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   Table of Contents      
ORIGINAL ARTICLE
Year : 2020  |  Volume : 6  |  Issue : 2  |  Page : 97-99

Delayed Vaccination in Infants in an Urban Health Center in Delhi, India: Evidence from a Retrospective Audit of Secondary Data


Department of Community Medicine, Maulana Azad Medical College, New Delhi, India

Date of Submission16-Mar-2020
Date of Decision23-Mar-2020
Date of Acceptance07-May-2020
Date of Web Publication29-Aug-2020

Correspondence Address:
MBBS Aditi Sajwan
Department of Community Medicine, Maulana Azad Medical College, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mamcjms.mamcjms_20_20

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  Abstract 


Background: Delayed vaccination in infants significantly increases the susceptibility window for vaccine preventable diseases. Objective: We conducted a retrospective audit of secondary data to determine the rates of delayed vaccination among infants reporting for routine immunization at an urban primary healthcare clinic in Delhi, India. Methods: Data were extracted from the manual register of the health clinic and entered in MS-Excel 2013. Results: We analyzed a total of 811 vaccination encounters in infants. Delayed vaccination was observed in 144 (17.8%) vaccination encounters. The proportion of delayed vaccination encounters progressively increased from penta-1 (lowest) to penta-3 (highest). However, the proportion of overall delayed vaccination encounters did not differ significantly across gender (P = 0.71). Conclusions: Delayed vaccination among infants continues to exist as a significant but largely avoidable public health challenge in certain health settings in India.

Keywords: Delayed vaccination, immunization, India


How to cite this article:
Basu S, Sajwan A, Bhatnagar N. Delayed Vaccination in Infants in an Urban Health Center in Delhi, India: Evidence from a Retrospective Audit of Secondary Data. MAMC J Med Sci 2020;6:97-9

How to cite this URL:
Basu S, Sajwan A, Bhatnagar N. Delayed Vaccination in Infants in an Urban Health Center in Delhi, India: Evidence from a Retrospective Audit of Secondary Data. MAMC J Med Sci [serial online] 2020 [cited 2020 Nov 23];6:97-9. Available from: https://www.mamcjms.in/text.asp?2020/6/2/97/293882




  Introduction Top


Vaccine preventable diseases (VPDs) are responsible for more than 1.5 million deaths annually, while another 19.3 million infants continue to be at risk, worldwide.[1],[2] It is well-established that delayed vaccination in infants significantly increases the susceptibility window for VPDs.[3] According to the World Health Organization (WHO), infants who have received all vaccinations within four weeks from the recommended schedule date are considered as being fully and timely vaccinated.[4]

India has globally the largest birth cohort in the world, sized at nearly 26.5 million requiring the largest universal immunization program. The National Immunization Schedule (NIS) of India ensures early protection against a minimum of seven VPDs including polio, diphtheria, pertussis, tetanus, hepatitis B, haemophilus influenza type B, measles, with Japanese encephalitis vaccine in endemic areas and an ongoing rolling out of vaccines against rotavirus, and pneumococcal disease.[5] Vaccination coverage among infants in India has accelerated in the previous 5 years (2015–2019), through a relentless, politically committed, multi-sectoral campaign to boost immunization.[6] However, there is paucity of data on the prevalence of delayed vaccination among Indian infants during the same period. Previously, the results of a large-scale national-level cross-sectional survey (2015–2016) in India reported delayed vaccinations in 29.3% and 34.8% infants for diphtheria pertussis and tetanus (DPT)-1 and Measles vaccine respectively.[7]

We, therefore, conducted the study to determine the rates of delayed vaccination among infants reporting for routine immunization at an urban primary healthcare clinic in an urban resettlement colony in the north-east district of Delhi, the Indian capital city.


  Methods Top


Study design

Secondary data analysis (Single-center Retrospective audit study).

Study setting

A primary urban health centre (Gokalpuri) in an urban resettlement colony in the north-east district of Delhi, India, provided services to a population of nearly 30,000. Resettlement colonies in Delhi were created from relocation of people from unauthorized slums and typically located in the periphery of the city having inadequate civic facilities.

