Immunization status of children admitted to a tertiary hospital in India

INTRODUCTION

To date, immunization has turned out to be one of the most cost-effective public health interventions. It has helped in saving millions of lives and has also played an important part in preventing disability and illness in countless children. Global coverage rates for the third dose of the diphtheria, tetanus and pertussis vaccine (DTP3) had increased to 86.0% in 2018 from 72.0% in 2000 and 20.0% in 1980. However, it has not improved over this decade. The Global vaccine action plan target of 90.0% or greater coverage of DTP3 has not yet been achieved by 83 countries.¹ Moreover, over last several years the proportion of the world’s children who receive recommended vaccines has not changed much.² One of the most noticeable finding in the National Health and Family Survey (NHFS) over the years has been the decline in the number of children fully immunized (Bacillus Calmette Gurein (BCG), measles and 3 doses each of oral polio vaccine (OPV) and DTP) in the 12-23 months age group for the state of Maharashtra. The figures have come down from 78.4% in NHFS 2 to 58.8 in NFHS 3 and the present 56.3% as per NFHS4.^3,4 This trend is alarming. There is a paucity of data on the determinants of incomplete immunization in an urban area especially in a population already in connect with health care system. Hence this study was undertaken to detect the status of immunization and factors determining immunization status in children from an urban population already utilizing the health care facilities.

Objectives

• • To find the status of immunization of 12 to 23 months age children admitted to pediatric wards of a tertiary care hospital.
• • To ascertain factors affecting the immunization status of the study population.

METHODS

This was a prospective, cross sectional, observational, hospital-based study. The study was carried out in the Pediatric wards of a tertiary care teaching hospital.

Inclusion criteria

• • All children from 12 months to 23 months admitted to Pediatric ward of the hospital were included in this study over a four-month period (January to April 2018).

Exclusion criteria

• • Only critically ill patients were excluded.

The study was approved by the Institutional Ethics Committee. An informed consent was obtained from each subject. The caretaker, preferably mother if available, was interviewed. Information was entered in a proforma prepared to record the details of immunization as well as demographic information, gender, birth order, place and method of delivery, place of immunization, education of the father and mother independently and the employment status of both the parents. For children with incomplete immunization/ no immunization the possible reasons for not completing the immunization were recorded. The vaccines used in the national immunization program were considered while assessing immunization status, viz., BCG vaccine, OPV, DPT vaccine and the measles vaccine. OPV received on national immunization days were not considered.

Immunization status was confirmed from the record of vaccination cards whenever available. In absence of immunization card, history obtained from parents was considered. A child who has received BCG vaccine after birth, three doses of DPT and OPV, and one dose of measles vaccine were deemed to be completely immunized. A child who had not received any vaccine listed above were considered unimmunized. All children between complete immunization and no immunization were considered incompletely/partially immunized. Partially immunized and unimmunized children were studied together as a group. The children who were incompletely immunized/unimmunized were administered the pending immunizations before discharge from the hospital.

For a power of 80 and alpha of 0.05, sample size was calculated as 237 using a previous study in which the proportion of completely immunized children was 76.0%.⁵

Statistical analysis

The data was analyzed using Microsoft excel, primer of biostatistics and the Minitab software. Chi square test was applied to find out the significance of association between various factors and immunization status and a p-value <0.05 was taken as significant.

RESULTS

A total 418 children fulfilling the inclusion criteria were included in the study. There were 276 boys and 142 girls in this population with a male to female ratio of 1.94:1. The demographics of the study subjects is shown in Table 1.

As seen in Figure 1, a total of 294 (70.3%) children out of 418 were completely immunized for age. Out of the 124 remaining children, 8 (1.9%) were totally unimmunized while 116 (27.8%) were incompletely immunized for age.

When considering only Pulse Polio immunization, 384 (91.9%) had received both the doses while single dose was received by 8 (1.9%) and no doses by 26 (6.2%). On considering the reasons given by the caretakers for incomplete or no immunization (Table 2), absence of knowledge about immunization was the most common reason. Other common reasons included ‘child not well’ at the scheduled date of immunization, no information about place of vaccination, fear of untoward effects and child gone to native place at scheduled date of vaccination. Miscellaneous causes put forth by the parent for incomplete immunization included loss of wages in three, sibling not well in one, mother not well in two and neither parent available in two.

When the statistical association between various factors and immunization status was studied (Table 3), birth order more than second, mother’s education, father’s education, mode of delivery, place of delivery and employment status (both paternal and maternal) were associated with the immunization status of the child where as sex of the child, availability of immunization card, place of immunization and migrant status were not related with level of immunization.

*Hospital based study.

