Inequalities in full immunization coverage: trends in low- and middle-income countries

ObjectiveTo investigate disparities in full immunization coverage across and within 86 low- and middle-income countries.MethodsIn May 2015, using data from the most recent Demographic and Health Surveys and Multiple Indicator Cluster Surveys, we investigated inequalities in full immunization coverage – i.e. one dose of bacille Calmette-Guérin vaccine, one dose of measles vaccine, three doses of vaccine against diphtheria, pertussis and tetanus and three doses of polio vaccine – in 86 low- or middle-income countries. We then investigated temporal trends in the level and inequality of such coverage in eight of the countries.FindingsIn each of the World Health Organization’s regions, it appeared that about 56–69% of eligible children in the low- and middle-income countries had received full immunization. However, within each region, the mean recorded level of such coverage varied greatly. In the African Region, for example, it varied from 11.4% in Chad to 90.3% in Rwanda. We detected pro-rich inequality in such coverage in 45 of the 83 countries for which the relevant data were available and pro-urban inequality in 35 of the 86 study countries. Among the countries in which we investigated coverage trends, Madagascar and Mozambique appeared to have made the greatest progress in improving levels of full immunization coverage over the last two decades, particularly among the poorest quintiles of their populations.ConclusionMost low- and middle-income countries are affected by pro-rich and pro-urban inequalities in full immunization coverage that are not apparent when only national mean values of such coverage are reported.     

Country-level predictors of vaccination coverage and inequalities in Gavi-supported countries

BackgroundImportant inequalities in childhood vaccination coverage persist between countries and population groups. Understanding why some countries achieve higher and more equitable levels of coverage is crucial to redress these inequalities. In this study, we explored the country-level determinants of (1) coverage of the third dose of diphtheria-tetanus-pertussis- (DTP3) containing vaccine and (2) within-country inequalities in DTP3 coverage in 45 countries supported by Gavi, the Vaccine Alliance.MethodsWe used data from the most recent Demographic and Health Surveys (DHS) conducted between 2005 and 2014. We measured national DTP3 coverage and the slope index of inequality in DTP3 coverage with respect to household wealth, maternal education, and multidimensional poverty. We collated data on country health systems, health financing, governance and geographic and sociocultural contexts from published sources. We used meta-regressions to assess the relationship between these country-level factors and variations in DTP3 coverage and inequalities. To validate our findings, we repeated these analyses for coverage with measles-containing vaccine (MCV).ResultsWe found considerable heterogeneity in DTP3 coverage and in the magnitude of inequalities across countries. Results for MCV were consistent with those from DTP3. Political stability, gender equality and smaller land surface were important predictors of higher and more equitable levels of DTP3 coverage. Inequalities in DTP3 coverage were also lower in countries receiving more external resources for health, with lower rates of out-of-pocket spending and with higher national coverage. Greater government spending on heath and lower linguistic fractionalization were also consistent with better vaccination outcomes.ConclusionImproving vaccination coverage and reducing inequalities requires that policies and programs address critical social determinants of health including geographic and social exclusion, gender inequality and the availability of financial protection for health. Further research should investigate the mechanisms contributing to these associations.     

Determinants of geographical inequalities for DTP3 vaccine coverage in sub-Saharan Africa

