VACCINE ADMINISTRATION TO CHILDREN AT 0-5 YEARS; PROBLEMS AND PROSPECT

CHAPTER ONE

INTRODUCTION

BACKGROUND OF THE STUDY

Despite the fact that immunization is proven to be the most successful and cost-effective public health intervention in reducing childhood morbidity and mortality (as it averts 2 to 3 million deaths every year), the global vaccination coverage has remained stalled at 86% since 2010, with no significant changes during the past years David, (2005). Of the estimated 19.5 million infants that were not reached with routine immunization services worldwide in 2016, 60% of them live in 10 countries including Nigeria. Of serious concern is the abysmally low full immunization coverage in Nigeria with a concomitant high mortality (largely attributed to vaccine preventable individuals are immune to the disease particularly through vaccination (as it provides a measure of protection for those who are not immune); and for herd immunity to occur, the mass vaccination (critical immunization threshold) of the vaccines must be achieved.8,9 To achieve the critical vaccination coverage for most of the vaccine preventable diseases, the Global Vaccine Action Plan 2011-2020 endorsed by the World Health Assembly in 2012, calls on all countries to reach > 90% national coverage for all vaccines in the respective countries’ routine immunization schedule by 2020.

Doctor Edward Jenner (1749-1823) has been recognized as the first doctor to have given sophisticated immunization. The early years of 19^th century saw widespread but haphazard use of Jenner’s vaccine against smallpox. After successful vaccination campaigns throughout the 19th and the 20^th centuries, World Health Organization (WHO) certified the eradication of vaccine preventable disease through immunization.

The United Nations Millennium Development Goals (MDGs), goals four and five, lay specific emphasis on reducing child mortality through child survival interventions and improving maternal health in general which in turn recognizes immunization as key component in reducing vaccine preventable diseases. Failure to reach the Millennium Development Goal four (MDG 4) for child survival will result in an estimated forty million children’s lives lost by 2015 (Human Development Trends, 2004). As nearly a quarter of global under–five mortality is attributable to vaccine–preventable diseases, vaccination can contribute significantly to attaining MDG 4 (World Health Organization, 2004). Global health initiatives like Global Alliance for Vaccine and Immunization (GAVI), established in the year 2000, set the objective of reaching 80 percent DPT3 coverage in 80 percent of all districts in developing countries by the year 2005. GAVI, UNICEF, WHO, Rotary International etc are organizations that have been very instrumental in funding, supply of logistics, monitoring, and evaluation of Expanded Programme on Immunization (EPI) activities worldwide.

The success of routine immunization programmes has been measured by the coverage achieved with the third dose of diphtheria, tetanus, pertussis vaccine (DPT) among children aged 12-23 months, (World Health Statistics, 2005). Immunization currently averts more than 2.5 million deaths every year in all age groups from diphtheria, tetanus, pertussis (whooping cough), and measles (WHO, 2002)

Considering that more than 130 million children are born each year worldwide and need to be immunized, over 27 million children, who live mainly in disadvantaged rural communities, are not reached by routine immunization services and significant variations in coverage exist between and within regions and countries. Unless this gap is closed, 2 million children under five years of age will continue to die annually from preventable diseases for which vaccines are available or will be available in the near future (unicef, 2005).

 

Nearly one million adults die each year from liver cancer in part because they were not vaccinated against hepatitis B during childhood. (UNICEF, 2001).An unprotected number of children under one year of age who did not receive DTP3 were 26.3 million and 28.1 million in 2005, (WHO/UNICEF, 2007). The total number of children who died in 2002 from diseases preventable by vaccines currently recommended by WHO, plus diseases for which vaccines are expected soon were 2.5 million, (WHO 2007).

 

In Nigeria, the Expanded Programme on Immunization (EPI) was introduced in 1978 as a strategy to improve child health. Since 1985 the programme has been operational in all the regions and districts (NHS annual report, 2002) Although EPI was introduced in Nigeria in 1978, it actually became firmly established in 1986 when the Head of State declared a National Mass Immunization against measles. Since then, EPI activities have become the focus of Public Health activities at the regional, the district, the sub district and institutional levels of the health sector.

