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ESTIMATING ORAL POLIO VACCINE COVERAGE DROPOUTS FOR EQUITABILITY: EVIDENCE FROM PAKISTAN.

Byline: Aneel Salman, Muhammad Iftikhar Ul Husnain and Tahir Ul Mulk Kahlon

Abstract

Objective: To analyze the effectiveness of expanded program on immunization (EPI) in Pakistan by finding proportion of children who have received at least one dose of oral polio vaccine (OPV) to pre vent poliomyelitis but failed to receive 2nd and 3rd dose before the end of their 1st year of life.

Study Design: Retrospective study.

Place and Duration of Study: The study was carried out at Sustainable Development Institute, COMSATS Institute of Information Technology and National Defense University Islamabad, from Jan 2015 to Mar 2016.

Material and Methods: Method of multivariate regression and odds ratio were used on Pakistan demographic and house hold survey micro-datasets to analyze the effectiveness of expanded program on immunization (EPI) in Pakistan by finding the proportion of children who have received at least one dose of oral polio vaccine (OPV) to prevent poliomyelitis. Drop-out (DO) rate was calculated in order to assess effectiveness of coverage-breadth.

Results: Gaps in service delivery, ineffective communication with mothers and entwined poverty dimensions are contributors to low coverage statistics and Drop-out (DO) rate of children in context of polio vaccination. Female children do not benefit to the same extent from polio vaccination efforts as male counterparts. Empowered mothers with good health seeking behavior care better for their children. Education is another key factor with major impact on health system service utilization and acceptability.

Conclusion: Gaps in service delivery, ineffective communication with mothers and entwined poverty dimensions are contributors to low coverage statistics. Education is the key factor with major impact on health system service utilization and acceptability. Due to cultural norms in society gender discrimination is observed in all provinces which shows that girls are more likely to be vulnerable as compare to their male counterparts.

Keywords: Equitable delivery, Polio, Program evaluation, Systems research.

INTRODUCTION

Vaccination is a cost effective intervention to prevent humans from viral disease morbidity1. World Health Organization targets 12-23 month children for 8 doses1 of vaccines against Tuberculosis, Diphtheria, Pertussis, Neonatal tetanus, Hepatitis-B, Hemophilic influenzae Type B [Hib], Poliomyelitis, and Measles. Pakistan is fighting against these diseases since 1978. On average 40 polio cases are reported in Pakistan annually for the period (2008-12) (figure). In recent years, international pressure on Pakistan has mounted being the one of only two nations in the world to not have eradicated polio2.

Initially expanded program on immunization (EPI) in Pakistan aimed to eradicate Polio by 2012, measles and tetanus by 20153. In 2002, vaccine against Hepatitis was included, then Hib meningitis and pneumonia added in 2008 and pneumococcal was added in 2012 to the program to meet the standard 8 dose full immunization against 9 preventable diseases i.e. poliomyelitis, neonatal tetanus, measles, diphtheria, pertussis (whooping cough), hepatitis-B, Hib pneumonia, meningitis and childhood tuberculosis among 12-23 month children2. EPI in Pakistan is focusing polio through a schedule presented in table-I.

The rationale of this study was to assess the effectiveness of service delivery by EPIP through estimation of trend of the proportion of children who have received at least one dose of oral polio vaccine (OPV) to prevent poliomyelitis, but failed to receive their second and third dose to complete the schedule before the end of the first year of life.

Table-I: Expanded program on immunization in Pakistan immunization schedule.

