Education

Possibilities: The Far-Reaching Benefits of Immunization

Nurse preparing Immunization
Posted on by stacy

The story of immunization is often headlined with the remarkable health benefits—millions of lives saved, and illnesses and hospitalizations prevented. But the true impact of vaccination is even more far-reaching, touching many areas of people’s lives from supporting early childhood growth and development to improving educational outcomes and productivity, promoting economic stability, and helping to address equity gaps: It’s seemingly impossible to undersell the importance of vaccination.

This World Immunization Week, the VoICE editors highlight some of the broader benefits of immunization—not only helping to prevent illness and save lives, but also promoting healthy development, productivity, economic stability, and equity for all.

Key Messages

  1. Only looking at the direct impact of vaccination on morbidity and mortality grossly underestimates the wider value of vaccination on overall health and development
  2. Several studies show that immunization has the potential to increase productivity by averting preventable illness
  3. Vaccines are associated with improved cognitive ability, education, and healthy physical development – which translates into increased economic productivity
  4. Vaccine-preventable diseases disproportionately affect the poorest children and families, but immunization can be a cost-effective tool to improve equity across geographies, gender, and marginalized populations

Preventing Pandemics Supports Economic Stability

The global health community is now facing an unprecedented challenge in the COVID-19 pandemic. As countries across the world attempt to slow the virus’s spread, this event has become a potent reminder of the vital importance of vaccination; we are seeing today just how much an infectious disease outbreak can ravage both national and global economies. Vaccines are important tools to help avert potentially catastrophic health costs that arise from preventable infectious disease outbreaks. Several studies have found that vaccines can bring additional stability to national economies by preventing the high costs incurred by illnesses.

  • A 2009 study in Africa found an economic loss of US $43-72 million resulting from the 110,837 cases of cholera reported in 20071.
  • Researchers modeling the costs of potential pandemic influenza in the UK estimated costs of illness between £8.4 and £72.3 billion depending on the severity of the fatality rate, and even larger still for an extreme pandemic. In such a scenario, vaccination could limit the overall economic impact of pandemics2.
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Vaccines Help Promote Productivity

 Productivity—the measure of output by a working individual or a population—is an important determinant of standard of living. By preventing illness, vaccination can help promote productivity by supporting healthy cognitive development and success in school, ultimately helping children achieve their full potential across the lifespan.

  • A 2019 longitudinal study followed almost 6,000 children in India, Ethiopia, and Vietnam throughout childhood, finding that those vaccinated against measles scored better on cognitive tests of language development, math, and reading compared to children who did not receive measles vaccines3.
  • In a 2011 study in the Philippines, children vaccinated against six diseases performed significantly better on verbal reasoning, math and language tests than unvaccinated children4.
  • Vaccine-preventable diseases lead to both work and school absenteeism, which can negatively impact productivity and cause a substantial economic burden. A Norwegian study found that children hospitalized with rotavirus were absent from daycare for 6.3 days, on average, and 73% of their parents missed work5.

Vaccines Support Healthy Child Growth and Development

Some vaccine-preventable diseases can delay or interrupt normal growth and development in early childhood, leading to long-lasting damage that can adversely impact children for the rest of their lives. Persistent or recurrent infections in early life can lead to poor growth and stunting, which in turn can adversely affect adult health, cognitive capacity, and economic productivity.

  • Childhood vaccination programs can be a tool for mitigating undernutrition in developing countries. Children enrolled in Universal Immunization Programs observe improvements in terms of age-appropriate height and weight as per results of a study focused on 4-year-old children in India. On average, height and weight deficits were reduced by 22-25% and 15% respectively6.
  • A study in Kenya revealed that polio, BCG, DPT and measles immunization had protective effects with respect to stunting in children. In children under the age of 2 years, children immunized with polio, BCG, DPT, and measles vaccines were 27% less likely to experience stunting compared to unimmunized children7.
  • A 2013 study conducted in several developing countries found that children with moderate-to-severe diarrhea grew significantly less in length in the two months following an episode of illness compared to age- and gender-matched controls8.
  • Modeling of data from India’s 2005-2006 National Family Health Survey indicated that vaccinations against DPT, polio, and measles were significant positive predictors of a child’s height, weight, and hemoglobin concentration. Such indicators, in turn, influence children’s cognitive development and hence the future supply of skilled labor that is critical for economic growth9.

