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A survey on immunization coverage among children of rural South Kerala.

INTRODUCTION: 'Research', (1) means 'to examine closely and carefully, to test and try to probe again anew, over again'. Immunization (2) is the process by which an individual is made immune or resistant to an infectious disease, typically by the administration of a vaccine. Vaccine-preventable diseases are a major source of mortality and morbidity among children throughout the developing world, causing deaths in millions every year.

To prevent these diseases, vaccines are delivered through routine health services and through supplemental immunization activities to the children targeted. Measuring immunization coverage helps evaluation of immunization services and when linked to surveillance data, assessment of the success of immunization strategies in preventing disease. Although most countries routinely assess immunization coverage using administrative data, results can usually be unreliable.

When new vaccines are being introduced to the health system by the Government, there are chances of low immunization coverage due to various reasons related to both the beneficiaries and the service providers.

Government of India launched the Expanded Programme (3) on Immunization in 1978 to protect children against diphtheria, pertussis, tetanus, and typhoid. Vaccination against polio through oral polio vaccine (OPV) was added to the programme in 1979-80 and BCG vaccination against tuberculosis was added in 1981-82.

Vaccination against measles was included in 1985-86. In the late 1980s, the World Health Organization developed the Expanded Program on Immunization (EPI) Survey Methodology, (4) which has since then been widely used to assess immunization coverage achieved by 'routine immunization' provided through health services. WHO emphasized the goal of achieving universal immunization by 1990 and the Global Program was renamed as "Universal Child Immunization-1990".

The Strategy under Universal Immunization Program was:

a) Hundred percent coverage of expectant mothers with two doses of Tetanus Toxoid

b) At least 85 % coverage of infants with 3 doses of DPT and OPV and one dose each of BCG and Measles Vaccine before the child celebrates first birthday.

In India, the current National Immunization schedule followed is recommended under NRHM. (5)

Roughly 3 million children die each year of vaccine preventable diseases (VPDs) with a large number of these children residing in developing countries. (6) Recent estimates show that approximately 34 million children are not completely immunized with almost 98 % of them residing in developing countries. (7) Vaccination coverage in India is also far from complete in spite of the longstanding commitment to universal coverage. Gains in coverage was rapid throughout the 1980s, but subsequent gains have been limited. (8)

In India, as per CES 2009, there are 4 states including Kerala where >80% of children between 12-23 months of age are fully immunized for age. (9) CES 2009 reported BCG, OPV and DTP3 doses coverage, and measles first dose coverage as 86.9%, 70.4%, 71.5%, and 74.1%, respectively. (10)

According to DLHS-3 and NFHS-3 the figures were 86.7%, 66%, 63.5%, and 69.5%, and 78.1%, 78.2%, 55.3%, and 58.8%, respectively. (11)

If immunization coverage survey is done frequently it will help to get a true picture of the Immunization status of the target population, the agency through which the immunizations are given in the area and various reasons for immunization failure and drop out and to identify operational and programmatic challenges in new vaccine introductions.

Now Government of India has also expanded the Universal Immunization Progranme (UIP) by introducing 2nd dose of Measles, Hepatitis B and Pentavalent vaccination (9). Pentavalent vaccine is a combination of vaccines against five diseases (Diphtheria, Pertussis, Tetanus, Hepatitis B and Haemophilus influenza B).

Since November 2012, pentavalent vaccine is being administered in India instead of DPT1, DPT2, DPT3, Hep Bl, Hep B2, Hep B3, Hibl, Hib2 and Hib3 from 42 days after birth.

The Immunization coverage survey of a primary health centre area, for the year 2013 is an attempt to find out the true picture of the immunization status of this rural area in South Kerala where the maternal and child health services are rendered through the department of Health services and private institutions of the area. The knowledge can be used for devising strategies based on the out-come of the study to attain 100% immunization coverage, which enables to prevent the vaccine preventable diseases successfully.