###Causes of

Disease###Vaccine###Doses###Age of administration

###infection

Childhood Tuberculosis###Bacteria###BCG###1###0 age or at birth

Poliomyelitis###Virus###OPV###4###OPV-0 : At birth

Diphtheria###Bacteria###Pentavalent###Penta-1 : 6 weeks

Tetanus###Bacteria###vaccine (DPT +###3###Penta-2 : 10 weeks

Pertussis###Bacteria###Hep. B + Hib)###Penta-3 : 14 weeks

Pneumoniae and###Pneumo-1 : 6 weeks

Meningitis due to###Bacteria###PCV10###3###Pneumo-2 : 10 weeks

S. Pneumonia###Pneumo-3 : 14 weeks

###Measles-1 : 9 months

Measles###Virus###MMRV3###2

###Measles-2 : 15months

MATERIAL AND METHODS

This study was conducted at COMSATS Institute of Information Technology and National Defense University Islamabad from January 2015 to March 2016. This is a retrospective study that utilizes data from three rounds 1990-91, 2006-07, 2012-13 of Pakistan demographic health survey (PDHS) to analyze polio dropout incidences. Observation unit comprised of children 12-23 months of age. A total of 4811 children were selected using stratified random sampling technique from all three rounds (1215 from 1990-91, 1522 from 2006-07 and 2074 from 2012-13 round respectively). The sample size was selected on the availability of subjects in the relevant cohort. PDHS collects extensive information on basic health indicators of children under 5 and women of reproductive age i.e. 15 years-49 years. Information about children 12-23 months of age on immunization status; viz, health attributes and vaccine uptake is available from "Child vaccination, health and nutrition" section of "Women Questionnaire".

Table-II: Percent distribution of children age 12-23 months by their status of vaccination against Polio virus (OPV1-OPV3) and Socio-Demographic characteristics in Pakistan.

N (Total)###Mother Education###Gender of Child###Birth Order###Mother's Age at 1st###Variables###Survey Year

###Marriage

###Secondary###Primary to###Uneducated###Female###Male###<5###3-4###1-2###19###Levels

###and Above###Secondary

522###58.8###58.2###38.2###40.2###45.8###44.6###43.9###40.3###53.7###48.8###38.4###Yes (%)

693###41.2###41.8###61.8###59.8###54.2###55.4###56.1###59.7###46.3###51.2###61.6###No (%)###Full doses

1215###97###189###929###629###586###448###358###409###83###406###726###N

392###4.1###11.1###39.5###34.6###29.7###37.3###31.3###27.4###28.9###23.9###37.2###Yes (%)

823###95.9###88.9###60.5###65.4###70.3###62.7###68.7###72.6###71.1###76.1###62.8###No (%)###Never###PDHS 1990-91

1215###97###189###929###629###586###448###358###409###83###406###726###N

302###84###69.9###76.7###73.8###78.7###69.8###75.4###81###60###72.4###80.1###Yes (%)

96###16###30.1###23.3###26.2###21.3###30.2###24.6###19###40###27.6###19.9###No (%)###Drop-outs

398###44###83###271###214###184###116###118###164###25###152###221###N

1264###89.5###87.6###79.9###81.6###84.4###83.7###80.8###84###83###83.7###82.7###Yes (%)

258###10.5###12.4###20.1###18.4###15.6###16.3###19.2###16###17###16.3###17.3###No (%)###Full doses

1522###228###346###948###706###816###496###407###619###341###510###871###N

107###2.6###3.8###9.1###7.4###6.5###7.1###7.1###6.6###5.7###4.5###8.5###Yes (%)

1415###97.4###96.2###90.9###92.6###93.5###92.9###92.9###93.4###94.3###95.5###91.5###No (%)###Never###PDHS 2006-7

1522###228###346###948###706###816###496###407###619###341###510###871###N

150###29.5###23.8###20.3###23.1###20.5###17###26.8###22.6###35.7###29.3###17.1###Yes (%)

535###70.5###76.2###79.7###76.9###79.5###83###73.2###77.4###64.3###70.7###82.9###No (%)###Drop-outs

685###61###126###498###334###351###253###179###252###43###198###444###N

1769###90.7###87.8###81.9###84.5###86.1###82.4###86.6###86.1###86.6###88.9###82.1###Yes (%)

305###9.3###12.2###18.1###15.5###13.9###17.6###13.4###13.9###13.4###11.1###17.9###No (%)###Full doses

2074###439###517###1118###1024###1050###535###575###964###186###844###1044###N

160###5###6.4###9.4###8.3###7###7.5###7.3###8###5.9###5.8###9.6###Yes (%)

1914###95###93.6###90.6###91.7###93###92.5###92.7###92###94.1###94.2###90.4###No (%)###Never###PDHS 2012-13

2074###439###517###1118###1024###1050###535###575###964###186###844###1044###N

139###22###20.1###16.3###17.8###17.4###20.8###13.1###18.3###32.6###14.1###18.3###Yes (%)

