Equity in vaccination policies to overcome social deprivation as a risk factor for invasive meningococcal disease

Figures & data

Figure 1. WHO road map goals for vaccination against meningococcal disease Created from the WHO road map of the goals for vaccination against meningococcal disease [31] Men A: meningitis A; MenACWY: meningitis A, C, W or Y; MenACWXY: meningitis A, C, W, X or Y; MenB: meningitis B; WHO: World Health Organization.

Table 1. Summary of studies evaluating the association of social deprivation with the risk of meningococcal disease

Reference	Location and year	Type of study	Measure of deprivation	Findings
Stuart et al [65]	UK, 1998	Enhanced surveillance in specific area	Townsend deprivation score Calculated as a composite score of four variables: 1. Proportion of all economically active residents aged older than 16 years who are unemployed 2. Proportion of households in the area with 1 person per room and over 3. Proportion of households with no car 4. Proportion of households not owning their own home Measures social and economic deprivation in a particular locality. Does not capture data for individuals	Risk of meningococcal disease in most versus least deprived areas: RR 1.76 (95% CI 1.14, 2.72) overall population RR 1.90 (95% CI 1.01, 3.58) <5 years of age
Fone et al [66]	UK, 1996 − 1999	Cases identified from statutory notification records in specific area		Risk of meningococcal disease in most versus least deprived areas: RR 2.4 (95% CI 1.7, 3.6) Overcrowding associated with highest risk
Heyderman et al [67]	UK, 1991 − 1999	Ecological study across England of hospital episode statistics among children <5 years of age		Incidence of hospitalization for IMD (linear increase with increasing deprivation): 33.5/100,000 in most affluent areas and 63.0/100,000 in least affluent areas (boys) 27.4/100,000 in most affluent areas and 51.0/100,000 in least affluent areas (girls) IMD mortality (non linear increase with increasing deprivation): 0.6/100,000 in most affluent areas and 2.2/100,000 in least affluent areas (boys) 0.7/100,000 in most affluent areas and 2.1/100,000 in least affluent areas (girls)
Williams et al [68]	UK, 1999 − 2000	Enhanced surveillance in specific area		Risk of meningococcal disease in most versus least deprived areas: RR 1.97 (95% CI 1.55, 2.51)
Olowokure et al [69]	UK, 1996 − 2001	Retrospective review of statutory notifications, laboratory records and death registrations in a specific area		Risk of meningococcal disease in most versus least deprived urban areas: RR 3.33 (95% CI 1.68, 6.60) No association between deprivation and risk of disease in rural areas
Stanton et al [70]	UK, 1977 − 2007	Hospitalization among children for meningococcal disease in a single hospital trust		Hospitalized children had higher Townsend scores (indicating greater deprivation) than the reference population for the area
Taha et al [71]	France, 2012 − 2017	Observational, case-control study using public health insurance database	1. Government-funded insurance that is available for individuals in employment whose income is below a specific threshold was used as a proxy measure of low income (reflects deprivation level of individuals) 2. Validated social deprivation index, a composite ecological marker classifying level of deprivation in a municipality of residence (reflects deprivation in a particular locality but does not capture data for individuals)	Low household income (threshold determining health insurance status) was strongly associated with risk of hospitalization for IMD in a multivariate analysis, with the strongest association in children <1 year of age and 1 − 4 years of age: OR 1.68 (95% CI 1.49, 1.89) overall population OR 4.81 (3.56, 6.49) <1 year of age OR 2.27 (95% CI 1.78, 2.89) 1 − 4 years of age Living in a socially deprived community was associated with IMD hospitalization in a univariate analysis (OR 1.07 [95% CI 1.00, 1.11], but not in a multivariate analysis. Low income is a marker of individual status, while living in a socially deprived community is a composite of several markers associated with the community. This study suggests that low income might reflect a specific individual risk factor for IMD that could be considered in targeted vaccination programs against IMD
Baker et al [72]	New Zealand, 1997 − 1998	Case-control study in children <8 years of age	Questionnaire developed for the study including measures of household crowding, use of public transport, bed-sharing, passive exposure to tobacco smoke, dampness in house, ventilation, heating, exposure to fumes, dust and animals, home and car ownership, parental education, parental employment, household income and receipt of community services benefits	Risk of meningococcal disease increased with increasing number of adults and adolescents per room (median 0.43 for controls, 0.60 for cases): OR 10.7 (95% CI 3.9, 29.5)
McCall et al [73]	Australia, 2000 − 2001	Case-control study	Questionnaire developed for the study including questions on socioeconomic indicators	Risk of IMD in children <6 years of age sharing a bedroom with ≥2 people versus fewer people: OR 7.4 (95% CI 1.5, 36.1)

CI: confidence interval; IMD: invasive meningococcal disease; OR: odds ratio; RR: relative risk; UK: United Kingdom.