Tackling Immunization Inequities Can Have Substantial Benefits

While huge progress has been made in introducing and scaling up access to important vaccines, we still have a long way to go. There is significant evidence of inequities in vaccine coverage that exists between and within countries, as well as between and within different populations. In Gavi-supported countries, there are still an estimated 10.4 million “zero-dose children” who have not received any doses of DTP-containing vaccine.

  • Results of a 2019 study in Kenya found that immunization outreach for remote or hard-to-reach populations can still be highly cost-effective. The study found that failure to vaccinate hard-to-reach children against measles would result in more than 1,400 measles cases, 257 deaths, and cost nearly U.S. $10 million over the course of 4 years, mainly due to productivity losses from caretakers missing work10.
  • A 2018 study found that children of poor labor migrants living in Delhi, India are much less likely to be fully vaccinated than the general population and thus are at greater risk of vaccine-preventable diseases. Only 31% – 53% of children from migrant families were fully immunized (against 7 diseases) by 12 months of age, compared to 72% in the overall population of Delhi — with recent migrants having the lowest rates11.
  • 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-containing vaccine and three doses of DTP vaccine than children of the most educated mothers12.

The evidence shows that vaccines offer cross-cutting benefits for individuals, families, communities, and truly everyone across the globe. Cross-disciplinary research from many global health perspectives demonstrates that vaccines as a versatile, impactful tool that does so much more than just preventing millions of deaths and illness every year: Vaccines benefit global economies, boost productivity, and help close gaps in equity.

As we respond to COVID-19, the reality that infectious disease outbreaks anywhere in the world can quickly become a threat anywhere further highlights the importance of investment in vaccination as a part of strong, resilient health systems. As countries across the world grapple with containing the COVID-19 outbreak, we must also work together to ensure that the world’s most vulnerable children don’t miss out on the vaccines that prevent devastating illnesses like measles, polio, diarrhea, and pneumonia. In the face of this current challenge, it’s essential that we work together to protect essential health services like immunization to ensure that all people have a shot at living a healthy life protected from preventable disease.

Visit the VoICE World Immunization Week 2020 Social Media Toolkit for messaging and images to promote the broad benefits of vaccines. The toolkit is also available on the official World Immunization Week 2020 website.

References

  1. Kirigia, J.M., Gambo, L.G., Yolouide, A., et al 2009. Economic burden of cholera in the WHO African Region. BMC International Health and Human Rights. 9(8). doi: 10.1186/1472-698X-9-8
  2. Smith, R.D., Keogh-Brown, M.R., Barnett, T., et al 2009. The economy-wide impact of pandemic influenza on the UK: a computable general equilibrium modeling experiment. BMJ. 339. https://doi.org/10.1136/bmj.b4571
  3. Nandi A, Shet A, Behrman JR, et al. 2019. Anthropometric, cognitive, and schooling benefits of measles vaccination: Longitudinal cohort analysis in Ethiopia, India, and Vietnam. Vaccine. 37. https://doi.org/10.1016/j.vaccine.2019.06.025
  4. Bloom, D. E., Canning, D., & Shenoy, E. S. (2011). The effect of vaccination on children’s physical and cognitive development in the Philippines. Applied Economics, 44(21), 2777-2783. https://doi.org/10.1080/00036846.2011.566203
  5. Edwards CH, Bekkewold T, Flem E. 2017. Lost workdays and healthcare use before and after hospital visits due to rotavirus and other gastroenteritis among young children in Norway. Vaccine. 35. https://doi.org/10.1016/j.vaccine.2017.05.037
  6. Anekwe, T.D., Kumar, S. 2012. The effect of a vaccination program on child anthropometry: Evidence from India’s Universal Immunization Program. Journal of Public Health. 34(4). https://doi.org/10.1093/pubmed/fds032
  7. Gewa, C.A. and Yandell, N. 2011. Undernutrition among Kenyan children: contribution of child, maternal and household factors. Public Health Nutrition. 15(6). https://doi.org/10.1017/S136898001100245X
  8. Kotloff, K.L., Nataro, J.P., Blackwelder, W.C., et al 2013. Burden and aetiology of diarrhoeal disease in infants and young children in developing countries (the Global Enteric Multicenter Study, GEMS): a prospective, case-control study. Lancet. 382(9888). https://doi.org/10.1016/S0140-6736(13)60844-2
  9. Bhargava, A., Guntupalli, A.M., Lokshin, M. 2011. Health Care Utilization, socioeconomic factors and child health in India. Journal of Biosocial Sciences. 43(6). https://doi.org/10.1017/S0021932011000241
  10. Lee BY, Brown ST, Haidari LA et al. 2019. Economic value of vaccinating geographically hard-to-reach populations with measles vaccine: a modeling application in Kenya. Vaccine. 37(17). https://doi.org/10.1016/j.vaccine.2019.03.007
  11. Kusuma YS, Kaushal S, Sundari AB, et al. 2018. Access to childhood immunization services and its determinants among recent and settled migrants in Delhi, India. Public Health. 158. https://doi.org/10.1016/j.puhe.2018.03.006
  12. Arsenault, C., Harper, S., Nandi, A., et al. 2017. Monitoring equity in vaccination coverage: A systematic analysis of demographic and health surveys from 45 Gavi-supported countries. Vaccine. 5(6). https://doi.org/10.1016/j.vaccine.2016.12.041