The Immunization coverage survey is conducted with the objectives: a) to assess the immunization coverage of children of 12 to 24 months of age in Thiruvananthapuram district, Kerala and b) to find out any socio demographic factors associated with immunization coverage.


Study Design: Community-based Cross sectional study.

Study Area: Thiruvananthapuram district, Kerala.

Study population: Children below the age of 12 to 24 months and their mothers.

Sample size: Is calculated using the formula 4pq/[d.sup.2].

Prevalence, P = 85

Q = 100-50 = 15

Precision = 5

Sample size = 4 x 85 x 15/25 = 5100/25 = 204 the sample size is = 210

K = N/n Total population 5 x 800 = 4000; n=210; K=4000/210=19

By systematic random sampling method, every 19th house having children of age group of age 12 to 24 months is visited to get the sample subjects.

Selection of Study subjects: Survey was carried out by Cluster Sampling Technique. Based on the population thirty clusters were selected from all 7 wards. List of thirty clusters selected is given in the appendix. The selection of clusters was done as stipulated in the WHO module.

Multistage Random sampling is used at the level of Grama panchayats in Thiruvananthapuram district and wards in Grama panchayats. From the wards selected each cluster of children are obtained. By systematic random sampling method, every 19th house having children of age group 12 to 24 months is visited to get the sample subjects.

The survey was conducted from 24th December 2013 to 16th January 2014.

Study Period: Three months from December 2013. Before starting the study, Ethics Committee clearance is obtained from the Institutional Ethics Committee. Informed consent is obtained from the parents of study subjects.

Method of Data Collection: Data are collected using UIP child coverage survey household form and UIP mother coverage survey household form from all the thirty clusters by interviewing mothers and examining vaccination cards. Socio demographic details and data on newly introduced vaccines are collected through the questionnaire administered to the mother. Socio economic status is assessed using modified Kuppuswamy's scale.

Statistical Analysis: Data are entered in Excel spreadsheet. Descriptive statistical analysis is done with the help of computer package SSPS.

Immunization Coverage of each vaccine for age is computed.

Analysis of association between immunization coverage and various socio demographic variables is done by using Chi square test.


Base Line Data:

Total number of households visited: 1507

Average number of household visited/cluster: 51

Number of Children under 5 years: 612

Number of children between 12 to 23 months: 210

Number of male children: 105

Number of female children: 105

IMMUNIZATION STATUS OF CHILDREN: According to immunization schedule all primary vaccinations (BCG, DPT, OPV, HepB V and Measles) should be completed by the time the child is 12 months old i.e., fully immunized. If any one dose for age is not administered, it is considered partially immunized. If no vaccine has been administered, it is referred to as non-immunized or unimmunized.

After the introduction of Hepatitis B Vaccine (HepBV1, HepBV2 and HepBV3) it was received by children along with DPT1, 2 & 3. After the introduction of Pentavalent vaccine (in November 2012) that includes DPT, HepB V and Heamophyllus influenza (Hib) vaccines was received by children instead of DPT & HBV.

Out of 210 children surveyed, 189(90%) were fully immunized for age, 21(10%) were partially immunized for age and no child was unimmunized.

Out of 105 male children, 95 (90.48%) were fully immunized, 10(9.52%) were partially immunized.

Out of 105 female children 94(89.52%) were fully immunized and 11(10.48%) were partially immunized.

The immunization coverage of female children was more than that of male children.

Table II: Immunization Coverage of individual Vaccines

Vaccine       Female        Male          Total

              No.     %     No.     %     No.     %

DPT1&HBV1     105    100    105    50     210    100
DPT2, HBV 2   105    100    105    50     210    100
DPT3, HBV 3   100   95.23   98    93.33   198   94.28
OPV.I         105    100    105    100    210    100
OPV.II        105    100    105    100    210    100
OPV.III       100   95.23   98    93.33   198   94.28
Measles       99    94.28   97    92.38   196   93.33
BCG           105    100    105    100    210    100

Regarding the coverage at various vaccines maximum coverage was for BCG (100%) followed by DPT and Hep B (94.28%) and OPV (94.28%) and Measles (93.33%). Only 15 children received pentavalent vaccine.

