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.

57 Key Ideas, 53 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

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

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

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

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Key Idea

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

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Key Idea

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

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Key Idea

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

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Key Idea

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

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Key Idea

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

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Key Idea

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

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Key Idea

In 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

Tens of millions of volunteers, social mobilizers, and health workers have participated in the Global Polio Eradication Initiative. The program contributes to efforts to deliver other health benefits, including health systems strengthening. Polio eradication legacy efforts include documenting and applying the lessons learned from polio eradication and transitioning the capacities, assets, and processes of polio to other key health priorities.

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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

In a study modeling the economic impact of immunization in 41 low- and middle-income countries, the authors estimate that 24 million cases of medical impoverishment would be averted through the use of vaccines administered from 2016-2030. The largest proportion of poverty cases averted would occur in the poorest 40% of these populations, demonstrating that vaccination can provide financial risk protection to the most economically vulnerable.

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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 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

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

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Key Idea

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 Idea

In a study in The Gambia – a setting where healthcare is free of charge to patients – pneumococcal disease nonetheless placed a heavy financial burden on families seeking treatment before arrival at the hospital, with families paying for transportation costs, drugs, diagnostic tests and even burial in the case of death. 50-80% of the cost of treating an episode of pneumococcal disease was born by the health system, which still left families to cover a cost up to 10 times their average daily household budget. In addition the estimated treatment cost for inpatient pneumonia of US$109 is nearly 4 times the annual per capita expenditure for health in The Gambia.

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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

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

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Key Idea

Vaccines that can protect against pneumonia – Hib and S. pneumoniae vaccines – can together prevent over 1.25 million cases of poverty over 15 years, found researchers modeling the economic impact of immunization in 41 low- and middle-income countries.

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

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

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Key Idea

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

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A study conducted in Pakistan, designed to explore the association of maternal education and empowerment with childhood polio vaccination, showed that mothers with more education are more likely to vaccinate their children – 74% of children of mothers with higher education were completely vaccinated compared to 67% of those with primary education and only 47% of those with no education.

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

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

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Key Idea

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

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

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Key Idea

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

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

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In a systematic review of qualitative research from low- and middle-income countries, women’s low social status was shown to be a barrier to their children accessing vaccinations. Specific barriers included access to education, income, resource allocation, and autonomous decision-making related to time. The 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 study conducted in Pakistan exploring the association of maternal education and empowerment with childhood polio vaccination found a positive association between maternal empowerment, defined as mother’s involvement in decision-making regarding family, healthcare, and other issues, and complete polio vaccination of their children.

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The level of women’s community-level autonomy is associated with an increased number of children immunized above and beyond that which is seen with individual-level women’s autonomy. These results indicate that empowering women within households not only improves the individual mother’s children’s health, but also serves to improve the lives of other children within the community.

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

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

View Source >

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

In a study in The Gambia – a setting where healthcare is free of charge to patients – pneumococcal disease nonetheless placed a heavy financial burden on families seeking treatment before arrival at the hospital, with families paying for transportation costs, drugs, diagnostic tests and even burial in the case of death. 50-80% of the cost of treating an episode of pneumococcal disease was born by the health system, which still left families to cover a cost up to 10 times their average daily household budget. In addition the estimated treatment cost for inpatient pneumonia of US$109 is nearly 4 times the annual per capita expenditure for health in The Gambia.

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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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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 Idea

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

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Key Idea

Polio eradication investments in health infrastructure have been concentrated in some of the lowest performing health systems in the world, challenged internally by geography, poverty, armed conflict, etc. These assets can be leveraged to improve the health system and immunization overall nationally.

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Key Idea

Children in slum settings have higher burdens of vaccine-preventable disease (one study found children in slums in Manila, Philippines were 9 times more likely to have tuberculosis than other urban children) and lower rates of immunization (a study in Niger found 35% coverage in slums vs. 86% in non-slum urban areas).

