Introduction:
Vaccination is one of the most successful, and cost-effective public health interventions involving the stimulation of the body’s adaptive immunity, for preventing childhood morbidity and mortality, especially in environments where children are in dire conditions of undernourishment and hygiene.(1)
Though commonly known to be given to children and adolescents, vaccines are also provided to adults. It is also a simple and efficient strategy to protect the entire populace from a series of major life-threatening diseases, known as vaccine-preventable diseases. (Sinha, 2018)[2] Vaccinations promote the prevention of an infection rather than curing it. Further, when a significant proportion of the community is vaccinated, it offers protection to the few who have not been vaccinated due to a phenomenon known as herd immunity, thus making the community safe. These significant features, overall, have a net benefit on society and global welfare. (3)
In India, the Universal Immunization Programme (UIP) has the National Immunization Schedule and is one of the most extensive health programmes globally, whose beneficiaries are infants, children, and pregnant women. As per National Family Health Survey 4, 2015-16, in India the national average for complete immunisation is 62% while 38% failed to receive complete vaccination due to various reasons. The most common reasons for incomplete immunisation were a lack of awareness and the fear of children getting Adverse Events Following Immunization (AEFI), resistance to vaccination, religious beliefs, and the child being unavailable or travelling at the time of immunisation (4,5)
A study conducted by Tikamani et.al,. to determine the vaccination status showed that 80.4% were fully vaccinated and the remaining 19% were not. Similarly, another study conducted by Ntenda et al., to determine the immunization status in a tertiary care setting in Malawi revealed that 72% were fully vaccinated, 26% were under vaccinated and about 2% were non-vaccinated. These studies also showed that lack of awareness of vaccination, busy parents, illness of children and poor households were the most common reasons for incomplete vaccination.(6)
The study was framed with an aim to evaluate the status of vaccination and address the reason that led to missed vaccinations.
Materials and Methods
The study protocol was approved by the Human Ethics Committee and Institutional Scientific Committee (document number), and all recommendations were acknowledged.
The study included children aged 16 years or younger visiting the paediatric outpatient department of a tertiary care hospital in south India. We proceeded to exclude the individuals who did not want to participate in the study. Data was collected through a face-to-face interview with the caretaker and transcribed into a digital data collection form.
The data were collected mainly from three domains, viz childhood characteristics, maternal characteristics, and household characteristics. The childhood domain includes age, gender, and birthplace of the child. The Maternal variables included the number of living children, mother's education, employment status, and type of birth. Along with this, household and socioeconomic variables such as type of family (nuclear or joint), type of residence (urban or rural), and monthly family income were also recorded.
We followed the Universal Immunization Programme (UIP), which mainly intends to provide protection against 13 vaccine-preventable diseases to measure the immunization status. The vaccines listed under UIP are BCG (Bacillus Calmette-Guerin), OPV (Oral Polio Vaccine), Hepatitis B vaccine, Pentavalent vaccine, Rotavirus vaccine, PCV (Pneumococcal Conjugate Vaccine), fIPV (Fractional Inactivated Poliomyelitis Vaccine), Measles/MR vaccine (Measles and Rubella vaccine), JE vaccine (Japanese Encephalitis), DPT booster (Diphtheria, Pertussis, and Tetanus booster), TT (Tetanus Toxoid).
Definitions
Fully immunized child: A fully immunized child is defined as receiving one dose of BCG and hepatitis B birth dose followed by 3 doses of OPV, 3 doses of DPT or 3 doses of Pentavalent followed by Measles 1st dose in infants. In children and adolescents, the vaccination under UIP are booster doses of DPT 1st & 2nd, OPV followed by measles 2nd dose and TT.
Incomplete Immunization:
It is defined as a child having missed, delayed, on hold, or unimmunized vaccination status as by UIP.
Missed Vaccination:
Children having a missed vaccination status implies that any one dose has not been given as per UIP.
Delayed Vaccination:
The vaccination status is said to be delayed if any one dose was given after the specified time period as per the UIP.
Vaccination on Hold:
If a child is not receiving routine vaccinations due to recommendation by doctor as safety precaution due to comorbidities, the status of immunization is said to be on hold.
Study Procedure
A detailed history was taken from the caretaker regarding the child's vaccination status. The vaccination diary was carefully assessed and correlated with the answers given by the caretaker. If a missed vaccine or incomplete vaccination was identified, the reason for the same was investigated. All possible measures were made to rectify the incomplete vaccination.
