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vaccination has been consolidated as one of the most cost effective and successful public health interventions and a right of every human being
This study aimed to assess the spatial dynamics of the vaccine coverage (VC) rate of children aged &lt; 1 year per municipality in the Brazilian Northeast at 2016 and 2017
This is a mixed-type ecological study that use a Public domain data Health Information
Vaccine doses were obtained from the Information System of the Brazilian National Immunization Program
and live births from the Brazilian Information System of Live Births of the Brazilian Unified Health System
Descriptive analysis of the coverage of all the vaccines for each year of the study was conducted
and Mann–Whitney U test was used to compare VC between the study years
Chi-squared test was used to evaluate the association between the years and VC
Spatial distribution was analyzed according to both each study year and vaccine and presented as thematic maps
Spatial autocorrelation was analyzed using Moran’s Global and Local statistics
In the spatial analysis of the studied vaccines
the Global Moran’s Index did not show any spatial autocorrelation (p &gt; 0.05)
but the Local Moran’s Index showed some municipalities
and a positive influence on neighboring municipalities (p &lt; 0.05)
most municipalities with low VC were concentrated in the Mata Paraibano region
negatively influencing their neighbors (p &lt; 0.05)
Uneven geographic regions and clusters of low VC for children aged &lt; 1 year in the State of Paraíba were spatially visualized
Health policy makers and planners need to urgently devise and coordinate an action plan directed at each state’s regions to fulfill the vaccination calendar
thereby reversing the vulnerability of this age group
which is at a higher risk of diseases preventable by vaccination
the objective of this study is to use a geographic information system (GIS) and spatial analysis techniques to analyze the spatial dynamics of the VC rates and each vaccine’s spatial autocorrelation in children under the age of 1 year per municipality in the northeast Brazilian State in 2016 and 2017
This is a mixed-type ecological study with the municipality of residence as the analysis unit [<a data-track="click" data-track-action="reference anchor" data-track-label="link" data-test="citation-ref" aria-label="Reference 9" title="Morgenstern H. Ecologic studies in epidemiology: concepts, principles, and methods. Annu Rev Public Health. 1995;16:61–81." href="/articles/10.1186/s12889-022-13589-9#ref-CR9" id="ref-link-section-d384009975e711">9</a>]
This research is part of a broader project titled Spatial Analysis of Children’s Vaccine Coverage and its Relationship with Socioeconomic and Health Characteristics in Brazil
funded by the Bill and Melinda Gates Foundation and the Brazilian National Council for Scientific and Technological Development (CNPq)
Data were collected from the Department of Informatics of the Brazilian Unified Health System
and publishing health information nationwide
data from the Information System of the National Immunization Program (SI–PNI) and Information System on Live Births (SINASC) were used
The applied doses of each vaccine for calculating VC were obtained from SI-PNI and data on live births were obtained from SINASC
both collected by year and municipality of residence
VC was calculated by antigen administered to children aged under 1 year as a fraction using either the number of doses applied (for single-dose vaccines) or the number of last doses applied (for multiple-dose vaccines) as the numerator
and the live-birth data per year and municipality as the denominator
The vaccines considered in the calculation of VC are part of the Brazilian National Vaccination Calendar for children aged under 1 year: Bacillus Calmette–Guérin (BCG) at birth; vaccine against Hepatitis B (HepB) at birth and at 2
and 6 months; vaccine against meningococcus type C (MnCc) at 3 and 7 months; vaccine against Diphtheria–Tetanus–Pertussis (DTP)
vaccine against Haemophilus influenzae type B (HiB)
The following formula was used to calculate the coverage of each vaccine:
The PNI agreed upon the target of 90% of the population below the age of 1 year to be immunized with the BCG and rota vaccines
Attaining these coverage rates is considered to be adequate and signifies that the target has been met
A descriptive analysis of all the study variables was performed
Quantitative variables were analyzed in terms of their central tendency and dispersion values
Qualitative variables were analyzed in terms of their absolute and relative values
and Chi-squared test was used to evaluate the association between the years and the categorized VCs
USA) was used for the statistical analysis of the study data
thematic maps were built from the calculation of VC for each vaccine by municipality and year
using thematic cartography of Geographic Information System (GIS)
The maps were built in QGIS 3.10 (QGIS Development Group)
a free and open-source GIS that allows for the analysis of georeferenced data
According to the definitions of thematic representation
meaning above the target; and two light colors
which translate into below target and far below target
This study used the neighborhood matrix “w” of first order
which signified that municipalities sharing a common physical border are considered as neighbors
The connected regions are believed to interact more than unconnected ones
and these connections are represented by matrix
wherein a value of 1 signifies a common border and 0 signifies no border
The spatial autocorrelation analysis was initially performed using the Global Moran’s Index (I)
which identified the State of Paraíba as a unique study area and allowed a general measurement of the spatial association
as it does not allow for the detailed analysis of spatial patterns
the identification of the spatial correlations between the municipalities
the Local Index of Spatial Association (LISA) was used to identify areas with values of similar attribute (clusters) and they were visualized through Moran’s Map
which indicated a municipality with high VC and a positive influence on its neighbors (i.e.
