International Journal of Community Medicine and Public Health

Thakur R et al. Int J Community Med Public Health. 2020 Dec;7(12):5229-5236

http://www.ijcmph.com

pISSN 2394-6032 | eISSN 2394-6040

Review Article

DOI: https://dx.doi.org/10.18203/2394-6040.ijcmph20205209

The evaluation of immunization coverage under mission Indradhanush: a review

Ruchi Thakur1, Aanchal Anant Awasthi2*, Neha Taneja1, Rajiv Janardhanan1,2

1Laboratory of Disease and Dynamics and Molecular Epidemiology, Amity Institute of Public Health, Amity University Uttar Pradesh, Noida, India

2Health Data Analytics and Visualization Environment Laboratory Amity Institute of Public Health, Amity University Uttar Pradesh, Noida, India

Received: 30 August 2020

Accepted: 16 October 2020

*Correspondence:

Dr. Aanchal Anant Awasthi,

E-mail: aaawasthi@amity.edu

Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

The government of India introduced mission Indradhanush (MI) to strengthen the routine immunization planning and delivery mechanism. It was launched on 25th December 2014 with an objective to achieve more than 90% full immunization (FI) coverage in the country. To evaluate universal immunization coverage, barriers encountered for not achieving the target and problem solving in removing the barriers. PubMed and google scholar were used to search the relevant articles. PRISMA tool was used for the review process and for inclusion of potential articles. The studies conducted in Manipur, Madhya Pradesh, Bihar and south Kerala reported successful achievement of MI goal. The minimum FI percentage was 57% and the maximum was 96.4%. The most common reason for not achievement of the goal was lack of awareness, illiteracy, child illness, fear of adverse effects.

Keywords: MI, Evaluation, Awareness

INTRODUCTION

India’s immunization programme, launched in 1985, was one of the largest health programmes in the world. The programme provided vaccination against eight life‐threatening diseases (diphtheria, whooping cough, haemophilus influenzae type B (Hib), tetanus, polio, tuberculosis, measles and hepatitis B) in the entire country.1 After the introduction of the UIP there had been steady fall of infant mortality from 80 per 1000 live births in 1991 to 37 per 1000 live births in 2015 (SRS).2

As per NFHS-3, the immunization coverage in 12-23 months old children was 43.5% which has increased to 62% in NFHS-4.3 On 25th December 2014 union health minister Mr. J. P. Nadda has introduced MI with an objective to achieve more than 90% FI coverage within the country, which would reduce immunity gaps and strengthen immunization coverage.4

According to immunization status estimated from routine immunization monitoring and MI data, it had been estimated that annually more than 70 lakh (7 million) children in the country did not receive all vaccines that were available under the UIP.2 The first two phases of MI contributed to a rise of 6.7% points in FIC according to the integrated child health and immunization survey (INCHIS). Analysing the coverage trend and progress, it had been clearly understood that MI alone is going to be inadequate to reach the target of 90% FIC by December 2018. An intensified IMI was launched by the honourable prime minister in October 2017 to accelerate vaccination coverage and meet current gaps.4,5

The purpose of this review is to examine literature on MI. Specifically, seek to understand evaluation of universal immunization coverage, barriers encountered for not achieving target and problem solving in removing barriers.

METHODS

This paper is based on the literature review of assorted articles on MI. PubMed and other database were used to search the relevant articles. Process included assessment of literature using specific keywords such as MI, assessment/evaluation/analysis, awareness/knowledge.

Study selection

The study selection was done by using the PRISMA (preferred reporting items for the systematic review and meta-analysis) flow diagram to identify data included and excluded, and their rationale for exclusion.

The studies conducted within last five years related to awareness and utilization of MI, assessment of knowledge of care giver regarding immunization schedule in India were included. The studies were screened using their titles and abstracts then, the included studies were further thoroughly reviewed to select the potential articles.

Figure 1: Prisma flow diagram. | Records identified through database searching (n=33) Screening Included Eligibility Identification Additional records identified through other sources (n=18) Records after duplicates removed (n=33) Records screened (n=33) Records excluded (n=11) (Not related to the topic) Full-text articles assessed for eligibility (n=22) Full-text articles excluded, with reasons (n=4) (Research articles did not mention about the full, partial and no immunization status) Studies included in qualitative synthesis (n=18)
Figure 1: Prisma flow diagram.

RESULTS

Total 18 studies were reviewed. Most of the study participants belonged to the age group of 12-23 months. Out of 18 studies the minimum sample size was 100, considered in the studies conducted in Bhubaneshwar (urban slum) and Uttarakhand, maximum sample size was 108057 considered in district level analytical based study conducted in 601districts of India. Highest FI status was reported by south Kerala (96.4%) and lowest reported by study conducted in 601 districts of India (57%) (Table 1).

Coverage status for individual vaccine for different states

Out of 18 studies reviewed, coverage status for individual vaccination was given in 6 studies. Bihar has the highest BCG coverage (99.21%) followed by Manipur (98.6%), Telangana (96.7%) and Vellore (93.5%). The coverage of Penta (1, 2 and 3) and OPV (1, 2 and 3) was found highest in Manipur (98.6%). Telangana has reported highest measles coverage (96.7%) followed by Manipur (96.2%) and Bihar (92.5%) (Table 2).

Table 1: Immunization coverage status of various states.
Table reproduced from source PDF page 3, part 1 of 2
Table reproduced from source PDF page 4, part 2 of 2

*NA indicates not available.

Table 2: Coverage status for individual vaccine for different states.
Table reproduced from source PDF page 5

*NA indicates not available

Reason for partial/no immunization

Most common reason for partial and NI was lack of information/awareness (69.23%) followed by illiteracy, childhood illness, fear of adverse effects (30.76%) each, mother too busy (23.07%), unavailability of vaccination, religion disparity and vaccination site too far away from home (15.38%) each (Table 3).

