Introduction:
India has been one of the first countries to adopt the World Health Organization’s Expanded Programme of Immunization (EPI). The program started globally in 1974 and was initiated in India in 1978. Since its inception, considerable progress has been made in terms of reduction in disease burden. Despite these achievements and tremendous advances in economic and technological spheres in recent years, the burden of vaccine-preventable diseases remains unacceptably high, in comparison to developed countries and also many developing countries.(1)
There is gradual, albeit a slow progress in the performance of routine immunization (RI)in India over last few years. There is marginal improvement in many states recently. Six states with high population contribute to 80% of 8.1 million unimmunized children in the country out of which 52% of the total unimmunized reside in Uttar Pradesh and Bihar alone.(2) According to DLHS 07-08(District Level Household and Facility survey), in Uttar Pradesh, only 30.3% children aged 12-23 months were fully immunized.(3) Uttar Pradesh, the most populous Indian State, with nearly 11 million urban poor, houses the largest number of urban poor in a single state. Not only does the state have a heavy burden of poverty, it also ranks low in terms of other social indicators among the states in the country. United Nation Development Programme's (UNDP) Urban Poverty Report, 2009 has pegged the number of slum dwellers in Uttar Pradesh at 44 lakh.(4)
With this background this study was planned to find out the immunization coverage in the slums of one of the biggest industrial city of Kanpur Nagar, Uttar Pradesh.
Materials and Methods
The present cross sectional study was carried out in slums of Kanpur Nagar from January 2013-August 2013 using 30 cluster sampling technique proposed by WHO. The study sample included 30 clusters from 380 identified urban slums of Kanpur Nagar District.
A list of all the slums with their population under Kanpur Nagar District was procured. A cluster interval of 18147 was obtained by dividing the total cumulative population by 30 (no. of clusters). A random number (10449) less than the cluster interval were generated with the help of currency note. The cluster, which represents the number, was picked up as the first cluster and subsequent clusters were selected by adding the cluster interval to the selected cluster population. In this way 30 clusters were selected. Mothers of seven children aged 12-23 months were interviewed from each cluster on pre tested, predesigned questionnaire, thus giving us the sample size of 210.
The immunization status of the child was assessed by vaccination card, BCG scar and mother's recall where vaccination card was not available. If the mother could not remember regarding the vaccination or in presence of any other confounding factors the child was considered as not immunized with the vaccine under consideration.
The coverage of BCG, OPV, DPT, Hepatitis B & Measles vaccine was taken under consideration. The results were categorized into three groups of Completely, Partially and Unimmunized children. The OPV given in Pulse Polio Immunization (PPI) was not considered for classification. Child was considered fully immunized if it received BCG (1), DPT (3), OPV (3), and measles (1); partially immunized if some doses were given but immunization not completed and unimmunized if received none of these vaccines.
Drop out rate for OPV/DPT I-III was calculated as: [(No.of children received the 1st dose – No.of children received the 3rd dose of the vaccine) x 100]/[No. received the 1st dose of the vaccine]
Overall Drop out rate = [(BCG coverage-Measles coverage)/BCG Coverage]×100
Statistical analysis: The collected data was analysed using appropriate statistical tools like percentages, chi square test etc., and conclusions were drawn accordingly. P values < 0.05 were considered significant.
Results
Out of 210 children, 51.43% were males and 48.57% were females. Majority of the study subjects were Hindus (86.70%) while 13.30% were Muslim. Maximum (48.57%) study subjects belonged to OBC category followed by SC/ST (32.38%) and General category(19.05%). Socio-economic status was assessed according to Modified Kuppuswamy socio economic classification. A total of 79% study subjects belonged to social class IV followed by social class III (12.9%) and social class V(8.1%). No study subjects belonged to class I & II.(Table 1)
In the present study 52.38% study subjects were fully immunized, 29.52% were partially immunized and 18.10% were not immunized. Among males were 58.33% fully immunized as compared to 46.08% females; however the difference was not statistically significant (c2 =3.158, df =1, p>.05)(Table 2). Immunization card was available with 45.70% study subjects .
Of the study subjects, 62.79% had received immunization at anganwadi centre while only 3.49% study subjects availed services at private hospital. Total of 33.72% children received immunization at government hospitals.