657###78###79.9###83.7###82.2###82.6###79.2###86.9###81.7###67.4###85.9###81.7###No (%)###Drop-outs

796###92###139###565###411###385###255###246###295###43###284###469###N

Response indicator was defined as whether the child (12m-23m) has been dropped out (coded '1') or not (coded '0'). Drop-out (DO) rate was calculated in order to assess effectivity of coverage breadth. The DO formula was consistent under assumption that it pertains to those children (12m-23m) who (a) 'Missed' i.e. did not receive OPV1, OPV2, OPV3 (b) 'Discontinued' i.e. did not receive OPV1 through OPV3 sequentially according to schedule. Hence, coverage for target population remains partial and confounded as failure of planning objective.

Difference of ratio between incidences of initial vaccine dose OPV1 and final vaccine dose OPV3 was calculated using the formula; DO = Rate of dropout = [OPV1 - OPV3/OPV1]. DO may range from 0% to 100%. A decreasing dropout rate would implicate stronger coverage for outcome. Multinomial Logit model was used to find odd ratios that helped to draw comparison across different groups of the sample. As OPV is part of polio campaign yet in Pakistani context it covers a substantial part of this activity and hence considered an appropriate measure for polio.

SPSS software (version 18) was used to analyze data.

RESULTS

Total number of subjects in the study is 4811 selected from three rounds of PDHS based on the availability of subjects in the relevant cohort.

Table-III: Odds ratio of immunization status among children 12m-23m by their Background Characteristics.

###PDHS 1990-91###PDHS 2006-07###PDHS 2012-13

Predictors###Full###Drop###Full###Drop###Full###Drop

###Never###Never###Never

###doses###outs doses###outs doses###outs

Regions###PUNJAB (Reference)

Sindh###0.432###2.619###1.359 1.075###1.422###0.520 0.295###5.590###1.168

KPK###0.836###1.388###1.420 0.791###1.862###0.891 0.304###6.537###1.456

Baluchistan###0.415###2.693###1.501 0.302###9.673###0.665 0.151###9.915

GENDER OF CHILD (MaleRef)

Female###0.748###1.413###0.860 0.536###1.130###1.209 0.875###1.177###1.225

FATHER'S EDUCATION (Secondary and above Ref)

Uneducated###0.897###0.721###2.215 0.536###3.081###1.004 0.721###1.457###1.143

Primary to

###0.975###0.726###1.313 0.566###2.489###1.225 1.027###1.212###0.683

Middle

MOTHER'S EDUCATION (Secondary and above Ref)

Uneducated###1.004###8.447###0.259 0.511###1.853###1.308 0.837###0.986###0.742

Primary to

###1.439###2.337###0.315 0.811###1.188###1.111 0.841###1.066###1.112

Middle

GENDER OF HH'HEAD (MaleRef)

Female###1.982###0.800###0.336 1.553###0.304###0.926 0.775###1.871###0.788

WEALTH STATUS (RichRef)

Poor###0.309###3.351###2.057 1.291###0.902###0.553 0.706###1.504###0.806

Middle###0.533###2.155###0.703 1.707###0.432###0.432 0.891###0.897###1.068

Sample size###1215###1215###398 1522###1522###685 2074###2074###796

First, percented distribution of children age 12-23 months by their status of vaccination against polio virus (OPV1-OPV3) and socio-demographic characteristics in Pakistan were present in table-II. Then, deterministic probabilities were calculated of maternal variables and marital age, level of reproductive health care, health seeking behavior, education level, household size in nuclear family, and household wealth were found significant (p=0.03). In 2007 and 2013, reported drop outs are more for children delivered at health facility. Same year, 11% never vaccinated against polio and 66% dropped out.

Across 1991 to 2013 mother's age at first marriage was a relevant factor in determination of dropout percentage. Reproductive health care service is significant across the years but father's education is significant for 1991 and 2013. It insignificantly measures vertical equity for OPV. In 2013, house-hold wealth was a significant characteristic in relation to vaccination intake (table-II). The significance level is based on standard T and F statistics.

A significant difference in polio immunization was found among the regions of Pakistan with Baluchistan performing poorest of all. From 1991 to 2013, probability of polio dropouts increased. The highest one was observed in 2007 where children were nearly 10 times more likely to dropout (OR 9.673; 95% CI: 4.758-19.664) as compared to Punjab (table-III).