Vaccination: Helping children think, learn and thrive

Infographic describing Immunization, schooling and future prospects
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A selection of VoICE evidence in this issue

Berger JT, Villalobos ME, Clark AM et al. 2017. Cognitive development one year after infantile critical pertussis. Pediatric Critical Care Medicine. 19(2).

Lorntz, B., Soares, A.M., Moore, S.R., et al 2006. Early childhood diarrhea predicts impaired school performance. Pediatric Infectious Disease Journal. 25(6).

Krauss-Mars, A.H., and Lachman, P.I. 1992. Social factors associated with tuberculosis meningitis. South African Medical Journal. 81(1).

Niehaus, M.D., Moore, S.R., Patrick, P.D., et al 2002. Early childhood diarrhea is associated with diminished cognitive function 4 to 7 years later in children in a northeast Brazilian shantytown. American Journal of Tropical Medicine and Hygiene. 66(5).

Driessen J, Razzaque A, Walker D, et al. 2015. The effect of childhood measles vaccination on school enrolment in Matlab, Bangladesh. Applied Economics. 47(55).

Mina, M.J., Metcalf, C.J. de Swart, R.L., et al 2015. Long-term measles-induced immunomodulation increases overall childhood infectious disease mortality. Science. 348(6235).

Nandi A, Shet A, Behrman JR, et al. 2019. Anthropometric, cognitive, and schooling benefits of measles vaccination: Longitudinal cohort analysis in Ethiopia, India, and Vietnam. Vaccine. 37.

A healthy child is more likely to attend school, performs better in school and attends school for longer than a child who is often ill or has suffered permanent disabilities as a result of illness. In this Feature, VoICE explores how vaccine-preventable infections affect cognitive development and schooling, and highlights evidence of the effect vaccination can have in protecting a child’s neurologic development, educational prospects and ultimately, future productivity.

Key Messages

  1. Common childhood illnesses cause children to miss school. Immunized children miss less school.
  2. Recurring episodes of diarrhea in young childhood can delay a child from starting school and affect physical growth and normal cognitive development during childhood. Vaccine-preventable rotavirus is the most common cause of severe diarrhea.
  3. Immunization against measles can increase the number of years of schooling a child achieves and may also improve cognitive scores, compared to unimmunized children.
  4. Some vaccine-preventable infections carry the risk of long-term hearing, psychosocial and neurological disabilities that negatively impact a child’s social functioning and educational prospects.
  5. On average, globally, each additional year of schooling can increase a child’s future adult earnings by more than 12%.