At the national level, EPI comes under the Disease Control Unit together with other programmes that fall directly under the Directorate of Public Health. At the regional level, EPI service is integrated into the public health system under the leadership of the Regional Director for Health Services. There are EPI coordinators or Disease Control officers who are responsible to the Senior Medical Officer (Public Health) of the region for the day-to-day management of immunization programmes in all regions. At the district level, the District Health Management Team (DHMT) led by the District Director of Health Services manages EPI activities. There are designated Disease Control Technical Officers who are responsible to the DHMT for EPI and Surveillance activities in the districts.

They team up to plan, implement and monitor immunization activities. They collate activity reports from the sub-districts for onward transmission on monthly basis.

World Health Organization (W.H.O) has described the commonest childhood killer diseases as poliomyelitis, tetanus, diphtheria, whooping cough, measles, yellow fever, and tuberculosis. WHO, 1994 reported that some 1.7 million deaths from measles, neonatal tetanus and pertussis and over 100,000 cases of poliomyelitis could have been prevented through immunization. In view of this international concerns have been raised to either control or eradicate these killer diseases from the world through an Expanded Programme on Immunization (E.P.I). In 1974, United Nations International Children’s Emergency Fund (UNICEF) and (W.H.O) developed the E.P.I. to combat the six (6) childhood vaccine- preventable diseases, which was aimed at achieving universal childhood immunization (U.C.I) by 1990 with at least 80 percent of infants fully immunized by their first birthday (WHO, 1998). Success was measured by vaccine coverage levels in children aged 12 to 23 months. WHO recommended that children receive the complete schedule of vaccination before twelve months of age, otherwise such children are considered drop outs or defaulted. The world Health Assembly (WHA) established a target to eradicate poliomyelitis world- wide by the year 2000, (WHA, 1998). However, achieving this target on the Africa Continent became one of the major setbacks in achieving global eradication by the target date. Many countries in Africa have severe constraints in maintaining coverage levels at 80 percent. These constraints include inadequate financing; insufficient equipment and supplies; cold chain and transport; inadequate access to facilities: inadequate trained personnel; inadequate information to the populace as well as poor receptivity (WHO, 1998).

The system in Nigeria consists of the operational component (Immunization service, vaccine management, logistics, Surveillance of Vaccine Preventable Infections, and Advocacy and social mobilization) and the supportive components (Management, Capacity building and financing) of immunization services. In 1995, the figures reported for Nigeria based on a nation-wide survey for the various antigens were; BCG- 85 percent DPT3-71 percent, OPV- 71 percent, measles 68 percent (WHO,1998). These coverage levels were well below the WHO target of 80 percent coverage.

Table 1.1 Ikpaja EPI figures from 2004 to 2007.

ANTIGEN	2004		2005		2006		2007
	Target		Target		Target		Target
	6,548		6,771		7001		7,239
	NO	%age	NO	%age	NO	%age	NO	%age
BCG	5,601	85.5	7,046	104	8,020	114.5	8,572	114.4
MEASLES	4,820	73.6	5,506	82.4	5,346	76.3	6,008	83.4
PENTA 3	4,837	73.8	5,343	78.9	5,040	72	5,482	75.7
OPV3	4,755	72.6	5,297	78.2	5,040	72	5,480	75.7
YF	4,797	73.2	5,505	81.3	5,082	71.8	5,991	82.7

Source: District Health Directorate Report, 2007.

Table 1.1 shows Pentavalent vaccine (Penta3) Percentage values as; 73.8 percent, 78.9 percent, 72.0 percent and 75.7 percent representing 2004, 2005, 2006 and 2007 respectfully. These percentages are indicative of coverage below what has been prescribed by WHO i.e. 80 percent coverage with pentavalent vaccine as the proxy indicator.