Childhood immunization is one of the most effective health interventions, making it a key indicator of progress towards universal health coverage. In the last decade, improvements in coverage have been made globally, however, slow progress has been documented in sub-Saharan Africa with considerable subnational variations. We explore potential drivers of equitable immunization services based on subnational DTP3 coverage estimates.Using vaccine coverage at the 5 by 5 km area from 2000 to 2016, we quantify inequality using three measures. We assess the shortfall inequality which is the average deviation across subnational units from that with the highest coverage for each country. Secondly we estimate the threshold index, the proportion of children below a globally set subnational coverage target, and lastly, a Gini coefficient representing the within-country distribution of coverage. We use time series analyses to quantify associations with immunization expenditures controlling for country socio-economic and population characteristics.Development assistance, maternal education and governance were associated with reductions in inequality. Furthermore, high quality governance was associated with a stronger relationship between development assistance and reductions in inequality. Results from this analysis also indicate that countries with the lowest coverage suffer the highest inequalities. We highlight growing inequalities among countries which have met national coverage targets such as South Africa and Kenya. In 2016, values for the shortfall inequality ranged from 1% to 43%, the threshold index from 0% to 100% and Gini coefficient from 0.01 to 0.37. Burundi, Comoros, Eswatini, Lesotho, Namibia, Rwanda, and Sao Tome and Principe had the least shortfall inequality (<5%) while Angola, Ethiopia and Nigeria had values greater than 40%. A similar picture was noted for the other dimensions of inequality among these particular countries.Immunization program investments offer promise in addressing inequality, however, domestic mechanisms for resource implementation and accountability should be strengthened to maximize gains in coverage.     

Factors associated with routine immunization coverage of children under one year old in Lao People’s Democratic Republic

BackgroundRoutine vaccination is administered free of charge to all children under one year old in Lao People’s Democratic Republic (Lao PDR) and the national goal is to achieve at least 95% coverage with all vaccines included in the national immunization program by 2025. In this study, factors related to the immunization system and characteristics of provinces and districts in Lao PDR were examined to evaluate the association with routine immunization coverage.MethodsCoverage rates for Bacillus Calmette-Guerin (BCG), Diphtheria-Tetanus-Pertussis-Hepatitis B (DTP-HepB), DTP-HepB-Hib (Haemophilus influenzae type B), polio (OPV), and measles (MCV1) vaccines from 2002 to 2014 collected through regular reporting system, were used to identify the immunization coverage trends in Lao PDR. Correlation analysis was performed using immunization coverage, characteristics of provinces or districts (population, population density, and proportion of poor villages and high-risk villages), and factors related to immunization service (including the proportions of the following: villages served by health facility levels, vaccine session types, and presence of well-functioning cold chain equipment). To determine factors associated with low coverage, provinces were categorized based on 80% of DTP-HepB-Hib3 coverage (<80% = low group; ≥80% = high group).ResultsCoverages of BCG, DTP-HepB3, OPV3 and MCV1 increased gradually from 2007 to 2014 (82.2–88.3% in 2014). However, BCG coverage showed the least improvement from 2002 to 2014. The coverage of each vaccine correlated with the coverage of the other vaccines and DTP-HepB-Hib dropout rate in provinces as well as districts. The provinces with low immunization coverage were correlated with higher proportions of poor villages.ConclusionsRoutine immunization coverage has been improving in the last 13 years, but the national goal is not yet reached in Lao PDR. The results of this study suggest that BCG coverage and poor villages should be targeted to improve nationwide coverage.     

National vaccine coverage trends and funding in Latin America and the Caribbean

BackgroundFrom 2006 to 2011 nearly 174,000 deaths were prevented in Latin America and the Caribbean through vaccination of children under five, which is widely attributed to the Expanded Program on Immunization (EPI). Despite near global adoption of EPI recommendations, vaccination coverage shows substantial variation across world regions. Causes for low immunizations within regions are multifaceted and include vaccination program costs. To date, publications regarding vaccine coverage across Latin America and the Caribbean are not readily available. This study aimed to: (1) compare vaccine coverage trends across nations within the region; and (2) assess whether national immunization program expenditures are correlated with vaccine coverage.MethodsCoverage for nine vaccines were collected by nation using publicly available data from WHO. National immunization program expenditures for each country were collected from the World Bank Index. The proportion of countries achieving 90% coverage in the years 2013 and 2017 for each vaccine were compared. Pearson correlation coefficients were calculated to measure the relationship between financing variables and DTP3 coverage for 2017.ResultsIn 2017, fewer Latin American and Caribbean nations were able to achieve 90% vaccine coverage for five vaccines compared to 2013. Mostly weak to moderate positive relationships were found between national immunization program expenditures and DTP3 coverage for 2017. Excluding Haiti, a weak negative relationship was found between total government expenditure on vaccines per infant and DTP3 coverage for 2017. Countries across Latin America and the Caribbean were largely self-reliant in funding vaccine expenditures.ConclusionsFewer countries across Latin America and the Caribbean are currently achieving optimum national vaccine coverage and weak to moderate relationships between routine immunization and vaccine expenditures and coverage were observed. Additional factors contributing to national vaccine coverage should be concomitantly examined to implement strategies which optimize delivery of childhood immunizations.     