Immunization protects our children’s future prospects

Most people think of vaccines as important for preventing specific diseases and infections during childhood, but may not realize the extent to which immunization can strengthen a child’s future prospects well into the school years and beyond. Growing evidence is illuminating the link between vaccination and improved cognitive functions, education, and ultimately, adult productivity. In essence, vaccination may help improve a child’s ability to learn, think and thrive in society as a result of educational attainment, cognitive reasoning and thinking skills.

Immunization, Schooling and future Prospects

Vaccine-preventable diseases, immunization and educational attainment

Vaccinated kids miss less school

The most obvious link between immunization and education is that preventing bouts of illness means kids miss fewer school days. A study of school absenteeism in the US found that nearly 50% of absences were due to illness. A second US study found that schools that offered flu vaccine to their students reduced the risk of any child getting the flu by 30%, regardless of vaccination status. Children vaccinated against the flu missed 1.5 fewer days of school per 100 school days compared to those who did not receive flu vaccine. Thirty years ago, Varicella infections (chickenpox) caused a child to miss nearly 9 days of school, not to mention work missed by parents taking care of a sick child. But the introduction of chickenpox vaccine in 1995 has drastically reduced infections, hospitalizations and deaths from this common infection, preventing more than 3.5 million cases each year in the US, according to the CDC.

Infections and schooling delays

Rotavirus is the most common cause of severe diarrhea in young children worldwide, and researchers in Brazil found that recurrent bouts of diarrhea affect school readiness and long-term educational attainment. In children living in a Brazilian shantytown, the greater the number of episodes of persistent diarrhea before age two, the more delayed a child was in terms of school readiness. Overall, each episode of diarrhea delayed a child’s starting school by 0.7 months. Likewise, 6-10 years later, increasing episodes of diarrhea before age two predicted delays in age-appropriate educational attainment. Some infections, such as tuberculosis meningitis, although rare, significantly increase the risk of major educational delays. From a study in Western Cape, South Africa, among children who were well enough to attend school after surviving tuberculosis meningitis, more than half had failed at least one school grade.

Measles vaccine can help increase extent of education received

Measles infection has a well-known prolonged negative impact on the immune system, increasing the risk of other illnesses for up to 3 years after recovering from measles. A 2019 analysis of survey data from school aged children in Ethiopia, India and Vietnam shows that children vaccinated against measles achieved 0.2-0.3 years of additional schooling compared to children who did not receive the measles vaccine. As depicted in the graphic below, note that this value is as high as 0.8 years of schooling by age 11-12. Similarly, data from a poor, largely rural South African community found that for every 6 children vaccinated against measles, one additional grade of school was achieved. In terms of initial enrollment in school, the phased introduction of measles in Bangladesh in the 1980’s resulted in boys being more than 7% more likely to be enrolled in school if they were vaccinated during the first year of life, compared to unvaccinated boys or those vaccinated later in childhood. This effect was not observed for girls, but may suggest that overall physical and cognitive health of children – as a result of their measles vaccination status – played a role in parent’s decisions to enroll their children in school.

Measles Vaccination Associated with Increased Schooling

Maternal vaccination can help a child’s education

In 1974, a randomized trial of tetanus vaccine was designed to determine how well maternal vaccination would protect infants born to mothers in Bangladesh from tetanus. The study showed a significantly reduced risk of tetanus infection and death among infants born to mothers who had received the vaccine. Notably, 20 years later, researchers found a clear pattern of increased educational attainment among children whose mothers received tetanus vaccine during pregnancy. Helping to explain this observation is the fact that up to 50% of children who survive neonatal tetanus may have long-term cognitive impairment as a result of the infection.

Vaccine-preventable diseases affect the ability to learn, think and function socially

Long-term impairments resulting from vaccine-preventable infections can reduce a child’s educational prospects in several ways. Not only may the impairment itself represent a barrier to learning and future productivity, as in the case of significant cognitive delays, but educational support for children affected by these and other impairments may be lacking or nonexistent. In many places around the world, educational systems and local school are stretched exceedingly thin and unable to provide specialized assistance to children with hearing, vision, developmental or other impairments.

