The COVID-19 pandemic likely increased vaccine inequity in pediatric patients, according to a systematic review published by Nicholas Spencer, FRCPCH, and colleagues in Vaccines. The review found moderate evidence for inequity in reduced vaccination coverage of children during COVID-19 lockdowns and moderately strong evidence for an increase in inequity compared with pre-pandemic months (ie, before March 2020).
“The study arose from discussions about the impact of COVID-19 on children established jointly by the International Society for Social Pediatrics and Child Health (ISSOP) and the International Network for Research in Inequality in Child Health (INRICH),” Dr. Spencer says. “Both organizations are committed to child health equity and the rights of all children to optimal services. Public health services were disrupted by measures to control the pandemic. We hypothesized that routine childhood vaccination coverage, an essential child public health measure, would be reduced among disadvantaged and marginalized children compared with their more advantaged peers.”
The systematic review included 13 studies. All studies analyzed reported data by equity stratifies on routine vaccination coverage in pediatric patients within or between high-income countries (HICs) and low- and middle-income countries (LMICs) during the COVID-19 pandemic. Equity stratifies were factors that could identify groups at risk for healthcare disparities, such as parental education, wealth, race/ ethnicity, employment, and country income category. The researchers assessed five outcomes:
(1) change in vaccine coverage by equity stratifies during the pandemic; (2) change in inequity in vaccine coverage during the pandemic compared with pre-pandemic period; (3) differences in vaccine-specific inequity in coverage.
(4) differences in age-group specific inequity in coverage; and (5) differences in inequity coverage between HICs and LMICs.
“Children have suffered many fewer direct effects of COVID-19 than adults, but they have been severely affected by indirect effects,” Dr. Spencer explains. “Consequences of the pandemic for children, such as loss of schooling and loss of caregivers, have received relatively little attention. Studies such as ours have a role in redressing the balance and ensuring the impact of the pandemic on children is more fully recognized.”
Equity-Based Change in Vaccine Coverage During the Pandemic
Seven studies examined vaccine coverage by equity stratifies during the pandemic. Those assessing the impacts of parental education on childhood vaccination during the pandemic showed varying results, with some studies showing that low maternal education reduced vaccination rates and others showing that paternal, but not maternal, education had an impact. While lower education was generally associated with delayed vaccinations, a study from China showed the opposite, with less educated parents less likely to delay vaccination than more educated parents. When considering other equity stratifies, rural dwellers, Black and ethnic minority households, and less wealthy households were generally more likely to miss childhood vaccinations. Additionally, missed vaccinations were significantly more likely in both middle-income and high-income countries in households with parents who were employed full- or part-time versus those who were unemployed, retired, or students.
Change in Vaccine Coverage During Pandemic vs PrePandemic Perio
Six studies included vaccination coverage data during lockdowns versus pre-pandemic. In the US studies, inequity in vaccine coverage during the pandemic was found to be pronounced in younger children, especially those who were Medicaid recipients and non-White. Overall, evidence for increasing inequity in vaccine coverage during the pandemic was considered moderately strong.
Three studies examined coverage rates in different age groups by equity stratifies. Collectively, these studies showed inequity to be higher in younger cohorts, particularly children aged 7-18 months. Race/ethnicity and Medicaid enrollment were associated with higher rates of reduced vaccination coverage.
Only one study directly compared vaccination coverage between HICs and LMICs. “The pandemic and associated lockdowns increased inequity in routine vaccination coverage in high-income countries, such as the US, and middle-income countries, such as Pakistan,” Dr Spencer says. In the study, households in middle-income countries were more likely than those in HICs to report missed routine childhood vaccinations during the pandemic (7.6% vs 3.0%, respectively).
“Globally inequity is a key factor in the failure of many countries to achieve full routine vaccination coverage,” Dr. Spencer continues. “The pandemic is likely to have further jeopardized coverage by increasing existing inequity, but more robust evidence from a wider range of countries using routinely collected and household survey data is needed to identify the extent of the pandemic’s short, medium, and long-term effects on coverage.”