Routine Childhood Immunization Coverage and Tuberculosis Incidence in ASEAN and China: Evidence from a Two-Way Fixed-Effects Panel, 2000–2022
DOI:
https://doi.org/10.65166/adzwj863Keywords:
Tuberculosis incidence, immunization coverage, DPT, measles, panel data, two-way fixed effects, ASEAN, China, health systems capacity, World Development IndicatorsAbstract
Tuberculosis (TB) incidence remains uneven across ASEAN economies and China, reflecting differences in health-system capacity and broader development conditions. This study examines whether routine immunization performance—treated as a measurable proxy for primary healthcare delivery capacity—is associated with TB incidence over time. Using a balanced country–year panel covering 11 economies from 2000 to 2022 (N = 253), the analysis constructs an Immunization Index as the mean of DPT and measles immunization coverage. The outcome is TB incidence per 100,000 population, estimated in both level and logarithmic forms. The empirical strategy combines descriptive association tests with multivariable panel regressions, including two-way fixed effects (country and year) to account for time-invariant national characteristics and common temporal shocks. In pooled and fixed-effects level models, immunization is negative but not statistically significant. In a two-way fixed-effects log specification, immunization is marginally significant (β = −0.0034, p < .10). The preferred lagged log fixed-effects model indicates a statistically significant delayed association: a one-point increase in the prior-year immunization index is associated with approximately a 0.54% reduction in current-year TB incidence (β = −0.0054, p < .01), implying roughly a 5.26% reduction for a 10-point improvement. Electricity access and internet use are consistently negative and significant in log fixed-effects models, highlighting the role of enabling infrastructure and connectivity. Findings support an interpretation of immunization performance as a system-capacity indicator linked to subsequent reductions in communicable disease burden, while recognizing the observational design and limited number of country clusters.
Downloads
References
Amponsah-Dacosta, E., Kagina, B., & Olivier, J. (2020). Health systems constraints and facilitators of human papillomavirus immunization programmes in sub-Saharan Africa: A systematic review. Health Policy and Planning, 35(6), 701–717. https://doi.org/10.1093/heapol/czaa017
Arat, A., Burström, B., Östberg, V., & Hjern, A. (2019). Social inequities in vaccination coverage among infants and pre-school children in Europe and Australia – a systematic review. BMC Public Health, 19, Article 290. https://doi.org/10.1186/s12889-019-6597-4
Atento, A. G., & Atento, R. G. (2025). A Case Study of Mercury Drug Corporation: Strategic Adaptation to Universal Healthcare and Digital Disruption in the Philippines. International Journal of Health & Business Analytics, 1(1). https://doi.org/10.65166/zhw7dd39
Atento, R. G. (2025). The credibility imperative 2025: Governance integrity, economic resilience, and strategic adaptability in Philippine diplomacy. International Journal of Health and Business Analytics, 1(2). https://doi.org/10.65166/6amaz997
Atento, R. G. O., Quinto, L. F., & Espelita, C. A. M. H. (2025b). Bridging global health workforce gaps 2050: A multilevel analysis of global demand, Philippine supply fragilities, and competency alignment. International Journal of Health and Business Analytics, 1(2), 1–30. https://doi.org/10.65166/kgbpey79
Atento, R. G. O., Quinto, L. F., Espelita, C. A. M., & San Juan, F. M. (2025c). Narrative health analytics: Integrating empathy, data, and ethics in patient-centered healthcare. International Journal of Health and Business Analytics, 1(2), 1–33. https://doi.org/10.65166/yxgx8e59