Vaccine preventable infections in childhood can negatively affect a child's education

Hearing impairments

In the era before the introduction of pneumococcal conjugate vaccine (PCV) in the US, pneumococcus was the most common cause of serious and recurring ear infections in children. In comparison to life-threatening meningitis or severe pneumonia brought on by pneumococcal infection, an ear infection may seem trivial. But from the perspective of learning, ear infections can have serious consequences. Multiple ear infections in early childhood increase the risk of hearing loss, and that speech and language develops during the same time in which most children are at the greatest risk of ear infections. These factors help explain why children who spent more time with ear infections during early childhood had lower cognitive, speech, language development and even IQ than children who suffered less time with ear infections, according to a 1990 study in the US. More recently, a 2015 review of long-term impairments resulting from invasive meningococcal disease – which is relatively rare in the era of meningococcal vaccines – was significantly associated with permanent hearing loss in survivors.

Social and psychological impairments

Another set of challenges presented to survivors of vaccine-preventable diseases includes behavioral, social and psychological disorders. The invasive meningococcal disease review above highlighted evidence that children who survived invasive meningococcal infections were nearly 15% more likely to have a significant psychological disorder 3-5 years after the disease than children who did not have the disease, and two studies found a significant association between the disease and later development of Attention Deficit Hyperactivity Disorder (ADHD).

Vaccine-preventable brain and brain-related infections and long-term cognitive impairment

Vaccines can prevent several infectious causes of severe brain and brain-related infections such as meningitis or encephalitis. These types of infections are not only life-threatening but are highly associated with impaired thinking and learning after infection, sometimes for the rest of one’s life. Vaccines that prevent these infections thus help protect and preserve one’s future ability to learn, engage socially and thrive in society.Infection with Japanese encephalitis virus (JEV), which circulates almost exclusively in Asia, usually results in mild or undetectable symptoms. However, in those who develop encephalitis, a serious inflammation of the brain, 1 in 4 do not survive. Among those who do survive, up to 50% are left with permanent cognitive, psychological or neurological disabilities. An effective vaccine is available and the WHO recommends its inclusion in the national immunization schedules of heavily affected countries.Another life-threatening infection of the central nervous system is meningitis, which may have viral or bacterial causes. A large portion of the most severe meningitis infections were caused by three bacteria – pneumococcus, Hib and meningococcus – which are now largely vaccine-preventable. Pneumococcal, Hib and meningococcal infections have been responsible for the majority of meningitis deaths among children and for significant numbers of permanent cognitive disabilities, making their prevention high on the list of priorities for safeguarding a child’s future prospects. In The Gambia, 58% of children who survived pneumococcal meningitis had long lasting negative health outcomes. Half had major disabilities such as mental retardation, hearing loss, motor abnormalities, and seizures. A systematic literature review of studies across Africa found that 25% of children who survived pneumococcal or Hib meningitis had neuropsychological deficits.

The link between diarrhea, physical growth and cognition

Especially during early childhood, good nutrition and physical growth are needed for normal cognitive development. Diarrhea, especially severe or recurring diarrhea, limits the absorption of nutrients in the body, which can affect physical and cognitive development in the long-term. (See the VoICE Featured Issue on Nutrition, Growth and Development). Many rotavirus infections can be prevented through the use of existing vaccines. Prevention of diarrhea is another way to safeguard cognitive development, based on these sobering facts:

Some vaccines have been linked to improved learning and cognitive development

Some evidence in the last 10 years points to a positive link between vaccination in early childhood and a corresponding gain in cognitive and learning tests in later childhood. A small study from the Philippines found that children immunized with 6 basic vaccines scored better on three cognitive tests (verbal, mathematics and language) at age 11 compared to children who received none of these 6 vaccines. A 2019 analysis of survey data from India, Ethiopia and Vietnam found that children vaccinated against measles scored better on cognitive tests of language development, math and reading than children who did not receive measles vaccines.