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Key Idea

Among both HIV positive and HIV negative parents in a study in Kenya, 99% of pneumococcal strains found and tested were resistant to one or more antibiotics. HIV positive parents carried 16% more strains that were resistant to penicillin than those carried by HIV negative parents.

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In a study of national surveillance records in South Africa, HIV positive people over 5 years of age were found to have a 43-fold risk of invasive pneumococcal disease compared to HIV negative person. This risk was highest among children age 5-19 who were found have a more than 120-fold risk of invasive pneumococcal disease compared to HIV negative uninfected children of the same age. 90% of South Africa’s invasive pneumococcal disease cases during the 5 year period occurred in the 18% of the population who are HIV positive.

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“HIV-infected individuals are living longer, and non-AIDS-defining conditions are affecting this population in increasing numbers. HPV infections are more prevalent and persistent in HIV-infected women and men. Earlier studies reported anal HPV prevalence rates of 76% in HIV-infected women and 46% in HIV-uninfected women and cervical prevalence rates of 48% to 73% compared to 28% in HIV-uninfected women.” In addition, the burden of HPV infections and HPV-associated diseases is higher in HIV-infected women compared with HIV-uninfected women.

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Key Idea

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

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

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Key Idea

In survivors of pediatric and young adult cancers in the US, the risk of mortality from infectious complications is 4 times higher than in their cancer-naïve siblings. Within the first five years after cancer diagnosis, the risk of some vaccine-preventable infections such as pneumonia and hepatitis is more than 9-fold and 6-fold higher, respectively. More than 5 years after cancer diagnosis, the risk of these two infections remains high at 3.7 and 2.5 times higher than siblings.

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Among children and young adults being treated for certain cancers, immunosuppressive therapies can erase immunity previously acquired through vaccination, dramatically increasing the risk of vaccine-preventable infections. The authors assert that vaccination during and after immunosuppressive treatment is necessary to rebuild immunity and protect the most at-risk children.

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Key Idea

A review of evidence for the use of pneumococcal conjugate vaccine in South Africa showed that children who are HIV positive are at significantly increased risk of pneumococcal disease, and so will benefit the most from vaccination, despite decreased vaccine efficacy in this group compared to healthy children.

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A large randomized controlled trial of a pneumococcal conjugate vaccine in South Africa found that use of the vaccine prevented 10 times as many cases of pneumococcal pneumonia in HIV positive children than in HIV negative children.

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Key Idea

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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In a long-term study of Canadian surveillance data researchers found that immunocompromised people were at a 12-fold risk of invasive pneumococcal disease (IPD) compared to healthy people. In addition, the risk of death from IPD in immunocompromised people was found to be 30-80% higher than healthy individuals who had contracted IPD. 10 years after introduction of PCV7 in Canada, the incidence of IPD due to serotypes included in the vaccine had decreased by 90%.

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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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A study of Kenyan children under 5 years of age found that immunization with polio, BCG, DPT, and measles to be protective against stunting in young children (27% less likely to be stunted than unimmunized children under age 2 years). In addition, children with diarrhea and cough in the 2 weeks prior to the survey were 80-90% more likely to be underweight or to suffer from wasting.

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An analysis of undernutrition and mortality in young children found that among the principal causes of death, 60.7% of deaths 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

In a US-based study of more than 65,000 longterm survivors of pediatric and young adult cancers spanning nearly three decades, researchers found an increased risk of later HPV infections and malignancies among these survivors. Female survivors of childhood and young adult cancers were found to have a 40% greater chance of developing HPV-associated malignancies compared to cancer-naïve females. This risk was even greater in male cancer survivors who had a 150% relative excess of HPV malignancies compared to cancer-naive males.

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A study in the US found that the incidence of invasive pneumococcal disease was 22 to 38 times higher in adults with cancer than in healthy adults.

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Key Idea

In a long-term study of Canadian surveillance data researchers found that immunocompromised people were at a 12-fold risk of invasive pneumococcal disease (IPD) compared to healthy people. In addition, the risk of death from IPD in immunocompromised people was found to be 30-80% higher than healthy individuals who had contracted IPD.

