title: Social inequalities in vaccination uptake among children aged 0-59 months living in Madagascar: an analysis of Demographic and Health Survey data from 2008 to 2009.
abstract: BACKGROUND
  Socioeconomic inequalities in vaccination can reduce the ability and efficiency of global efforts to reduce the burden of disease. Vaccination is particularly critical because the poorest children are often at the greatest risk of contracting preventable infectious diseases, and unvaccinated children may be clustered geographically, jeopardizing herd immunity. Without herd immunity, these children are at even greater risk of contracting disease and social inequalities in associated morbidity and mortality are amplified.
  
  
  METHODS
  Data on vaccination for children under five came from the most recent Demographic and Health Survey in Madagascar (2008-2009). Vaccination status was available for diptheria, pertussis, tetanus, hepatitis B, measles, tuberculosis, poliomyelitis, and H. influenza type-B. Multilevel logistic regression was used to analyze childhood vaccination by parental socioeconomic status while accounting for shared district, cluster, and household variation. Maps were created to serve as a roadmap for efforts to increase vaccination.
  
  
  RESULTS
  Geographic variation in vaccination rates was substantial. Districts that were less covered were near other districts with limited coverage. Most districts lacked herd immunity for diphtheria, pertussis, poliomyelitis and measles. Full herd immunity was reached in a small number of districts clustered near the capital. While within-district variation in coverage was substantial; parental education and wealth were independently associated with vaccination.
  
  
  CONCLUSIONS
  Socioeconomic inequalities in vaccination reduce herd immunity and perpetuate inequalities by allowing infectious diseases to disproportionately affect the most vulnerable populations. Findings indicated that most districts had low immunization coverage rates and unvaccinated children were geographically clustered. The result was inequalities in vaccination and reduced herd immunity. To further improve coverage, interventions must take a multilevel approach that focuses on both supply- and demand-side barriers to delivering vaccination to underserved regions, and to the poorest children in those regions.
authors.affiliation: Department of Preventive Medicine & Program in Public Health, Stony Brook University, United States. Electronic address: sean.clouston@stonybrookmedicine.edu.
authors.forename: S
authors.initials: S
authors.lastname: Clouston
authors.affiliation: Department of Preventive Medicine & Program in Public Health, Stony Brook University, United States.
authors.forename: R
authors.initials: R
authors.lastname: Kidman
authors.affiliation: Department of Preventive Medicine & Program in Public Health, Stony Brook University, United States.
authors.forename: T
authors.initials: T
authors.lastname: Palermo
mesh_terms: D002675:Child, Preschool; D005260:Female; D005843:Geography; D019538:Health Care Surveys; D054625:Healthcare Disparities / Q000706:statistics & numerical data*; D006801:Humans; D032521:Immunity, Herd; D007223:Infant; D007231:Infant, Newborn; D016015:Logistic Models; D008270:Madagascar; D008297:Male; D015999:Multivariate Analysis; D012959:Socioeconomic Factors; D014611:Vaccination / Q000706:statistics & numerical data*
keywords: Geographic variation; Global health; Herd immunity; Madagascar; Multilevel analysis; Social inequalities and health; Vaccine coverage