Comparison of inflation of third dose diphtheria tetanus pertussis (DTP3) administrative coverage to other vaccine antigens

Third dose diphtheria tetanus pertussis (DTP3) administrative coverage is a commonly used indicator for immunization program performance, although studies have demonstrated data quality issues with administrative DTP3 coverage. It is possible that administrative coverage for DTP3 may be inflated more than for other antigens. To examine this, theory, we compiled immunization coverage estimates from recent country surveys (n = 71) and paired these with corresponding administrative coverage estimates, by country and cohort year, for DTP3 and 4 other antigens. Median administrative coverage was higher than survey estimates of coverage for all antigens (median differences from 26 to 30%), however this difference was similar for DTP3 as for all other antigens. These findings were consistent when countries were stratified by income level and eligibility for Gavi funding. Our findings demonstrate that while country administrative coverage estimates tend to be higher than survey estimates, DTP3 administrative coverage is not inflated more than other antigens.     

The impact of new vaccine introduction on the coverage of existing vaccines: A cross-national,multivariable analysis

Background

A surge of new and underutilized vaccine introductions into national immunization programmes has called into question the effect of new vaccine introduction on immunization and health systems. In particular, countries deciding whether to introduce a new or underutilized vaccine into their routine immunization programme may query possible effects on the delivery and coverage of existing vaccines. Using coverage of diphtheria–tetanus–pertussis (DTP) vaccine as a proxy for immunization system performance, this study aims to test whether new vaccine introduction into national immunization programs was associated with changes in coverage of three doses of DTP vaccine among infants.

Methods and findings

DTP3 vaccine coverage was analyzed in 187 countries during 1999–2009 using multivariable cross-national mixed-effect longitudinal models. Controlling for other possible determinants of DTP3 coverage at the national level these models found minimal association between the introduction of Hepatitis-, Haemophilus influenzae type b-, and rotavirus-containing vaccines and DTP3 coverage. Instead, frequent and sometimes large fluctuations in coverage are associated with other development and health systems variables, including the presence of armed conflict, coverage of antenatal care services, infant mortality, the percent of health expenditures that are private and total health expenditures per capita.

Conclusions

Introductions of new vaccines did not affect national coverage of DTP3 vaccine in the countries studied. Introductions of other new vaccines and multiple vaccine introductions should be monitored for immunization and health systems impacts.     

Socioeconomic inequalities and mortality trends in BRICS, 1990–2010

Objective

To explore the presence and magnitude of – and change in – socioeconomic and health inequalities between and within Brazil, the Russian Federation, India, China and South Africa – the countries known as BRICS – between 1990 and 2010.

Methods

Comparable data on socioeconomic and health indicators, at both country and primary subnational levels, were obtained from publicly available sources. Health inequalities between and within countries were identified and summarized by using standard gap and gradient metrics.

Findings

Four of the BRICS countries showed increases in both income level and income inequality between 1990 and 2010. The exception was Brazil, where income inequality decreased over the same period. Between-country inequalities in level of education and access to sanitation remained mostly unchanged but the largest between-country difference in mean life expectancy increased, from 9 years in 1990 to 20 years in 2010. Throughout the study period, there was disproportionality in the burden of disease between BRICS. However, the national infant mortality rate fell substantially over the study period in all five countries. In Brazil and China, the magnitude of subnational income-related inequalities in infant mortality, both absolute and relative, also decreased substantially.

