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.


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34 Key Ideas, 31 Sources
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

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

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Key Idea

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VoICE : Search Immunization Evidence

Key Idea

Those who experienced more frequent or longer episodes of diarrhea as an infant were more likely to have metabolic syndrome as adults. A longitudinal study in Guatemala found that diarrhea episodes in early infancy are associated with chronic health issues later in life. Each 1% increase in diarrhea burden in children 0-6 months was associated with a 3% increased prevalence in high blood pressure in adulthood. Similarly, a 1% increase in diarrhea burden in older infants 6-12 months was associated with a 4% increased prevalence in elevated waist circumference in adulthood.

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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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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

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

This study based on active surveillance in the US before and after introduction of PCV estimated 38,000 cases of invasive pneumococcal disease were averted in the first 5 years of vaccine use, at an estimated cost of US$112,000 per life year saved. However, after inclusion of 71,000 cases of disease that were prevented through herd effects, researchers estimate a cost of US$7,500 per life year saved.

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Key Idea

Assuming 90% coverage, a program in The Gambia using a 9-valent PCV (PCV9) would prevent approximately 630 hospitalizations, 40 deaths, and 1,000 DALYs over the first 5 years of life of a birth cohort. The estimated cost would be US$670 per DALY averted in The Gambia.

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Key Idea

A large longitudinal study in the Philippines found that children suffering bouts of diarrhea and respiratory infections were at a significantly increased risk of physical stunting which is associated with “poor functional outcomes such as impaired cognitive development.”

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Key Idea

In The 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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In a systematic literature review of studies in Africa, it was found that one quarter of children who survived pneumococcal or Hib meningitis had neuropsychological deficits.

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Key Idea

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

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Key Idea

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

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Key Idea

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

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

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

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Key Idea

A study including thousands of children from the US state of Texas found that children born in counties with high coverage of HepB, Polio, and Hib vaccines were 33%, 37%, and 42% less likely to develop a specific type of leukemia than children in counties with lower coverage of each vaccine.

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Key Idea

A study from South Africa shows that reduced birth rates (fertility) lead to: 1) “decreasing ratio of economically dependent people” 2) “increasing labour force per capita” 3) “[increased] savings 4) “savings can be invested in the physical and human capital needed for economic growth” 5)”As average family size decreases, parents are likely to invest more in the education and health of each child, leading to improved productivity in adulthood.”

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Key Idea

Declining child mortality results in decreased fertility (birth rates), influencing a demographic transition on the national and regional scale. Improvements in public health are at the heart of the this transition due to improved sanitation, immunization programs, antibiotics, and contraceptives.

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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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This study, conducted in the United States, demonstrates an association between immunization with the inactivated influenza vaccine during pregnancy and reduced likelihood of prematurity during local, regional, and widespread influenza activity periods. Moreover, during the period of widespread influenza activity there was an association between maternal receipt of influenza vaccine and reduced likelihood of small for gestational age (SGA) birth.

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Universal Immunization Programs (UIP) increased the average age-appropriate height and weight of 4 year old children in a study in India. The magnitude of effect suggests that, on average, UIP reduced the height deficit of these children by 22–25% and their weight deficit by 15%.

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A study of Kenyan children under 5 years of age found 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

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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A meta-analysis of data from studies measuring the impact of rotavirus vaccine (RVV) on severe gastroenteritis morbidity and mortality reported a median herd immunity effect for severe rotavirus gastroenteritis in children less than one year of age of 22% (US and El Salvador).  In studies in Latin America reporting an all-cause gastroenteritis benefit the median herd effect for severe gastroenteritis was 24.9%.

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Rotavirus hospital admissions in unvaccinated children aged 2-5 yrs. of age, who where not age-eligible to receive the Rotavirus vaccine (RVV), were reduced by 41%-92% in the US, 30-70% in Australia, 20-64% in Belgium, 35% in Austria, and 41-81% in El Salvador following the introduction of RVV. In addition, there was a reduction in hospitalizations due to gastroenteritis of any cause by 17-51% in the US and 40% in Australia.

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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

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 large longitudinal study in the Philippines found that children suffering bouts of diarrhea and respiratory infections were at a significantly increased risk of physical stunting which is associated with “poor functional outcomes such as impaired cognitive development.”

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

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Key Idea

In a 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

This study based on active surveillance in the US before and after introduction of PCV estimated 38,000 cases of invasive pneumococcal disease were averted in the first 5 years of vaccine use, and an additional 71,000 cases of disease were prevented through herd effects.

View Source >

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.

View Source >

Key Idea

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

View Source >

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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In a systematic literature review of studies in Africa, the authors conclude: “Bacterial meningitis in Africa is associated with high mortality and risk of neuropsychological sequelae. Pneumococcal and Hib meningitis kill approximately one third of affected children and cause clinically evident sequelae in a quarter of survivors prior to hospital discharge. The three leading causes of bacterial meningitis are vaccine preventable, and routine use of conjugate vaccines could provide substantial health and economic benefits through the prevention of childhood meningitis cases, deaths, and disability.”

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Key Idea

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

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Key Idea

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

Immunization against tetanus, pertussis, and influenza during pregnancy has been shown to have a profound affect on the health of the mother and fetus and increases survival of infants in their first months of life.

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Key Idea

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

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Key Idea

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

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Key Idea

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

View Source >

Key Idea

Increased uptake of immunization for vaccine-preventable diseases, particularly in low- and middle-income countries, could save the lives of thousands of mothers and children each year. The disease burden of tetanus, influenza, and pertussis has been minimized in many countries through maternal immunization, but wider applications of this strategy are now needed.

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Key Idea

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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