neighbors with high VC); “low-low” was identified in blue and indicated a municipality with low VC and a negative influence on its neighbors (i.e.
municipalities with low VC); “high-low” was identified in green and indicated the municipalities with high VC surrounded by low VC municipalities; “low–high,” indicated in light blue included the municipalities with low VC surrounded with cities with high VC; and nonsignificant was indicated in white and included municipalities with no statistically significant spatial autocorrelation (p ≤ 0.05)
and Moran’s Map analyses were performed using the free and open-source software R Studio (R Development Core Team
2019) with the spatial autocorrelation and LISA tools
In this study, the VC data, one of the PNI performance indicators, were analyzed for 2016 and 2017 in the 223 municipalities of the State of Paraíba (Table <a data-track="click" data-track-label="link" data-track-action="table anchor" href="/articles/10.1186/s12889-022-13589-9#Tab1">1</a>)
Paraiba’s total CV was 50.10% and in 2017 it was 70.08%
Spatial analysis using the spatial autocorrelation indicator Global Moran’s Index found no statistically significant spatial autocorrelation in the two years (Table <a data-track="click" data-track-label="link" data-track-action="table anchor" href="/articles/10.1186/s12889-022-13589-9#Tab2">2</a>)
When calculating the Spatial Association Index
it is possible to perform the local spatial autocorrelation
visualize the municipalities with similarities and form clusters of high and low VC
which consequently positively or negatively influence their neighbors
</a>Vaccine coverage for Bacillus Calmette–Guérin (BCG), Diphtheria–Tetanus–Pertussis (DTP), hepatitis B, and Haemophilus influenzae type B (HiB) in 2016 and 2017, State of Paraíba, Brazil
</a>Moran’s Map of the vaccines given to children under 1 year of age
some agglomerations of Sertão Paraibano municipalities were seen
including one cluster toward the north and another in the center of the region with high VC and high similarity
and a third cluster toward the east with low VC and a negative influence on their neighbors
except for DTP in one municipality of the Mata Paraibano
which showed low VC and a negative influence on its neighbors
Figure <a data-track="click" data-track-label="link" data-track-action="figure anchor" href="/articles/10.1186/s12889-022-13589-9#Fig4">4</a> shows that the polio, rota, and pneumo vaccines had completely different spatial patterns in the two years analyzed. These vaccines must be simultaneously administered with the application of DTP, HiB, and HepB, according to the child vaccination calendar recommended by the Brazilian PNI.