Table 3: Reason for partial and no immunization (n=13).
Table reproduced from source PDF page 5

Solutions to overcome barriers

Most of the studies suggested that imparting health education to parents/guardians (58.33%) regarding importance of immunization, its benefits, immunization schedule will be helpful in achieving universal immunization coverage and will reduce drop outs rates. (33.33%) studies focused on strengthening IEC services. Few studies suggested that measures should be taken to increase institutional deliveries and active involvement of ASHA (accredited social health activist) workers (25%). (16.66%) studies concluded that education to health workers about correct vaccination schedule and need for adherence to the schedule is essential (Table 4).

Table 4: Solution to overcome the barriers (n=12).
Table reproduced from source PDF page 5

MI coverage status

Out of 18 studies,16 studies in which FI was reported were considered to assess the MI coverage status. Studies conducted in Manipur, Madhya Pradesh, South Kerala and Bihar reported successful achievement of 90% immunization coverage (Figure 2).

Figure 2: MI coverage status (n=16). | 4 12 Achieved Not Achieved
Figure 2: MI coverage status (n=16).

DISCUSSION

The national family health survey (NFHS-4) conducted during 2015-16, contains some key indicators that reflects the country’s present status. The key indicators include infant and child mortality rates, maternal and child health, child immunization and vitamin A supplementation, child feeding practices, nutritional status and many more..24 As per the analysis of NFHS-4, infant mortality rate (IMR) has reduced from 57 to 41 per thousand live births and a higher reduction has been seen in under-5-mortality rate from 74 to 50 per thousand live births. The state with the highest IMR was Uttar Pradesh (64 per 1000 live births) and that with the lowest IMR was Kerala (6 per 1000 live births).3 At the national level, the percentage of children aged 12-23 months who were fully immunised (one dose of BCG, three doses of diphtheria, pertussis and tetanus (DPT) vaccine, and one dose of measles vaccine) increased by 18% points from 44% in 2005-06 to 62% in 2015-16.24

A study conducted in Bihar reported higher BCG (99.2%), OPV (1, 2, 3) (97.2%) and measles coverage (92.5%) which was comparatively higher than that reported in NFHS-4.25 A study conducted in Ahmedabad district of Gujarat reported BCG coverage (85.7%) and measles coverage (74.6%) which was similar to the data reported by NFHS-4.26 A district level analysis done in India reported BCG coverage (85.9%), DPT (1, 2, 3) (70.7%) and measles coverage (71.2%) which in contrast was lower than the NFHS-4 data fact sheet.27 Similarly study conducted in Telangana reported BCG coverage (96.7%) which was similar to the NFHS-4 fact sheet, whereas measles coverage (85.3%) which was comparatively lower than the data reported by NFHS-4 fact sheet.28

All the sixteen studies reviewed for the evaluation of universal immunization coverage concluded that four states have achieved the MI goal that was Madhya Pradesh (91.2%), Bihar (90.85%), Manipur (91.90%) and South Kerala (96.40%). Some states have achieved more than 80% immunization coverage such as Telangana (83.60%) and Vellore (84%).11-13,15,18,21

Most common reason reported for partial and no immunization includes lack of information, illiteracy, childhood illness, mother too busy in their work, unavailability of vaccination at health centres, religion disparity and vaccination site too far away from home. A study conducted in Madhya Pradesh revealed that more than 90% of the children were completely immunized or fully immunized which were only 69% before the implementation of MI programme. Other than the most common barriers, this study focused on various other determinants such as myths about vaccination like impotency, disease and death, lack of interest of villagers towards vaccination and migration of villagers as a responsible factors for not availing 100% immunization.13 A study conducted in south India (Vellore) mentioned that misplaced vaccination card on due date and unavailability of health care workers at the immunization site to record the date of immunization were also some of the other determinants for partial or no immunization.15

Most of the studies reported certain common solutions to remove barriers in achieving full immunization coverage such as promoting health education campaigns, strengthening IEC services related to MI program, promoting institutional deliveries, active involvement of ASHA worker in immunization awareness program and at immunization session site and education to health workers.

Apart from all these solutions, a study conducted in Lucknow (Uttar Pradesh) suggested that surveillance and referral system in the area needs to be reinforced so as to identify defaulters of immunization and to reduce dropout rates.14 Whereas a study conducted in Mumbai emphasis on scaling up use of post-natal services and a study conducted in Madhya Pradesh suggested the need for intensive planning of immunization campaigns.9,13

A descriptive study conducted in urban slum of Ludhiana found that only 0.5% mothers had good knowledge regarding immunization, on contrary a cross sectional study conducted in south Kerala revealed, 48% of mothers had good knowledge.18,23 A study conducted in Bangalore concluded 72.7% care givers had good knowledge, 21.8% had average knowledge and 5.40% have poor knowledge.20

Furthermore, a cross-sectional study conducted. in Madhya Pradesh (Indore) revealed,88% care givers were aware about immunization.13 A cross sectional study conducted among 100 selected mothers in Rudraprayag town of Uttarakhand found that 97% mothers have adequate knowledge regarding immunization and vaccination whereas only 3% have inadequate knowledge.19

Strengths and limitations

The review has provided summary statistics of MI in last 5 years. Information related to number of immunization session planned under the program, evaluation of cold chain and logistics managements, human resource availability at the immunization session site were not included due to unavailability of the information in the selected articles.

CONCLUSION

The most common reason for not achievement of MI goal was lack of awareness, illiteracy, child illness and fear of adverse effects. Further research studies could be conducted to evaluate health system readiness for MI. This would be helpful in identifying the bottlenecks in implementation of the program and formulation of strategies to overcome it.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: Not required

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