Conclusion

Despite the economic prosperity and general improvements in health seen since 1990, profound inequalities in health persist both within and between BRICS. However, the substantial reductions observed – within Brazil and China – in the inequalities in income-related levels of infant mortality are encouraging.     

Association of vaccine hesitancy and immunization coverage rates in the European Union

While previous studies have validated vaccine hesitancy scales with uptake behavior at the individual level, the conditions under which aggregated survey data are useful are less clear. We show that vaccine public opinion data aggregated at the subnational level can serve as a valid indicator of aggregate vaccine behaviour. We use a public opinion survey (Eurobarometer EB 91.2) with data on vaccine hesitancy for the EU in 2019. We link this information to (subnational) regional immunization coverage rates for childhood vaccines – DTP3, MCV1, and MCV2 -- obtained from the WHO for 2019. We conduct multilevel regression analyses with data for 177 regions in 20 countries. Given the variation in vaccine hesitancy and immunization rates between countries and within countries, we affirm the valuable role that surveys can play as a public health surveillance tool when it comes to vaccine behavior. We find statistically significantly lower regional vaccine immunization rates in regions where vaccine hesitancy is more pronounced. Our results suggest that different uptake rates across subnational regions are due, at least in part, to differences in attitudes towards vaccines and vaccination. The results are robust to several alternative specifications.     

Comparative Distributional Impact of Routine Immunization and Supplementary Immunization Activities in Delivery of Measles Vaccine in Low- and Middle-Income Countries

ObjectivesIn many countries, measles disproportionately affects poorer households. To achieve equitable delivery, national immunization programs can use 2 main delivery platforms: routine immunization and supplementary immunization activities (SIAs). The objective of this article is to use data concerning measles vaccination coverage delivered via routine and SIA strategies to make inferences about the associated equity impact.MethodsWe relied on Demographic and Health Survey and Multiple Indicator Cluster Surveys multi-country survey data to conduct a comparative analysis of routine and SIA measles vaccination status of children by wealth quintile. We estimated the value of the angle, θ, for the ratio of the difference between coverage levels of adjacent wealth quintiles by using the arc-tangent formula. For each country/year observation, we averaged the θ estimates into one summary measurement, defined as the “equity impact number.”ResultsAcross 20 countries, the equity impact number summarized across wealth quintiles was greater (and hence less equitable) for routine delivery than for SIAs in the survey rounds (years) during, before, and after an SIA about 65% of the time. The equity impact numbers for routine measles vaccination averaged across wealth quintiles were usually greater than for SIA measles vaccination across country-year observations.ConclusionsThis analysis examined how different measles vaccine delivery platforms can affect equity. It can serve to elucidate the impact of immunization and public health programs in terms of comparing horizontal to vertical delivery efforts and in reducing health inequalities in global and country-level decision-making.     

Contribution of polio eradication initiative to strengthening routine immunization: Lessons learnt in the WHO African region

