The World Health Organization (WHO) has released a new report, “Expectations of inequality: Childhood Immunization” that details the status of childhood immunization in 10 priority countries.

Background information:

Childhood immunization is a key intervention to promote the health, well-being and survival of children. Despite marked success in many aspects of immunization
programmes, inequalities in childhood immunization remain a challenge.

This report provides a closer look at the factors associated with childhood immunization. The report focuses on the 10 countries that Gavi, the vaccine alliance,  identified as the highest priority for childhood immunization. These countries face the most severe immunization challenges, and together account for more than 70% of children
who do not get a full course of basic vaccines.

Methodology

Data sources: For each priority country, data were sourced from the latest publicly available Demographic and Health Surveys (DHS), ranging from 2012 to 2016.

Surveys were conducted with a representative sample of women aged 15–49 years and
included questions about childhood immunization and background characteristics.

Childhood immunization indicator: The childhood immunization indicator featured in this report is DTP3 immunization: the percentage of children aged 12–23 months who had received three doses of the combined diphtheria, tetanus toxoid and pertussis vaccine (DTP3) (or any DTP-containing vaccine, including pentavalent and tetravalent).

Descriptive analysis: Disaggregated data show childhood immunization coverage broken down by: child’s sex, birth order, mother’s age at birth, mother’s education, mother’s ethnicity or caste/tribe, sex of household head, household economic status, place of residence and subnational regions. Concentration curve and concentration index were used to measure how DTP3 coverage varied by socioeconomic status.

Multiple regression analysis: A logistic regression model was used to assess the associations between DTP3 immunization coverage and selected child, mother, household and geographic characteristics. Estimated associations are presented as
odds ratios.

Key Messages:

The report focuses on 10 priority countries:

1. Afghanistan,
2. Chad,
3. Democratic Republic of the Congo,
4. Ethiopia,
5. India,
6. Indonesia,
7. Kenya,
8. Nigeria,
9. Pakistan and
10. Uganda.

 

Major findings by country

Afghanistan

Nationally, only three in five one-year olds in Afghanistan received three doses of the DTP vaccine.

Childhood immunization demonstrated no inequality by child sex, and low levels of inequality by birth order; however, coverage varied substantially according to mother’s characteristics (age at birth, education and ethnicity), household economic status, place of residence and subnational region.

Certain ethnic groups (especially the Nuristanis) and regions (including Nooristan and Urozgan) registered very low levels of coverage.

Other things equal, the odds of coverage were 2.7 times larger for children in the richest quintile than in the poorest quintile, and almost twice as large among mothers aged 35–49 years (compared to those aged 15–19 years) and among mothers with secondary school or more (compared to those with no education).

In Afghanistan in 2015, a child of a teenaged mother with no education had one third the chance of being vaccinated as a child of a mother 20–49 years of age with secondary education or higher; if the child of the uneducated, teenaged mother belonged to
the poorest 20%, this chance dropped to one ninth (compared to a child of a highly educated mother aged 20–49 years in the richest 20%).

Chad

Childhood immunization coverage in Chad was very low, with just one third of children reporting DTP3 immunization.

DTP3 coverage showed no difference between boys and girls, but there was some inequality by birth order, mother’s age at birth, sex of household head and place of
residence.

When adjusted for other characteristics, the odds of immunization were 2.5 times higher in the richest than the poorest quintile and twice as high in mothers with secondary
education or more as in mothers with no education.

The regions of Mandoul and Mayo Kebbi Ouest had 27 and 19 times higher odds of coverage than Chari Baguirmi, respectively.

In Chad in 2014–2015, a child of a mother aged 20–34 years with secondary education or higher and belonging to the richest 20% had up to 7.2 times higher chance of receiving DTP3 immunization compared with a child of a teenaged mother with no education, from the poorest 20% household.

Democratic Republic of the Congo

Overall, the Democratic Republic of the Congo had national DTP3 immunization covering three out of five one-year-olds.

Controlling for other factors, immunization coverage was associated with mother’s ethnicity, household economic status and subnational region. The odds of receiving the third dose of the DTP vaccine were 9 times higher for children in the Nord-Kivu province than children in the Katanga province, other things equal.

Ethiopia

About half of one-year-olds in Ethiopia were covered by DTP3 immunization.

