Immunization Practices of Pediatricians for Children Younger Than Five Years in Coastal South India

Abstract

Context

Immunization helps in controlling infectious diseases. Child immunization is an important component of child survival programs in India, which mainly follows the National Immunization Schedule. Also, many of the injection practices followed are not safe.

Aims

To study the practices of pediatricians toward the immunization of children younger than 5 years and injection-related waste management.

Settings and Design

Cross-sectional study carried out in the city of Mangalore, a rapidly developing city in southern India.

Methods and Material

All the practicing pediatricians were included in the study and an interview was done on prior appointment using pretested interview schedule in March 2012, after obtaining clearance from the institutional ethics committee. Data were analyzed using the Statistical Package for Social Sciences version 11.5.

Results

Among the 54 practicing pediatricians in Mangalore, 42 were included in this study after exclusion criteria were applied. Among them, 71.4% were following the National Immunization Schedule, 5% did not prefer to give combination vaccines, 17% reported vaccine failure at least once in their practice, and 85.7% motivated the parents for future doses. Distance to the clinic and affordability were the major reasons for loss of follow-up. Only 38.1% used auto-disabled syringes, 11.9% did not observe the children following the immunization, and 45.2% did not use color coding for disposal of injection-related wastes. Mechanical hub cutters were preferred by 41% of the respondents.

Conclusion

The study showed the diversity in immunization practices. The National Immunization Schedule is the most commonly followed schedule. However, the safety of the injection practices was limited.

Introduction

The development and use of immunizations against infectious agents have been important and successful steps toward disease prevention.¹ Immunization is a mass means of controlling the spread of infectious diseases by using vaccines, immunoglobulins, antisera, and so on. Child immunization is an important component of child survival programs in India, which has the National Immunization Schedule (NIS). The Indian NIS is based on the Universal Immunization Program (UIP) and includes oral polio vaccine (OPV), bacillus Calmette Guerin (BCG), diphtheria, pertussis, and tetanus toxoid (DPT), measles, hepatitis B, and the newly added hemophilus influenza (HiB) vaccines in select states.^2,3 In addition to the NIS, the Indian Academy of Pediatrics has its own schedule for immunization.⁴

There are several schedules of immunization across developing countries, including India.^5,6 The pediatricians and health care providers have liberty to follow the immunization schedules of their choice. Also, there is paucity of information on the profiling of immunization practices among pediatricians. Current challenges in immunization in countries like India are with several newer vaccines available in the open market, which include expensive combination vaccines with less documented adverse effects of the available new vaccines.⁷

Injections are an important part of the immunization process. A safe injection does not harm the recipient, provider, and the community. Studies have reported a convincing link between unsafe injections and the transmission of hepatitis B and C, HIV, Ebola, and Lassa virus infections.⁸ Both the materials used for immunization and the waste handling procedures have important roles in the overall effectiveness of the immunization injections. Auto-disabled syringes have been introduced throughout India in 2005 for the safety of these injections along with specifications for various items to be used for the disposal of syringes/needles.⁹

Overall, among the developing countries, at least 50% of injections were found to be unsafe. Risk of transmitting blood-borne diseases depends on the local injection practices.⁸ The current study was carried out to assess the practices of pediatricians toward the immunization of children younger than 5 years and injection-related waste management in the city of Mangalore in south India, which is a rapidly developing area with health indicators comparable to the developed areas.

Subjects and Methods

This cross-sectional study was conducted among the practicing pediatricians in March 2012, who held postgraduate diploma or masters in the field of pediatrics, in the city of Mangalore, in Karnataka state of southern India. The participants included those practicing independently as well as those attached to the medical colleges. The qualified general practitioners who provide immunization services form a small number in the study area, hence were excluded from the study.

After obtaining clearance from the Institutional Ethics Committee of Kasturba Medical College, Manipal University, Mangalore, the list of pediatricians was obtained from the Indian Academy of Pediatrics, Mangalore Chapter. All of them were included as study participants and were visited in their clinic for data collection on a preinformed date. Medical graduates trained in data collection communication techniques were involved in the data collection. A written informed consent was taken after providing the information sheet and assuring confidentiality.

The data were collected using a pretested semistructured questionnaire, which was divided into 2 parts. The first part included information on compliance to the NIS and the schedule actually followed by them, the action taken to maintain compliance among the parents/caretakers of the children, reasons for preferring the schedule they followed, and extra vaccines introduced in their practice. The NIS of India is depicted in Table 1.³ The second part of the questionnaire included the use of hub cutters, color coding of the wastes generated, and disposal practices related to their immunization items and sharps. The study included 42 pediatricians, after excluding 12 pediatricians, who were not available despite 3 repeated visits. The information was collected on immunization practices. The collected data were analyzed using the Statistical Package for Social Sciences version 11.5.

