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 Concepts, 33 Sources
Key Concept

Key Evidence: In an effort to reach children with vitamin A deficiency in the African countries of Angola, Chad, Cote d’Ivoire, and Togo, vitamin A supplementation was administered during Polio vaccine campaigns. This led to a minimum coverage of 80% for vitamin A and 84% for polio vaccine in all of the immunization campaigns. During the second year of vitamin A integration into the polio vaccination campaign, coverage exceeded 90% for both vitamin A and polio vaccination in all four countries.

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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: Among 33,000 preschool children in the UK (who received at least one prescription of amoxicillin) there were ~15% fewer amoxicillin prescriptions given during the influenza season to children who had received the live attenuated influenza vaccine than among children who were not vaccinated. This suggests that flu vaccination may lead to a reduction in excess, inappropriate prescribing of antibiotics for influenza in children.

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Key Evidence: Over a four-year period following the introduction of PCV-10 in Finland, purchases of antimicrobials that are recommended for the treatment of acute otitis media (middle-ear infection) for children born during these years fell by nearly 18%, compared to pre-vaccine years, and the rate of surgeries to place ear tubes for severe cases fell 15%. Although it is considered a mild disease, acute otitis media caused by pneumococcus is 1,000 times more common in young children than invasive pneumococcal disease, such as pneumonia or meningitis, and thus the public health impact of the vaccine in reducing otitis media cases and in saving health care costs is considerable.

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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 Evidence: 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 Evidence: Efforts to eliminate measles — which has been called a public health “canary in the coalmine” since it’s a sign of weak health systems — can also serve to strengthen immunization programs as well as the broader health systems. These efforts include improving infection prevention and control practices in health care facilities, disease surveillance and outbreak detection systems, and countries’ ability to prepare for and respond to infectious disease outbreaks.

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Key Concept

Key Evidence: 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 Concept

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 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: 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: In New Zealand, Maori and Pacific children have historically suffered high hospitalization rates for invasive pneumococcal disease (IPD), all cause pneumonia (ACP), and otitis media. Following the introduction of conjugate vaccines in the country, Maori and Pacific children’s rates of admission for IPD dropped by 79% and 67%, respectively, while significant reductions in ACP and otitis media admissions were also noted, resulting in reductions in disparities for these populations.

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Key Concept

Key Evidence: In a review of studies from Europe and Australia, researchers found evidence that primary care models which utilize well-baby clinics had fewer gaps in vaccination coverage associated with socioeconomic inequities compared to similar countries which did not make use of these types of clinics.

From the VoICE Editors: All countries included in the review were high-income countries; the authors note potential limitations in translation of findings to low- and middle-income countries.

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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: 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 study of over 80,000 children in Kenya designed to understand the role of inadequate health systems on childhood survival beyond 59 months of age showed that a higher per capita density of heath facilities resulted in a 25% reduction in the risk of death. However, user fees for sick-child visits increased the risk of death by 30%.

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Key Concept

Key Evidence: A series of studies in the U.S. estimated that the average savings in direct healthcare costs from rotavirus and acute gastroenteritis were between $121 million and $231 million per year once rotavirus vaccines were introduced.

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Key Concept

Key Evidence: A study of insurance claims in the U.S. for children under five estimated that, from 2007 to 2011, rotavirus vaccination prevented more than 176,000 hospitalizations, 242,000 emergency room visits and more than 1.1 million outpatient visits due to diarrhea — saving an estimated $924 million in direct health care costs over four years.

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Key Concept

Key Evidence: A study in Australia estimated that adding dTpa vaccination for pregnant women to the current pertussis immunization program for children would prevent an additional 8,800 symptomatic pertussis cases (mostly unreported) and 146 hospitalizations each year in all ages, including infants and their mothers, as well as one death every 22 months. The study found maternal pertussis vaccination to be cost-effective.

From the VoICE Editors: Note: The formulation used in this study is abbreviated dTpa.

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Key Concept

Key Evidence: Children in the U.S. whose mothers were not educated beyond high school have significantly lower vaccination rates for rotavirus than children of mothers with advanced degrees (68% vs. 84%).

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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 Concept

Key Evidence: Children in U.S. families living below the poverty line have significantly lower rotavirus vaccination rates than children at or above the poverty line (67% vs. 77%).

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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 Concept

Key Evidence: A large U.S. study of surveillance data examining the impact of switching from PCV7 to PCV13 for infants demonstrated how important vaccination is in combating antimicrobial resistance. While the incidence of antibiotic-resistant invasive pneumococcal disease (IPD) was increasing before the introduction of PCV13, drug resistant IPD declined 78-96% in children under five after the vaccine introduction.