Controlling for other factors, immunization coverage was associated with mother’s age at
birth, mother’s education, sex of household head, household economic status and subnational region.

In Ethiopia in 2016, the chance of receiving the third dose of DTP vaccine was 6.7 times higher among a child whose mother is 20–49 years of age and primary school educated, and who lived in a male-headed household, compared with a child of a teenaged mother with no education in a female headed household.

India

DTP3 immunization coverage in India reached nearly four out of five one-year-olds.
Coverage was equal in boys and girls and female and male-headed households, and there was little difference between coverage in urban and rural areas.

Adjusting for other factors, immunization coverage was associated with birth order, mother’s education and economic status, and there was large variation in the odds of coverage across regions. There was a weak, although significant, association
for mother’s age at birth and mother’s caste/tribe as well as for place of residence (demonstrating higher likelihood of coverage in rural areas).

In India in 2015–2016, children with highly educated mothers aged 20–49 years who belonged to the richest 20% of the population had a 5.3 times higher chance of being vaccinated, compared with children born to teenaged mothers with no education, in the poorest 20% of the population.

Indonesia

Indonesia reported 72% DTP3 immunization coverage among one-year-olds.

Controlling for other factors, immunization coverage was strongly associated with birth order, mother’s education, household economic status and subnational region. Across provinces, the odds of childhood immunization demonstrated large variation: children in DI Yogyakarta, Bali, East Nusa Tenggara and North Sulawesi were more than 8
times as likely to be covered as those in Banten.

In Indonesia in 2012, a child who was part of a household in the richest 20%, and whose mother was aged 35–49 years, had a 6.4 times greater chance of being vaccinated compared to a child living in a household of the poorest 20%, and whose mother was a teenager.

Kenya

Nine out of 10 one-year-olds in Kenya were covered by DTP3 immunization.

After controlling for background characteristics, DTP3 immunization coverage was positively associated with mother’s education and household economic status. The odds of reporting DTP3 coverage were over 2 times higher for 1st to 5th born children, compared to those 6th born or higher. Statistically significant associations with DTP3 immunization were also reported across subnational regions in Kenya.

In Kenya in 2014, children had a higher chance of being vaccinated if they belonged to the richest 40% of households and their mother had at least primary school education: compared to those who were part of the poorest 20% and whose mother had no education, their chances were 6.3 times higher.

Nigeria

In Nigeria, two in five one-year-olds received the third dose of DTP-containing vaccine.

After adjusting for other factors, immunization coverage was significantly associated with most background characteristics (birth order and place of residence were nearly significant and child’s sex was not significant). Strong associations were evident for
mother’s education, household economic status and subnational regions.

In Nigeria in 2013, children of mothers aged 20–34 years who were highly educated, living in a rich household in the South South region were among the most advantaged in terms of childhood immunization: their chance of being vaccinated was 300 times higher than children with teenaged mothers with no education, living in poor households in the North West region.

Pakistan

Among one-year-olds in Pakistan, national DTP3 immunization coverage was 65%.

After controlling for other characteristics, immunization coverage was strongly associated with mother’s education and especially household economic status, and
subnational region. The odds of coverage differed greatly across regions, with ICT Islamabad having 7.8 times higher odds of coverage than Sindh.

In Pakistan in 2012–2013, a child of a mother aged 20–34 years with higher than secondary education and from the richest 20% of the population had a 28 times higher chance of being vaccinated, compared with a child of a teenaged mother with
no education and from the poorest 20% of the population.

Uganda

Four out of five one-year-olds in Uganda were covered by DTP3 immunization.

After adjusting for other characteristics, childhood immunization was significantly associated with birth order, mother’s age at birth and subnational region. For instance,
children of mothers with more than secondary school education had twice as high odds of receiving the DTP3 vaccine than children whose mothers had no education.

Multiple Comparison

Mother’s education 

The above graphs show inequalities in DTP3 coverage at one year age by mother’s education. Generally, the higher the mother’s educational achievement, the better the immunization coverage.

The above graphs show inequalities in DTP3 coverage at one year age by household economic status. Generally, the higher the household economic status, the better the immunization coverage.

Useful Links:

Link to the WHO news release:

http://www.who.int/gho/health_equity/explorations-of-inequality-childhood-immunization

Link to the new Report (English) [PDF]: 

http://www.who.int/gho/health_equity/report_2018_immunization/en/