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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 8  |  Issue : 4  |  Page : 390-397

A hospital-based cross-sectional study for assessment of immunization status of children in western Maharashtra, India


Department of Community Medicine, Smt. Kashibai Navale Medical College and General Hospital, Pune, Maharashtra, India

Date of Submission24-Sep-2021
Date of Acceptance23-Nov-2021
Date of Web Publication22-Dec-2021

Correspondence Address:
Dr. Harishchandra Dyanoba Gore
Department of Community Medicine, Smt. Kashibai Navale Medical College and General Hospital, Pune 411041, Maharashtra.
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mgmj.mgmj_71_21

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  Abstract 

Background: Immunization against vaccine-preventable diseases is a fundamental right of children and a way to reduce childhood mortality and morbidity; thus, it is a way to improve the health of the community. Delayed vaccination increases the susceptibility of a child to vaccine-preventable diseases and also affects herd immunity. So this study was undertaken to assess the immunization status of children attending a tertiary care hospital that caters to urban as well as rural populations, focusing on the timeliness of vaccination, and to explore the predictors of vaccination delay. Materials and Methods: A cross-sectional study was carried out among 302 immunization attendees of 12–23 months of age in the immunization outpatient department of a tertiary care hospital. Parents were interviewed, and vaccination dates were obtained from vaccination cards and assessed for vaccination delay. Results: From a total of 302 children of age 12 to 23 months who enrolled in the study, 165 (54.64%) children were vaccinated on time and 137 (45.36%) children had vaccination delays. When assessing vaccination delay, 24 (7.95%), 44 (14.57%), and 118 (39.07%) children were found to have vaccination delay for Bacille Calmette-Guerin (BCG), pentavalent vaccine (PENTA1), and magnetic resonance imaging (MR1), respectively. Out of them, 49 (16.22%) children had vaccination delay for more than one vaccine. Age at first pregnancy, place of delivery, gender, birth order, and birth weight of the child were found to be statistically significant for delayed vaccination. Conclusion: Delays in vaccination can be addressed by offering mobile vaccination clinic facilities to migrant people as well as raising community knowledge about the importance of timely child vaccination through the targeted approach: Information, Education, and Communication (IEC) activities.

Keywords: Children, immunization status, tertiary care hospital


How to cite this article:
Bansod VP, Nannaware MN, Kulkarni SS, Gore HD, Agawane SU, Chawla PS, Kalra KG. A hospital-based cross-sectional study for assessment of immunization status of children in western Maharashtra, India. MGM J Med Sci 2021;8:390-7

How to cite this URL:
Bansod VP, Nannaware MN, Kulkarni SS, Gore HD, Agawane SU, Chawla PS, Kalra KG. A hospital-based cross-sectional study for assessment of immunization status of children in western Maharashtra, India. MGM J Med Sci [serial online] 2021 [cited 2022 Jan 18];8:390-7. Available from: http://www.mgmjms.com/text.asp?2021/8/4/390/333328




  Introduction Top


The expanded program on immunization was launched in 1978 in India. The diseases targeted were tuberculosis, polio, pertussis, diphtheria, tetanus, and measles. Over a period, an immunization program has evolved in terms of the population covered and several vaccine-preventable diseases covered. The Hepatitis B vaccine was added in 2002 as a pilot project and then expanded all over in 2007–2008. New vaccines such as Pentavac, Rota vaccine, and Injectable polio vaccine had been added to the universal immunization program. In 2014, Mission Indradhanush was launched to increase vaccination coverage among under-five children.[1] Coverage was scaled up by Intensified Mission Indradhanush, which was launched in 2017 to reach the unreached with all available vaccines and complete immunization coverage of children and pregnant women in critically identified districts.[2] Vaccines are one of the very important cost-effective interventions in health and their timeliness is a very important indicator to decide the quality of the program.[3]

As per the National Family Health Survey (NFHS-5), the percentage of fully vaccinated children in Maharashtra had been increased from 78.4% in NFHS-4 to 81.7% in NFHS-5. As per NFHS-4, the percentage of fully vaccinated children in Pune was 81.0%. [data of NFHS-5 for Pune district was not available on the government website].[4] Even though vaccination coverage for BCG, PENTA 3 doses, and the first dose of measles vaccine are 93.8%, 83.4%, and 83.4%, respectively, age-appropriate vaccination is just 37.4% in India and 41.2% in Maharashtra.[5],[6] As per a study done by Choudhary et al.[7] using NFHS-4 data, 23.1%, 29.3%, and 34.8% of children aged 10–23 months had delayed vaccination for BCG, Diphtheria Pertussis Tetanus (DPT1), and measles, respectively.

