This population based cross sectional coverage assessment was conducted during October 2010 to February 2011 in all 24 villages under the Union Territory of Chandigarh. Subsequently, a cross sectional survey was conducted in 10 randomly selected sub-centers (out of 19) quality assessment, for immunization service. Standard 30 by 7 cluster sampling technique devised by WHO was adopted to assess the levels of immunization of children and pregnant mothers [4]. Child and mother immunization coverage performa was used [5].

Children’s immunization status was classifed as immunized or not, based on the immunization card [6]. A child who has received three doses of DPT and OPV vaccine and one dose each of BCG and Measles vaccine was considered ‘Fully Immunized’. A child who missed any one or more of the above doses was labelled ‘Partially Immunized’. A child who did not receive even a single dose of any of the above vaccine was labeled ‘Unimmunized’. Hepatitis B status was not considered while calculating the coverage rates. The drop out rate was defined as:

For mothers, immunization cards and recall were used to get requisite information. Full immunization was defined when a primigravida had received both the doses of TT or a multigravida had received single dose of TT, if the second/subsequent pregnancy ocuured with in 3 years. Partial Immunization was defined when a primigravida had recived only one dose of TT or a multigravida had received one dose of TT but had the previous pregnancy more than 3 years back. Mothers who did not receive even single dose of TT were labeled as unimmunized. Along with the TT coverage, other aspects of antenatal care (ANC) evaluated were: iron and folic acid tablets, 3 antenatal check-ups, and place of delivery.

Based on the information given in immunization modules of WHO, a quality assessment performa was devised [7]. Nine domains were included in the proforma. The proforma included: (i) observations, and (ii) responses given by the health workers to the questions posed by the investigator. Of these, 5-6 domains were similar to the domains included in the study by Streefland, et al. [3] (Web Table I). Some of other domains like side effects, registration of the eligible children were included as sub-components in our study [3]. The sub-centers were visited on Wednesdays and Saturdays (immunizations days).

Information on 210 children was collected while 17 children were excluded from the study as their records were not available. The overall coverage for various vaccines for children was BCG-81.2%; DPT-75.2%; OPV-75.2%; Hepatitis B-18.1% and Measles-69%. Dropout rates were 7.4%, 7.2%, and 15.6% for DPT, OPV, and Hepatitis-B, respectively. Overall, 69% of children were fully immunized, 15% were partially immunized and 16% were unimmunized. Majority (79%) of the pregnant mothers were fully immunized. 11.4% were partially immunized and 9.5% were unimmunized.

Most (95%) of the mothers received at least one ANC visit and 44% received three or more ANC visits. Most (85%) of women were without ANC cards. Source of ANC was government hospital in 92.4%, and private hospital in 5.7%. Majority (62%) of the women had their first pregnancy below the age of 20. Place of delivery was government hospital in 63.8%, private hospital in 10.4% and home in 25.7% of the deliveries. Only 29.7% of the home deliveries were attended by the trained dais. Most (80.4%) of the women were provided with iron and folic acid tablets at the time of ANC check-ups.

Quality of immunization services is shown in Table I. None of the sub-centers had any specific strategy to cover the migrants. Except for one, list of the pregnant mothers and under five children was maintained in all the sub-centers. Meeting for planning of the immunization activity before the start of the session was held at only two sub-centers. None of the health workers made any calculations regarding the number of vials required during each session. All the sub-centers except one had ice lined refrigerator (ILR) for the storage of vaccines. Temperature of the ILR was monitored twice a day and placements of the vials in the ILR were found to be correct in all the sub-centers. Only four auxillary nurse midwives (ANMs) knew about the maximum number of vials that can be kept in a vaccine carrier. No sub-center had alternate storage system at the time of defrosting/power failure. Direct exposure to sunlight of the vaccination area was not found in any of the sub-centers. Freeze sensitive vaccines were checked by the shake test and freezing was not reported in any of the sub-centers. Health workers at all the sub-centers checked the vaccine vial marker (VVM) and expiry date of the vaccines before reconstituting or injecting the vaccine. All the ANMs had a clear idea about the right time to discard the reconstituted vaccines. Labels, expiry date and VVMs were found to be correct in all the sub-centers. Eight out of ten ANMs were found to have the correct knowledge about the indications and contraindications of the vaccines. Emergency kit to handle the life threatening conditions was available in only five sub-centers.

TABLE I Quality of the Immunization Services at Sub-centers

					

Practice of washing the hands before reconstituting the vaccine and after injecting the patient was noticed in only seven sub-centers. Working sterilization equipments; availability of cleaning materials like soap, towel and water; and adequate ventilation of workup area were present in all the sub-centers except one. Needle cutter to destroy the used needles and syringes were available in all the sub-centers. Seven sub-centers had the waiting area for the patients. Eight sub-centers had a separate gate for the entry and exit of the patients. Seven sub-centers had a separate space for screening and registration of the patient. Five sub-centers had a separate space for the services other than immunization. Working area was found to be well organized in six sub-centers. Out of the 10 sub-centers visited, physical presence of the supervisor was verified in the seven sub-centers.

Eight out of ten ANMs marked the next immunization dates on the cards. Parents were informed verbally about the next immunization date, time and place by only two workers. Purpose of the vaccination was explained by only one ANM. Only two ANMs explained the parents the possible side effects of the vaccines. Rapport/way of talking with the patients was good in all the sub-centers. Completion of the tally sheets and taking care of the remaining vaccines at the end of the session was observed. Waste generated at the end of the immunization session was properly disposed off in all sub-centers.

To improve immunization coverage adequate planning and adequate supervision is required. Improvement can also be achieved by better follow-up to reduce the dropout rates. Efforts should be made to educate the mothers about the importance of immunization by organizing information, education and communication (IEC) activities. The district health authority should conduct frequent outreach camps in underserved areas and give emphasis on immunization of eligible population. Efforts should be intensified to ensure complete immunization in slums and rural areas.

Contributors: VA: dissertation work; design, execution/data collection, analysis and report writing; AS: conceived the idea; helped in design, execution, analysis and report writing; and VS: guided data collection, analysis and report writing.

Funding: None; Competing interests: None stated.