BackgroundImportant investments were made in countries for the polio eradication initiative. On 25 September 2015, a major milestone was achieved when Nigeria was removed from the list of polio-endemic countries. Routine Immunization, being a key pillar of polio eradication initiative needs to be strengthened to sustain the gains made in countries. For this, there is a huge potential on building on the use of polio infrastructure to contribute to RI strengthening.MethodsWe reviewed estimates of immunization coverage as reported by the countries to WHO and UNICEF for three vaccines: BCG, DTP3 (third dose of diphtheria-tetanus toxoid- pertussis), and the first dose of measles-containing vaccine (MCV1).We conducted a systematic review of best practices documents from eight countries which had significant polio eradication activities.ResultsImmunization programmes have improved significantly in the African Region. Regional coverage for DTP3 vaccine increased from 51% in 1996 to 77% in 2014. DTP3 coverage increased >3 folds in DRC (18–80%) and Nigeria from 21% to 66%; and >2 folds in Angola (41–87%), Chad (24–46%), and Togo (42–87%). Coverage for BCG and MCV1 increased in all countries. Of the 47 countries in the region, 18 (38%) achieved a national coverage for DTP3 ⩾90% for 2 years meeting the Global Vaccine Action (GVAP) target. A decrease was noted in the Ebola-affected countries i.e., Guinea, Liberia and Sierra Leone.ConclusionsPEI has been associated with increased spending on immunization and the related improvements, especially in the areas of micro planning, service delivery, program management and capacity building. Continued efforts are needed to mobilize international and domestic support to strengthen and sustain high-quality immunization services in African countries. Strengthening RI will in turn sustain the gains made to eradicate poliovirus in the region.     

Cost-effectiveness of maternal pertussis immunization: Implications of a dynamic transmission model for low- and middle-income countries

ObjectiveThis study evaluates the cost-effectiveness of maternal acellular pertussis (aP) immunization in low- and middle-income countries using a dynamic transmission model.MethodsWe developed a dynamic transmission model to simulate the impact of infant vaccination with whole-cell pertussis (wP) vaccine with and without maternal aP immunization. The model was calibrated to Brazilian surveillance data and then used to project health outcomes and costs under alternative strategies in Brazil, and, after adjusting model parameter values to reflect their conditions, in Nigeria and Bangladesh. The primary measure of cost-effectiveness is incremental cost (2014 USD) per disability-adjusted life-year (DALY).ResultsThe dynamic model shows that maternal aP immunization would be cost-effective in Brazil, a middle-income country, under the base-case assumptions, but would be very expensive at infant vaccination coverage in and above the threshold range necessary to eliminate the disease (90–95%). At 2007 infant coverage (DTP1 90%, DTP3 61% at 1 year of age), maternal immunization would cost < $4,000 per DALY averted. At high infant coverage, such as Brazil in 1996 (DTP1 94%, DTP3 74% at 1 year), cost/DALY increases to $1.27 million. When the model’s time horizon was extended from 2030 to 2100, cost/DALY increased under both infant coverage levels, but more steeply with high coverage. The results were moderately sensitive to discount rate, maternal vaccine price, and maternal aP coverage and were robust using the 100 best-fitting parameter sets. Scenarios representing low-income countries showed that maternal aP immunization could be cost-saving in countries with low infant coverage, such as Nigeria, but very expensive in countries, such as Bangladesh, with high infant coverage.ConclusionA dynamic model, which captures the herd immunity benefits of pertussis vaccination, shows that, in low- and middle-income countries, maternal aP immunization is cost-effective when infant vaccination coverage is moderate, even cost-saving when it is low, but not cost-effective when coverage levels pass 90–95%.     

Widening Socioeconomic Inequalities in Smoking in Japan, 2001–2016

BackgroundJapan is one of the world’s largest tobacco epidemic countries but few studies have focused on socioeconomic inequalities. We aimed to examine whether socioeconomic inequalities in smoking have reduced in Japan in recent times.MethodsWe analyzed data from the Comprehensive Survey of Living Conditions, a large nationally representative survey conducted every 3 years (n ≈ 700,000 per year) in Japan, during 2001–2016. Age-standardized smoking prevalence was computed based on occupational class and educational level. We calculated smoking prevalence difference (PD) and ratio (PR) of (a) manual workers versus upper non-manual workers and (b) low versus high educational level. The slope index of inequality (SII) and relative index inequality (RII) by educational level were used as inequality measures.ResultsOverall smoking prevalence (25–64 years) decreased from 56.0% to 38.4% among men and from 17.0% to 13.0% among women during 2001–2016. The PD between manual and upper non-manual workers (25–64 years) increased from 11.9% (95% confidence interval [CI], 11.0–12.9%) to 14.6% (95% CI, 13.5–15.6%) during 2001–2016. In 2016, smoking prevalence (25–64 years) for low, middle, and highly educated individuals were 57.8%, 43.9%, and 27.8% for men, and 34.7%, 15.9%, and 5.6% for women, respectively. SII and RII by educational level increased among both sexes. Larger socioeconomic differences in smoking prevalence were observed in younger generations, which suggests that socioeconomic inequalities in smoking evolve in a cohort pattern.ConclusionsSocioeconomic inequalities in smoking widened between 2001 and 2016 in Japan, which indicates that health inequalities will continue to exist in near future.Key words: epidemiology, smoking, socioeconomic factors, Japan, trends     