Methodology

We obtained information on all the vaccination encounters with infants (child up to 12 months of age) during Jan-March’ 2019 at the health clinic using the available vaccination records. Data in the clinic’s vaccination register is entered manually by a public health nurse. We extracted the following variables:
  1. Vaccine(s) name and dose administered
  2. Sex of the child
  3. Age of the child: The date of birth was not recorded in most cases, and instead the age of the infant at the time of vaccination in months was only recorded. Moreover, after interviewing the nurses, we found the practice of recording the infant’s age after rounding in months to the completed and nearest 0.5 or whole integer months. Consequently, the age of the infants was likely to be inflated by 1 to 7 days for those born during 8th to 14th or 23rd to 29th day of the month and similarly deflated by 1 to 7 days for the infants born during 1st to 7th or 16th to 22nd day of the month.


Operational definition

The WHO defines vaccination delay as a delay period of >28 days from the minimum recommended age. However, considering the potential overestimation of the age of the child by up to 7 days in the available records, delayed vaccination for each vaccine was operationally defined as the administration of the scheduled vaccine dose after ≥36 days of the minimum recommended age as per the NIS of India.

Statistical analysis

We entered the data from the registers into MS-Excel and analyzed it with statistical package for social sciences (SPSS) Version 25. Categorical data were expressed in frequency and proportions and normal continuous data as mean and standard deviation, and non-normal continuous data as median and interquartile range. Delayed vaccination rates were calculated both using the WHO and the operational definition. A P-value < 0.05 was considered as statistically significant.

Ethics

The study was exempted from full review by the Institutional Ethics Committee, Maulana Azad Medical College & Associated Hospitals, New Delhi, India (F.1/IEC/MAMC/(72/07/2019/No10)


  Results Top


We analyzed a total of 811 vaccination encounters among infants up to 12 months of age attending the immunization clinic. The mean (SD) age of the infants at the time of vaccination episode was 4.4 (2.8) months and.ranged from 1.5 months to 12 months. A total of 430 (53%) vaccination encounters comprised male infants and 381 (47%) female infants.

Delayed vaccination was observed in 144 (17.8%) vaccination encounters as per the operational definition of delay beyond the 35th day of the earliest scheduled vaccination. A total of 324 (40%) encounters showed 0 days of delay, 149 (18.4%) had 15 days of delay, 194 (23.9%) had 30 days of delay and 144 (17.8%) had ≥45 days of delay. On using the standard WHO definition (>28 days), delayed vaccination was calculated in 338 (41.7%) encounters.

The distribution of delayed vaccination encounters across the scheduled vaccines is depicted in [Table 1]. The maximum proportion of delayed vaccination encounters occurred during the scheduled pentavalent third dose which includes the administration of fractionated IPV second dose and also the bivalent oral polio vaccine third dose. No difference in delay was recorded in case of oral polio virus vaccine and the injectable vaccines given during the course of an immunization session. The proportion of delayed vaccination encounters was more among girls than in boys, but it was not associated significantly with gender. This finding did not change on using either the operational definition (P = 0.71) or the WHO definition (P = 0.25) for delayed vaccination.
Table 1 Distribution of delayed vaccination during vaccination encounters (N = 1001)

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  Discussion Top


The present study shows that nearly one in five infants’ receiving vaccination from the Indian public (government) health system experience significantly delayed vaccination. These results suggest that despite the phenomenal increase in immunization coverage in India since 2015, the problem of delayed vaccination persists although the prevalence is likely to have declined during the same period.[7] Previously, Yadav et al.[8] have reported on the phenomenon of high vaccination coverage coexisting with a high proportion of delayed vaccination in Indian children.