Table 2. Summary of studies evaluating the association of social deprivation with access to vaccination against meningococcal disease

Reference	Location and year	Type of study	Vaccine and population	Measure of deprivation	Findings
Vallejo-Aparicio et al [74]	Spain, 2018 − 2019	Ecological study	MenB (4CMenB) (self-funded)	Average income per capita in municipality	There was a statistically significant correlation between vaccine uptake per birth and income per capita
Taylor et al [75]	South Australia, 2013	Survey study of family physicians	MenB (self-funded)	Not defined in study	Percentage of physicians considering factors as ‘definitely a barrier’ to prescription: High cost of vaccine: 61% Low socioeconomic status of family: 59%
Lu et al [77]	USA, 2015	Based on National Immunization Survey – Teen data	MenACWY Adolescents	Insurance status	Vaccine coverage was 72.9% in uninsured adolescents versus 81.7% in insured adolescents
Huang et al [78]	USA, 2017	Physician survey	MenACWY and MenB Adolescents and young adults	Insurance status	Among physicians who prescribed both MenACWY and MenB vaccines, private or commercial insurance was held by 61% of patients in their practice, whilst 22% of their patients were covered by Medicaid. Among physicians who prescribed only MenACWY, 53% of patients were covered by private/commercial insurance and 29% were covered by Medicaid
Watkins & Feemster [79]	USA, 2015 − 2017	Retrospective cohort study	MenB 16 − 23 years of age	Insurance status	Percentage of individuals completing vaccination series: Private insurance: 48% Medicaid: 26%
Srivastava et al [80]	USA, 2016	Household survey	MenB Households with adolescent 16 − 19 years of age	Not applicable	Relative importance of variables predicting MenB vaccination (based on Classification and Regression Tree analysis): Annual household income: 35.9%; HCP knows family well: 24.2%; age: 23.9%; race/ethnicity: 15.7%
Blagden et al [84]	UK, 2015 − 2016	Ecological, general practice-based study	MenACWY (part of NIP) Catch-up cohort: 17 − 18 years and first-time university students	English Indices of Deprivation score [87] Calculated for a small geographical area as a weighted composite score of seven variables: 1. Income 2. Employment 3. Education 4. Crime 5. Health 6. Barriers to housing and services 7. Living environment	Vaccine uptake decreased with increasing deprivation: RR 0.991 (95% CI 0.986, 0.995)
Tiley et al [85]	UK, 2016 − 2017	Ecological, school-based study	MenACWY (part of NIP) 13 − 14 years	English Indices of Deprivation score [87] As above	Vaccine coverage according to quintile of area deprivation: 1 (most deprived): 76.0%; 2: 82.8%; 3: 82.0%; 4: 83.6%; 5 (least deprived): 88.2%
Fletcher et al [86]	UK, 2017 − 2018	Ecological, school-based study	MenACWY (part of NIP) 14 − 15 years	Effectiveness of education delivery in an individual school as judged by the national school inspection body (Ofsted) Proportion of children in an individual school eligible for free school meals	Vaccine coverage according to effectiveness of education delivery:Inadequate: 62.5%; requires improvement: 76.4%; good: 81.8%; outstanding: 87.0% (OR 3.54 [95% CI 3.00, 4.19]) Vaccine coverage according to percentage of children eligible for free school meals:Above average: 76.6%; below average: 83.4% (OR 1.56 [95% CI 1.41, 1.78])

4CMenB: 4-component meningitis B vaccine; CI: confidence interval; HCP: health care professional; MenACWY: meningitis A, C, W or Y; MenB: meningitis B; NIP: national immunization program; OR: odds ratio; RR: relative risk; USA; United States of America; UK: United Kingdom.

Figure 2. Coverage of the MenACWY vaccine according to two measures of socioeconomic status in England Tiley et al [85]: Graph shows vaccine coverage according to quintile of social deprivation measured by the English Indices of Deprivation score, which is calculated for a small geographical area as a weighted composite score of seven variables: 1. Income; 2. Employment; 3. Education; 4. Crime; 5. Health; 6. Barriers to housing and services; 7. Living environment. Fletcher et al [86]: Graph shows vaccine coverage according to individual school effectiveness score: 1. Inadequate; 2. Requires improvement; 3. Good; 4. Outstanding. MenACWY: meningitis A, C, W or Y.

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