Bangura, J., Xiao, S., Qiu, D., Ouyang, F., & Chen, L. (2020). Barriers to childhood immunization in sub-Saharan Africa: A systematic review. BMC Public Health, 20, Article 1108. https://doi.org/10.1186/s12889-020-09169-4
Begha, V. (2023). Assessment of management approach and the effectiveness of primary health care systems in FCT Abuja, Nigeria. International Journal of Social Sciences and Management Research, 8(5), 149–158. https://doi.org/10.56201/ijssmr.v8.no5.2022.pg149.158
Bell, A., Fairbrother, M., & Jones, K. (2018). Fixed and random effects models: making an informed choice. Quality & Quantity, 53, 1051–1074. https://doi.org/10.1007/s11135-018-0802-x
Bermido, C. M., Quinto, L. F., & Atento, R. G. O. (2025). A qualitative thematic review of contemporary challenges affecting health professions education: Implications for higher education leadership. International Journal of Health and Business Analytics, 1(2). https://doi.org/10.65166/yfm5w791
Blanc, D., Grundy, J., Sodha, S., O'Connell, T., Von Mühlenbrock, H., Grevendonk, J., Ryman, T., Patel, M., Olayinka, F., Brooks, A., Wahl, B., Bar-Zeev, N., Nandy, R., & Lindstrand, A. (2022). Immunization programs to support primary health care and achieve universal health coverage. Vaccine. https://doi.org/10.1016/j.vaccine.2022.09.086
Brillianti, G., & Hendrati, L. (2022). Mapping of children's tuberculosis incidence by coverage of BCG immunization, malnutrition, and home environment. Jurnal Berkala Epidemiologi, 10(3), 303–311. https://doi.org/10.20473/jbe.v10i32022.303-311
Carvalho, F., Ramos-Silva, A., Pires, D., Oliveira, C., Cardoso, C., Sant'Anna, C., Lima, E., & Silva, A. (2025). BCG vaccination decline and pediatric tuberculosis rise in Brazil: spatial-temporal study. Revista de Saúde Pública, 59, 01. https://doi.org/10.11606/s1518-8787.2025059006458
Cortez, A., Melo, A., Neves, L., Resende, K., & Camargos, P. (2021). Tuberculosis in Brazil: one country, multiple realities. Jornal Brasileiro de Pneumologia, 47(2), e20200119. https://doi.org/10.36416/1806-3756/e20200119
Fernández-Val, I., & Weidner, M. (2018). Fixed Effects Estimation of Large-T Panel Data Models. Annual Review of Economics, 10(1), 109–138. https://doi.org/10.1146/annurev-economics-080217-053542
Hamaguchi, Y., Yamaguchi, T., & Yoshiyama, T. (2025). Incidence of infectious diseases in children with Mycobacterium tuberculosis in Japan. medRxiv. https://doi.org/10.1101/2025.03.26.25324665
Kropko, J., & Kubinec, R. (2020). Interpretation and identification of within-unit and cross-sectional variation in panel data models. PLoS ONE, 15(4), e0231349. https://doi.org/10.1371/journal.pone.0231349
Martinez, L., Cords, O., Liu, Q., Acuña-Villaorduña, C., Bonnet, M., Fox, G., Carvalho, A., Chan, P., Croda, J., Hill, P., López-Varela, E., Donkor, S., Fielding, K., Graham, S., Espinal, M., Kampmann, B., Reingold, A., Huerga, H., Villalba, J., … Andrews, J. (2022). Infant BCG vaccination and risk of pulmonary and extrapulmonary tuberculosis throughout the life course: a systematic review and individual participant data meta-analysis. The Lancet Global Health, 10(9), e1307–e1316. https://doi.org/10.1016/S2214-109X(22)00283-2
Nacino, G. E., & Basit, S. A. (2025). Microplastics, bacterial isolates, and antimicrobial resistance profiles in Decapterus macrosoma from Cavite, Philippines. International Journal of Health & Business Analytics, 1(2). https://doi.org/10.65166/bevs3330
Nugraha, R., & Setiyadi, N. (2025). Spatial analysis of childhood tuberculosis in Boyolali Regency. Journal La Medihealtico, 6(4), 424–431. https://doi.org/10.37899/journallamedihealtico.v6i4.2387