Exploring the subnational inequality and heterogeneity of the impact of routine measles immunisation in Africa

Despite vaccination being one of the most effective public health interventions, there are persisting inequalities and inequities in immunisation. Understanding the differences in subnational vaccine impact can help improve delivery mechanisms and policy. We analyse subnational vaccination coverage of measles first-dose (MCV1) and estimate patterns of inequalities in impact, represented as deaths averted, across 45 countries in Africa. We also evaluate how much this impact would improve under more equitable vaccination coverage scenarios. Using coverage data for MCV1 from 2000–2019, we estimate the number of deaths averted at the first administrative level. We use the ratio of deaths averted per vaccination from two mathematical models to extrapolate the impact at a subnational level. Next, we calculate inequality for each country, measuring the spread of deaths averted across its regions, accounting for differences in population. Finally, using three more equitable vaccination coverage scenarios, we evaluate how much impact of MCV1 immunisation could improve by (1) assuming all regions in a country have at least national coverage, (2) assuming all regions have the observed maximum coverage; and (3) assuming all regions have at least 80% coverage. Our results show that progress in coverage and reducing inequality has slowed in the last decade in many African countries. Under the three scenarios, a significant number of additional deaths in children could be prevented each year; for example, under the observed maximum coverage scenario, global MCV1 coverage would improve from 76% to 90%, resulting in a further 363(95%CrI:299–482) deaths averted per 100,000 live births. This paper illustrates that estimates of the impact of MCV1 immunisation at a national level can mask subnational heterogeneity. We further show that a considerable number of deaths could be prevented by maximising equitable access in countries with high inequality when increasing the global coverage of MCV1 vaccination.     

中国2012年国家免疫规划疫苗常规免疫报告接种率分析

目的分析2012年中国（未包括香港、澳门特别行政区和台湾地区,下同）国家免疫规划（NationalImmunizationProgram,NIP）疫苗常规免疫接种率监测报告,提出改进建议。方法通过描述性分析结合比值（Ratio,R值）评价,对2012年全国省（自治区、直辖市,下同）、县（区、市、旗、兵团师,下同）、乡（镇、街道、社区、兵团团场,下同）NIP疫苗常规免疫接种率监测报告接种率、报告数据质量进行分析评价。结果2012年全国常规免疫接种率监测报告县、乡报告率分别为97．87％和97．57％。2012年全国报告接种NIP疫苗共计387683777剂,全国22剂NIP疫苗报告接种率均≥99％,乙型肝炎疫苗首剂（TheFirstDoseofHepatitisBVaccine,HepB．）及时报告接种率95．74％。全国90．4％的县、79-3％的乡所有剂次NIP疫苗报告接种率〉90％,HepB．及时接种率≥90％的县、乡分别占87．0％、73．2％。报告接种率〈90％的县、乡主要分布于西藏、青海、内蒙古、新疆等西部地区。全国NIP疫苗以县为单位各剂平均报告接种率,除HepB．及时接种率、A＋C群脑膜炎球菌多糖疫苗第2剂、白喉．破伤风联合疫苗外,其余均≥98％。全国NIP疫苗22剂报告接种率以乡为单位总和平均为96．59％。中部地区最高（98．40％）,西部地区最低（94．26％）。全国33．8％的县白喉．破伤风一百日咳联合疫苗（Diphtheria．TetanusandPertussisCombinedVaccine;DTP）的脱漏率〉5％,8．99％的县DTP脱漏率≥10％,主要分布在中、西部地区。尺值评价结果显示,对应儿童不同年龄段疫苗剂次,可信度有所变化,其中36-48月龄段数据似可信度最高,其次为12月龄和18～24月龄段,儿童6岁段报告数据似可信度最低。结论全国NIP疫苗常规免疫接种率监测报告完整性和报告接种率均处于较高水平。全国省、县、乡报告接种率水平总体趋于一致,且处于较高水平,但地域差异依然存在,报告接种率较低的县、乡主要分布在西部地区。当前监测数据报告质量有待改善,直接识别低接种率地区能力较弱,需结合各地疾病监测、疫苗使用情况和接种率调查结果,综合评价各地接种率水平。     

