Yale University EliScholar – A Digital Platform for Scholarly Publishing at Yale Public Health Theses School of Public Health January 2020 An Impact Evaluation Of The Rollout Of The Pneumococcal Conjugate Vaccine In Uttar Pradesh State, India. 2017-2019 Elizabeth Edgerley [email protected] Follow this and additional works at: https://elischolar.library.yale.edu/ysphtdl Recommended Citation Edgerley, Elizabeth, "An Impact Evaluation Of The Rollout Of The Pneumococcal Conjugate Vaccine In Uttar Pradesh State, India. 2017-2019" (2020). Public Health Theses. 1933. https://elischolar.library.yale.edu/ysphtdl/1933 This Open Access Thesis is brought to you for free and open access by the School of Public Health at EliScholar – A Digital Platform for Scholarly Publishing at Yale. It has been accepted for inclusion in Public Health Theses by an authorized administrator of EliScholar – A Digital Platform for Scholarly Publishing at Yale. For more information, please contact [email protected]. 1 An Impact Evaluation of the Rollout of the Pneumococcal Conjugate Vaccine in Uttar Pradesh State, India. 2017-2019 Author: Elizabeth Edgerley May 2020 For Consideration for the Completion of the MPH Thesis Credit 2020 Dept. of Epidemiology of Microbial Diseases Committee Chair: Dr. Dan Weinberger Committee Member: Dr. Elsio Wunder 2 Abstract This paper is aimed toward examining whether methods currently being rolled out to administer the pneumococcal conjugate vaccine to children in the Indian state of Uttar Pradesh is effectively reducing morbidity and mortality. The fundamental question regarding this current effort is if it proves to be useful at reducing the prevalence of Streptococcus Pneumoniae and whether the surveillance methods examining the efficacy of healthcare interventions are helpful. Both rural and urban India are troubling areas for public health surveillance to reach, though many diseases of poverty and respiratory illnesses such as pneumonia flourish there. With no true quantification of burden, it is challenging to implement interventions and distribute resources. The data for this paper is challenging because it was collected through surveillance networks whose efficacy is yet to be determined. As further analysis was conducted it became apparent that the surveillance data utilized in this paper is not a strong indicator of occurring cases of pneumonia, however through time series analysis, regression analysis, and spatial analytics, useful general trends appeared. The Pneumococcal Conjugate Vaccine rollout is new and success is yet to be determined in the short time period since 2017. Through this detailed analysis of available information details arose that describe the holistic effectiveness of the program and can inform directions for the future. Overall mortality rates hinge on access to care, and this paper will integrate quantitative data analysis with a qualitative review of the systems involved. The results require follow up of several more years to account for disparities between districts and weakness of the data. However, an investigation into the districts where the vaccine was rolled out, which also experienced the heaviest burden of cases, revealed that the PCV rollout has the potential to achieve a tentative level of success. The complication is that as 3 surveillance improves, death counts of previously invisible individuals will ruse. The full effect of this effort will not be seen for 2-4 years due to the age of vaccination and the retooling of health systems. With proper administration, data management, and surveillance systems in place, a shift in vaccine access has a capacity to reduce childhood mortality. 4 Table of Contents Introduction Rollout 5 Burden 6 Host Factors 6 Treatment 7 Solutions 7 Methods 8 Results Time Series 9 Spatial Analysis 10 Regression Models 13 Discussion Early Impact Evaluation 14 Statistical PCV Impact Evaluation 15 Evaluation 16 Conclusion 17 Citations 19 5 Introduction Rollout According to research at the International Vaccine Center at Johns Hopkins University, a child dies every 8 minutes of pneumococcal disease in India[1]. The launch of the free Pneumococcal Conjugate Vaccine is following a time of extreme need. As a greater understanding of the state of public health in the developing areas in a nation of one billion grows, the importance of joining 120 other countries in the fight against this disease is critical. The government of India made an official promise in May of 2017 to launch the PCV under the Universal Immunization program. The Union Minister for Health and Family welfare Shri J P Nadda declared the government’s commitment to reducing morbidity and mortality in young children[2]. As pneumonia kills more children under five than any other infectious disease in the region, the government considered this movement a long-term investment in the future of India and the 27 million children born each year. Of that figure, 2 million of those children do not make it past the age of five[3].This effort is a part of a larger movement under President Modi to expand healthcare to bolster India’s status on the path of development. Overall vaccine coverage has also been improved according to the Minister for Health, growing from protecting against 6 preventable infectious diseases to 12. The government is promoting the program heavily through posters, TV commercials, and radio [2]. In addition to two other states, the six districts in the northern state of Uttar Pradesh that were determined to have the most “need” by the government were Balrampur, Bahraich, Kheri, Sitapur, Siddharthnagar and Shravasti. [12]. The overall burden of disease was paired with the prevalence of secondary risk factors such as poverty, illiteracy rates, housing security, poor sanitation conditions, and lack of healthcare access for consideration [13]. The vaccines would be available starting June 10, 2017 for free for children under one at six weeks old, fourteen weeks old, and nine months. The government determined that the economic offset of the reduction of healthcare and hospitalization costs due to infections would justify the cost of the free vaccine. The PCV rollout was modeled on existing vaccine campaigns that were used to eradicate polio under the Universal Immunization Program [14]. 6 Complications arise from the fact that a significant amount of background information comes from the Indian government itself, which has strong interests in making a efforts to improve quality of life. As a rising global economy, public health is a key part of developing infrastructure. However, much of the data describing the extent of the reach of the vaccine program has come from the government itself. The prevalence statistics provided by the National Health Profile of India do not supply sources and methodologies. There is a concern among the global community that countries like India understate their poor health outcomes in order to build power. However, it is the thought of this paper that understatement is inevitable, because the systems to account for every community effectively do not exist. The WHO and individual research studies also carry their own figures. Further discussion is needed on which source should be the touchstone for the global health community as severe knowledge gaps exist. My data will be coming from private efforts from HMIS, which will be further discussed in the methods section. This paper will reflect community and local based surveillance and healthcare delivery approaches that are common in the region. Burden of Pneumonia No national review of this issue exists in India. As stated above, exact counts of sickness and death are challenging and disparate reporting exists. According to the Million Death Study the statistics in the above Rollout section are confirmed with some slight discrepancies in the thousands[4]. Further research under this study revealed that a higher percentage of rural children suffered than urban children, though only by a slight margin: 28.9% as opposed to 25% [4]. Cases within slums lie in a grey area, which is problematic considering the ties of slum life to risk indicators. Cases also vary by state, though our scope will be limited to the state with the most severe situation. These distinctions will be considered. Host Factors There is extensive research on the risk indicators and implications of childhood pneumonia. Environmental and behavioral circumstances integrate to shape the susceptibility of communities and children. Some of the primary indicators for pneumonia mortality are whether or not the child is breastfed, low birth weight, malnutritioned, experiencing poor air quality outdoors and indoors, living in overcrowding, and failed to receive measles immunization[5]. 7 Some publications rank these risk factors by severity, but for the purposes of this paper risk factors will be supplemental information. Further epidemiological evidence revealed that time trends are incredibly important when conducting a review of both cases and mortality, which supports the work done in this paper. Another study identified socioeconomic status as an indicator that should be taken under consideration, especially given India’s wealth gap[6]. An important trend that literature also revealed is very few studies identify the etiology of pneumonia cases. Like this paper, diagnostics are often the main source of detection. When diagnostics are weak and healthcare access is poor, portions of the populations are missed and direct links to risk factors