Table III: Dropout Rate of DPT, OPV & Hep B

Vaccine     First   Second   Third   Drop    %

DPT, HepB    210     210      198     12    5.72
OPV          210     210      198     12    5.72

The drop rate for DPT and Hep B from 1st to 3rd dose was 5.72% and that for OPV was 5.72%.


198(94.28%) showed the scar. 5.72% did not develop a scar after B.C.G vaccination.

Table V: Age in months at the time of starting immunization

Month             BCG       DPT & HepB      OPV        Measles

1              96(45.72%)   3 (1.54%)    3 (1.54%)
2               42(20%)     66(33.33%)   66(33.33%)
3              29(13.8%)    74(37.37%)   74(37.37%)
4               4(1.90%)    26(13.13%)   26(13.13%)
5               3(1.43%)     4(2.02%)     4(2.02%)
6               3(1.43%)     2(1.01%)     2(1.01%)
9              1 (0.48%)     1(0.5%)      1(0.5%)     65(30.95%)
10                           1(0.5%)      1(0.5%)     39(21.67%)
11                                                    16(8.89%)
12                           1(0.5%)      1(0.5%)     35(19.44%)
13              2(0.96%                                 17(8%)
Date Unknown   30 (14.28%   20(10.10%)   20(10.10%)   24(13.33%)
Total          210 (100%)   198 (100%)   198(100%)    196(100%)

An enquiry into the age of the child at the time of starting the immunization revealed that 45.72% of infants had BCG vaccination during the 1st month it-self. In the case of OPV, 89.3% had completed the primary immunization at the age of 6 months. 73.80% of children had measles immunization at the recommended age of 9 to 12 months.

Table VI: Immunization by source

SOURCE              BCG          MEASLES     DPT, HBV

                                                  I            II

Hospital        190 (90.47%)   12 (5.71%)        NIL           NIL
Health centre    12 (5.71%)    64 (30.47%)   80 (38.1%)    80 (38.1%)
Out reach           NIL            NIL           NIL           NIL
Private          2 (0.95%)      10 (4.7%)     20 (9.5%)     20 (9.5%)
Subcentre         6 (3.8%)     110 (52.3%)   110 (52.3%)   110 (52.3%)
TOTAL               210            196           198           210

SOURCE          DPT, HBV                       OPV

                   III            I            II           III

Hospital           NIL           NIL           NIL          NIL
Health centre   80 (38.1%)   80 (38.1%)    80 (38.1%)    80 (38.1%)
Out reach          NIL         NILNIL          NIL          NIL
Private         20 (9.5%)     20 (9.5%)     20 (9.5%)    20 (9.5%)
Subcentre       98 (52.3%)   110 (52.3%)   110 (52.3%)   98 (52.3%)
TOTAL              198           210           210          198

Out of 210 children 182(86.6%) had their immunization card. Out of 210 children 190(90.47%) received BCG vaccination form hospitals, 12 (5.71%) from health centre, 2 (0.95%) from private institutions, and 6(3.8%) from subcentres.

In the case of DPT and OPV 110 (52.3%) children got vaccinated from subcentres and 80(38.1%) from health centre and 20 (9.5%) from private institutions. 110 (52.3%) Children got vaccinated for measles from subcentres.

Table VII: Awareness about vaccine
preventable diseases in households

DISEASES           No. s     %

None Known           0       0
Diphtheria          256    45.7
Pertussis           320    57.14
Tetanus             392     70
Poliomyelitis       510     91
Measles             480    85.7
T B                 520    92.85
Total Households    560

520 (92.85%) were aware of Tuberculosis. Awareness about Poliomyelitis and Pertussis was 91% and 57.14% respectively. None gave a negative answer.