DISCUSSION

In 1974, the expanded program on immunization (EPI) was globally launched by the World Health Organization. Prevention of six common childhood vaccine-preventable diseases by the year 2000 was the main objective of this program. This program was endorsed in 1978 by Government of India. Subsequently, on November 19, 1985, India introduced the Universal Immunization Program with the focus on covering not less than 85.0% of all infants by 1990.⁶ The National population policy 2000 set a goal to achieve universal immunization of children against all vaccine preventable diseases by 2010.⁷

Several factors play a role in the variations seen in immunization of children. These factors may be related to the individual characteristics like gender and birth order or may be family related viz. area of residence, socio-economic status and education level of parents. Demographic characteristics like religion and caste as well as factors specific to the society like ease of access to and availability of health-care, health seeking behavior etc., also contribute to the inequities. An environment needs to be created, wherein each child in the country gets an equal opportunity of immunization. Also, groups at greatest risk of remaining unvaccinated need to be recognized, these measures may contribute to equity in immunization bridging the imbalances as much as possible.⁸

The present study was performed to evaluate the immunization status of children attending a health care facility as well as to find out the reasons and factors associated with incomplete immunization. In this study, authors found about 70.3% of the children were completely immunized while about 27.8% were partially immunized and nearly 1.9% were unimmunized. As seen in Table 4, similar studies have shown variable results for children completely immunized or unimmunized.^5,9-12

The wide variation in different studies probably reflects the immunization coverage in different areas of the country. Also, the present study being hospital based, the study population belonged to a group with health seeking behavior thus reflecting a larger proportion of children who had been immunized completely. Availability of immunization cards was seen in only 20.1% of study population. Other studies have shown a variable figure with some showing immunization card available in around 32.0% subjects while others showing its availability in around 74.0% subjects.^9,13 Maintenance of immunization records is of great importance and needs to be stressed during the immunization visits. Also, the caregiver needs to be advised to carry the immunization card with them for all child health related visits as well as during change of residence for a longer time. 81.0% of the partially immunized children had been immunized by pulse polio immunization which is similar to a study carried out by Kumar D et al.⁹

Out of the children who were not completely immunized, the most common reason was absence of knowledge about immunization (46.7%) followed by ‘child not being well’ at scheduled time of vaccination (16.9%) and lack of information about place and time of vaccination (16.1%). Fear of untoward effects of vaccination was also one of the common reasons (10.4%) given by the parent. Several other studies have given similar reasons for incomplete immunization.^5,9-12 These findings demonstrate the need of continuous activities and efforts to spread knowledge about vaccination and its benefits. Use of mass media like television and utilization of services of prominent personalities in the field of arts and/or sports can be considered as was done in the case of pulse polio immunization campaign should also be considered. Minor illnesses are no contraindications for routine immunization. This fact needs to be reinforced repeatedly in the minds of health care workers as well as parents especially mothers during counseling at time of discharge after delivery. Similarly, the fear of untoward effects needs to be dispelled from the minds of the parents. Serious adverse effects after immunization are extremely rare and the benefits of vaccination far outweigh the risk.

The present study also attempted to determine the factors which were associated with incomplete immunization. Children delivered by caesarean section and those delivered institutionally were significantly more likely to be completely immunized. Similar findings were also reported by Kumar D et al.⁹ Place where the delivery occurred was also shown to be significantly related with the immunization status by some other studies.^11,12,14,15 Mothers who deliver at home in general tend to be poor users of health services. More focus on ensuring that all deliveries take place at an institution may indirectly help in improving immunization coverage. Also, delivery at hospital ensures early start to the routine immunization and more information imparted to the parents regarding subsequent immunizations. Birth order more than second was associated statistically with incomplete immunization. This has also been demonstrated in other studies.^12,14 Studies have showed that later born children are a disadvantaged group within the family with respect to health outcomes.¹⁶ Higher order of births had lower vaccination coverage as per analysis of the first 3 NFHS surveys.⁸

Education of the mother and father independently were significantly associated with incomplete immunization. Illiteracy has been shown to be associated with partial and unimmunized children in several studies.^9-12 A direct relationship has been found between paternal education and vaccination status of children by previous studies.^17,18 Similarly, several other studies have documented relationship between maternal education and immunization status.^14,19-22 Parental education, both maternal and paternal is an important indicator of the child’s immunization. In situations where both the parents were employed, the chances of the child being incompletely immunized was significantly higher. A study by Nath et al, found that the most common factor associated with incomplete immunization of a child was absence of both parents due to their being occupied with activities for livelihood.²³

The present study did not find any statistical relationship between immunization status and factors like gender of the child, place of immunization, presence of immunization card and whether the child belonged to a migrant family.

It is the right of every child to receive complete immunization against preventable childhood diseases. With the aim of strengthening and invigorating the program and to rapidly cover all children as far as immunization is concerned. Mission Indradhanush was launched by the Government of India in December 2014. Complete immunization with all available vaccines for children up to two years and pregnant women is the objective of this program.²⁴ This study illustrates the likely factors which need to be considered for improving the overall immunization coverage.