Further, the drop–out rates were computed to be 13.9 percent, 21.9 percent, 33.3 percent, and

• percent for the years 2004, 2005, 2006, 2007

Table 1.2  Sub-districts and District EPI Performance on Maternal Tetanus Vaccine  (at least TT2 dose received) for 2004 – 2007.

Sub   districts	2004   No             %age		2005   No            %age		2006   No            %age		2007   No            %age
Mampong	1866	73.6	2578	101.8	1623	62.0	2790	103.0
Nsuta	907	70.1	907	70.1	470	35.1	1099	79.5
Kwamang	392	40.4	461	47.6	290	29.0	398	38.4
Kofiase	546	66.5	294	35.8	522	62.0	1041	118.8
Birim	202	39.2	276	53.5	274	52.0	274	49.8
Asubuaso	233	57.3	242	59.6	145	35.0	332	76.4
Oku	184	77.6	76	32.0	41	18.0	149	58.8
District	4330	66.1	4833	71.3	3324	47.5	6083	84.0

 

Source: District Health Directorate Report, 2007.

 

The figures reported for maternal immunization against tetanus in the district, from 2004 to2007, indicated coverage levels below the 80 percent in TT2 except for 2007, which recorded 84 percent. Maternal vaccination is administered to mothers who attend antenatal care (ANC) at the institutional level. ANC attendance is the indicator for measuring the status of maternal immunization because that is the time expectant mothers could be available. For an ANC average target of four visits before delivery at the district, records

 

showed the following averages; 3.3, 2.5 and 2.5 for 2005, 2006 and 2007 years respectfully which were below the ANC average target of four.

The schedules for tetanus toxoid for mothers are as follows;

• 1^st vaccination-No protection to the mother,
• 2^nd vaccination, one month after first vaccination-3 years protection to the mother,
• 3^rd vaccination, six months after second vaccination-5 years protection to the mother,
• 4^th vaccination, one year after third vaccination-10 years protection to the mother,
• 5^th vaccination, one year after fourth vaccination-protects the mother for

Maternal tetanus prevention is achieved through the vaccination of the expectant mother with tetanus toxoid vaccine according to the schedules specified above. A recommendation by UNFPA/UNICEF/WHO identified three key strategies for achieving maternal and neonatal tetanus elimination as:

• Provision of at least two doses of tetanus toxoid to all pregnant mothers and three doses to all child – bearing aged mothers,
• Promotion of clean delivery services to all pregnant mothers,
• Effective surveillance for MNT.

The elimination of neonatal tetanus is defined as the achievement of less than one NT case per 1000 live births in every district of every country. It is operationally defined by an algorithm which assesses four major indicators;

• The reported incidence of NT,
• The reliability of NT surveillance,
• The proportion of mothers reached with at least two doses of TT2,
• The estimated clean delivery

STATEMENT OF THE PROBLEM

The national EPI policy specifies that each child should receive one dose of BCG at birth; three doses of DPT (at sixth, tenth, and fourteenth weeks); four doses of OPV (at birth, sixth, tenth, and fourteenth weeks); one dose of Measles (at ninth month); one dose of Yellow Fever ( at ninth month) and five doses of Tetanus Toxoid of every child-bearing woman (between 12- 44 years). One of the major objectives of EPI is to fully immunize 80 percent of the target population using DPT as proxy indicator (WHO, 1992) and immunize all child- bearing mothers against tetanus. According to the WHO there is a problem with the immunization programme whenever the drop-out rate or defaulter rate exceeds 10 percent. The defaulter rate is estimated by the following formula;

The No of children                  The No of children

Who received BCG        –        immunized for measles      x     100 The No of children immunized against BCG

Conversely, the district EPI performance as per the indicators stipulated by the health partners showed a drop-out rate above 10 percent regarded to be the acceptable level. The drop-out rates or defaulter rates for the years 2004, 2005, 2006 and 2007 were 13.9 percent,

• percent, 33.3 percent and 29.9 percent respectively. Further, the coverage levels achieved by the EPI team at the district for the years 2004, 2005, 2006 and 2007 were 73.8 percent, 78.9 percent, 72 percent and 75.7 percent respectively indicating figures that are below the acceptable

