VoICE Immunization Evidence: Geographic inequity
Significant evidence of geographic inequity in vaccine coverage exists within countries, within states, and between populations living in rural, peri-urban, and urban areas.
Key Evidence: In India, inequities in vaccination coverage exist between states, within states, and in urban vs. rural settings. Lower parental education resulted in lower coverage, girls had lower coverage than boys and infants born to families with a large number of children also had lower coverage than others. A direct relationship between household wealth and coverage was also found.
Key Evidence: Full immunization coverage varies drastically with geography. In the Democratic Republic of Congo, 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.
Key Evidence: Inequity in vaccination coverage in India was found between states, within states, and in urban vs. rural. Lower parental education resulted in lower coverage, girls had lower coverage than boys, and infants born to families with a large number of children also had lower coverage than others. A direct relationship between household wealth and coverage was also found.
Those living farther from health facilities are less likely to be immunized – or to be immunized on time – than children living closer to facilities
Key Evidence: An study using GIS to quantify the percent of pregnant women in Mozambique without access to tetanus toxoid (TT) vaccine at varying distances from health facilities estimated that, if women cannot travel more than 5 km. to a TT immunization site, there will be almost 18,000 neonatal tetanus cases each year that could be prevented, costing the country more than $362 million in treatment costs and lost productivity. Covering 99% of women with TT will currently require people to travel up to 35 km. to obtain an immunization.
From the VoICE Editors: GIS, a geospatial information system, is a computer system capable of capturing, storing, analyzing, and displaying geographically referenced information.
Key Evidence: 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.
Despite improvement in equitable vaccination rates across geographies at the national level, local level disparities persist.
Key Evidence: 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.
Key Evidence: A study in Kenya estimated that the failure to vaccinate the 21% of children considered hard-to-reach (living beyond a 5 km radius of a vaccination post) against measles would result — over 4 years — in more than 1,400 measles cases and 257 deaths and cost nearly $10 million, mainly in productivity losses from caretakers missing work.
Polio eradication investments in some of the countries with the most fragile health systems, provide an opportunity to leverage polio vaccination for other health priorities.
Key Evidence: 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.
Children living in slum conditions who are at greater risk of infectious diseases than those in urban areas, are less likely to be vaccinated.
Key Evidence: Children in slum settings have higher burdens of vaccine-preventable disease (one study found children in slums in Manila, Philippines were 9 times more likely to have tuberculosis than other urban children) and lower rates of immunization (a study in Niger found 35% coverage in slums vs. 86% in non-slum urban areas).
Key Evidence: Wealth and mother’s education are significant predictors of vaccination rates in both urban and rural settings. However, low paternal education, lack of antenatal care, and home births were significantly associated with low vaccination rates only in rural settings. This suggests the need of tailored vaccine programs.
From the VoICE editors: This study compared the significance of risk factors for low vaccination rates in rural versus urban settings in Tanzania.
Key Evidence: Globally, coverage of the third dose of DTP is 8% higher among urban dwellers compared to children raised in a rural environment.