Vaccination as an investment in future productivity

Reporting on the Philippine study of cognition and vaccination, David Bloom and colleagues at Harvard University note that improvements in a child’s health translate into better earning potential and productivity as an adult, and thus describe vaccination as “an investment in human capital”, highlighting several studies that support this idea. Educational attainment is an important part of the equation for reaping the rewards of such investments. A 2014 World Bank review of the returns to schooling worldwide found a significant positive relationship between additional years of schooling and future adult wage earnings. Not only were the returns from schooling greatest in low- and middle-income countries, but the highest returns to schooling came from the primary years of education – years in which the influence of early childhood illnesses is the strongest. On average across Africa, the report concludes that an additional year of schooling would yield a 12.4% increase in future adult earnings.A healthy child is more likely to attend school, performs better in school and attends school for longer than a child who is often ill or suffering permanent disabilities as a result of illness. The list of consequences from vaccine-preventable illnesses is long and frightening. Each threat erased from that list by vaccination is another hurdle removed from a child’s path to an education and a full and productive adulthood.

Commentary from the VoICE editors

The literature investigating the linkages between immunization, education and cognition represents a complex web of research areas spanning epidemiology, neuroscience, economics, education and demography. Studies specifically and quantitatively looking at the relationships between vaccines and education or cognition are relatively few, and some are older than the literature typically covered in VoICE. Although the positive link between immunization and educational attainment is generally accepted, the lack of new studies on this topic highlights the need for additional focus on this area of study. Although the complexity of these linkages makes quantifying the effect of immunization on education and future productivity difficult, all the literature reviewed in VoICE demonstrates a clear positive – and logical – relationship between immunization and improvements in thinking, social development, schooling and educational success.

Gender Equity and Vaccines: an equal shot at health

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Last month at the G7 meeting in Canada, global leaders met to consider gender equality, one of the 5 key themes Canada will advance during their tenure. Partners, experts and representatives in the immunization world echoed this emphasis on gender at the Global Immunization Meeting in Kigali, Rwanda just a few days ago. The issues of gender and gender equity within immunization are complex, and designing research to study equity gaps can be difficult. To understand what we do know about immunization and gender, women’s empowerment and gender equity, the VoICE team this month features an overview of these issues.

A selection of VoICE evidence in this issue

Brinda, E.M., Rajkumar, A. P., Enemark, U. 2015. Association between gender inequality and index and child mortality rates: a cross-national study of 138 countries.. BMC Public Health. 15(97).

Gupta, M., Angeli, F., Bosma, H., et al. 2016. Effectiveness of Multiple-Strategy Community Intervention in Reducing Geographical, Socioeconomic, and Gender Based Inequalities in Maternal and Child Health Outcomes in Haryana, India.. PLoS ONE. 11(3).

Merten, S., Hilber, A.H., Biaggi, C., et al. 2015. Gender Determinants of Vaccination Status in Children: Evidence from a Meta-Ethnographic Systematic Review.. PloS ONE. 10(8).

Thorpe, S., VanderEnde, K., Peters, C., et al. 2016. The influence of women’s empowerment on child immunisation coverage in low, lower-middle, and upper-middle income countries: a systematic review of the literature.. Maternal and Child Health Journal. 20(1).

Devasenapathy, N., Ghosh Jerath, S., Sharma, S., et al. 2016. Determinants of childhood immunisation coverage in urban poor settlements of Delhi, India: a cross-sectional study. BMJ Open. 6:e013015.

Arsenault, C., Johri, M., Nandi, A., et al. 2017. Country-level predictors of vaccination coverage and inequalities in Gavi-supported countries.. Vaccine. 35(18).

Key Points 

  1. Global and national level estimates of vaccine coverage obscure persistent gender inequity in some populations.
  2. At the national level, gender inequality for women is correlated with higher child mortality and lower childhood immunization rates.
  3. Reaching higher levels of education greatly increases the likelihood that a woman’s children will be vaccinated.
  4. The more empowered women are – i.e. have control over family decision-making, financial resources, etc. – the more likely their children are to be vaccinated.
  5. An equity approach to immunization and child health is both a moral imperative and an efficient use of resources.

Equity matters for the health of women and children

While much progress has been made to reduce child mortality and increase vaccine coverage in the last few decades, inequities still exist from a variety of perspectives, and gender influences vaccine access in several ways.  When considering both between and within country inequities; geographic, wealth, and educational for example, female specific gender inequity remains a common thread.