CONCLUSION

The present study throws light on the immunization status of children in an urban population with health seeking behaviour. Better communication with and education of parents during antenatal visits, delivery period and during routine health visits may help in reducing the number of children remaining incompletely immunized. Special focus needs to be placed on finding those groups with high chances of remaining incompletely unimmunized so as to achieve optimum results with missions like Indradhanush.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

REFERENCES

1. 1. Unicef.org. New York: UNICEF. Available at: https://data.unicef.org/topic/child-health/immunization/. Accessed on 2^nd March 2020.
2. 2. WHO. int. Geneva: World Health Organization. Available from https://www.who.int/en/news-room/fact-sheets/detail/immunization-coverage. Accessed on 2^nd March 2020.
3. 3. International Institute for Population Sciences. India National Family Health Survey (NFHS-3), 2005-06. Mumbai: International Institute for Population Sciences, 2007. Available at: http://rchiips.org/NFHS/pdf/Maharashtra.pdf. Accessed on 2^nd March 2020.
4. 4. International Institute for Population Sciences. India National Family Health Survey (NFHS-4), 2015-16. Mumbai: International Institute for Population Sciences, 2017. Available at: http://rchiips.org/NFHS/pdf/NFHS4/MH_FactSheet.pdf. Accessed on 2^nd March 2020.
5. 5. Muranjan M, Mehta C, Pakhare A. An observational, health service-based survey for missed opportunities for immunization. Indian Pediatr. 2011;48:633-6.
6. 6. Chapter VI. Annual report. Ministry of Health and family Welfare: New Delhi; 1992-93:2.
7. 7. National Health Portal. National Population policy 2000. New Delhi, National Health Portal; 2015.
8. 8. Mathew JL. Inequity in childhood immunization in India: a systematic review. Indian Pediatr. 2012;49:203-23.
9. 9. Kumar D, Aggarwal A, Gomber S. Immunization status of children admitted to a tertiary care hospital of north India: reasons for partial immunization or non-immiunization. J Health Popul Nutr. 2010;28:300-4.
10. 10. Agrawal SC, Kumari A. Immunization status of children and the influence of social factors: A hospital-based study in western Uttar Pradesh. Pediatr Infect Dis. 2014;6:25-30.
11. 11. Imran SS, Ramzan M, Maqsood I. Status of immunization of children and factors related to partial and non-immunization. Biomed. 2014;30:1-4
12. 12. Gupta P, Prakash D, Srivastava JP. Determinants of immunization coverage in Lucknow district. North Am J Med Sci. 2015;7:36-40.
13. 13. Saxena P, Prakash D, Saxena V, Kansal S. Assessment of routine immunization in urban slum of Agra district. Indian J Prev Soc Med. 2008;39:60-2.
14. 14. Nath B, Singh JV, Awasthi S, Bhushan V, Kumar V, Singh SK. A study on determinants of immunization coverage among 12-23 months old children in urban slums of Lucknow district,India. Indian J Med Sci. 2007;61:598-606.
15. 15. Jani JV, De-Schacht C, Jani IV, Bjune G. Risk factors for incomplete vaccination and missed opportunity for immunization in rural Mozambique. BMC Public Health. 2008;8:161.
16. 16. Mturi AJ, Curtis SL. The determinants of infant and child mortality in Tanzania. Health Policy Plan 1995;10:384-94.
17. 17. Xeuatvongsa A, Hachiya M, Miyano S, Mizoue T, Kitamura T. Determination of factors affecting the vaccination status of children aged 12-35 months in Lao People's Democratic Republic. Heliyon. 2017;21:e00265.
18. 18. Torun SD, Bakirci N. Vaccination coverage and reasons for non-vaccination in a district of Istanbul. BMC Public Health. 2006;5:125.
19. 19. Singh P, Yadav RJ. Immunization status of children of India. Indian Pediatr. 2000;37:1194-9.
20. 20. Yadav JR, Singh P. Immunization status of children and mothers in the state of Madhya Pradesh. Indian J Community Med. 2004;29:147-8.
21. 21. Suresh K, Saxena D. Trends and determinants of immunization. coverage in India. J Indian Med Assoc. 2000;98:10-4.
22. 22. Maina LC, Karanja S, Kombich J. Immunization coverage and its determinants among children aged 12-23 months in a peri-urban area of Kenya. Pan Afr Med J. 2013;14:3.
23. 23. Nath B, Singh JV, Awasthi S, Bhushan V, Kumar V, Singh SK. A study on determinants of immunization coverage among 12-23 months old children in urban slums of Lucknow district, India. Indian J Med Sci. 2007;61:598-606.
24. 24. Immunization Technical Support Unit-MOHFW; itsuorg.wordpress.com. New Delhi. Available at: https://itsuorg.wordpress.com/2016/10/12/mission-indradhanush-for-seven-vaccine-preventable-diseases/. Accessed on 2^nd March 2020.