High Immunization Coverage but Delayed Immunization Reflects Gaps in Health Management Information System (HMIS) in District Kangra, Himachal Pradesh, India—An Immunization Evaluation

Rajesh Kumar Sood^1*, Anjali Sood², Omesh Kumar Bharti³, Vidya Ramachandran⁴, Archana Phull⁵

¹District Epidemiologist, Kangra, Himachal Pradesh, India.
²College of Home Science, CSKHPKV, Palampur, India.
³State Institute of Health & Family Welfare, Parimahal, India.
⁴National Institute of Epidemiology, Chennai, India.
⁵Daily Post, Shimla, India.

DOI: 10.4236/wjv.2015.52009                

Abstract

Background: Complete and timely childhood immunization is one of the most cost-effective interventions in improving child survival in developing countries. Computerized HMIS has been recently introduced to collect aggregated data on service beneficiaries in Himachal Pradesh. HMIS provides coverage estimates for immunization while information on timeliness is currently not available. Hence we conducted a study to validate coverage and assess the timeliness of immunization in Kangra District of Himachal Pradesh. We surveyed mothers (224) of children aged 12 - 23 months (as on January 2008) and selected 32 clusters in the district between January and March 2008. Design/Methods: We conducted a cross sectional survey and selected 32 clusters by probability proportional to size method whereas seven eligible children per cluster were randomly selected. We interviewed mothers using a structured interview schedule, examined immunization card & looked for Bacillus Calmette Guierre (BCG) Scar. Vaccination after 30 days from national schedule was considered “delayed”. We computed proportions of children completely immunized, immunization delayed, frequency of reasons for delay and 95% Confidence Interval (CI) for significance of associated factors. We conducted a case control analysis of factors associated with timely immunization by taking timely immunized children as cases and delayed immunized ones as controls. Results/Outcome: Reported coverage was universal (100%). Validated full immunization coverage was 94.2% by card/record & 99% by history. Only 29.5% (CI = 20.6% - 37.4%) of children were fully immunized as per schedule (delay less than 30 days). Median delay was 21 days for BCG, 28 days for Diptheria Pertussis Tetanus (DPT 3) and 25 days for measles. Among those with delayed vaccinations, reasons were forgetfulness (36%), lack of correct knowledge (27%) & mother gone to parents’ home (27%) & insufficient children in a camp to open full dose BCG vial (22%). Our case control analysis of timely vaccinated versus delayed vaccination revealed that “precall” (reminder) was significantly [OR = 0.1, CI = 0.2 - 0.5] protective against delayed vaccination. Logistic Regression of delay > 30 days revealed that having returned unimmunized from immunization camp earlier due to insufficient children to open vaccine vial (because of high wastage factor) was significantly associated with delayed immunization (p = 0.0000), while knowledge of date of immunization camp was significantly protective from delayed immunization (p = 0.0026). 68% of the children were having at least one immunization delayed over 30 days from recommended schedule, while the proportion of children whose immunization was delayed by over 90 days was 9.4%. Conclusions: Validated field coverage estimates are lower than reported which can be due to inclusion of children of migrants in numerator & not in the denominator. High proportion of children (>70%) were delayed, suggesting implications for WHO’s strategy of measles control & national Tuberculosis (TB) control programmes, as 4.5% of them had suffered from measles. To avoid delays we recommend (i) use of mono dose vials for BCG; (ii) precall notice to mothers; (iii) modification of HMIS software to track immunization status and timeliness of individual beneficiaries rather than aggregate numbers.

Keywords

Immunization Coverage, Delay, Gaps, Information Technology, Health Information Systems

Conflicts of Interest

The authors declare no conflicts of interest.

References

[1]	Ministry of Health & Family Welfare, Government of India (2002) National Health Policy. http://www.mohfw.nic.in
[2]	IIPS (2002) District Level Household Survey on Reproductive and Child Health DLHS-RCH, India, 2002-04. International Institute for Population Sciences, Mumbai. http://www.rchiips.org/pdf/state/Himachal_Pradesh.pdf
[3]	International Institute for Population Sciences (IIPS) and Macro International (2007) India: National Family Health Survey (NFHS-3), 2005-06, Volume I. http://dhsprogram.com/pubs/pdf/SR128/SR128.pdf
[4]	Bolton, P., Hussain, A., Hadpawat, A., Holt, E., Hughart, N. and Guyer, B. (1998) Deficiencies in Current Childhood Immunization Indicators. Public Health Reports, 113, 527-532. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1308436/
[5]	Dombkowski, K.J., Lantz, P.M. and Freed, G.L. (2004) Risk Factors for Delay in Age-Appropriate Vaccination. Public Health Reports, 119, 144-155. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1497606/pdf/15192901.pdf
[6]	WHO (2005) Immunization Coverage Cluster Survey Reference Manual. WHO/IVB/04.23. http://whqlibdoc.who.int/hq/2005/who_ivb_04.23.pdf
[7]	Ministry of Health & Family Welfare, Government of India (1992) National Immunisation Schedule in National Child Survival and Safe Motherhood Training Module on Immunisation: MCH division.
[8]	Rahman, M.M., Islam, M.A. and Mahalanabis, D. (1995) Mothers’ Knowledge about Vaccine Preventable Diseases and Immunization Coverage of a Population with High Rate of Illiteracy. Journal of Tropical Pediatrics, 41, 376-378. http://tropej.oxfordjournals.org/content/41/6/376.abstract
[9]	Ughade, S.N., Zodpey, S.P., Deshpande, S.G. and Jain, D. (2000) Factors Responsible for Delayed Immunisation among Children under 5 Years of Age. Journal of the Indian Medical Association, 98, 14. http://www.popline.org/node/170134
[10]	Lieu, T.A., Black, S.B., Ray, P., Chellino, M., Shinefield, H.R. and Adler, N.E. (1994) Risk Factors for Delayed Immunization among Children in an HMO. American Journal of Public Health, 84, 1621-1625. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1615076/