This map illustrates vaccine equity and is interesting in and of itself. But the purpose of this post is different: to highlight the indicator used to construct it. Global comparisons of vaccination progress commonly use vaccination rates and vaccine coverage ratios. But these suffer from serious drawbacks and often produce apple-and-orange comparisons. We have a solution.
Cross-country comparisons of global vaccination progress typically use vaccination rates, vaccine coverage ratios or some combination of both. The problem is that all of these indicators suffer from serious drawbacks. We can think of four:
First, vaccination rates require data that are not always contemporaneously available, including for some of the largest countries in the world. Vaccination rates are indicators in the people space. For example, the share of people fully vaccinated. Or the share of people partially vaccinated, with at least 1 dose or exactly 1 dose, 2 doses or even 3 doses. These indicators provide detail and, unsurprisingly, also require detail to construct them: they require a comparison of vaccination progress against established vaccine protocols at the level of each individual and each protocol.
Several countries however do not regularly publish information on the split between full and partial vaccination. Some countries have yet to produce any data at all. Others do publish the data but only irregularly. This complicates individual country comparison. It also complicates the aggregation of data into global totals, regional totals or totals by income group. This can be particularly problematic if the country is large, as is the case of China.
Let’s zoom into the Chinese data to illustrate this, even though the issue arises in many other countries too (check this post for additional detail):
Similar issues apply to other vaccination rates for China (e.g. vaccination rate with at least 1 dose).
Second, data issues aside, vaccination rates by themselves offer a highly partial view of vaccination progress. They’re detailed and that comes with the drawback that they only capture the detail being measured. Take for example countries A and B that are respectively 5 and 10% fully vaccinated and 80% and 10% vaccinated with at least 1 dose. Most would agree that A is ahead of B thanks to the progress on partial vaccination. But such a conclusion would only be possible by examining both indicators. If we had just looked at the full vaccination rate we would have concluded that B is better off.
Third, vaccine coverage ratios almost always lead to incorrect comparisons across countries because they do not control for the type of vaccine protocols in place (1, 2 vs 3 doses). Vaccine coverage ratios are indicators in the dose space. They’re ratios because the numerator is not part of the denominator. For example, the ratio of total doses administered relative to the size of the total population. This indicator is commonly used for cross-country comparison. Unfortunately, it is almost always used incorrectly. Two reasons:
Equally problematic is that the full-vaccination milestone would vary from country to country depending on the mix of vaccines in use. Not only would we therefore not be able to compare vaccination progress across countries, we would also lack a common measure of the distance that still needs to be travelled to achieve full vaccination. If we’re at 50 doses per 100 people, will we have completed population-level vaccination when we reach 100, 200, 300 or somewhere in between? There is no way to tell since the threshold will depend on the mix of vaccines used. If we only use single-dose protocols, 100 would be the goal post. It would be 200 or 300 if we only used double- or triple-dose protocols. It would be somewhere in the middle if we use a mix.
Fourth, many make comparisons in the dose space by lumping together primary vaccinations and booster doses, which distorts the measurement of progress. There are two issues here:
From the perspective of vaccine equity, we note that a large share of the global population has yet to get a first shot and an even-larger share has yet to complete the primary vaccination cycle. By lumping primary vaccinations and boosters, we can’t measure the degree of inequity accurately. Having a well-vaccinated population that starts boosting certainly enlarges vaccine inequity if other countries remain poorly vaccinated on their primary cycle. But it is often necessary to make comparisons based on primary vaccinations only if we are to assess the extent to which countries lag behind on these primary cycles.
The typical response is that we can skirt around the issues by using multiple indicators simultaneously, but that’s not really a solution. While complementing eg the full vaccination rate with a partial vaccination concept provides a more complete picture, it does not resolve the data availability issues. And it does not resolve the other weaknesses mentioned earlier that affect individual indicators. On top of that, considering multiple indicators simultaneously also creates an additional problem: confusion. Individual indicators move in different directions and tell different stories.