Pan, J., Wang, Y., Cao, L., Wang, Y., Zhao, Q., Tang, S., Gong, W., Guo, L., Liu, Z., Wen, Z., Zheng, B., & Wang, W. (2021). Impact of immunization programs on 11 childhood vaccine-preventable diseases in China: 1950–2018. The Innovation, 2(2), 100113. https://doi.org/10.1016/j.xinn.2021.100113
Pezzotti, P., Bellino, S., Prestinaci, F., Iacchini, S., Lucaroni, F., Camoni, L., Barbieri, M., Ricciardi, W., Stefanelli, P., & Rezza, G. (2018). The impact of immunization programs on 10 vaccine preventable diseases in Italy: 1900-2015. Vaccine, 36(11), 1435–1443. https://doi.org/10.1016/j.vaccine.2018.01.065
Prameswari, A., & Hendrati, L. (2024). Correlation between livable housing, BCG immunization coverage, and population density with child tuberculosis incidence in East Java Province 2020-2022. Jurnal Kesehatan Lingkungan, 16(3), 213–221. https://doi.org/10.20473/jkl.v16i3.2024.213-221
Quinto, L., & Atento, R. G. (2025). Economic Growth and Developmental Equity in Four ASEAN Economies: Linking Macroeconomic Trends to Employment and Child Nutrition (1999–2024). International Journal of Health & Business Analytics, 1(1). https://doi.org/10.65166/nq75nv94
Rüttenauer, T., & Ludwig, V. (2019). Fixed Effects Individual Slopes: Accounting and Testing for Heterogeneous Effects in Panel Data or Other Multilevel Models. Sociological Methods & Research, 52(1), 43–84. https://doi.org/10.1177/0049124120926211
Shattock, A., Johnson, H., Sim, S., Carter, A., Lambach, P., Hutubessy, R., Thompson, K., Badizadegan, K., Lambert, B., Ferrari, M., Jit, M., Fu, H., Silal, S., Hounsell, R., White, R., Mosser, J., Gaythorpe, K., Trotter, C., Lindstrand, A., … Bar-Zeev, N. (2024). Contribution of vaccination to improved survival and health: modelling 50 years of the Expanded Programme on Immunization. The Lancet, 403(10440), 2307–2316. https://doi.org/10.1016/S0140-6736(24)00850-X
Valdecantos, R., Sorrentino, M., Mercogliano, M., Giordano, V., Trama, U., Triassi, M., & Palladino, R. (2025). The structural and organizational aspects of human papillomavirus vaccine affecting immunization coverage in Europe: a systematic review. BMC Public Health, 25, Article 154. https://doi.org/10.1186/s12889-025-22343-w
Wang, Y., Liu, Q., Chen, Z., Liu, M., Chen, B., Zhao, Y., & Liu, J. (2025). Disparities in the burden of tuberculosis associated with urbanization across 178 countries and territories: an observational study. Frontiers in Public Health, 13, 1658814. https://doi.org/10.3389/fpubh.2025.1658814
Wolde, H., Clements, A., & Alene, K. (2025). Health system and environmental factors affecting global progress towards achieving End TB targets between 2015 and 2020. Journal of Global Health, 15, 04004. https://doi.org/10.7189/jogh.15.04004
Ylagan, H. M., Aguirre, K. A. G. C., Briones, L. A., Briones, P. N. P., Canapi, C. V. T., Corpuz, K. M. R., Esmelo, A. J. M., Ganacial, V. J. M., Gasid, K. M. M., Ledesma, A. F. P., Marasigan, K. V. O., Miraples, M. B., Santos, E. G. D.,
Valdez, J. F. L., & Quinto, L. F. (2025). Post-rehabilitation heavy metal contamination analysis of kangkong (Ipomoea aquatica) cultivated in the Pasig River Waterway, Manggahan Floodway. International Journal of Health & Business Analytics, 1(2). https://doi.org/10.65166/xf4mm102
Zhang, Q., Song, W., Liu, S., An, Q., Tao, N., Zhu, X., Yang, D., Wan, D., Li, Y., & Li, H. (2022). An ecological study of tuberculosis incidence in China, from 2002 to 2018. Frontiers in Public Health, 9, 766362. https://doi.org/10.3389/fpubh.2021.766362
Downloads
Published
Issue
Section
License
Copyright (c) 2026 Dr. Leah F. Quinto, Dr. Ramon George Atento, Dr. Kristoffer C. Nemis (Author)
This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.
This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.
Authors retain copyright of their articles but grant the International Journal of Health & Business Analytics (IJHBA) the right of first publication.