Results
A total of 347 number of study participants were enrolled for the study out of which 207 (60.3%) belonged to the infant category. Our study population had almost equal (male to female: 54.5% to 45.5%) gender distribution with regards to birth order of the index child (child who was included in the study) 95% of children were 1st born and 2nd born at an equal proportion, and the rest 5% consisted of 3rd born children. However, it predominantly included an urban community (94.52%) and a very small proportion of rural (4.32%) and urban slum (1.15%) dwelling individuals.
| Table 1: Association of Socio-Demographic Variables on Vaccination Status |
Demographic Variable |
Total
(343) |
Completely vaccinated
(326) n (%) |
Incomplete vaccination
(17) n (%) |
P value (chi square) |
Age of Child |
Neonates (0-1months) |
6 (1.7%) |
6 (100) |
0 |
Chi square test not applicable |
Infants (1month- 23months) |
207 (60.3%) |
195 (94.20%) |
12 (5.79%) |
Children (24 months - 143 months) |
120 (34.9%) |
116 (96.66%) |
4 (3.33%) |
Adolescent (144 months - 192 months) |
10 (2.9%) |
9 (90%) |
1 (10%) |
Gender |
Male |
187 (54.5%) |
178 (95.18%) |
9 (4.81%) |
0.89 (not significant) |
Female |
156 (45.5%) |
148 (94.87%) |
8 (5.12%) |
Birth Order |
1st born |
190 |
181 (95.26%) |
9(4.73%) |
0.03 (significant) |
2nd born |
137 |
132 (96.35%) |
5(3.64%) |
3rd born |
16 |
13 (81.25%) |
3 (18.75%) |
Birth Size |
Normal |
281 |
268 (95.37%) |
13 (4.62%) |
0.54 (not significant) |
Small/poor |
62 |
58 (93.54%) |
4 (6.45%) |
Mother’s Number of living children |
1 |
176 |
168 (95.45%) |
8 (4.54%) |
0.07 (not significant) |
2 |
148 |
142 (95.94%) |
6 (4.05%) |
3 or more |
19 |
16 (84.21%) |
3 (15.78%) |
Mother’s Age |
<20 years |
0 |
0 |
0 |
Chi Square test not applicable |
20-34 |
309 |
295 (95.46%) |
14 (4.53%) |
35+ |
34 |
31 (91.17%) |
3 (8.82%) |
Mother’s Education Level |
Illiterate |
15 |
14 (93.33%) |
1(6.66%) |
0.64 (not significant) |
Primary |
50 |
46 (92%) |
4 (8%) |
Secondary |
67 |
65 (97.01%) |
2 (2.98%) |
Higher |
211 |
201 (95.26%) |
10 (4.73%) |
Mother’s Employment Status |
Employed |
100 |
93 (93%) |
7 (7%) |
0.26 (not significant) |
Unemployed |
243 |
233 (95.88%) |
10 (4.11%) |
Father’s Age |
<20 years |
0 |
(0) 0% |
(0) 0% |
Chi Square test not applicable |
20-34 |
212 |
201 (94.81%) |
11(5.18%) |
35+ |
129 |
123 (95.34%) |
6 (4.65%) |
Father’s Education Level |
Illiterate |
8 |
7 (87.95%) |
1 (12.50%) |
0.47 (not significant) |
Primary |
60 |
59 (98.33%) |
1 (1.66%) |
Secondary |
56 |
53 (94.64%) |
3 (5.35%) |
Higher |
217 |
205 (94.47%) |
12(5.52%) |
Father’s Employment Status |
Employed |
334 |
318 (95.20%) |
16 (4.79%) |
0.25 (not significant) |
Unemployed |
7 |
6 (85.71%) |
1 (14.28%) |
Type of Family |
Joint family |
167 |
158 (94.61%) |
9 (5.38%) |
0.71 (not significant) |
Nuclear family |
176 |
168 (95.45%) |
8 (4.54%) |
Type of Residential Area |
Urban |
324 |
308 (95.06%) |
16 (4.93%) |
0.75 (not significant) |
Urban slum |
4 |
4 (100%) |
0 (0%) |
Rural |
15 |
14 (93.33%) |
1( 6.66%) |
A vast majority (90%) of the mothers interviewed were in the age group of 20 – 34 years, the rest were over 35, and none younger than 20 years of age. Most of the mothers had received some form of schooling, with more than half having a degree and the rest being educated at the primary and secondary levels, while only a small percent was illiterate. Although the literacy levels were high, the employment levels were rather low, with around 71% of them being unemployed. Following a similar trend as mothers in the sample, more than half of the sample of fathers were in the age group of 20 – 34 years old, and the rest over 35 years, and none were under 20 years of age. Likewise, on the literacy front, both fathers and mothers share a similar pattern of education. The employment level of fathers was much higher at 97.97% being employed. Additionally, almost half of the respondents were from a joint family and an equal number were from nuclear families.
