title: State of inequality in diphtheria-tetanus-pertussis immunisation coverage in low-income and middle-income countries: a multicountry study of household health surveys.
abstract: 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.
  
  
  
  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.
  
  
  
  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.
  
  
  
  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.
  
  
  
  None.
authors: Department of Information, Evidence and Research, World Health Organization, Geneva, Switzerland. Electronic address: hosseinpoora@who.int.
authors: Ahmad Reza
authors: AR
authors: Hosseinpoor
authors: Department of Information, Evidence and Research, World Health Organization, Geneva, Switzerland; Faculty of Health Sciences, University of Ottawa, Ottawa, ON, Canada.
authors: Nicole
authors: N
authors: Bergen
authors: Department of Information, Evidence and Research, World Health Organization, Geneva, Switzerland.
authors: Anne
authors: A
authors: Schlotheuber
authors: Department of Immunization, Vaccines and Biologicals, World Health Organization, Geneva, Switzerland.
authors: Marta
authors: M
authors: Gacic-Dobo
authors: Gavi, the Vaccine Alliance, Geneva, Switzerland.
authors: Peter M
authors: PM
authors: Hansen
authors: Department of Immunization, Vaccines and Biologicals, World Health Organization, Geneva, Switzerland.
authors: Kamel
authors: K
authors: Senouci
authors: Department of Information, Evidence and Research, World Health Organization, Geneva, Switzerland.
authors: Ties
authors: T
authors: Boerma
authors: International Center for Equity in Health, Federal University of Pelotas, Pelotas, Brazil.
authors: Aluisio J D
authors: AJ
authors: Barros
mesh_terms: D003906:Developing Countries; D015721:Diphtheria-Tetanus-Pertussis Vaccine / Q000008:administration & dosage*; D005260:Female; D014943:Global Health; D006306:Health Surveys; D006801:Humans; D017589:Immunization Programs / Q000706:statistics & numerical data*; D007223:Infant; D008297:Male; D011203:Poverty; D012959:Socioeconomic Factors; D000073887:Vaccination Coverage
chemical_list: D015721:Diphtheria-Tetanus-Pertussis Vaccine