In our study, the proportion of delayed vaccination encounters progressively increased from penta-1 (lowest) to penta-3 (highest). This finding suggests the development of complacency among caregivers and this phenomenon was more commonly observed in females compared to male infants although without statistical significance. Intentional delay in vaccine administration by parental concerns has been frequently reported from developed countries.[9]

Limitations

The study was based on retrospective audit data with rounding off errors that subject the analysis to application of age-corrections resulting in the use of a non-standard definition of vaccination delay. Definite evidence of delayed vaccination even after accounting for age-inflation was seen in 144 (17.8%) encounters, while the vaccination delay based on the WHO definition was estimated in 338 (41.7%) encounters, which is a likely overestimation. Nevertheless, the possibility of underestimation of the prevalence of vaccination delay is extremely unlikely since delay beyond the 30th day and up-to the 45th day was also present in 144 (17.8%) encounters only. No unique identifiers were being recorded to identify the subset of infants that experienced recurrent delayed vaccination. Variables like socioeconomic status, religion and migration history that are known to be associated with delayed vaccination were absent in the records.[7],[10] However, health system-related factors including vaccine stock-outs contributing to delayed vaccination were not significantly applicable in our study settings. Nevertheless, the data were collected from a single-site that limits the generalizability of the study findings.

In conclusion, delayed vaccination among infants continues to exist as a significant but largely avoidable public health challenge in certain health settings in India. There needs to be a renewed programmatic focus on preventing delayed immunization with more intensified awareness counselling of parents and caregivers of infants towards the potentially harmful consequences due to lack of timeliness of vaccine administration.

Financial support and sponsorship

None.

Conflicts on interest

There are no conflicts of interest.



 
  References Top

1.
World Health Organization. Global Health Observatory Data Repository: vaccine-preventable communicable diseases. Available at: http://apps.who.int/gho/data/node.main.170?lang=en (Accessed March 9, 2020)  Back to cited text no. 1
    
2.
Bhadoria AS, Mishra S, Singh M, Kishore S. National Immunization Programme − Mission Indradhanush Programme: newer approaches and interventions. Indian J Pediatr 2019;86:633-8.  Back to cited text no. 2
    
3.
The SAGE Working Group. Summary WHO SAGE conclusions and recommendations on vaccine hesitancy. Available at: http://www.who.int/immunization/programmes_systems/summary_of_sage_vaccinehesitancy_2pager.pdf?ua=1 (Accessed October 27, 2019).  Back to cited text no. 3
    
4.
World Health Organization. The guide to tailoring immunization programmes. World Health Organization, 2013. Available at: http://www.euro.who.int/__data/assets/pdf_file/0003/187347/The-Guide-to-Tailoring-Immunization-Programmes-TIP.pdf?ua=1 (Accessed October 27, 2019).  Back to cited text no. 4
    
5.
National Immunization Schedule (NIS). Available at: https://mohfw.gov.in/sites/default/files/2454 53521061489663873.pdf (Accessed October 27, 2019)  Back to cited text no. 5
    
6.
Vandana G, Aggarwal MK, Chauhan A, Arora NK. Improving vaccination coverage in India: lessons from Intensified Mission Indradhanush, a cross-sectoral systems strengthening strategy. BMJ 2018;363.  Back to cited text no. 6
    
7.
Choudhary TS, Reddy NS, Apte A, Sinha B, Roy S, Nair NP et al. Delayed vaccination and its predictors among children under 2years in India: insights from the national family health survey-4. Vaccine 2019;37:2331-9.  Back to cited text no. 7
    
8.
Yadav K, Srivastava R, Kumar R, Chinnakal P, Rai SK, Krishnan A. Significant vaccination delay can occur even in a community with very high vaccination coverage: evidence from Ballabgarh, India. J Trop Pediatr 2012;58:133-8.  Back to cited text no. 8
    
9.
Smith PJ, Humiston SG, Parnell T, Vannice KS, Salmon DA. The association between intentional delay of vaccine administration and timely childhood vaccination coverage. Public Health Rep 2010;125:534-41.  Back to cited text no. 9
    
10.
Riise ØR, Laake I, Bergsaker MA, Nøkleby H, Haugen IL, Storsæter J. Monitoring of timely and delayed vaccinations: a nation-wide registry-based study of Norwegian children aged < 2 years. BMC Pediatr 2015;15:180.  Back to cited text no. 10
    



 
 
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