title: Public health workers and vaccination coverage in Eastern China: a health economic analysis.
abstract: BACKGROUND
  Vaccine-preventable diseases cause more than one million deaths among children under 5 years of age every year. Public Health Workers (PHWs) are needed to provide immunization services, but the role of human resources for public health as a determinant of vaccination coverage at the population level has not been assessed in China. The objective of this study was to test whether PHW density was positively associated with childhood vaccination coverage in Zhejiang Province, East China.
  
  
  METHODS
  The vaccination coverage rates of Measles Containing Vaccine (MCV), Diphtheria, Tetanus and Pertussis combined vaccine (DTP), and Poliomyelitis Vaccine (PV) were chosen as the dependent variables. Vaccination coverage data of children aged 13-24 months for each county in Zhejiang Province were taken from the Zhejiang Immunization Information System (ZJIIS). Aggregate PHW density was an independent variable in one set of regressions, and Vaccine Personnel (VP) and other PHW densities were used separately in another set. Data on densities of PHW and VP were taken from a national investigation on EPI launched by Ministry of Health of China in 2013. We controlled other determinants that may influence the vaccination coverage like Gross Domestic Product (GDP) per person, proportion of migrant children aged <7 years, and land area. These data were taken from Zhejiang Provincial Bureau of Statistics and ZJIIS.
  
  
  RESULTS
  PHW density was significantly influence the coverage rates of MCV [Adjusted Odds Ratio(AOR) = 4.29], DTP3(AOR = 2.16), and PV3 (AOR = 3.30). However, when the effects of VPs and other PHWs were assessed separately, we found that VP density was significantly associated with coverage of all three vaccinations (MCV AOR = 7.05; DTP3 AOR = 1.82; PV3 AOR = 4.83), while other PHW density was not. Proportion of migrant children < 7 years and Land area were found as negative and significant determinants for vaccination coverage, while GDP per person had no effect on vaccination coverage.
  
  
  CONCLUSIONS
  A higher density of PHWs (VP) would improve the availability of immunization services over time and space, which may increase the possibility of achieving a higher childhood vaccination coverage rate. It was indicated that the level of GDP per person had no association with the improved vaccination coverage after controlling for other potential factors. Our findings implicated that PHW density was a major constraint on immunization coverage in Zhejiang Province.
authors.affiliation: Institute of Immunization and Prevention, Zhejiang Center for Disease Control and Prevention, Hangzhou 310051, China. husix@163.com.
authors.forename: Yu
authors.initials: Y
authors.lastname: Hu
authors.affiliation: Institute of Immunization and Prevention, Zhejiang Center for Disease Control and Prevention, Hangzhou 310051, China. lzhshen@cdc.zj.cn.
authors.forename: Lingzhi
authors.initials: L
authors.lastname: Shen
authors.affiliation: Institute of Immunization and Prevention, Zhejiang Center for Disease Control and Prevention, Hangzhou 310051, China. jguo@cdc.zj.cn.
authors.forename: Jing
authors.initials: J
authors.lastname: Guo
authors.affiliation: Institute of Immunization and Prevention, Zhejiang Center for Disease Control and Prevention, Hangzhou 310051, China. shyxie@cdc.zj.cn.
authors.forename: Shuyun
authors.initials: S
authors.lastname: Xie
mesh_terms: D002648:Child; D002675:Child, Preschool; D002681:China; D005843:Geography; D006280:Health Workforce / Q000191:economics* / Q000458:organization & administration*; D006801:Humans; D017589:Immunization Programs / Q000191:economics* / Q000458:organization & administration; D007223:Infant; D007231:Infant, Newborn; D032541:Mass Vaccination / Q000191:economics* / Q000458:organization & administration; D015999:Multivariate Analysis; D011634:Public Health; D012044:Regression Analysis