Quotes From Government Of Canada
Policy on Gender Equality, Government of Canada

According to UNICEF, children in sub-Saharan Africa are 10 times more likely to die before their fifth birthday than children in high-income countries, a gap that has not changed much in the last 25 years. At the same time, low- and middle-income countries have significantly greater gender inequality and higher under-5 mortality rates than high-income countries. This gender inequality is significantly correlated with lower immunization coverage, and with higher neonatal, infant and under-5 mortality.

Child gender and immunization

In some parts of the world, gender influences a child’s access to vaccines and health care.

Differential vaccine coverage of childhood immunization between boys and girls is an inequity largely invisible at the global level but which persists in certain geographic and social settings.  This is reported in studies from regions of the world where there is strong cultural preference for sons over daughters.  A study conducted in the urban poor in India which examined household and neighborhood-level determinants of childhood immunization, researchers found that girls were 22% less likely than boys to be fully immunized.  This trend has not changed despite increasing overall vaccine coverage rates nationally.

Another study that examined the gender gap in immunization coverage in a rural sub-district of Bangladesh showed that although poverty, low maternal education, and larger number of children in a family decreased the likelihood that any child would be vaccinated, the effect of these factors was more pronounced for girls than for boys. In other words, given the same set of pressures on families that negatively impact immunization, girls fared worse than boys in terms of likelihood of receiving vaccines.

There is a small amount of evidence that girls have less access to care if sick in specific settings. In an Indian study from the northern state of Bihar, girls who were ill were less likely to receive care in a health facility than boys, although the study did not find different rates of immunization coverage between the sexes.

Gender differences in child health care utilization for both prevention and treatment of disease may be a contributing factor driving excess mortality for girls in South Asia.  South Asia is the only region of the world in which a slight natural survival advantage in female infants compared to male infants is reversed.  This means that in South Asia, male infants have a better chance of surviving to their first birthday than females.  It is estimated that the excess female infant mortality in India results in 9 additional deaths/1000 live births of girls compared to boys, and this disparity has worsened since 1990.1

Critically, it must be acknowledged that local attitudes and motives that underpin vaccination and health seeking behaviors can vary significantly between countries and communities and are often driven by a set of complex interrelated factors that, in addition to gender, include parental education, socioeconomic status, geographic access, cultural preferences and biases.

Mothers and childhood immunization

Mariam (pictured left of frame in the green and yellow skirt) a community influencer who lives in Anguar Hausawa and helps to co-ordinate vaccine drives chats to local mothers about vaccination and health issues.
Mariam (pictured left of frame in the green and yellow skirt) a community influencer who lives in Anguar Hausawa and helps to co-ordinate vaccine drives chats to local mothers about vaccination and health issues.

Gender equality for women, and maternal empowerment in particular, are factors which can significantly influence the health of children and a child’s access to immunization.  Two recent studies have examined this relationship between child health and overall gender equity at the national level. In a 2015 study looking at the degree of gender inequality among 138 countries with data from the United Nations Development Program,  greater inequality between women and men was significantly correlated with a country having higher under-5 mortality rates and lower immunization rates. A second study found that among 45 low- and lower-middle income countries supported by Gavi, countries with the least gender equality (as measured by reproductive health, women-held parliamentary seats, educational attainment and other factors) also had lower vaccine coverage rates overall.

There are many ways in which a woman’s empowerment affects the health of her children.  A child’s health – including the likelihood that they will be immunizated – in turn benefits from programs and policies that empower and educate women.

Empowerment definition

Educating women means children are more likely to get vaccinated

Studies have shown that maternal education is significantly associated with children’s immunization coverage.  Researchers looking at vaccination coverage in 45 low- and middle-income countries found that children of the least educated mothers are 55% less likely to have received measles-containing vaccine and three doses of DTP vaccine compared to children of the most educated mothers.  Another 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.  The increased likelihood of timely vaccination likely plays a role in the improved chances of child survival that are also associated with maternal education.  An analysis conducted by UNICEF in 2015 found that across many South Asian and sub-Saharan African countries, children with mothers who received no formal education were almost 3 times more likely to die before reaching age 5 than those born to mothers with some secondary education.

