Ethnic disparities in immunisation: analyses of zero-dose prevalence in 64 countries

Abstract

Background The Sustainable Development Goals (SDGs) recommend stratification of health indicators by ethnic group, yet there are few studies that have assessed if there are ethnic disparities in childhood immunisation in low- and middle-income countries (LMICs). Methods We identified 64 LMICs with standardized national surveys carried out since 2010, which provided information on ethnicity or a proxy variable and on vaccine coverage; 339 ethnic groups across the 64 countries were identified after excluding those with fewer than 50 children in the sample and countries with a single ethnic group. Lack of vaccination with diphtheria-pertussis-tetanus (DPT) vaccine – a proxy for no access to routine vaccination or ‘zero-dose’ status – was the outcome of interest. Differences among ethnic groups were assessed using a chi-squared test for heterogeneity. Additional analyses controlled for household wealth, maternal education and urban-rural residence. Findings The median gap between the highest and lowest zero-dose prevalence ethnic groups in all countries was equal to 10 percentage points (interquartile range 4-22; range 1 to 84) and the median ratio was 3.3 (interquartile range 1.8-6.7; range 1.1-30.4). In 35 of the 64 countries, there was significant heterogeneity in zero-dose prevalence among the ethnic groups. In most countries, adjustment for wealth, education and residence made little difference to the ethnic gaps, but in four countries (Angola, Benin, Nigeria, and Philippines) the high-low ethnic gap decreased by over 15 pp after adjustment. Children belonging to a majority group had 29% lower prevalence of zero-dose compared to the rest of the sample. Interpretation Statistically significant ethnic disparities in child immunisation were present in over half of the countries studied. Such inequalities have been seldom described in the published literature. Regular analyses of ethnic disparities are essential for monitoring trends, targeting resources and assessing the impact of health interventions to ensure zero-dose children are not left behind in the Sustainable Development Goals era.