Again the maternal vaccination against tetanus also showed low figures below the 80 percent TT2 coverage level all mothers except for 2007 which recorded a figure above the 80 percent. Moreover, there has been under performance of the ANC attendance at the district where figures are below the average of four visits before delivery. Although, vaccine preventable diseases have been reduced by routine vaccination, surveillance activities at Ikpaja revealed suspected yellow fever cases increasing from 4 in 2005 to 7 in 2007 and suspected measles increasing from 3 in 2005 to 6 in 2007 in the district (Sekyere West Annual Health Report, 2007). The district health directorate has therefore expressed interest in knowing the problems that are associated with such an under utilization of service on the part of the mothers and the entire health system and to identify key strategies to improve service utilization and consequently increase coverage levels.

RATIONALE OF THE RESEARCH 

The commonest childhood diseases namely: measles, tuberculosis, diphtheria, poliomyelitis, tetanus, yellow fever, whooping cough which were mainly responsible for the child mortality in Nigeria, And tetanus (lockjaw) which was identified as the major cause of maternal death in Nigeria are now less or are not reported at all in our health facilities due to the introduction of immunization. Therefore efforts towards achieving healthier childhood and motherhood days are very critical to all stakeholders or health partners. An assessment of the activities of the programme therefore is vital in realizing the extent to which the immunization service, which is regarded as a child survival intervention, is being utilized by the target population in the respective districts.

The research seeks to assess the EPI service utilization by children and the nursing mothers, find out possible reasons that might account for under utilization of the EPI service by nursing mothers/carers. Again, the findings of the study will be used as a confirmatory evidence to either support previous reports given by the district health administration on EPI or identify differences and suggest corrective measures accordingly. The study will inform the DHMT, policy makers, funding agencies and other stakeholders on the management tools to employ to increase EPI service utilization and to reduce defaulter rates, increase coverage levels for both child and mother immunization and finally reduce the incidence of vaccine preventable diseases in our societies. The research will set the platform for which further studies can be conducted for the purposes of improving EPI service utilization. Finally, monitoring and evaluation can be done by making reference to the outcome of this study by comparing the findings to a given standard and making inference to the entire population.

RESEARCH QUESTIONS

1. What are the coverage levels and drop-out rates for recommended antigens?
2. What are the major reasons for immunization failure as perceived by mothers?
3. What is the immunization coverage status of mothers for tetanus toxoid vaccine?
4. Which immunization strategy is preferred by MCH/FP staff?
5. What recommendation can be stated to help improve EPI service delivery?

GENERAL OBJECTIVE

To assess the expanded programme on immunization service utilization of Ikpaja.

SPECIFIC OBJECTIVES OF THE RESEARCH

1. To describe the coverage levels and drop-out rate for the antigens in EPI Services delivery.
2. To identify the major reasons for immunization failure as perceived by nursing mothers.
3. To examine mothers immunization coverage status for tetanus toxoid
4. To rank the preferred immunization strategy (immunization centre) from Maternal and Child Health/Family Planning staff point of
5. To make recommendations for all stake holders and funding agencies as to how to improve EPI Service utilization by nursing mothers, MCH/FP staff, and other concerned

Table 1.3 Population Sizes and Growth Rates Ikpaja.

Year	Population	Year	Growth Rates
1960	55,108	1960-1970	3.3%
1970	76,551	1970-1984	3.0%
1984	117,081	1984-2000	1.3%
2000	143,206	2000	1.3%
2006	155,755	2000-2006	1.4%

Source: Ikpaja Statistical Service, 2006.

Household Sizes/Characteristics

 The current average Household size of 6.4 is higher than the National figure of 5.24 and the 1995 survey figure of 5.5 of the District showing an increase due to the growth of the population. The implication is that each Household has a large number of Dependants to feed, cloth and house. Given the low average Household Income, most families have a low Living Standard as evidenced by both Income and Expenditure pattern where the bulk of family income goes into food.

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