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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

Previous studies show that the prevalence of HIV-related risk behaviors and Sexually Transmitted Infections (STIs) among incarcerated adolescents is high. Most adolescents with a sentence to serve time in a U.S. correctional facility are offered preventive vaccination against hepatitis B. Medical clinics in correctional facilities have the ability to provide vaccination services to these adolescents who may not otherwise seek or have access to preventive health services.

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Key Idea

A publicly funded 23vPPV (23 valent pneumococcal polysaccharide vaccine) program in Victoria, Australia not only dramatically increased vaccination coverage among the elderly in the public purchase program, but in other Australian states and territories that did not have a public program, the number of prescriptions issued for 23vPPV actually increased over the same period.

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Key Idea

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

View Source >

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.

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Key Idea

A group of experts evaluated a number of maternal, neonatal, and child health interventions for equity across wealth quintiles using data from 1990-2006. Immunization was found to have the narrowest differences in coverage of services between the poorest and wealthiest children. In other words, of the interventions evaluated, immunization was the most equitable across income groups.

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Key Idea

In 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.

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

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

View Source >

In a study designed to explore the association of maternal education and empowerment with childhood polio vaccination rates in Pakistani mothers, it was observed that the highest percentage of completely vaccinated children (72.6%) was seen among mothers of the richest quintile, followed by 63.4%, 58.0%, 49.8%, and 39% for the richer, middle, poorer, and poorest wealth quintiles, respectively.

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

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Key Idea

A group of experts evaluated a number of maternal, neonatal, and child health interventions for equity across wealth quintiles using data from 1990-2006. Immunization was found to have the narrowest differences in coverage of services between the poorest and wealthiest children (28% higher coverage in the highest wealth quintile compared to the lowest). By contrast, indicators of treatment coverage for children sick with diarrhea and pneumonia were nearly 60% higher in the highest wealth quintile compared to the poorest. This means that poor children are at a much greater disadvantage with respect to receiving treatment for pneumonia and diarrhea than they are for receiving vaccines to prevent these infections.

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

View Source >

Key Idea

A study modeling the economic impact of 10 childhood immunizations in 41 low- and middle-income countries found that the bulk of poverty averted through vaccination occurs in poor populations. For most of the vaccines in the study, at least 40% of the poverty averted would occur in the poorest wealth quintile. Particularly for pneumonia, more than half of the two million deaths averted by pneumococcal and Hib vaccines would occur in the poorest 40% of the population.

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Key Idea

Among both HIV positive and HIV negative parents in a study in Kenya, 99% of pneumococcal strains found and tested were resistant to one or more antibiotics. HIV positive parents carried 16% more strains that were resistant to penicillin than those carried by HIV negative parents.

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Key Idea

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

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Key Idea

A study of Kenyan children under 5 years of age found immunization with polio, BCG, DPT, and measles to be protective against stunting in young children; they were 27% less likely to be stunted than unimmunized children under age 2 years. In addition, children with diarrhea and cough in the 2 weeks prior to the survey were 80-90% more likely to be underweight or to suffer from wasting.

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Key Idea

Children with cancer often rely on herd immunity as protection from vaccine-preventable diseases, so vaccinating family members and health workers is critical. Herd effects may be the only source of protection against diseases for which the vaccines are not recommended for immunosuppressed children, such as measles.

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Key Idea

A study of Kenyan children under 5 years of age found that children with diarrhea and cough in the 2 weeks prior to the survey were 80-90% more likely to be underweight or to suffer from wasting.

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Key Idea

Children in slums suffer from higher rates of 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 Idea

Tens of millions of volunteers, social mobilizers, and health workers have participated in the Global Polio Eradication Initiative. The program contributes to efforts to deliver other health benefits, including health systems strengthening. Polio eradication legacy efforts include documenting and applying the lessons learned from polio eradication, and transitioning the capacities, assets, and processes of polio to other key health priorities.

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Key Idea

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

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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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