State of inequality in diphtheria-tetanus-pertussis immunisation coverage in low-income and middle-income countries: a multicountry study of household health surveys

Abstract

Background: Immunisation programmes have made substantial contributions to lowering the burden of disease in children, but there is a growing need to ensure that programmes are equity-oriented. We aimed to provide a detailed update about the state of between-country inequality and within-country economic-related inequality in the delivery of three doses of the combined diphtheria, tetanus toxoid, and pertussis-containing vaccine (DTP3), with a special focus on inequalities in high-priority countries.

Methods: We used data from the latest available Demographic and Health Surveys and Multiple Indicator Cluster Surveys done in 51 low-income and middle-income countries. Data for DTP3 coverage were disaggregated by wealth quintile, and inequality was calculated as difference and ratio measures based on coverage in richest (quintile 5) and poorest (quintile 1) household wealth quintiles. Excess change was calculated for 21 countries with data available at two timepoints spanning a 10 year period. Further analyses were done for six high-priority countries-ie, those with low national immunisation coverage and/or high absolute numbers of unvaccinated children. Significance was determined using 95% CIs.

Findings: National DTP3 immunisation coverage across the 51 study countries ranged from 32% in Central African Republic to 98% in Jordan. Within countries, the gap in DTP3 immunisation coverage suggested pro-rich inequality, with a difference of 20 percentage points or more between quintiles 1 and 5 for 20 of 51 countries. In Nigeria, Pakistan, Laos, Cameroon, and Central African Republic, the difference between quintiles 1 and 5 exceeded 40 percentage points. In 15 of 21 study countries, an increase over time in national coverage of DTP3 immunisation was realised alongside faster improvements in the poorest quintile than the richest. For example, in Burkina Faso, Cambodia, Gabon, Mali, and Nepal, the absolute increase in coverage was at least 2·0 percentage points per year, with faster improvement in the poorest quintile. Substantial economic-related inequality in DTP3 immunisation coverage was reported in five high-priority study countries (DR Congo, Ethiopia, Indonesia, Nigeria, and Pakistan), but not Uganda.

Interpretation: Overall, within-country inequalities in DTP3 immunisation persist, but seem to have narrowed over the past 10 years. Monitoring economic-related inequalities in immunisation coverage is warranted to reveal where gaps exist and inform appropriate approaches to reach disadvantaged populations.

Funding: None.

Figure 1

Latest situation of DTP3 coverage among children aged 12–23 months in 51 low-income and middle-income countries, by economic status Data taken from DHS and MICS 2010–13. Box and whisker plots show the distribution of DTP3 coverage within wealth quintiles of 51 low-income and middle-income countries. Whiskers represent maximum and minimum values; the centre line denotes the median value; and the shaded box indicates the IQR (middle 50% of country estimates). DHS=Demographic and Health Survey. DTP3=three doses of the combined diphtheria, tetanus toxoid, and pertussis vaccine. MICS=Multiple Indicator Cluster Survey.

Figure 2

Change over time in national average of DTP3 coverage among children aged 12–23 months, and in quintile 1 compared with quintile 5, in 21 low-income and middle-income countries Data taken from DHS and MICS 2000–03 and 2010–13. Every country is represented by a shape, which corresponds to its WHO region. For every study country, the annual absolute change in national average was calculated by subtracting the national coverage in survey year 1 (2000–03) from coverage in survey year 2 (2010–13) and dividing by the number of intervening years. The annual absolute excess change was calculated by subtracting the annual absolute change in quintile 5 from the annual absolute change in quintile 1. Red and blue boxes portray undesirable and desirable scenarios, respectively. DHS=Demographic and Health Survey. DTP3=three doses of the combined diphtheria, tetanus toxoid, and pertussis vaccine. MICS=Multiple Indicator Cluster Survey.

Figure 3

Change over time in DTP3 coverage among children aged 12–23 months in six high-priority countries, by economic status Data taken from DHS 2000–13. For each country, disaggregated data are presented for wealth quintiles by coloured dots; the horizontal lines indicate the difference between the most extreme quintile values. DHS=Demographic and Health Survey. DTP3=three doses of the combined diphtheria, tetanus toxoid, and pertussis vaccine.

Figure 4

Latest situation of DTP3 coverage among children aged 12–23 months in three high-priority countries, by economic status Data taken from DHS 2011–13. DHS=Demographic and Health Survey. DTP3=three doses of the combined diphtheria, tetanus toxoid, and pertussis vaccine.