A delay in vaccination results in more vulnerability to vaccine-preventable diseases. As per a study done by Roy et al.,[8] delaying BCG vaccination until six weeks of age increased tuberculosis fatalities by 0.2%. As per evidence from previous studies, children who receive their first dose of measles vaccination after the age of one year are more vulnerable to infection because they are not protected by maternal antibodies, resulting in a measles outbreak even with high vaccination coverage.[9],[10] So timeliness of vaccination is very much important in reducing mortality and morbidity in children and should be considered while analyzing vaccination coverage.[11]

The predictors for delayed vaccination were found to be religion, area of residence, higher birth order, mother’s education, children born to mother <20 years of age, > three previous pregnancies, larger family size, place of delivery, gender of the child, etc.[12],[13],[14],[15] Various reasons for delayed vaccination were traveling at the time of vaccination, unavailability of the vaccine in a health-care facility etc.[16]

So this study was planned to assess immunization status, mainly focusing on the timeliness of vaccination, and to explore the predictors of vaccination delay among children 12–23 months of age attending the immunization outpatient department in tertiary care hospitals, which caters to both urban and rural populations.


  Materials and methods Top


The study was approved by the Institutional ethical committee (Reference number SKNMC/ethics/App/2019/517). This hospital-based cross-sectional study was carried out among children in the age group of 12–23 months attending the immunization outpatient department in a tertiary care hospital. The study was conducted during the period August 2019 to January 2020. An average of 40, under-five children were vaccinated daily in the immunization outpatient department, and of these children, all those who fulfilled the eligibility criteria and whose parents were willing to participate in the study were included in this study. A total of 302 children were included in this study. The sampling method is convenient sampling. Data were collected from parents by a face-to-face interview with the help of a work interview schedule based on the World Health Organization (WHO) guidelines after explaining to them the objective of the study. The work interview schedule was pilot tested in the same setting for 20 participants and suitably modified to meet the study objectives. The pilot study subjects were excluded from the main study. Parents were interviewed for sociodemographic details, and vaccination dates were obtained from vaccination cards and assessed for vaccination delay. In the absence of a vaccination card, vaccination details were taken from parents. In the presence of a vaccination delay, mothers were probed to elicit reasons for the delay.

Vaccination delay was defined as the administration of a vaccine after 28 days of minimum recommended age according to the National immunization schedule. Vaccination was considered delayed if given on day 28 or later for BCG, 71 days or later for PENTA1, and 303 days or later for MR1.[7] Data were collected and entered in an MS-Excel spreadsheet, analyzed using SPSS version software 26.0, and assessed for immunization status. The percentage of children with delayed vaccination for BCG, PENTA1, and MR1 was calculated. Univariate analysis was done to study the association between sociodemographic variables and vaccination delay for BCG, PENTA1, and MR1. A forward stepwise approach was used for multivariate logistic regression to find out independent predictors for delayed vaccination of BCG, PENTA1, and MR1. The strength of association was expressed as odds ratio (OR) with a 95% confidence interval (CI). A p-value of <0.05 was considered statistically significant. The reasons for delayed vaccination were reported.


  Results Top


[Table 1] shows the sociodemographic characteristics of children. A total of 302 children of age 12 to 23 months were enrolled in the study and assessed for vaccination delay. The median age of vaccination for BCG, PENTA1, and MR1 was one day, 47 days, and 290 days, respectively. Overall, 165 (54.64%) children were vaccinated on time and 137 (45.36%) children had vaccination delay as shown in [Figure 1]. When assessing vaccination delay for each vaccine separately, 24 (7.95%), 44 (14.57%), and 118 (39.07%) children were found to have vaccination delay for BCG, PENTA1, and MR1, respectively, as shown in [Table 2]. Out of them, 49 (16.22%) children had vaccination delay for more than one vaccine. [Table 3] and [Table 4] show the predictors of vaccination delay on bivariate analysis and multivariate analysis, respectively. On bivariate analysis, age of the mother at the first pregnancy, place of delivery, and birth weight were found to be statistically significant for BCG vaccination delay; gender, birth order, and birth weight were found to be statistically significant for PENTA1 vaccination delay; and gender, birth order were found to be statistically significant for MR1 vaccination delay. As shown in [Figure 2], the child being ill was the most frequently stated reason for vaccination delay.
Table 1: Sociodemographic characteristics of children

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Figure 1: Overall vaccination delay among children

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Table 2: Vaccination delay and type of vaccine

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Table 3: Predictors of vaccination delay

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Table 4: Multivariate analysis

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Figure 2: Reasons for overall vaccination delay among children

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  Discussion Top


In the present study, from the 302 children of age 12–23 months who enrolled in the study, 54.30% of children were males and 45.70% were females. Similar results were found in other similar studies.[17],[18] Of the total children, 39.40% were from an urban area and 60.60% were from a rural area; 35.76% were from a joint family and 64.24% were from a nuclear family. These results could be due to the presence of tertiary care hospitals in a rural location that cater to both urban and rural populations and there being a greater preference for small family size in both urban and rural settings.[6]

The median age of vaccination for BCG, PENTA1, and MR1 was one day, 47 days, and 290 days, respectively. Similar results were also found in other similar studies.[19],[20],[21]

A total of 45.36% of children had vaccination delays. When assessing vaccination delay for each vaccine separately, 24 (7.95%), 44 (14.57%), and 118 (39.07%) children were found to have vaccination delay for BCG, PENTA1, and MR1, respectively. Similar results were also found in other similar studies.[22],[23],[24],[25] The delay in vaccination for BCG was the lowest, which might be due to a higher rate of institutional deliveries. Vaccination delay was found to be more for the MR1 vaccine, which might be the effect of delay in birth doses due to home deliveries and low-birth-weight babies with a higher birth order.