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Key Concept

Key Evidence: In Iceland, a study of all children born over an 11-year period, before and after the introduction of pneumococcal conjugate vaccine (PCV) into the national immunization program, found a 6% decrease in all antibiotic prescriptions for children during their first four years of life and a 22% reduction in prescriptions for otitis media after the vaccine was introduced. Thus, in addition to reducing the burden of pneumococcal disease, PCV may also slow the spread of antibiotic resistance.

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Key Concept

Key Evidence: Several studies in the U.S. have shown that hospitalizations due to rotavirus fell sharply in children too old to be vaccinated as well as in adults after rotavirus vaccines were introduced, indicating herd protection. In one large study, rotavirus hospitalizations in 2008 — two years after the first vaccine was introduced — declined by 71% in 5-14 year old children and by 65% in 15-24 year olds compared to the pre-vaccine period.

From the VoICE Editors: For more information also see Lopman 2011. https://academic.oup.com/jid/article/204/7/980/810889

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Key Concept

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 Evidence: After PCV13 replaced PCV7 in the U.S. infant immunization program in 2010, the incidence of invasive pneumococcal disease (IPD) caused by the 6 additional serotypes in the new vaccine declined by 75% in children too old to be vaccinated (5-17 years) by the third year following the switch, and by 58-72% in adults, compared to the expected incidence if PCV7 alone had been continued. This led to overall reductions in IPD incidence of 53% in 5-17 year olds and of 12-32% in adults within three years of the switch from PCV7 to PCV13.

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Key Concept

Key Evidence: 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 Concept

Key Evidence: A study in Australia estimated that adding dTpa vaccination for pregnant women to the current pertussis immunization program for children would prevent an additional 8,800 symptomatic pertussis cases (mostly unreported) and 146 hospitalizations each year in all ages, including infants and their mothers, as well as one death every 22 months. The study found maternal pertussis vaccination to be cost-effective.

From the VoICE Editors: Note: The formulation used in this study is abbreviated dTpa.

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Key Evidence: Immunization against tetanus, pertussis and influenza during pregnancy has been shown to have a profound effect on the health of the mother and fetus, and increases survival of infants in their first months of life. Maternal immunizations with tetanus toxoid-containing vaccines has been one of the main contributors to the 94% reduction in global deaths due to tetanus since 1988. Between the 1970s to the early 2000s, maternal immunization against pertussis brought disease incidence down to 5,000 cases per year from the earlier 100,000-250,000 cases per year in the United States. Vaccination of mothers for influenza has brought down confirmed cases of the disease by 63%.

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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 Evidence: 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 Concept

Key Evidence: 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 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 Evidence: A systematic review of studies examining the broader economic impact of vaccination in low-middle income countries (LMICs) found that vaccination programs may improve the financial sustainability and affordability of healthcare programs in LMICs. The use of vaccines as part of a treatment cluster, or in combination with other infrastructure projects (such as water management systems) to maximize community health outcomes, offers opportunities for cost sharing between programs.

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Key Concept

Key Evidence: 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 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 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 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 Evidence: A systematic review of studies examining the broader economic impact of vaccination in low-middle income countries (LMICs) found that vaccination programs may improve the financial sustainability and affordability of healthcare programs in LMICs. The use of vaccines as part of a treatment cluster, or in combination with other infrastructure projects (such as water management systems) to maximize community health outcomes, offers opportunities for cost sharing between programs.

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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: 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 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: Prior to the introduction of rotavirus vaccines in the U.S., there were an estimated 205,000 – 272,000 emergency department visits and 55,000 – 70,000 hospitalizations due to rotavirus in children each year. A series of studies found that hospitalizations in children under five due to rotavirus declined, on average by 80% from the pre-vaccine to the post-vaccine era, while both outpatient visits and emergency department visits due to rotavirus declined 57%.

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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 study based on population- and lab-based surveillance of bacterial infections in the U.S. estimated that, of the estimated 400,000 cases and 30,000 deaths from invasive pneumococcal disease (IPD) that were likely prevented from 2001 to 2012 with the introduction of PCV7 (in 2000) and PCV13 (in 2010) in the infant immunization schedule, more than half of cases prevented and nearly 90% of prevented deaths were among people older than 5 years of age.

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Key Evidence: A study in Australia estimated that adding dTpa vaccination for pregnant women to the current pertussis immunization program for children would prevent an additional 8,800 symptomatic pertussis cases (mostly unreported) and 146 hospitalizations each year in all ages, including infants and their mothers, as well as one death every 22 months. The study found maternal pertussis vaccination to be cost-effective.

From the VoICE Editors: Note: The formulation used in this study is abbreviated dTpa.

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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 Evidence: Following introduction of PCV in New Zealand, hospitalizations of children under 6 years of age due to invasive pneumococcal disease decreased by 73%, due to all-cause pneumonia decreased by 8%, and due to otitis media decreased by 25%.

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Key Evidence: 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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