DISCUSSION

Poor parental knowledge about child health preventive measures, poor geographical access to health services, lack of technical skill of health staff, lack of resources/logistics, misconceptions in population, fear of side effects, conflicting priorities, socio-cultural norms, missed opportunities and unreliable services can be considered responsible for under coverage of vaccination4. Previously the education of mother had been proved as a significant factor affecting immunization status of children5. Inversely speaking the dropout percentage is increasing as level of mother's education decreasing. This finding is in line with previous studies on the subject6. Households headed by female were less likely to remain unvaccinated during Polio campaigns7 (table-III).

Different trends among full and no vaccination coverage categories were observed in contrast to drop out cases. This shows that determinants of full, partial and no immunization are different. Increased dropout rates for births at health facilities indicate unsatisfactory service delivery status. Improved probability to vaccination exists for highly educated parents, male children and male head of households. Gender discrimination is due to cultural norms in society. Among all indicators mother's age at marriage, reproductive health care behavior of mothers, parental education, household size and wealth status of mothers were statistically significant and most influential variables. Results of multivariate analysis suggest that improvement in socioeconomic status of women will decrease the chance of polio dropout cases hence improving service delivery and implementation of vaccination program.

Behavior change modification and family planning are the most important strategies to improve outcomes of immunization drive against polio virus. Mismanagement within tall structure health system, misallocations and inappropriate utilization of available resource for access to immunization services, irregular monitoring and evaluation, lack of literacy or awareness, incapacity of stewardship and deteriorated security situation especially in north-western regions are hampering performance by health departments in Pakistan8-10.

CONCLUSION

Gaps in service delivery, ineffective communication with mothers and entwined poverty dimensions are contributors to low coverage statistics. Education is the key factor with major impact on health system service utilization and acceptability. Due to cultural norms in society gender discrimination is observed in all provinces which shows that girls are more likely to be vulnerable as compare to their male counterparts.

CONFLICT OF INTEREST

This study has no conflict of interest to be declared by any author.

REFERENCES

1. Ozawa S, Mirelman A, Stack ML, Walker DG, Levine OS. Cost effectiveness and economic benefits of vaccines in low and middle income countries: A systematic review. Vaccine 2012; 31(1): 96-108.

2. World Health Organization 2014. Poliomyelitis: Fact sheet. Available at http://www.who.int/mediacentre/factsheets/ fs114/en/

3. Sheikh A, Iqbal B, Ehtamam A, Rahim M, Shaikh AH, Usmani HA, et al. Reasons for non-vaccination in pediatric patients visiting tertiary care centers in a Polio-prone country. Archives of Public Health 2013; 71(1): 19.

4. Favin M, Steinglass R, Fields R, Banerjee K, Sawhney M. Why children are not vaccinated: A review of the grey literature. International Health 2012; 4(4): 229-38.

5. Basaleem HO, AL-Shakkaf KA, Shamsuddin K. Immunization coverage and its determinants among children 12-23 months of age in Aden Yemen. Saudi Med J 2010; 31(11): 1221-26.

6. Sekhar B, Manju R, Timothy DB. The impact of the national Polio immunization campaign on levels and equity in immunization coverage: Evidence from rural North India. Soc Sci Med 2003; 57(10): 1807-19.

7. Patra N. Universal immunization programme in India: The determinants of childhood immunization 2012. Available at SSRN 881224.

8. Mangrio NK, Alam MM, Shaikh BT. Is expanded programme on immunization doing enough? Viewpoint of health workers and managers in Sindh, Pakistan. J Pak Med Assoc 2008; 58(2): 64-7.

9. Pakistan 2009a. National Health Policy 2009, Final draft. Ministry of Health. Islamabad. Available at http://www. health. gov.pk/

10. Masud T, Navaratne V. The Expanded Program on Immunization in Pakistan, Recommendations for Improving Performance. HNP discussion paper. 2012 (http:// relief web. int/ sites/reliefweb. int/ files/resources/ The% 20 expanded% 20program% 20on% 20 immunization% 20in% 20 Pakistan. pdf).
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Publication:Pakistan Armed Forces Medical Journal
Geographic Code:9PAKI
Date:Apr 30, 2018
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