Table 2 shows the vaccination coverage of the study where 93% of the sample showed complete vaccination while remaining were categorized as incomplete vaccination which indicated either the child has had a missed vaccination, delayed vaccination or might be on hold.
| Table 2: Vaccination coverage |
Status |
Distribution, n (%) (347) |
Completed |
326 (93.94%) |
Incomplete |
17 |
Missed
Delayed
On Hold |
5
10
2 |
Maybe |
4 (1.44%) |
The immunization coverage in our study, was an overall of 93.94%, while incomplete vaccinations, which consisted of missed, delayed, and vaccinations on hold due to comorbidities comprised a mere 6%. The most commonly missed vaccinations were found to be Measles first dose (58.82%) followed by Japanese Encephalitis(JE) first dose. The vaccination with the lowest incomplete immunizations, conversely, highest coverage, is the OPV zero dose and the Hepatitis B birth dose, additionally booster doses of Hepatitis B also show better coverage than compared to booster doses of OPV. The most common reason given by respondents for a child's incomplete vaccination was that the child was unwell at the time of vaccination, followed by lack of recommendation by a healthcare professional.
The preferred centre of vaccination was found to be private centres (78.09%) rather than government (21.90%). Preference of centre was largely dependent on ease of access to centre/convenience followed by the child being born in the same hospital where vaccination is currently being given. Besides this, the reasons for choosing private centres over government was the belief that in comparison to government centres, private centres provide all vaccines (0.57%), and also that private centres have more facilities/higher quality of services (4.61%). Further, the most frequently used sources of information regarding vaccination were found to be doctor/hospital (92.50%) followed by Anganwadi Centres. Our study also collected information on AEFI where the most common one was fever which accounted for 58.3% of the sample and this was followed by swelling at the injection site.
Our study further tested the association of sociodemographic variables, summarised in table 2, with the vaccination status. It was found that the birth order of the index child showed a significant association with the vaccination status, while other variables failed to show any significance. Age of Child, Mother’s Age, Father’s Age were not tested for significance as they failed to fill the minimum cell count criteria for chi square test.
Discussion
The aim of this study was to assess the vaccination status of the paediatric population visiting a tertiary care setting, and this was done through a face-to-face interview with the respondents. The vaccination status was determined by interview and confirmed by examination of the vaccination card. It was mainly found that childhood vaccination coverage for different age groups varied from 81.81% for adolescents to 100% for neonates, with an average of 92.74%. However, since the sample is not representative enough for individual age group analysis, an overall coverage of 93.94% was seen without regard to age group.
The immunization coverage obtained in our study was 93.94%, while the state average of Karnataka is 65%, and the national average 62%. (7-8) This difference could be explained by the large time gap from when our study was conducted to when the state and national level surveys were undertaken.
As mentioned earlier, the most missed vaccinations were Measles first dose followed by JE first dose, the commonalities that these two vaccinations share is the time of vaccination being after completion of 9 months, however the significance of this finding should be further explored. Measles vaccination was also reported in a study by Ingale, Dixit, and Deshpande, 2013 as the vaccine that was most frequently missed. (9) The vaccination with the highest coverage is the OPV zero dose and the Hepatitis B birth dose. The reason for the former, could be potentially due to the fact that these two vaccinations are given at the hospital immediately after birth of the child. It can further be attributed to the rigorous vaccinations and awareness created by government programmes particularly the Pulse Polio Programme.
The most common reasons given by respondents for incomplete vaccinations was that the child was unwell at the time of vaccination, followed by lack of recommendation by healthcare professionals. The former reason can be classified as a gap in awareness, as children with minor illnesses are still recommended for vaccinations. The primary reason for incomplete vaccinations in our study coincides with the results of a study by Ingale, Dixit, and Deshpande, which also cites Ill health as the chief reason for missed vaccination.(9) The second most common reason in our study was ‘lack of recommendation by healthcare professionals’. It is of particular importance when correlated to the most frequently used source of information regarding vaccinations, which was found to be doctor/hospital. This emphasizes the importance of healthcare professionals in spreading awareness and ensuring complete vaccinations, as a vast majority of people depend on them for information as demonstrated in our study. Further, Anganwadi centres are mother and childcare centres established by the Indian Government, in rural and certain urban slum areas, to improve nutrition and healthcare options available to them. These centres were reported as the second most used source of information regarding vaccinations, thus emphasizing the importance and success of this government facility as well.
