Inequality in measles vaccination coverage in the "big six" countries of the WHO South-East Asia region

Abstract

The "big six" countries (Bangladesh, India, Indonesia, Myanmar, Nepal, and Thailand) in the World Health Organization South-East Asia Region (WHO SEAR) are currently facing severe challenges in measles elimination and consequent childhood mortality reduction, with inadequacies and inequalities in the coverage of the measles-containing-vaccine first-dose (MCV1) being major obstacles. However, these issues of inequality in MCV1 coverage have not yet been systematically examined. We used data from the latest Demographic and Health Surveys and Multiple Indicator Cluster Surveys. To provide a comprehensive picture of existing MCV1 coverage gaps, data were disaggregated by geographic location, as well as by socioeconomic and nutritional dimensions. National MCV1 coverage ranged from 77% in Myanmar to 92% in Thailand. Only nine of the 104 sub-national districts had achieved the 95% MCV1 coverage goal as set by the WHO. Geographic inequalities were more pronounced in countries with lower coverage levels. Areas in clusters with poor MCV1 coverage performances as well as disadvantaged socioeconomic profiles require increased attention. Inequalities were evident in all countries, except Thailand, and were more pronounced in the sectors of wealth, education, antenatal care (ANC) status, and vitamin A supplementation (VAS) when compared against the areas of gender and urban/rural residence. Wealth-related inequality in Bangladesh, education-related inequality in Indonesia, ANC-related inequalities in Myanmar and Nepal, and VAS-related inequalities in Indonesia and Myanmar were all noteworthy. Equity-oriented changes in policies focusing on health promotion and integrated interventions among disadvantaged populations need to be implemented in order to increase MCV1 coverage and reduce childhood mortality.

Keywords: Southeast Asia; child health; equity; measles; vaccines.

Figure 1.

Distribution of MCV1 coverage at the district level for the “big six” countries in the WHO SEAR. Each dot displays the MCV1 coverage in second administrative units for each country. The box portion of the plot is defined by the upper lines at the 25th percentile, the middle lines at the 50th percentile, and the lower lines at 75th percentile. WHO and UNICEF estimates of MCV1 coverage are shown as red triangles.

Figure 2.

MCV1 coverage at the district level, spatial clustering of low MCV1 coverage, and clusters based on both socioeconomic status (SES) and MCV1 coverage for in the “big six” countries in the WHO SEAR. (a) The district-level MCV1 coverage. (b) Using the Kulldorff’s statistic, we identified the low-coverage clusters and classified them by the relative risk, i.e., the ratio of the probability of receiving MCV1 inside the cluster to that outside the cluster. (c) Using the k-means analysis, we identified clusters with similar SES and MCV1 coverage.