Vaccination Utilization and Subnational Inequities during the COVID-19 Pandemic: An Interrupted Time-Series Analysis of Administrative Data across 12 Low- and Middle-Income Countries
George Mwinnyaa,
Michael A. Peters,
Gil Shapira,
Rachel Neill,
Husnia Sadat,
Sylvain Yuma,
Pierre Akilimali,
Shahadat Hossain,
Naod Wendrad,
Wisdom K. Atiwoto,
Anthony Adofo Ofosu,
Jean Patrick Alfred,
Helen Kiarie,
Chea Sanford Wesseh,
Chris Isokpunwu,
Desmond Maada Kangbai,
Abdifatah Ahmed Mohamed,
Kadidja Sidibe,
Salome’ Drouard,
Pablo Amor Fernandez,
Viviane Azais,
Tawab Hashemi,
Peter M. Hansen,
Tashrik Ahmed
Affiliations
George Mwinnyaa
The Global Financing Facility for Women, Children, and Adolescents, Washington, DC 1818, USA
Michael A. Peters
The World Bank, Washington, DC 20433, USA
Gil Shapira
The World Bank, Washington, DC 20433, USA
Rachel Neill
The Global Financing Facility for Women, Children, and Adolescents, Washington, DC 1818, USA
Husnia Sadat
The Global Financing Facility for Women, Children, and Adolescents, Washington, DC 1818, USA
Sylvain Yuma
Ministe’re de la Sante, Kinshasa 4310, Democratic Republic of the Congo
Pierre Akilimali
Kinshasa School of Public Health, University of Kinshasa, Kinshasa P.O. Box 11850, Democratic Republic of the Congo
Shahadat Hossain
Ministry of Health and Family Welfare, Dhaka 1000, Bangladesh
Naod Wendrad
Ministry of Health, Addis-Ababa 1234, Ethiopia
Wisdom K. Atiwoto
Ministry of Health, Accra P.O. Box M 44, Ghana
Anthony Adofo Ofosu
Ghana Health Service, Accra P.O. Box M 44, Ghana
Jean Patrick Alfred
Ministère de la Sante Publique et de la Population, Port-au-Prince HT6123, Haiti
Helen Kiarie
Ministry of Health, Nairobi P.O. Box 30016-00100, Kenya
Chea Sanford Wesseh
Ministry of Health, Monrovia 20540, Liberia
Chris Isokpunwu
Federal Ministry of Health, Abuja 900242, Nigeria
Desmond Maada Kangbai
Ministry of Health and Sanitation, Freetown 232, Sierra Leone
Abdifatah Ahmed Mohamed
Federal Ministry of Health & Human Services, Mogadishu 28RX+5W6, Somalia
Kadidja Sidibe
The Global Financing Facility for Women, Children, and Adolescents, Washington, DC 1818, USA
Salome’ Drouard
The World Bank, Washington, DC 20433, USA
Pablo Amor Fernandez
The World Bank, Washington, DC 20433, USA
Viviane Azais
The Global Financing Facility for Women, Children, and Adolescents, Washington, DC 1818, USA
Tawab Hashemi
The Global Financing Facility for Women, Children, and Adolescents, Washington, DC 1818, USA
Peter M. Hansen
The Global Financing Facility for Women, Children, and Adolescents, Washington, DC 1818, USA
Tashrik Ahmed
The Global Financing Facility for Women, Children, and Adolescents, Washington, DC 1818, USA
Background: During and after the SARS-CoV-2 (COVID-19) pandemic, many countries experienced declines in immunization that have not fully recovered to pre-pandemic levels. This study uses routine health facility immunization data to estimate variability between and within countries in post-pandemic immunization service recovery for BCG, DPT1, and DPT3. Methods: After adjusting for data reporting completeness and outliers, interrupted time series regression was used to estimate the expected immunization service volume for each subnational unit, using an interruption point of March 2020. We assessed and compared the percent deviation of observed immunizations from the expected service volume for March 2020 between and within countries. Results: Six countries experienced significant service volume declines for at least one vaccine as of October 2022. The shortfall in BCG service volume was ~6% (95% CI −1.2%, −9.8%) in Guinea and ~19% (95% CI −16%, 22%) in Liberia. Significant cumulative shortfalls in DPT1 service volume are observed in Afghanistan (−4%, 95% CI −1%, −7%), Ghana (−3%, 95% CI −1%, −5%), Haiti (−7%, 95% CI −1%, −12%), and Kenya (−3%, 95% CI −1%, −4%). Afghanistan has the highest percentage of subnational units reporting a shortfall of 5% or higher in DPT1 service volume (85% in 2021 Q1 and 79% in 2020 Q4), followed by Bangladesh (2020 Q1, 83%), Haiti (80% in 2020 Q2), and Ghana (2022 Q2, 75%). All subnational units in Bangladesh experienced a 5% or higher shortfall in DPT3 service volume in the second quarter of 2020. In Haiti, 80% of the subnational units experienced a 5% or higher reduction in DPT3 service volume in the second quarter of 2020 and the third quarter of 2022. Conclusions: At least one region in every country has a significantly lower-than-expected post-pandemic cumulative volume for at least one of the three vaccines. Subnational monitoring of immunization service volumes using disaggregated routine health facility information data should be conducted routinely to target the limited vaccination resources to subnational units with the highest inequities.