Trends in mental health inequalities in urban Canada

ObjectivesCanadians do not all enjoy equal levels of health. The presence of income-related health inequalities has been well established in Canada, but there is a lack of consistent reporting of mental health inequalities in Canada’s largest cities. This study reports the prevalence and inequalities in mental health outcomes at the city, provincial, and national levels over time.MethodsSelf-reported poor mental health, life stress, and physician-diagnosed self-reported mood and anxiety disorder from the Canadian Community Health Survey were pooled over five-year intervals and combined with neighbourhood income information from the Canadian Census. First, prevalence rates were calculated for each interval at the neighbourhood level for urban communities. Second, the distributions of these neighbourhood rates were summarized at the city level and for Canada as a whole using overall prevalence rates and concentration indices of inequality. Finally, trends in these city- and country-level outcomes were also explored.ResultsAt the national level, starting from 2001 to 2005, the prevalence of poor mental health (27.9%), mood disorder (7.3%), and anxiety disorder (6.8%) had significantly increased by 2011–2015. Inequalities were present in 2001–2005 and worsened over time. The prevalence rate at the national level of life stress was 66.6% in 2001–2005 and decreased over time.ConclusionThe large and increasing values of inequalities and the difference in prevalence rates and inequalities in cities highlight the necessity for mental disorder-specific data and for city-level analysis of inequalities. The next steps in reducing inequalities involve deconstructing the health inequalities, and continued monitoring.     

Assessing the continuum of care for maternal health in Mexico, 1994–2018

ObjectiveTo describe the temporal and geographical patterns of the continuum of maternal health care in Mexico, as well as the sociodemographic characteristics that affect the likelihood of receiving this care.MethodsWe conducted a pooled cross-sectional analysis using the 1997, 2009, 2014 and 2018 waves of the National Survey of Demographic Dynamics, collating sociodemographic and obstetric characteristics of 93 745 women aged 12–54 years at last delivery. We defined eight variables along the antenatal–postnatal continuum, both independently and conditionally. We used a pooled fixed-effects multivariable logistic model to determine the likelihood of receiving the continuum of care for various properties. We also mapped the quintiles of adjusted state-level absolute change in continuum of care coverage during 1994–2018.FindingsWe observed large absolute increases in the proportion of women receiving timely antenatal and postnatal care (from 48.9% to 88.2% and from 39.1% to 68.7%, respectively). In our conditional analysis, we found that the proportion of women receiving adequate antenatal care doubled over this period. We showed that having social security and a higher level of education is positively associated with receiving the continuum of care. We observed the largest relative increases in continuum of care coverage in Chiapas (181.5%) and Durango (160.6%), assigned human development index categories of low and medium, respectively.ConclusionDespite significant progress in coverage of the continuum of maternal health care, disparities remain. While ensuring progress towards achievement of the health-related sustainable development goal, government intervention must also target underserved populations.     