The majority, 480(85.7%) had received the information on vaccine preventable diseases from the health staff and 80(14.2%) from the newspapers, posters and from the radio and television and other sources of information like the relatives, neighbors and volunteers.

Table VIII: Reason for Immunization Failure

Reasons                                              No

I Lack of information

1. Unaware of need for immunization
2. Unaware of need to return for 2nd and 3rd dose    3
3. Place and time of immunization unknown            --
4. Fear of side reaction                             8
5. Wrong ideas about contra indications              4

II Lack of motivation

1. Postponed till another time                       8
2. No faith in immunization                          --
3. Rumors                                            2

III Obstacles

1. Place of immunization too far to go               --
2. Time of immunization inconvenient                 --
3. Vaccinator absent                                 --
4. Vaccine not available                             --
5. Mother too busy                                   1
6. Family problems including illness of mother       2
7. Child ill not brought                             9
8. Child ill, brought, not given                     1
9. Long waiting time                                 --

The reasons for failure of immunization were considered under three headings namely Lack of information, Lack of motivation and Obstacles. 8(3.8%) abstained from getting the vaccine because of fear of side reaction and an equal number postponed immunization till another time. In the case of 9(4.2%) children, immunization failure was attributed to the fact that the child was ill and hence not bought for immunization.

It is felt that strengthening of Health Education activities can improve the immunization coverage, by removing the misconception about immunization and the fear of side reactions. Since minor illnesses are not contradictions for immunization, majority of them could have received the vaccines if they were brought for immunization. Strengthening of health education can definitely improve the coverage to almost 100 percent

Table IX: Source of immunization of mothers against tetanus

TOXOID                 CENTRE     REACH               CENTRE     TAKEN

1st Dose   6 (2.8%)   90(42.8%)    Nil    4(1.9%)    110(52%)     Nil
2nd Dose   4 (1.9%)   92(43.8%)    Nil    6(2.8%)   108(51.4%)    Nil

Among the 210 mothers surveyed, all the mothers had received the full course of tetanus toxoid during the antenatal period. Source of immunization was the Sub-Centre in 52% and Health Centre 43%.

Table X: Place of delivery with persons attended



HEALTH STAFF                208             Nil     208
TRAINED DAI                 Nil             Nil     Nil
UNTRAINED DAI               Nil             Nil     Nil
OTHER REASON                Nil              2       2
TOTAL                       208              2      210

Out of 210 deliveries 94.8% were hospital deliveries and 2 home deliveries attended by relatives and taken to hospital after delivery.

LOW SOCIO ECONOMIC STATUS AND PARTIAL IMMUNIZATION STATUS: 48% the families belonged to low socio economic status according to Kuppuswamy's scale. There was statistically significant association between low socio economic status and partial immunization status (Chi-square 18.01, P < 0.001).

SUMMARY AND CONCLUSION: The universal immunization program coverage survey in Kunnathukal area was carried out during the period from December 2013 to January 2014 by cluster sampling technique. The total 210 children of 12 to 24 months of age and their mothers were surveyed. Out of 210 children covered 90% were fully immunized for age, 10% were partially immunized and no child was found unimmunized. The coverage was more among female children than for male children.

Measles coverage was 93.33%. 100% Children had received BCG immunization. The drop-out rate for DPT, HepB and OPV from 1st to 3rd dose was 5.7%. 91.28% of children developed a scar after BCG vaccine. 79.52% Children took BCG within three months of age. 73.80% of children had measles vaccine between 9th and 12th month. Almost 90% of the children received immunization from government hospital and health centers. Less than 10% got immunization from private sources.

The awareness of vaccine preventable diseases in the area was quite high. Better Health Education activities could have improved the immunization coverage to almost 100%.

100% of mothers of infants were immunized against Tetanus. 99% of deliveries were conducted in Hospitals or Health Centers and were attended by trained personnel.