The influence of empowerment and agency

Education is one important component or ‘resource’ that can empower women, but another key factor is a woman’s agency – her ability to define, and take action towards, personal goals. The degree of agency a woman may have is mediated by factors such as power over decision-making, access to money, social status, and freedom of movement. A 2016 systematic review of studies covering forty years of data from primarily African and Southeast Asian countries, found a trend where higher levels of women’s agency were linked to higher likelihood of complete immunization for their children. In another systematic review,  in which qualitative research from low- and middle-income countries was analyzed to understand gender-related reasons for low vaccination rates, women’s low social status was shown to be a barrier to accessing vaccinations for their children.  Specifically, key drivers of likelihood of vaccination included maternal education, family income, as well as a woman’s ability to control resource allocation and autonomous decision-making related to how her time is used.

One explanation for this effect may be that as agency increases, a woman may have more decision-making power to choose how household resources such as money and time are allocated; and if given the means, women often prioritize children’s health. In effect, her children’s good health is the goal towards which she will apply available family resources, to the degree her level of agency and resources allow.

Enticing evidence from one study indicates that empowerment and its positive benefits can be contagious. In a study of the impact on child immunization rates of a women’s empowerment program conducted among socially and economically disadvantaged women in India, it was noted that not only were the children of the women who had direct participation in the program immunized, but there was a measurable spill-over effect of vaccination to non-participants in program villages. Non-participating children in villages where the program occurred were anywhere from 9 to 32% more likely to be immunized against measles than children in villages without the empowerment program.

What can progress toward gender equity look like?

Sustainable Development Goal (SDG) 5

The Sustainable Development Goal (SDG) 5—to achieve gender equality and empower all women and girls—is a goal that is inextricably linked with progress on many fronts, particularly in the arena of women and children’s health. Similarly, the achievement of SDG 3 – to ensure healthy lives and promote wellbeing for all at all ages – rests on many factors, but both immunization and a concerted focus on gender disparities in low-income countries will be absolutely essential to this goal.

This focused approach on inequity makes both practical and financial sense.  A 2010 study from UNICEF concluded that an equity-focused strategy would hasten progress towards health goals and be cost-effective, especially in low-income, high-mortality countries.2 Specifically, investment in a package of interventions designed to increase health equity, including access to immunization, was estimated to improve child mortality reductions by more than 20% over the status quo. Focusing programmatic efforts and supportive policies on the poorest or worst off in a population yields the greatest positive change with limited resources. Equity analyses can aid decision-makers in understanding both who is left behind or left out of progress on health and social fronts, and why.

Strategies which specifically target the health of women and children in an integrated way across interventions may be able to reverse gender inequity in immunization in some contexts. The National Rural Health Mission in Haryana, India, for example, implemented a multi-strategy community intervention program intended to reduce maternal and child health inequalities by improving healthcare at the household level in villages.  Through the use of local incentives including cash, payment of travel costs, free hospital services for pregnant women, hospital-based treatment of neonatal illnesses, and locally appointed Health Activists, the program was able to eliminate gender inequalities for full immunization between male and female children. While such synergy between immunization visits and essential health care can be more involved to implement programmatically, the collateral gains make it worth pursuing in the service of creating healthier, more equitable societies.

Although much work has been done to identify child and family dynamics that underpin gender inequalities, more research and attention is needed to create change at the local and regional levels. Tailored strategies will be necessary in each setting to improve women’s agency and eliminate differential vaccination coverage for girls.  Concentrating resources to improve gender equity in access to health will be integral to attaining global immunization and child survival goals, and can reinforce efforts to empower women worldwide.

For Additional Information:

1Alkema L, Chao F, et al.  National, regional, and global sex ratios of infant, child, and under-5 mortality and identification of countries with outlying ratios: a systematic assessment.  Lancet Global Health 2014; 2: e521-530.

2UNICEF.  Narrowing the gaps to meet the goals, UNICEF, New York, September 2010.

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