With regards to other vaccination practices, as mentioned earlier, government centres for vaccination were not preferred, unless it was easy to access/convenient or it was the centre where the child was born. Private centres were preferred due to various beliefs such as private setting has fresh stock available, provides all vaccines and also has a higher facilities/quality of services. The lack of popularity of government centres must further be explored and addressed. However, in a study conducted in Srinagar District, Jammu and Kashmir, the result was contrary, as the majority preferred government hospitals but the reason for this preference was not justified. (10)
Our study also provided information on AEFI where the most common adverse event following immunization was fever followed by swelling at injection site. Irrespective of this there was no resistance to vaccination due to AEFI which could be perceived as good awareness regarding vaccination and its consequences. This was comparable to a study conducted in Maharashtra which showed similar results as ours. (11)
Finally, our study assessed the association of various socio-demographic variables to immunisation coverage as they have been shown to influence it. It was found that there were no major differences in the coverage rates for mothers age and fathers age belonging to different age groups, however clustering of the sample disabled us from performing statistical analysis to support these findings. Similarly, child’s age was another demographic parameter for which statistical analysis could not be performed due to clustering of samples, but based on coverage rate, the infant age group showed highest coverage, while adolescent age group showed a lower rate. This low coverage amongst adolescents can be explained according to a review paper by Verma, Khanna and Chawla in 2015, which cites the reasons for inadequacy of adolescent immunization coverage as less contact with physicians when compared to younger children, and as a result missed opportunities for vaccination. Additionally, studies on immunization coverage largely focus on the children and infant age group, thus diverting attention from the adolescent age group, where there is a prevalence of vaccine preventable diseases such as Pertussis, Neisseria meningitidis and Human Papillomavirus infection, henceforth future studies must also include and focus on this age group. (12)
Among all other demographic variables assessed for statistical significance only birth order was found to be significant, where 3rd born children were found to be more susceptible to incomplete vaccinations. A plausible reason cited by a review, is that a feeling of resistance towards vaccination may have developed due to absence of incidence of the vaccine preventable diseases in neither the preceding children nor the population, this however requires further exploration. (13) Some of the other demographic variables that were of note but failed to achieve significance include gender of the child, parent’s education and employment levels, and type of residential area. The fact that these variables lacked significant influence on the immunization coverage could ultimately be hypothesised as a reflection of new and improved government programmes, such as the Mission Indradhanush and Intensified Mission Indradhanush, and of the positive attitudes and practices of the public towards vaccinations.
Conclusion
Vaccination is one of the best cost-effective public health interventions, to protect the entire populace from a series of major life-threatening diseases, known as vaccine preventable diseases, such as measles, tetanus, polio, etc. Overall, owing to the fact that our study population was majorly urban residents, most of them were completely immunized, but in the small percentage of the sample who were incompletely vaccinated, the most commonly missed vaccines were measles 1st dose followed by JE 1st dose. Lack of access to health care, less contact of adolescents to physicians, missed opportunities for vaccination, resistance towards immunization due to absence of vaccine preventable diseases and poor birth weight were some of the various reasons attributing to incomplete vaccination. Regardless of these multifactorial reasons, most of our sample showed complete immunization which indicated a positive attitude towards immunization. Also, in support to this statement, improved government facilities, various programs such as mission Indhradhanush, and better awareness among mothers regarding importance of immunization all seemed to play a vital role in enhancing vaccine coverage. As there is less adequate research at rural settings of India, extensive exploration is still required to further improve the vaccination coverage.
Ethics Statement: This study was performed in line with the principles of the Declaration of Helsinki. The study protocol was approved by Ramaiah Medical College, Human Ethics Committee and Institutional Scientific Committee (Ethics committee approval number- MSRMC/EC/AP-14/09-2019).
Acknowledgments: We express our sincere gratitude to Dr. Somasekhar AR, Professor and Head, Department of Pediatrics, Ramaiah Medical college hospital for his valuable input in planning and conducting this research study.
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