Table 1.

The National Immunization Schedule of India.

BCG (Bacillus Calmette Guerin)	1 dose at birth (up to 1 year if not given earlier)
DPT (diphtheria, pertussis, and tetanus toxoid)	5 doses; 3 primary doses at 6, 10, and 14 weeks and 2 booster doses at 16–24 months and 5 years of age
OPV (oral polio vaccine)	5 doses; 0 dose at birth, 3 primary doses at 6, 10, and 14 weeks; and 1 booster dose at 16–24 months of age
Hepatitis B vaccine	4 doses; 0 dose within 24 hours of birth, and 3 doses at 6, 10, and 14 weeks of age
Measles	2 doses; first dose at 9–12 months and second dose at 16–24 months of age
TT (tetanus toxoid)	2 doses at 10 years and 16 years of age
	For pregnant women, 2 doses or 1 dose if previously vaccinated within 3 years

Results

The study included 42 pediatric practitioners, among whom 52.4% were attached to medical colleges in the city of Mangalore. The general descriptions and details of the participants are presented in Table 2. Overall, 71.4% were following the NIS. This included the participants who were working in the district government hospitals and giving the government supply free of cost and also those with independent private practice, prescribing the NIS vaccines from outside. Others included extra vaccines (mumps, measles, and rubella [MMR], injectable polio vaccine, typhoid vaccine and human papillomavirus vaccine) and their combinations, not included in the NIS. Totally, 95% of the participants preferred combination vaccines. On further discussion, all of those who preferred combination vaccines opined that they are easy to administer, the number of pricks to the children younger than 5 years are minimal, and compliance was better.

Table 2.

Profile of the Immunization Practices of the Study Participants (N = 42).

Characteristic	n (%)
Predominant place of work
Medical college	22 (52.4)
Private practice	20 (47.6)
Immunization schedule followed
National Immunization Schedule	30 (71.4)
Others	12 (28.6)
Prefer the use of combination vaccines
Yes	40 (95.0)
No	2 (5.0)
Motivate the parents for follow-up
Yes	36 (85.7)
No	6 (14.3)
Counsel the parents regarding child immunization
Yes	13 (31.0)
No	29 (69.0)
No. of children immunized per week
<10	13 (30.9)
10–19	15 (35.8)
≥20	14 (33.3)
Vaccine failures ever
Yes	7 (17.0)
No	35 (83.0)

Also, 85.7% of them motivated the parents of the children younger than 5 years for regular follow-up in order to avoid missing any vaccine doses. But the counseling of the parents regarding the significance and compliance to child immunization was done by 31% of them. The main reason for not counseling, among those who did not counsel, was the busy schedule of practice and lack of time (88%), followed by other factors such as lack of perceived need for counseling. Among them, 11.9% did not observe the children following the immunization. The history of vaccine failures ever was reported by 17% of the participants.

Also, 11 participants (32.4%) observed that the distance to the clinic and 9 (26.5%) observed that affordability of the vaccines were the major reasons for loss of follow-up of the children reporting to their clinics or hospitals. As shown in Figure 1, the 40 study participants, who preferred combination vaccines in their practices, predominantly used the easy 5 combination (64.7%).

Figure 1.

The combination vaccines used by the study participants (n = 40).

Easy 4, DwPT + HiB; Easy 5, DwPT + HiB + HepB; MMR, mumps + measles + rubella.

The injection-related waste management practices are described in Table 3, 61.9% of them used auto-disabled syringes in their routine immunization practice. The proportion of the participants who used the color coding for the segregation of the injection-related waste was 54.8%. Also, 71.4% used hub cutters. Among those who used hub cutters, the mechanical hub cutters were preferred by 79.8%. All the participants had the emergency kit readily available at their sites of practice in case of adverse reactions followed immunizations. Totally, 80.9% of the respondents disposed the wastes to the city corporation waste collection system. For the corporation system, all the 34 participants responded as convenient and cost-effective. However, 92.3% of them had concern on the safety of the disposal methods finally adapted by the agencies and also about the proportion of the hospitals with sharps pit to dispose the used needles.

Table 3.

Injection-Related Waste Management Practices Among the Study Participants (N = 42).