We need an alternative approach. One that is less onerous in terms of data requirements, yields accurate comparisons and, ideally, combines sufficient information in a single indicator.
Here’s a proposed solution: “Primary doses administered converted into double-dose vaccine equivalents per 100 people”.
The indicator combines features of the vaccination rate (which embeds information about the protocol used) and the vaccine coverage ratio (which uses doses that are available easily). What distinguishes it from the simple doses per capita measure is that doses have been adjusted. They’ve been converted into double-dose equivalents (DDEs).
What are DDEs?
Converting into DDEs means that we multiply the number of single doses administered by 2 for a single-dose protocol and 2/3 for a three-dose protocol. So if a country had administered 100 doses under a single-dose protocol, we would count it as 200 adjusted doses. Conversely, if a country had administered 300 doses under a three-dose protocol, the number of adjusted doses would be 200. In both cases, we achieve full population coverage at 200 DDE-adjusted doses per 100 people.
This approach is less demanding in terms of the data that is required. It requires data about single versus multiple dose vaccinations, but it is agnostic and therefore less demanding about whether a dose of a multiple-dose vaccine represents full or partial vaccination. That helps as for several countries such data are not available on a timely basis.
Another advantage is that the indicator combines information about vaccination progress towards full coverage in a single number. With it, we can show a single map (as above) and don’t have to show two different maps to cover eg full and partial vaccination.
With the adjustment, we can finally accurately compare countries’ progress in the dose space regardless of the vaccine mix being used. We also have a common threshold of full coverage at 200 doses per 100 people. This threshold is invariant across countries and over time. It is a steady milestone against which progress can be evaluated.
So let’s consider changing, or at least complementing, the way we compare vaccination progress across countries. The DDE indicator is not perfect in that it does require information on different protocols (which is not always available everywhere). But it does considerably improve over vaccine coverage ratios in terms of the accuracy of comparison, can be less onerous data-wise than vaccination rates, and is much simpler communication-wise than using a slew of indicators each covering a partial aspect of the full picture.
Note on Cuban vaccines and data:
Cuba is notable not only for its impressive vaccination record thus far, but also for the fact that it has developed several vaccines of its own. What also sets Cuba apart is that the vaccines it has developed are not your typical 2-dose regimen. Cuba currently administers three types of protocols: Abdala (3-dose vaccine), Soberana 2 combined with Soberana Plus (considered a 3-dose vaccine for children) and Soberana Plus stand-alone (considered a 1-dose vaccine for those with prior COVID). Note that in the data Cuba publishes, Soberana Plus when combined with Soberana 2 is treated as the third dose of a three-dose vaccination protocol and not as a booster.
How do we take into account this diversity of vaccines in the DDE indicator? The logic is simple but getting the numbers adjusted requires a few permutations. We first need to scrape the data making sure we include among our variables the numbers for (1) total doses administered, (2) people vaccinated with three doses and (3) people fully vaccinated (data which is presently not available at Our World in Data). Total doses administered under the 1-dose protocol (Soberana Plus stand-alone) then equal (3) – (2), whereas total doses under 3-dose protocols (Abdala and the Soberana 2 and Plus mix) equal (1) – (3) + (2) . The next step is to multiply the single-dose protocol doses by 2 and the three-dose protocol doses by 2/3. Add up everything and then we have our adjusted measure that is comparable across countries.
The Cuban case clearly illustrates the value of the indicator. Let’s look at some data for October 29, 2021. If we were to use unadjusted doses per capita, Cuba’s vaccine coverage rate would stand at 225 doses per 100 people – the highest in the world among 196 countries. The adjusted coverage ratio on the other hand would be 154 doses per 100 people. This is a lot lower than the unadjusted number because currently about 99% of Cuban vaccine doses administered require three shots. Even so, late October 2021, Cuba remained among the top of the developing world, surpassed only by Cambodia and China, and globally (among all countries including also the high-income countries) it was the 16th most-vaccinated place.