</a>Moran’s Map of the vaccines given to children aged under 1 year
João Pessoa state capital city showed a lower VC and a negative influence on its neighbors
a few municipalities showed spatial autocorrelation (p &lt; 0.05)
with high VC and a positive influence on their neighbors
A cluster of municipalities can also be seen in the northwest and the south of the Mata Paraibana region
and in the southeast of the Agreste Paraibano region
with low rota VC and a negative influence on their neighbors
the municipalities with spatial autocorrelation (p &lt; 0.05) included a high VC cluster toward the north of Sertão Paraibano but not influence its neighbors
A few municipalities in the Mata Paraibana and Agreste regions showed low rota VC and a negative influence on their neighbors
showed high pneumo VC and a positive influence on their neighbors
A cluster of municipalities in the Mata Paraibana region was observed with low pneumo VC and a negative influence on their neighbors
13 municipalities showed statistical significance (p &lt; 0.05)
but only two municipalities showed high VC and a positive influence on their neighbors
both in the north of the Sertão Paraibano region
one in the Agreste Paraibano region and another in the Sertão Paraibano region
showed low pneumo VC and a negative influence on their neighbors
a few municipalities with positive spatial autocorrelation (p &lt; 0.05) were seen and only two municipalities with high MnCc VC
and a positive influence on their neighbors both in the Sertão Paraibano region
The Mata Paraibana showed spatial autocorrelation (p &lt; 0.05) with low MnCc VC and a negative influence on their neighbors
but none had high MnCc VC with a positive influence on its neighbors
a considerable number of municipalities with low or very low VC according to the PNI targets were observed for all the vaccines analyzed in this study
49.3% and 46.7% of the municipalities had VC &lt; 50% in 2016 and 2017
and only 15.2% of the municipalities had adequate VC in both the years
When analyzing the spatial distribution of all the evaluated vaccines
a large number of municipalities with no statistical significance were found
further corroborating that VC in the Paraíba region is far below the targets set by PNI
From all the results of the spatial analysis
the Sertão Paraibano region had the most municipalities with adequate VC
that region showed the largest number of spatial clusters with high VC and high similarity
presented clusters of low VC and a negative influence on neighboring municipalities
which analyzed areas with decreased VC in Brazil from 2006 to 2016
it was shown that BCG and polio had the lowest VC rates in 2016
The study also demonstrated the heterogeneous spatial distribution of the drop in VC among the country’s various regions
the study’s 2016 results agreed with those of the present study
which reported VC to be below target in both the years
the 2016 polio VC data in the above study are not similar with that of the present study
it was observed that the Sertão Paraibano region had the largest number of municipalities showed high VC and high similarity with their neighbors
we have been observed a low VC clusters negatively influencing the neighboring municipalities
identifying areas with low VC is important to avoid epidemics of diseases preventable by vaccination and the implementation of immunization strategies
no studies could be found that analyzed VC in children aged less than 1 year using Moran’s Index to measure spatial autocorrelation
It is important to highlight the possibilities presented by this study
including the formation of a database that allowed for a more accurate VC calculation and visualization of the spatial distribution of “vaccination clusters” through spatial analysis
assessing VC through spatial analysis is an innovative approach in health care
as few Brazilian and international studies have addressed this topic that is relevant to the worldwide public health
To resolve possible inconsistencies in the data regarding the doses administered in vaccination facilities
VC for each vaccine was calculated by extracting the SI–PNI data by the place of residence
We declare that the data used are from the public domain health (link: <a href="https://datasus.saude.gov.br">https://datasus.saude.gov.br</a>) and were obtained according to the criteria of good research practice and ethical precepts
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Applying an equity lens in the Decade of Vaccines
Spatial analysis of vaccination coverage in Paraíba in 2016
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This study was funded by the Bill &amp; Melinda Gates Foundation
National Council for Scientific and Technological Development (CNPq) and Brazilian Ministry of Health
in the so-called Grand Challenges Explorations – Brazil: Data Science To Improve Maternal and Child Health in Brazil
Number of CNPq No 443790/2018–3; Fundação Bill &amp; Melinda Gates OPP 1202115
Catholic University of Santos (Universidade Católica de Santos – Programa de Pós- Graduação strictu senso em Saúde Coletiva)
Ysabely de Aguiar Pontes Pamplona &amp; Lourdes Conceição Martins
Hospital das Clínicas - Faculdade de Medicina da Universidade de São Paulo
Nairmara Soares Pimentel Cunha &amp; Sylvia Costa Lima Fahrat
design of the work; the acquisition of database
interpretation of data; and in writing the manuscript
contributed with the analysis and interpretation of the data
substantial review of the manuscript and interpretation of the data
contributed with the analysis and interpretation of the data and substantial revision of the manuscript
interpretation of data; and revised the manuscript
substantial contributions to the conception
interpretation of data and revised the manuscript
All authors read and approved the final manuscript
We are informed that all the methods were performed in accordance with the relevant guidelines and regulation
The authors declare that they have no competing interests
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DOI: https://doi.org/10.1186/s12889-022-13589-9
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