Coverage and predictors of vaccination among children 12-23 months of age in district Muzaffarabad, Pakistan

Date of Award


Document Type


Degree Name

Master of Science in Epidemiology & Biostatistics (MSc Epidemiology & Biostats)


Community Health Sciences


Introduction: Vaccination against childhood communicable diseases through the Expanded Program on Immunization (E.P.I) is one of the most cost-effective public health interventions. By assessing the immunization coverage and factors responsible for under immunization in children of the area where a devastating earth quake badly affected the lives of families, this study will help the concerned policy makers and program mangers of EPI program in setting up the service priorities towards the children of community. Subjects and Methods: A community based cross-sectional study was conducted for children aged 12-23 months in district MuzaffarAbad from October 2007 to December 2007. Trained data collectors administered structured questionnaire to the parents of the 860 children using a multistage cluster sampling technique. The "up-to-date" and "age appropriate immunization" coverage for the children was determined using cluster analysis through the SAS version 9.1. The up-to-date immunization coverage was either reported by the parent of the child or recorded from the vaccination card in the children aged 12 to 23 months. It indicated the proportion of — children aged 12-23 months with complete immunization at the time of our study. The age-appropriate immunization by age of 1 year was determined only for those study children who had vaccination cards and were administered valid doses. It indicated the proportion of study children with vaccination cards that completed their immunization with valid doses before one year of age. We did two separate binary logistic regression analysis through the SAS version 9.1, to see the association of different study variables with the outcome variable. One of these Binary logistic regression analyses was run for up-to-date immunization as the outcome. Another set of binary logistic regression was run with the age-appropriate immunization as the outcome variable. Results: We found that up-to-date coverage for the children aged 12-23 months in District MuzaffarAbad is 74.1% (N=637, CI 67.8%-80.3%), and the age appropriate immunization coverage for the Dist. MuzaffarAbad for children by 1 year is 19.4% (N=223, CI 14.2%-24.7%). The coverage for OPV vaccine for all the doses was above 90%, while the coverage for all the doses of HBV and DTP is above 80%. The district MuzaffarAbad has achieved the target 80% for coverage of DTP3 (80.12%, CI 74.20- 86.03). The coverage of the measles vaccine found by our study is lowest of all the vaccines (78%). Our study found that after adjusting for all the variables in the model mother's education, ethnicity of child, socio-economic status of child, gender, and time taken to reach the nearby health facility were important factors affecting the up-to-date immunization of the children. Our study further found that socioeconomic status, family related obstacles (mother business or mother's illness), migration of the family after the earth quake, and time taken to reach the nearby health facility were factors that were responsible for a delay in age-appropriate immunization. Children belonging to low socioeconomic status (family owning no household article) had significantly lower up-to-date (adjusted OR=3.9, 95% CI=2.1-6.3) and lower age appropriate (adjusted OR=2.9, 95% CI=1.8-4.7) immunization as compared to children of high SES respectively (family owning more than 2 household articles). Similarly children with middle SES (family owning 2 household articles) had significantly lower up-to-date (adjusted OR=2.5, 95% CI=1.5-4.1) and age-appropriate (adjusted OR=2.2, 95% CI=1.3-3.8) immunization as compared to children belonging to high SES. In district MuzaffarAbad living at a distance of ten minutes from the nearby health facility had a negative impact on both up-to-date (adjusted OR=1.12 for 10 units of distance, 95% C1=1.08-1.17) and age-appropriate (adjusted OR=1.06, 95% CI=1.01-1.12) immunization of child. Children who had a family related obstacle (child's mother ill or child's mother too busy) were less likely to have up-to-date immunization (adjusted OR=2.3, 95% CI=1.4-3.7) or age appropriately immunized (adjusted OR=1.7, 95% CI=1.1-2.8) as compared to children with no such problem. Children who had gone through a migration were twice more likely (adjusted OR=2.0, 95% CI=1.04-4.0) to have a delay in age-appropriate immunization as compared to children with no migration after the earth quake. Children of illiterate mothers had significantly lower up-to-date immunization as compared to children whose mother had greater than eight years of education (adjusted OR=2.4, 95% CI=1.3- 4.4). Children whose mother had less than eight years of education were 2.1 (95% C1=1.1- 4.1) times less likely to be immunized as compared to children who had mothers with greater than eight years of education. Our study found a dose response relationship between the education status of the mother and the up-to-date immunization coverage. There was a significant interaction between ethnicity and gender of the child. Odds of inappropriate up-to-date immunization were 1.7 times (95% C1=1.0-2.5) for a female minority child as compared to a male Pahari ethnic child. Odds of inappropriate upto date immunization were 1.5 times (95% 0=1.1-1.9) for a male minority child as compared to a male and Pahari ethnic child. Conclusion: Our study found that while up-to-date coverage for district MuzaffarAbad is 74.1% the age-appropriate immunization is low (19.4%). The drop out rate of 9.1% (for DTP vaccine) and that for DTP1 and measles vaccine is 11.1 %. Measles vaccine coverage is also low for the area (78.7%). We recommend that increasing the awareness of the mothers and the families about immunization program will increase the immunization coverage in the area by increasing the mothers' knowledge of importance of immunization and decreasing the drop-outs by increasing their awareness of EPI schedule. Refresher Training of the EPI staff in the area is needed as one half of measles vaccine and one-fifth of DTP3 vaccine were not administered validly. Arranging out-reaches and mobile immunization activities will help to increase the immunization coverage in remote areas and among certain minorities in area.

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