There was significant association between low socio economic status and partial immunization status.


At state and district levels: Quality trainings, effective supervision and monitoring, improving documentation of data and reporting are key factors for improvement. The additional focus on Hep B birth dose administration may help in improving coverage of Hep B vaccination. The lessons from this survey can possibly be utilized for future introduction of any new vaccine in India or in any other developing country setting.

1. Short term recommendation--Strengthen health education to improve the knowledge regarding need and safety of immunization procedures and new vaccines being introduced.

2. Long term recommendations:

i. Improve infrastructure facilities wherever in adequate.

ii. Posts of health personnel to be filled in wherever there is vacancy

iii. Intensify supervision and monitoring so that quality of services can be improved and 100% immunization coverage for all vaccine preventable diseases may be ensured.

It is concluded that for successful introduction of any new vaccine in national or state immunization program, clear and timely central level instructions and oversight and improved stock management are required.

DOI: 10.14260/jemds/2014/3176


(1.) Module 1. Alexis Foundation [C] 2013.


(3.) GOI National CSSM Program: Manage the cold chain and other supplies. MOH & FW, New Delhi 1992.

(4.) Training for mid-level managers: the EPI coverage survey. Geneva: World Health Organization, 1991 (unpublished document WHO/EPI/91.10; available from Vaccines and Biologicals, World Health Organization, 1211Geneva 27, Switzerland.

(5.) NRHM Bulletin.2012; 7(4).

(6.) Bonu S, Rani M, Baker TD. The impact of the national polio immunization. Campaign on levels and equity in immunization coverage: Evidence from rural North, India. Social Science Medicine 2003,57:1807-19.

(7.) Das N, Mishra V, Saha P. Does Community Access Affect the Use of Health and family Welfare Services in Rural India? National Family Health Survey Subject Reports 2001. Number 18 May Indian Institute of Population Sciences, Mumbai India.

(8.) Frenkel LD, Nielsen K. Immunization issues for the 21st century. Ann Allergy Asthma Immunol 2003,90(6): Suppl 3: 45-52.

(9.) Ministry of Health and Family Welfare-16 January 2012,16-14:1ST.

(10.) UNICEF Coverage Evaluation survey, 2009 National Fact Sheet Accessed on Sep 14, 2012.

(11.) District Level Household and Facility Survey 2007-08. Available from: Accessed on Sep 14, 2012.


1. M. C. Vasantha Mallika

2. Siva Sree Ranga M. K.


1. Associate Professor, Department of Community Medicine, Dr. SMCSI Medical College, Karakonam, Thiruvananthapuram, India.

2. Assistant Professor, Department of Anatomy, Dr. SMCSI Medical College, Karakonam, Thiruvananthapuram, India.


Dr. M.C. Vasantha Mallika, Siva Sri Sadanam, Vellarada-695505, Thiruvananthapuram District, South Kerala, India.


Date of Submission: 25/07/2014. Date of Peer Review: 26/07/2014. Date of Acceptance: 08/08/2014. Date of Publishing: 11/08/2014.
Table I: Immunization Status of Children

Immunization status   No of       No of Males   No of Females

                      No     %    No      %     No      %

Fully immunized       189   90    95    90.48   94    89.52
Partially immunized   21    10    10    9.52    11    10.48
Non-Immunized         Nil   Nil   Nil    Nil    Nil    Nil
Total                 210   100   105    100    105    100

Table IV: Scar rate for BCG Vaccination

Scar rate for BCG vaccination

BCG            No.     %

Scar Present   198   94.28
Scar Absent    12    5.72
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Title Annotation:ORIGINAL ARTICLE; Kerala, India
Author:Mallika, M.C. Vasantha; Siva, Sree Ranga M.K.
Publication:Journal of Evolution of Medical and Dental Sciences
Article Type:Report
Geographic Code:9INDI
Date:Aug 11, 2014
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