Immunization Coverage was highest for BCG vaccine (81.90%) followed by DPT/OPV 1 (81%), DPT/OPV3(60%), Measles (52.90%) and lowest for hepatitis B3(41.90%). Immunization Coverage of all the vaccine was higher for males as compared to females.(Table 3)
Drop out rate for DPT /OPV (I-III), DPTI – Measles and Overall drop out rate (BCG – Measles) was 25.88%, 34.70% and 35.46% respectively. The dropout rate was found more among females as compared to males for all the vaccines.(Table 4)
Table 1: Socio Demographic profile of study subjects |
| Characteristics |
No. |
% |
Sex |
Male |
108 |
51.43 |
Female |
102 |
48.57 |
Religion |
Hindu |
182 |
86.70 |
Muslims |
28 |
13.30 |
Caste |
General |
40 |
19.05 |
OBC |
102 |
48.57 |
SC/ST |
68 |
32.38 |
Type of Family |
Nuclear |
136 |
64.76 |
Joint |
74 |
35.24 |
Social class* |
III |
27 |
12.90 |
IV |
166 |
79.00 |
V |
17 |
8.10 |
*according to Modified Kuppuswamy Socioeconomic Classification
Table 2:Immunization status of study subjects |
| Immunization status |
Male (%) |
Female (%) |
Total (%) |
Fully Immunized |
63 (58.33) |
47 (46.08) |
110 (52.38) |
Partially Immunized |
32 (29.63) |
30 (29.41) |
62 (29.52) |
Un-Immunized |
13 (12.04) |
25 (24.51) |
38 (18.10) |
Total |
108 (100) |
102 (100) |
210 (100) |
Table 3: Coverage of different vaccines included in UIP(Universal Immunization Programme) |
| Individual vaccines |
Male % |
Female (%) |
Total |
% |
P value |
BCG |
96 (88.88) |
76 (74.51) |
172 |
81.90 |
P<.05 |
DPT1/OPV1 |
93 (86.11) |
77 (75.49) |
170 |
81.00 |
p>.05 |
DPT 2/OPV2 |
78 (72.22) |
63 (61.76) |
141 |
67.10 |
p>.05 |
DPT 3/OPV3 |
70 (64.81) |
56 (54.90) |
126 |
60.00 |
p>.05 |
HEPATITISB1 |
65 (60.19) |
57 (55.88) |
122 |
58.10 |
p>.05 |
HEPATITISB2 |
60 (55.56) |
42 (41.18) |
102 |
48.10 |
p<.05 |
HEPATITISB3 |
51 (47.22) |
37 (36.27) |
88 |
41.90 |
p>.05 |
MEASLES |
63 (58.33) |
48 (47.06) |
111 |
52.90 |
p>.05 |
Table 4:Drop out rate for various vaccines |
| Drop out rate |
Male (%) |
Female (%) |
Total (%) |
DPT(I –III) |
24.73 |
27.27 |
25.88 |
OPV (I –III) |
24.73 |
27.27 |
25.88 |
BCG – Measles |
34.37 |
36.84 |
35.46 |
DPTI – Measles |
32.26 |
37.66 |
34.70 |
Discussion
In the present study, 52.38% study subjects were fully immunized which is more than that of the U.P. status (23% & 30.3%) according to NFHS-3(National Family Health Survey)(5) and DLHS-3(Uttar Pradesh)(3) respectively. The proportion of fully immunized children found in the present study was low in comparison to similar studies done in Jamnagar (73%) (6) and Goa (85%).(7) This could be due to interstate variation in infrastructure and implementation of health programmes. A World Bank report by Ramana et al(8) reported a complete immunization coverage of the slums of Bangalore, Delhi, Hyderabad and Kolkatta at 50%, 62%, 50% and 57% respectively. AM Kadri et al (9) in their study in urban slums of Ahmedabad (Gujarat)found that 62.7% of children were fully immunized.
The present study revealed that percentage of fully immunized was more for male (58.33%) than female (46.08%). Similar trend was also seen in studies done by S Yadav et al (6), RK Phuken et al (10), Varsha Chuadhary et al.(11) V Bhatia et al (2004)(12) however found no sex wise difference in their study in urban slums of Chandigarh. In contrast Rashmi Sharma et al (13) observed the proportion of fully immunized children was higher in females (27.3%) than males.(23.4%)
Sharma et al (13) found 51.7% partially immunized and 23.1% non immunized children which was much higher than the present study where corresponding figures are 29.52% and 18.10% while Chopra H et al (14) had reported lower percentage (5.25 %) of partially immunized children when compared to our study.
In our study 81.90% are immunized with BCG, 60% with OPV3 & DPT3 and 52.90% with Measles. These rates are higher than the study conducted by Timsi Jain et al (15) and Sharma et al.(13) The Hepatitis B3 coverage in the present study was 41.90% where as Sandeep Sachdeva et al (16) reported 44.60% coverage for the same in their study in Delhi.
P Chhabra et al (17) in their study in Delhi also reported high level of BCG coverage (82.7%), higher level of OPV3, DPT3 (70.7% both) and 65.3% for measles. Higher coverage rates than our study were also reported by S Yadav et al (6) and Rajaat Vohra et al.(18)
The drop out rate for OPV(I-III) & DPT (I-III) in our study was 25.88%. The corresponding figures revealed by Bholanath et al (19) was 23.6% in Lucknow, and 24.8% by Timsi Jain et al (15) in Meerut (Uttar Pradesh). Varsha Chudhary et al (11) found drop out rate of 19.76% for the same in Bareilly. The main reason for dropout of the children may be ignorance and illiteracy among parents which can be improved through effective communication efforts and other awareness campaigns.
The overall drop out rate ( i.e from BCG - measles) was 35.46 % in the present study which is similar to the results obtained by Bhola nath et al (33.24%).(19) Singh CM et al (20) and Sharma et al (13) however reported much higher overall drop out rate when compared to our study . They found a drop out rate of 48.1% in Etawah(Uttar Pradesh) and 60.2% in Surat, Gujarat respectively.
Conclusion:
The present study indicates that immunization coverage is steadily increasing but far behind than desired. Sustained efforts are required to achieve the target of universal coverage of immunization in children. Increased IEC (Information, education and communication) activities should be carried along with BCC (Behaviour Change Communication) strategy for scaling up of immunization coverage. BCC messages & tools based on characteristics of respective community viz. literacy, knowledge, myths, cultural and religious beliefs should be designed. Steps for improvement should focus on elimination of bottlenecks held responsible for high drop out rate from BCG to Measles and DPT-1 to Measles. More emphasis should be given on completing the immunization schedule.
Acknowledgement
We thank all the respondents who participated in our study. We also thank Dr Gaurav Pandey for their constant support through out the study.
References
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