The place of residence was not found to be a significant predictor for delayed vaccination for BCG, PENTA1, and MR1. Similar results were also found in another similar study.[26] This might be the effect of multiple factors such as women’s literacy, doorstep availability of health-care services, fixed and regular conduction of vaccination sessions, newer drives to increase vaccination coverage such as Mission Indradhanush, Intensified Mission Indradhanush to reach unreached children, and IEC (Information, Education, and Communication) activities regarding the vaccination of children, Indradhanush in both urban and rural areas.

The children with mothers of age ≤19 years at the first pregnancy had higher odds of delayed vaccination for BCG (OR 5.40, 95% CI 2.28–12.79) as compared with children with mothers of age ≥20 years at the first pregnancy. Similar results were also found in other similar studies.[7],[27] This outcome might be attributed to a lower education level of women and early marriage with an early pregnancy to understand the need and value of health-care services such as immunization.[28],[29] Also, complications such as preterm delivery, very low birth weight are more common in teenage pregnancies, leading to admission in the neonatal intensive care unit, which might result in a delay for BCG vaccination.[30],[31]

The children with home delivery had higher odds of delayed vaccination for BCG (OR 12.50, 95% CI 1.68–93.06) as compared with children with hospital delivery. Similar results were also found in other similar studies.[32],[33] This result could be related to a delay in seeking health care at birth in case of home delivery and the occurrence of birth vaccination of children before discharge in hospital delivery or institutional delivery.

Male children had higher odds of delayed vaccination for PENTA1 (OR 3.35, 95% CI 1.59 - 7.06) and MR1 (OR 1.66, 95% CI 1.03 - 2.65) as compared with female children. This outcome was contrary to other similar studies.[34],[35] This could be linked to increased gender equity awareness among people and also women empowerment has improved, which has a substantial impact on the uptake of child health services.[36],[37]

The children with a birth order of >2 had higher odds of delayed vaccination for PENTA1 (OR 4.69, 95% CI 1.68 -13.09) and MR1 (OR 3.05, 95% CI 1.09–8.48) as compared with children with a birth order of ≤2. Similar results were also found in other similar studies.[33],[38],[39] Parents will not have enough time and resources available while rearing many children.[40]

The children’s birth weight ≤2 kg had higher odds of delayed vaccination for BCG (OR 11.89, 95% CI 3.32–42.52) and PENTA1 (OR 5.38, 95% CI 1.57–18.49) as compared with children with birth weight >2 kg. Similar results were also found in other similar studies.[35],[41] This outcome might be attributed to parents’ concern about the child’s safety. Children with birth weight <2 kg usually require Neonatal Intensive Care Unit (NICU) admission for many associated morbidities at birth and if the NICU stays of these children is prolonged, then vaccination gets delayed.

In multivariate analysis, the forward stepwise conditional method was used to find out independent predictors for vaccination delay. Age of mother at first pregnancy (years), place of delivery, and birth weight were found to be significant independent predictors of delayed BCG vaccination. Gender was found to be a significant independent predictor of delayed PENTA1 vaccination and delayed MR1vaccination [Table 4].

In the present study, reasons for vaccination delay were found, such as a child being ill (31.98%), out of station/migration (27.92%), the vaccine not being available (24.87%), and lack of knowledge (10.15%), as shown in [Figure 2]. Similar results were also found in other similar studies.[27],[42] This is because when a child becomes ill, other medications are started or the child requires hospitalization, delaying vaccination. Similarly, when a family travels frequently or migrates, vaccination is usually delayed as parents are unaware of the vaccination centers in their new location. Similarly, sometimes vaccines might not be available at a particular visit to the vaccination center due to an interrupted supply of vaccines, thereby resulting in vaccination delay.


  Conclusion Top


Even though delay in vaccination was not so high, continuous awareness regarding vaccination timeliness and a targeted approach for groups with higher chances of delayed vaccination, that is, children delivered at home, children of mothers of age ≤19 years at first pregnancy, low-birth-weight newborns, and children with a birth order more than 2 might be used while planning and implementation of a routine immunization program at a primary health-care level. Delays in vaccination can be addressed by offering mobile vaccination clinic facilities to migrant people as well as raising community knowledge about the importance of timely child vaccination through IEC activities at the ground level.

Limitation

As this was a hospital-based study, perspectives of the community-based study were missed out on. This might result in an underestimation of delayed vaccination and many reasons for the delay in vaccination might have been missed out on. Thus, the results cannot be extrapolated to the whole population of India.

Acknowledgement

The authors are thankful to all the participants who participated in the study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Ethical policy and institutional review board statement

Ethical approval has been obtained for undertaking the noninterventional study project on “Assessment of immunization status of children attending tertiary care hospital” from the Institutional Ethics Committee of Smt. Kashibai Navale Medical College and General Hospital, Pune, Maharashtra, India, vide their letter no. SKNMC/Ethics/App/2019/517 dated July 1, 2019.



 
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