%. These effects on mortality are sizable as 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 area, for poor people, and for members of historically disadvantaged groups. The 0.5% 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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Key Evidence: Two years after the introduction of 10-strain pneumococcal conjugate vaccine (PCV-10) in Kenya, the percent of HIV-positive adults who carried pneumococcal bacteria declined significantly (from 43% to 28%), but did not decline in HIV-negative adults. However, the reduction in carriage of pneumococcal strains that are in PCV10 declined significantly in both HIV-positive and HIV-negative adults. This reduction was still four times higher in HI- positive vs. HIV-negative adults (2.8% vs. 0.7%), indicating that HIV positive adults continue to be at considerably higher risk of invasive pneumococcal disease than HIV-uninfected adults.

From the VoICE Editors: Nasopharyngeal carriage is an indicator of the risk for invasive pneumococcal disease and pneumonia. 

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Key Concept

Key Evidence: Over a five-year period following the introduction of PCV for infants in Kenya, the incidence of pneumococcal pneumonia in adults with HIV in a rural area fell sharply — narrowing the gap in incidence rates between HIV-infected and non-infected adults — as a result of both the herd effects of the vaccine and improved access to HIV care during this period.

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Key Concept

Key Evidence: Nearly a quarter of a million children are born with sickle cell disease in Africa each year. SCD was found to increase the risk of Hib infections by 13-fold and pneumococcal infections by 36 fold. This means that children with SCD stand to benefit enormously from PCV and Hib immunization.

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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 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 Concept

Key Evidence: A study looking at the impact of pneumococcal vaccine introduction and scaling up pneumonia treatment in Ethiopia found that 30-40% of all deaths averted by these interventions would be expected to occur in the poorest wealth quintile. Scaling up PCV13 to levels achieved with DTP3 in Ethiopia would be expected to avert nearly 3000 child deaths and 60,000 episodes of pneumococcal pneumonia annually, not including any potential herd benefit. A publicly financed program to scale up pneumococcal vaccines would cost about US$40 per year of healthy life gained.

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Key Evidence: 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 Concept

Key Evidence: Rates of vaccination in all studied countries were highest and risk mortality lowest in the top two wealth quintile’s coverage. Countries differed in the relative inequities in these two underlying variables. Cost per DALYs averted is substantially greater in the higher quintiles. In all countries, the greatest potential vaccine benefit was in the poorest quintiles; however, reduced vaccination coverage lowered the projected vaccine benefit.

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Key Evidence: A study of measles vaccine in Bangladesh found that children from the poorest quintile were more than twice as likely to die than 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 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: Non-Somali children in Kenya in the poorest households were nearly three times as likely to be unvaccinated than children from middle-income households, while wealthier children were significantly less likely to be unvaccinated.

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Key Evidence: In India, inequities in vaccination coverage exist between states, within states, and in urban vs. rural settings. 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 Evidence: 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 authors 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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Key Evidence: 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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Key Evidence: 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 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 of sickle cell disease patients in Ghana found that pneumoccocus bacteria found in their noses and throats had high rates of drug resistance with 37% of positive samples resistant to penicillin and 34% resistant to multiple drugs (typically penicillin + tetracycline + cotrimoxazole).

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Key Concept

Key Evidence: Two years after the introduction of 10-strain pneumococcal conjugate vaccine (PCV-10) in Kenya, the percent of HIV-positive adults who carried pneumococcal bacteria declined significantly (from 43% to 28%), but did not decline in HIV-negative adults. However, the reduction in carriage of pneumococcal strains that are in PCV10 declined significantly in both HIV-positive and HIV-negative adults. This reduction was still four times higher in HI- positive vs. HIV-negative adults (2.8% vs. 0.7%), indicating that HIV positive adults continue to be at considerably higher risk of invasive pneumococcal disease than HIV-uninfected adults.

From the VoICE Editors: Nasopharyngeal carriage is an indicator of the risk for invasive pneumococcal disease and pneumonia. 

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Key Concept

Key Evidence: In a study evaluating the impact of PCV7 on 40,000 recipients and control subjects in northern California revealed that the vaccine could significantly decrease the need for antibiotics to treat the disease. The children who had received the vaccine displayed a 5.4% reduction in the number of antibiotic prescriptions and a 12.6% reduction in the use of “second-line antibiotics” compared to the controls. Additionally, when looking at children in the time period between their first dose and attainment of the age of 3.5 years, receiving the vaccine had prevented 35 antibiotic prescriptions per 100 fully vaccinated children.

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Key Concept

Key Evidence: A community-based study in Vietnam found a high percent of children under five years of age were carrying pneumococcal bacteria in their noses and throats that were non-susceptible to commonly-used antibiotics. Of the strains tested, 18% were not susceptible to penicillin, 26% weren’t susceptible to cefotaxime, 76% were not susceptible to meropenem and 14% were not susceptible to all three nor to any of the “macrolide” drugs (e.g., erthromycin and azithromycin). However, 90% of the multi-drug resistant strains are serotypes that are in the 13-strain pneumococcal conjugate vaccine (PCV-13) and thus the introduction of a vaccine is expected to increase the susceptibility of circulating strains of the bacteria.

