Peer-reviewed article
Small-area variation in child under-vaccination in India: a multilevel analysis of cross-sectional data from 36 states and Union Territories, 707 districts, and 22,349 small-area clusters
Mira Johri, Sunil Rajpal, Rockli Kim, S. V. Subramanian ·
Summary
Written by AI, not yet AICS's view · claude-haiku-4-5-20251001This study analyzes vaccination coverage inequality across India using data from 22,349 small geographic clusters. It finds that while India has high overall immunization rates, significant gaps remain in specific areas, particularly in northeastern states and Uttar Pradesh. The research shows that local clusters account for more than half of the variation in vaccination gaps, indicating that pockets of under-vaccinated children exist even in states with good aggregate coverage. The study recommends focusing vaccination efforts at the sub-district level to reach vulnerable populations.
Key points
- 87,622 children aged 12-36 months were analyzed across 36 states, 707 districts, and 22,349 clusters
- Clusters accounted for 67.6% of variation in zero-dose children and over 50% for all vaccination indicators
- Northeastern states and Uttar Pradesh had the highest median under-vaccination for vaccines given in the first year of life
- Districts with higher under-vaccination prevalence tend to have greater within-district inequity in vaccination coverage
- Pockets of low vaccination coverage exist in most states despite high aggregate national coverage
Limitations
This is a cross-sectional analysis from 2019-2021 survey data, so it cannot identify causal factors driving vaccination inequities or track changes over time. The study describes patterns of inequality but does not evaluate interventions to address them.
Abstract
Background: India has made exceptional advances in child immunisation, but subnational inequities in vaccination coverage impede attainment of key programmatic goals. Our study provides an up-to-date national portrait of local variations in child vaccination using a comprehensive set of indicators relevant to routine immunisation. Methods: Indicators representing unvaccinated (zero-dose) children, incomplete basic immunisation, and vulnerability to measles and polio, were constructed from India's 2019-2021 National Family Health Survey. We used four-level random effects logistic regression models to partition the total outcome variation over state, district and cluster levels, and produce precision-weighted estimates of prevalence across clusters. District-level prevalence and within-district variation using standard deviation measures were derived for each outcome. Boxplots graphically summarised the distribution of precision-weighted mean cluster prevalence by state. Findings: The analysis included 87,622 children aged 12-36 months. Clusters accounted for 67.6% (var: 1.36; SE: 0.127) of the variation among zero-dose children, and more than 50% for all indicators. Districts with a higher prevalence of under-vaccination tended to have higher within-district heterogeneity, interpretable as greater within-district child vaccination inequities. For vaccines administered in the first year of life, the northeastern states and Uttar Pradesh had the highest median under-vaccination. Despite India's high aggregate vaccine coverage, the distribution of small-area (cluster) mean prevalence highlighted pockets of low coverage in most states, suggesting ongoing vulnerability to measles and polio. Interpretation: Achieving India's vaccination goals requires a strategic shift towards identification and targeting of low-immunity clusters at the sub-district level. Funding: Canadian Institutes of Health Research.