Higher mortality rates associated with rheumatoid arthritis in Saskatchewan,Canada, 2001–2019

ObjectivesTo estimate provincial all-cause mortality rates of Saskatchewan people with rheumatoid arthritis (RA) for comparison with the general population over time and between different geographic regions.MethodsSaskatchewan provincial administrative health databases (2001–2019) were utilized as data sources. Two RA case definitions were employed: (1) ≥ 3 physician billing diagnoses, at least 1 from a specialist (rheumatologist, general internist or orthopaedic surgeon) within 2 years; (2) ≥ 1 hospitalization diagnosis (ICD-9 code 714, and ICD-10-CA codes M05, M06). Data from these definitions were combined to create an administrative data RA cohort. All-cause mortality rates across geographic regions, between rural/urban residences and between sexes were examined.ResultsOver an 18-year span, between fiscal-year 2001–2002 and fiscal-year 2018–2019, age- and sex-adjusted mortality rates ranged from 17.10 to 21.04 (95% CI 14.77, 19.44; 18.03, 24.05)/1000 RA person-years, compared with mortality rates for the general Saskatchewan population without RA, which ranged from 9.37 to 10.88 (95% CI 9.23, 9.51; 10.72, 11.05)/1000 person-years. Fiscal-year mortality rate ratios ranged from 1.82 to 2.13 (95% CI 1.56, 2.13; 1.83, 2.46). Provincial mortality rates were higher in men than in women for both general and RA populations. Northern Saskatchewan mortality rates were significantly higher in the general population but did not achieve significance compared with other provincial regions for the RA population. Regression analysis identified age, male sex, RA and geographic region as factors contributing to increased mortality. A trend towards lower mortality rates over time was observed.ConclusionHigher mortality rates were observed in the RA population overall. Men had higher mortality rates, as did residents of Northern Saskatchewan compared with residents of other regions for the general population.     

Evaluation of the Universal Immunization Program and Challenges in Coverage of Migrant Children in Haridwar,Uttarakhand, India

Background:

Studies show that immunization among migrant children is poor. India has a dropout rate of 17.7% between Bacillus Calmette-Guιrin (BCG) and measles (District Level Household Survey (DLHS)-3). Haridwar district had the highest dropout rate of 27.4% from BCG to diphtheria, pertussis, and tetanus (DPT) 3 (DLHS-3) in Uttarakhand. We evaluated the Universal Immunization Programme (UIP) among migrants in Haridwar in two blocks.

Materials and Methods:

We developed input, process, and output indicators on infrastructure, human resources, and service delivery. A facility, session site and cross-sectional survey of 180 children were done and proportions for various indicators were estimated. We determined factors associated with not taking vaccination using multivariate analysis.

Results:

We surveyed 11 cold chain centers, 25 subcenters, 14 sessions, and interviewed 180 mothers. Dropouts were supposed to be tracked using vaccination card counterfoils and tracking registers. The dropout rate from BCG to DPT3 was 30%. Lack of knowledge (adjusted odds ratio (AOR) 6.6,95% confidence interval (CI) 2.6–16.7), mother not being decision maker (AOR 4.0,95%CI 1.7–9.2), lack of contact by Accredited Social Health Activist (ASHA; AOR 3.0,95%CI 1.1–7.7), not being given four post-vaccination messages (AOR 7.7, 95% CI 2.9–20.2), and longer duration of stay in Haridwar (AOR 3.0 95% 1.9–7.6) were risk factors for nonimmunization. The reasons stated by mothers included lack of awareness of session site location (67%) and belief that child should only be vaccinated in their resident district (43%).

Conclusions:

There was low immunization coverage among migrants within adequate supervision, poor cold chain maintenance, and improper tracking of dropouts. Mobile immunization teams, prelisting of migrant children, and change in incentives of ASHAs for child tracking were needed. A monitoring plan for sessions and cold chain needed enforcement.