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Key Evidence: A systematic review of studies from India found that prior to widespread use of the pneumococcal conjugate vaccine, antibiotic resistance in serious pneumoccocal infections among Indian children has been common. Penicillin resistance was found in 10% of invasive pneumococcal disease (IPD) cases, while trimethoprim/sulfamethoxazole resistance was found in more than 80% of these cases.

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Key Concept

Key Evidence: In a study modeling the cost-effectiveness of vaccination campaigns in Somalia – the country with the second largest number of refugees in 2012 – the use of Hib vaccine, PCV10, or both Hib and PCV10 were all found to be cost effective means to prevent excess morbidity and mortality from pneumonia in young Somali children. Such a vaccination campaign could conservatively reduce pneumonia cases and deaths by nearly 20%.

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Key Concept

Key Evidence: The ongoing conflict in Syria has caused the breakdown of immunization services, leading to outbreaks of vaccine preventable diseases in the region and the re-emergence of polio in Syria for the first time in 15 years. The potential for polio to re-emerge in neighboring areas with low coverage of inactivated polio vaccine (IPV) threatens the success of global efforts to eradicate polio.

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Key Evidence: 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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Key Concept

Key Evidence: The latest International Health Regulations (IHR) of the World Health Organization updated in 2005 contained several major changes compared to earlier versions. However, the need to report cases of cholera and yellow fever has remained along with an expansion of the concerned disease list. These diseases continue to be critical threats to national and international health security, making immunization against them a vital disease control approach.

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Key Concept

Key Evidence: An analysis of children aged 12-59 months in rural India showed that children who were not vaccinated against measles vaccine in infancy had a three times higher likelihood of death, with unvaccinated children from lower caste households having the highest risk of mortality (odds ratio, 8.9). However, the results also revealed a nonspecific reducing effect of the vaccine on the overall child mortality in this region. This indicates that vaccination against measles can benefit the overall population, especially those in lower castes who have not received the vaccine in infancy. Thus, making them the group that would receive the highest benefit.

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Key Concept

Key Evidence: Respiratory infections during pregnancy may exert indirect effects on the developing fetus through placental function and maternal immune responses. This in turn may lead to pre term births and reduced growth of the fetus. However, a review of recent studies, researchers show that administration of influenza vaccine during pregnancy adds 200 grams to newborn weight and that PCV7 vaccine given to infants translates into an additional 500 grams of growth in the first 6 months of life. In addition, maternal influenza vaccine led to a 15% reduction in low birth-weight. This indicates that immunization can improve intrauterine growth.

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Key Evidence: In a study of families living on 24 plantations in Indonesia, the community immunization rate was found to be protective against thinness for age in children. In other words, children in communities with higher overall levels of immunization had better nutritional status.

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Key Concept

Key Evidence: A study in rural Kenya, over a 4-year period following the introduction of the 10-strain pneumococcal conjugate vaccine for infants, that included a catch-up vaccination campaign for children 12-59 months of age, suggests that the catch-up vaccination for older birth cohorts may have been a key factor in protecting unvaccinated individuals and speeding up the reduction of the disease in the community. In contrast, a study in The Gambia, where no catch-up campaign took place, found no herd effects during the first three years following the introduction of PCV-13 for infants.

From the VoICE Editors: The Gambia study publication referenced can be found at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4909992/ 

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Key Evidence: In a major children’s hospital in the Indian state of Tamil Nadu, meningitis cases caused by Haemophilus influenzae type b (Hib) in children under two years declined by 79% within two years of the introduction of Hib vaccine. This decline was greater than expected given a vaccination coverage of ~70% for one dose of the vaccine and much greater than expected with a 53% coverage rate for three doses. This suggests that the vaccine protected unvaccinated children through 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 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: In a study conducted in Southern India, pneumococcal carriage at age 2 months was associated with a 3-fold risk of stunting and decreased weight, length, and length-for-age by 6 months of age. Pneumococcal carriage at 4 months of age did not affect growth.

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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: Assuming 90% coverage, a program in The Gambia using a 9-valent PCV (PCV9) would prevent approximately 630 hospitalizations, 40 deaths, and 1000 DALYs over the first 5 years of life of a birth cohort. The estimated cost would be $670 per DALY averted in The Gambia.

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Key Evidence: In one of the first studies of real-world use of pneumococcal conjugate vaccine (PCV) in Africa, the 10-strain vaccine introduced in Kenya for infants and provided to all children under five in “catch-up” campaigns reduced the incidence of any cause of pneumonia confirmed by a chest X-ray by nearly half (48%) in children 2-59 months of age over a five-year period. This sharp reduction in radiological-confirmed pneumonia is more than twice the reduction seen in several clinical trials of PCV in Africa and Latin America which was around 20-23%.

