Subnational inequalities in diphtheria–tetanus–pertussis immunization in 24 countries in the African Region

Abstract

Objective To analyse subnational inequality in diphtheria–tetanus–pertussis (DTP) immunization dropout in 24 African countries using administrative data on receipt of the first and third vaccine doses (DTP1 and DTP3, respectively) collected by the Joint Reporting Process of the World Health Organization and the United Nations Children’s Fund. Methods Districts in each country were grouped into quintiles according to the proportion of children who dropped out between DTP1 and DTP3 (i.e. the dropout rate). We used six summary measures to quantify inequalities in dropout rates between districts and compared rates with national dropout rates and DTP1 and DTP3 immunization coverage. Findings The median dropout rate across countries was 2.4% in quintiles with the lowest rate and 14.6% in quintiles with the highest rate. In eight countries, the difference between the highest and lowest quintiles was 14.9 percentage points or more. In most countries, underperforming districts in the quintile with the highest rate tended to lag disproportionately behind the others. This divergence was not evident from looking only at national dropout rates. Countries with the largest inequalities in absolute subnational dropout rate tended to have lower estimated national DTP1 and DTP3 immunization coverage. Conclusion There were marked inequalities in DTP immunization dropout rates between districts in most countries studied. Monitoring dropout at the subnational level could help guide immunization interventions that address inequalities in underserved areas, thereby improving overall DTP3 coverage. The quality of administrative data should be improved to ensure accurate and timely assessment of geographical inequalities in immunization.

Subnational Gender Inequality and Childhood Immunization: An Ecological Analysis of the Subnational Gender Development Index and DTP Coverage Outcomes across 57 Countries

“…These studies consistently find that gender equality, and the related construct of women's empowerment, are associated with improved immunization coverage, decreased child mortality, and other positive child health outcomes. Existing work has also demonstrated substantial subnational inequality in immunization, highlighting the relevance of subnational policies and outreach efforts, as well as intra-country variations in immunization access and resources [31,32]. Our study builds on this existing literature to demonstrate that within-country variation in gender inequality is associated with immunization coverage at the subnational level, and suggests that gender inequality may be one of many drivers of subnational inequalities in coverage.…”

Status of Routine Immunization Coverage in the World Health Organization African Region Three Years into the COVID-19 Pandemic

“…However, reaching zero-dose children requires context-specific interventions to overcome barriers to vaccination that are multifaceted and nuanced to each setting [ 30 ]. In addition, mechanisms need to be in place to reduce drop-out in an equitable manner so that children are not only reached once but receive all the vaccines they need [ 31 ]. The quest to ensure that no child is left behind requires a tailored approach that addresses multiple and intersecting economic vulnerabilities, sociocultural barrier, and health system challenges to deliver immunization services through the primary healthcare system [ 32 ].…”

Assessing Potential Exemplars in Reducing Zero-Dose Children: A Novel Approach for Identifying Positive Outliers in Decreasing National Levels and Geographic Inequalities in Unvaccinated Children

“…It is worth noting that declines in no-DTP prevalence—and thus increased coverage of DTP1, a marker of program reach—do not inherently equate to gains in broader program retention or complete immunization. For instance, in much of Ethiopia, DTP3 coverage has not improved in parallel amid sizeable increases in DTP1 [ 7 , 54 , 55 ]. This means that while more children are being reached by vaccination services—an unequivocally crucial milestone—an increasing percentage of them remain under-vaccinated and thus may still be vulnerable to preventable disease.…”