Characteristic	n (%)
Use of auto-disabled syringes
Yes	16 (38.1)
No	26 (61.9)
Color coding for wastes
Yes	23 (54.8)
No	19 (45.2)
Use of hub cutters
Yes	30 (71.4)
No	12 (28.6)
Method of disposal
Corporation waste collection system	34 (80.9)
Private organization	8 (19.1)
Availability of emergency kit
Yes	42 (100.0)
No	0 (0.0)

Discussion

This study highlights the practices of pediatricians with respect to their compliance toward the NIS, the reasons for noncompliance, and the injection-related waste disposal. There is a paucity of studies and information in this regard. Most of the studies focus on the policy aspects and the clinical outcomes along with efficacy issues. Mangalore is a rapidly developing city in Karnataka state. It has high level of literacy rate and health awareness along with the ever-expanding health care facilities. In a previous study conducted in Mangalore, the coverage for the individual vaccines were as follows: DPT 3 doses (91.9%), OPV 3 doses (92.3%), BCG (91%), and measles vaccine (69.5%). The dropout rates from first to third dose of both DPT and OPV were observed to be 2.5%.⁶ Since then, there have been limited individual studies measuring the coverage and utilization of the vaccines. The compliance of the immunization schedule was not looked into.

Our study had 71.4% of the participants following the NIS exclusively. However, the remainder was following schedules such as those of the Indian Academy of Pediatrics and others. They have more vaccine options than the NIS. But these vaccines could be more expensive. Also, this study highlights the variety in the immunization schedules that the pediatricians follow, which are similar to the previous study done in India and elsewhere. The need for compliance to an effective schedule and giving adequate number of vaccines and boosters was long felt and reported in a previous study conducted in India in 1994.¹⁰

Health professionals have an important role in maintaining the participation of the community in vaccination, simultaneously addressing parents’ concerns. They advocate respectful interactions that aim to guide parents toward quality decisions. Our study showed a high level of motivation of the parents by the pediatricians toward child immunization; however, the level of counseling done by them was low (31%). These findings were in line with those of a previous study done in the United States.¹¹

The World Health Organization estimates that 12 billion injections are given annually, 5% of which are administered for immunization. It is estimated that up to 160 000 HIV, 4.7 million hepatitis C and 16 million hepatitis B infections each year are attributable to unsafe injection practices.¹² At least 50% of injections were unsafe in 14 of 19 countries (representing 5 developing world regions) for which data were available.⁵ Five studies attributed 20% to 80% of all new hepatitis B infections to unsafe injections, while 3 implicated unsafe injections as a major mode of transmission of hepatitis C.⁵ Also, a previous study done in Pakistan shows the extent of unsafe injection practices in developing countries.¹³ However, our study had a higher level of safe injection practices when compared with the World Health Organization observations across other regions.

In this study, the use of auto-disabled syringes by the participants was low. However, there was a high level of preference for hub cutters. These findings are in line with the observations at the various health care facilities by a previous representative survey in India.⁹ Nearly two thirds of all injections administered in India were found to be unsafe. The danger arises from a combination of practices such as inadequately sterilized equipment (90.8%), reuse of disposable syringes/needles (53.3%), and improper technique of giving injections (53.1%).⁶

Conclusions

The study showed the diversity in immunization practices. The NIS is the most commonly followed schedule. However, the safety of the injection practices was limited. Also, significant dropout rate limits the success of the immunization program. The effort from the pediatricians was limited to preventing the dropouts. Significant proportion of the respondents did not follow the color coding system for waste disposal.

Limitations

The data collection was limited because of the time constraints of the participants. Also, the sample size of the study was limited.

Recommendations

The practicing pediatricians need to follow the immunization schedule after offering counseling to parents and providing them with choices. Also, continuing education to the practitioners needs to be carried out to educate them regarding the safe injection practices completely.

Biographies

Prasanna Mithra P., MD, DNB, is an Associate Professor of Community Medicine in Kasturba Medical College (Manipal University), Mangalore; India. His areas of interest include Primary care in Communicable and Non Communicable Diseases.

B. Unnikrishnan, MD, is the Professor & Head of Community Medicine Department, Kasturba Medical College (Manipal University), Mangalore; India. He is also the Deputy Director Student Affairs Manipal University (Mangalore Campus). His research interests focus on Communicable & Non Communicable Diseases and Evidence Based Health Care.

Rekha T., MD, is an Associate Professor of Community Medicine in Kasturba Medical College (Manipal University), Mangalore; India. Her research areas include Primary care, Occupational Health and Women & Child health issues.

Nithin Kumar, MD, is an Associate Professor of Community Medicine in Kasturba Medical College (Manipal University), Mangalore; India. He has research works focusing on Communicable diseases and Child health.

Pratik Kumar Chatterjee, MD, is an Assistant Professor of Physiology in Kasturba Medical College (Manipal University), Mangalore; India. He involves in research areas including Health Hevaiours and Primary Care.

Ramesh Holla, MD, is an Assistant Professor of Community Medicine in Kasturba Medical College (Manipal University), Mangalore; India. He is actively involved in Primary care research and Rabies.