Mira Johri , Sunil Rajpal , Rockli Kim , S.V. Subramanian
{"title":"印度儿童接种不足的小地区差异：对来自 36 个邦和中央直辖区、707 个县和 22,349 个小地区集群的横截面数据的多层次分析","authors":"Mira Johri , Sunil Rajpal , Rockli Kim , S.V. Subramanian","doi":"10.1016/j.lansea.2024.100504","DOIUrl":null,"url":null,"abstract":"<div><h3>Background</h3><div>India has made exceptional advances in child immunisation, but subnational inequities in vaccination coverage impede attainment of key programmatic goals. Our study provides an up-to-date national portrait of local variations in child vaccination using a comprehensive set of indicators relevant to routine immunisation.</div></div><div><h3>Methods</h3><div>Indicators representing unvaccinated (zero-dose) children, incomplete basic immunisation, and vulnerability to measles and polio, were constructed from India’s 2019–2021 National Family Health Survey. We used four-level random effects logistic regression models to partition the total outcome variation over state, district and cluster levels, and produce precision-weighted estimates of prevalence across clusters. District-level prevalence and within-district variation using standard deviation measures were derived for each outcome. Boxplots graphically summarised the distribution of precision-weighted mean cluster prevalence by state.</div></div><div><h3>Findings</h3><div>The analysis included 87,622 children aged 12–36 months. Clusters accounted for 67.6% (var: 1.36; SE: 0.127) of the variation among zero-dose children, and more than 50% for all indicators. Districts with a higher prevalence of under-vaccination tended to have higher within-district heterogeneity, interpretable as greater within-district child vaccination inequities. For vaccines administered in the first year of life, the northeastern states and Uttar Pradesh had the highest median under-vaccination. Despite India’s high aggregate vaccine coverage, the distribution of small-area (cluster) mean prevalence highlighted pockets of low coverage in most states, suggesting ongoing vulnerability to measles and polio.</div></div><div><h3>Interpretation</h3><div>Achieving India’s vaccination goals requires a strategic shift towards identification and targeting of low-immunity clusters at the sub-district level.</div></div><div><h3>Funding</h3><div><span>Canadian Institutes of Health Research</span>.</div></div>","PeriodicalId":75136,"journal":{"name":"The Lancet regional health. Southeast Asia","volume":"32 ","pages":"Article 100504"},"PeriodicalIF":5.0000,"publicationDate":"2024-11-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":"0","resultStr":"{\"title\":\"Small-area variation in child under-vaccination in India: a multilevel analysis of cross-sectional data from 36 states and Union Territories, 707 districts, and 22,349 small-area clusters\",\"authors\":\"Mira Johri , Sunil Rajpal , Rockli Kim , S.V. Subramanian\",\"doi\":\"10.1016/j.lansea.2024.100504\",\"DOIUrl\":null,\"url\":null,\"abstract\":\"<div><h3>Background</h3><div>India has made exceptional advances in child immunisation, but subnational inequities in vaccination coverage impede attainment of key programmatic goals. Our study provides an up-to-date national portrait of local variations in child vaccination using a comprehensive set of indicators relevant to routine immunisation.</div></div><div><h3>Methods</h3><div>Indicators representing unvaccinated (zero-dose) children, incomplete basic immunisation, and vulnerability to measles and polio, were constructed from India’s 2019–2021 National Family Health Survey. We used four-level random effects logistic regression models to partition the total outcome variation over state, district and cluster levels, and produce precision-weighted estimates of prevalence across clusters. District-level prevalence and within-district variation using standard deviation measures were derived for each outcome. Boxplots graphically summarised the distribution of precision-weighted mean cluster prevalence by state.</div></div><div><h3>Findings</h3><div>The analysis included 87,622 children aged 12–36 months. Clusters accounted for 67.6% (var: 1.36; SE: 0.127) of the variation among zero-dose children, and more than 50% for all indicators. Districts with a higher prevalence of under-vaccination tended to have higher within-district heterogeneity, interpretable as greater within-district child vaccination inequities. For vaccines administered in the first year of life, the northeastern states and Uttar Pradesh had the highest median under-vaccination. Despite India’s high aggregate vaccine coverage, the distribution of small-area (cluster) mean prevalence highlighted pockets of low coverage in most states, suggesting ongoing vulnerability to measles and polio.</div></div><div><h3>Interpretation</h3><div>Achieving India’s vaccination goals requires a strategic shift towards identification and targeting of low-immunity clusters at the sub-district level.</div></div><div><h3>Funding</h3><div><span>Canadian Institutes of Health Research</span>.</div></div>\",\"PeriodicalId\":75136,\"journal\":{\"name\":\"The Lancet regional health. Southeast Asia\",\"volume\":\"32 \",\"pages\":\"Article 100504\"},\"PeriodicalIF\":5.0000,\"publicationDate\":\"2024-11-08\",\"publicationTypes\":\"Journal Article\",\"fieldsOfStudy\":null,\"isOpenAccess\":false,\"openAccessPdf\":\"\",\"citationCount\":\"0\",\"resultStr\":null,\"platform\":\"Semanticscholar\",\"paperid\":null,\"PeriodicalName\":\"The Lancet regional health. 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Small-area variation in child under-vaccination in India: a multilevel analysis of cross-sectional data from 36 states and Union Territories, 707 districts, and 22,349 small-area clusters
Background
India has made exceptional advances in child immunisation, but subnational inequities in vaccination coverage impede attainment of key programmatic goals. Our study provides an up-to-date national portrait of local variations in child vaccination using a comprehensive set of indicators relevant to routine immunisation.
Methods
Indicators representing unvaccinated (zero-dose) children, incomplete basic immunisation, and vulnerability to measles and polio, were constructed from India’s 2019–2021 National Family Health Survey. We used four-level random effects logistic regression models to partition the total outcome variation over state, district and cluster levels, and produce precision-weighted estimates of prevalence across clusters. District-level prevalence and within-district variation using standard deviation measures were derived for each outcome. Boxplots graphically summarised the distribution of precision-weighted mean cluster prevalence by state.
Findings
The analysis included 87,622 children aged 12–36 months. Clusters accounted for 67.6% (var: 1.36; SE: 0.127) of the variation among zero-dose children, and more than 50% for all indicators. Districts with a higher prevalence of under-vaccination tended to have higher within-district heterogeneity, interpretable as greater within-district child vaccination inequities. For vaccines administered in the first year of life, the northeastern states and Uttar Pradesh had the highest median under-vaccination. Despite India’s high aggregate vaccine coverage, the distribution of small-area (cluster) mean prevalence highlighted pockets of low coverage in most states, suggesting ongoing vulnerability to measles and polio.
Interpretation
Achieving India’s vaccination goals requires a strategic shift towards identification and targeting of low-immunity clusters at the sub-district level.
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