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.

36 Key Ideas, 33 Sources
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

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

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Key Idea

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

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Key Idea

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

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Key Idea

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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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 Idea

An analysis of the impact of rotavirus vaccine in 25 Gavi countries found that the rates of vaccination in all countries were highest, and risk mortality lowest, in the top two wealth quintiles’ 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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A study of measles vaccine in Bangladesh found that children from the poorest quintile were more than twice as likely to die as those from the least quintile in the absence of measles vaccination. The difference in mortality between unvaccinated and vaccinated was statistically significant (p<0.10) and robust across alternative measures of socioeconomic status.

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Key Idea

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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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

The occurence of stunting in children, measured at age 24 months, increased with each diarrheal episode and with each day of diarrhoea prior to their second birthday. The adjusted odds of stunting increased by 13% for every five episodes.  In addition, once a child becomes stunted, only 6% of those stunted at 6 months of age recovered by 24 months of age.

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Key Idea

In an analysis of of data from India’s National Family Health Survey showed that, despite a decline in urban-rural and gender differences over time, girls and children residing in rural areas remained disadvantaged. Moreover, regions that had the lowest gender inequality in 1992 observed an increase in gender difference over time. Similarly, urban-rural inequality increased in one region during the data collection period.

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Key Idea

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 Idea

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

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Key Idea

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 Idea

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 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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Key Idea

In 1996, a follow-up study was conducted on a 1974 randomized trial of tetanus and cholera vaccine administered to mothers. At the time of follow up in 1996, there was a clear pattern of increased educational attainment among children whose mothers received tetanus vaccine during pregnancy. This pattern was significant for the group of children born to vaccinated mothers with very low levels of education.

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Key Idea

This study follows up on a 1974 randomized trial of tetanus and cholera vaccine administered to mothers in Bangladesh. At the time of follow up in 1996, there was a clear pattern of increased educational attainment among children whose mothers received tetanus vaccine during pregnancy. This pattern was significant for the group of children born to vaccinated mothers with very low levels of education.

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Key Idea

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 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

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 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 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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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 shows promise as a means to improve child health.

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Key Idea

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.

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.

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An analysis of data from India’s National Family Health Survey designed to examine the trends and patterns of inequalities over time showed that, despite a decline in urban-rural and gender differences over time, children residing in rural areas and girls remained disadvantaged. Moreover, regions that had the lowest gender inequality in 1992 showed an increase in gender difference over time. Similarly, urban-rural inequality increased in one region during the 1992–2006 data collection period.

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Key Idea

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 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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Key Idea

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

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Key Idea

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

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Key Idea

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

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Key Idea

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.

View Source >

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.

View Source >

Key Idea

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.

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 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.

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.

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Key Idea

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 Idea

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

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Key Idea

In 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.

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

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Key Idea

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 Idea

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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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 Idea

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 Idea

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

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Key Idea

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

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