From the VoICE Editors: The sharp reduction in radiological-confirmed pneumonia as a result of immunization in this study is likely because – unlike in some clinical trials – the herd effects of the vaccine on unvaccinated children were prospectively captured in the study.

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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 Concept

Key Evidence: In Gambia, 58% of children who survived a bout of pneumococcal meningitis “had clinical sequelae; half of them had major disability preventing normal adaptation to social life” (mental retardation, hearing loss, motor abnormalities, seizures).

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Key Evidence: A systematic literature review analyzing data from 21 African countries revealed that bacterial meningitis is associated with high case fatality and frequent neurophysiological sequelae. Pneumococcal and Hib meningitis contribute to one third of disease related mortality. They also cause clinically evident sequalae in 25% of survivors prior to hospital discharge. The three main causes of bacterial meningitis- Haemophilus influenzae type B; Streptococcus pneumoniae (pneumococcus) and Neisseria meningitidis (meningococcus) are vaccine preventable, routine use of conjugate vaccines have potential for significant health and economic benefits.

From the VoICE Editors: Neuropsychological sequelae includes hearing loss, vision loss, cognitive delay, speech/language disorder, behavioural problems, motor delays/impairment, and seizures. 

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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: An analysis of data from three studies showed that the rates of severe pneumonia in infants in their first six months of life was 20% lower overall in infants whose mothers received the influenza vaccination during pregnancy than in infants whose mothers had not, and the rates of severe pneumonia was 56% lower during periods when influenza circulation was highest. These findings correspond with evidence that influenza infection predisposes individuals to pneumococcal infection.

From the VoICE Editors: The incidence rate of severe pneumonia in the vaccine group compared to the control group was 43% lower in South Africa, 31% lower in Nepal, but not significantly different in Mali.

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Key Concept

Key Evidence: The expertise and assets gained through efforts to eradicate polio at least partially explain the improvement between 2013 and 2015 in vaccination coverage of DPT3 in six out of ten “focus” countries of the Polio Eradication Endgame strategic plan. This includes substantial increases in vaccination rates in India, Nigeria, and Ethiopia, which, combined, reduced the number of children not fully vaccinated with DPT by 2 million in 2 years.

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Key Concept

Key Evidence: The Government of Nigeria used the Incident Management System (IMS) to establish a national Emergency Operations Center (EOC) as part of a new national emergency plan for the global polio eradication initiative. The use of IMS through the EOC changed the operational tempo, accountability measures, and programmatic success of the polio program. This existing infrastructure was in place and leveraged to contain the outbreak of Ebola.

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Key Concept

Key Evidence: This study investigated the cost-effectiveness of multiple interventions against childhood pneumonia (including vaccination) and found that different combinations of expanded vaccine coverage with community or facility-based management, nutritional programs, or indoor air pollution measures maximized child health by providing the greatest health yield per dollar spent.

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Key Concept

Key Evidence: In Rwanda, HPV vaccine introduction through a new school-based delivery program provided the opportunity to offer additional health services to all school-children (girls and boys), including health promotion sessions, de-worming and opportunities for voluntary, free circumcision.

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Key Concept

Key Evidence: The Government of Nigeria used the Incident Management System (IMS) to establish a national Emergency Operations Center (EOC) as part of a new national emergency plan for the global polio eradication initiative. The use of IMS through the EOC changed the operational tempo, accountability measures, and programmatic success of the polio program. This existing infrastructure was in place and leveraged to contain the outbreak of Ebola.

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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: 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 Concept

Key Evidence: An analysis of rotavirus vaccine introduction in two Latin American countries (Honduras and Peru) suggests that the introduction of the vaccine might have had a favorable impact on coverage and timing of other similarly scheduled vaccinations.

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Key Concept

Key Evidence: In Rwanda, HPV vaccine introduction through a new school-based delivery program provided the opportunity to offer additional health services to all school-children (girls and boys), including health promotion sessions, de-worming and opportunities for voluntary, free circumcision.

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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 Concept

Key Evidence: Wealth and mother’s education are significant predictors of vaccination rates in both urban and rural settings.  However, low paternal education, lack of antenatal care, and home births were significantly associated with low vaccination rates only in rural settings. This suggests the need for tailored vaccine programs.

From the VoICE editors: This study compared the significance of risk factors for low vaccination rates in rural versus urban settings in Tanzania. 

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Key Evidence: Children living in urban areas are significantly more likely to be only partially immunized compared to children in rural areas. In this study, the authors suggest this may be the result of the tendency for those living in urban slums to move frequently, resulting in only partial immunization.

From the VoICE Editors: In this study, conducted in India, no significant difference was found in rates of non-vaccination (children receiving no vaccines) in rural versus urban communities.

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Key Evidence: 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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