Original Articles

Indian Pediatrics 2000;37: 1194-1199.

Immunization status of children of india

In the past few years, Coverage Evalualtion Surveys (CES) for Universal Immunization Programme (UIP) were done through United Nation Children Fund (UNICEF). For the year 1999, Department of Family Welfare, Ministry of Health and Family Welfare, requested the Indian Council of Medical Research (ICMR) to undertake CES in all the states and Union Territories. The CES undertaken by Institute for Research in Medical Statistics (IRMS), New Delhi covered 90 districts of the country. The present manuscript reports the results of this survey.

The WHO 30 cluster survey methodology with certain modifications was used in this survey. The number of districts covered from different States were broadly in proportion to their population. Further, while selecting the districts in each major State due representation was given to major geographical region in the State. From each district, a sample of 30 villages/ward was selected using probability proportional to size systematic sampling. Further, in each selected village/ward, with a random start, samples of seven children (age 12-23 months) were selected in the form of clusters of contiguous households. The immunization coverage levels were obtained at the State level and all India level. The sampling design was self weighting at district level and hence simple proportions and averages based on the sample represent unbiased estimates of corresponding popula-tion values. The estimates at all India levels were worked out by using appropriate weights based on estimated number of children at State level. The results were also evaluated by background characteristics of sample households using post stratified method-ology(1). Child coverage schedule, TT Immunization of women schedule and village level schedule were used in the survey. In the child coverage schedule, information was collected on religion, caste, literacy level of parents and sex of the child. Information of age of the child, caste, religion of the head of the household, education of women and her husband, availability of immunization card, immunization for TTI, TT2, booster, antenatal care visits, IFA tablets, reasons for no ANC/TT and place of delivery were collected in the schedule for TT immunization of pregnant women. Information on reasons for non-immunization were collected for each vaccine separately. A village level schedule was used with details on distance from health facility, metalled road, etc. in addition to village size and composition. The responsibility of survey work was borne by the IRMS, Delhi and conducted through ICMR network of Human Reproduction Research Centers (HRRCs), Institutes/Centers of ICMR (TRC Chennai, CJIL Agra, RMRC Dibrugarh, RMRC Jabalpur and RMRC Port Blair) and Medical Colleges (Kota, Rajasthan and Dibrugarh, Assam). The survey work was done mainly between June to October 1999.

The study covered about 19,000 children. The characteristics of sample households are presented in Table I. The higher representation of SC and ST in the sample was due to their relatively higher birth rates and because of coverage of minimum of one district from each of the seven NE states.

Immunization Status

Immunization coverage levels for different vaccines are presented in Table II. Eighty eight per cent received the first dose, 85% first two doses and 81% all the three doses of dpt/opv. Eighty six per cent received BCG vaccine and 67% measles. Sixty three per cent of the children received all the vaccines/doses; in about 27% of the cases there was partial immunization and 10% of children did not receive any immunization.

The coverage level by background characteristics is presented in Table III. The coverage levels were higher in urban areas for male children (marginally) and literate mother. The coverage levels were the lowest among scheduled tribes followed by scheduled castes as compared to others.

Information on Coverage levels of children in different states is presented in Table IV. Karnataka, Kerala, Tamil Nadu and Pondicherry had more than 90% full coverage levels.The States/UTs with full coverage levels between 75 to 90% were Maharashtra, Gujarat, Andhra Pradesh, Haryana, Punjab, Delhi, Goa, Sikkim, Andaman and Nicobar Islands, Lakshadweep and Chandigarh. The States/UTs with full coverage levels between 65 to 75% were West Bengal, Jammu and Kashmir, Himachal Pradesh and Daman and Diu.

The results on coverage level for children immunized for individual vaccines and for all according to size of village and distance of health facility from the village combined for the four states of Uttar Pradesh, Madhya Pradesh, Bihar and Rajasthan are presented in Table V.

For targeting the areas and groups it is of interest to study the profile of children not immunized. The details of children not receiving any immunization by states are presented in Table VI.

Source of Information

The source of information for immuniza-tion in relation to literacy of parents is depicted in Table VII. The source of awareness was mainly governmental (70%) ICDS staff was identified by 10%. The media was popular among urban and highly literate household.

The stated reasons for non-immunization are depicted in Table VIII. Lack of motivation was the main reason for non immunization for most of the vaccines.

The characteristics of sample households for children were similar and broadly in proportion to the characteristics of the all India population. It was heartening to note that the immunization services available in the country have touched nearly 90% of the target children. About 63% of the children received all the vaccine/doses; in about 27% of the cases there was partial immunization and 10% of children did not receive any immunization. Children not receiving any immunization were more in rural areas, scheduled tribes and illiterate mothers. The states of Bihar, Rajasthan, Uttar Pradesh and Madhya Pradesh together accounted for over two thirds of non immunized children.

Table IX compares the results of this survey with the evaluation of Routine Immunization Coverage (RIC 1997-98) conducted through UNICEF and Rapid household Survey (RHS) under Reproductive and Child Health Program (1998-99) through Indian Institute of Population Sciences, Mumbai(1,2). While comparing and inter-preting these results, the following facts may be noted: (i) The evaluation of Routine Immunization coverage survey through UNICEF covered children 12-23 months of age during 1997-1998 and hence relates to the children born between April 1996 to March 1997; (ii) The RHS survey covered children upto 3 years of age and hence related to children born between January 1995 to December 1997; and (iii) The current survey covered children 12-23 months of age between June to October 1999 and hence related to children born between June 1997 to October 1998. The coverage levels (full immunization) for the children born between January 1995 to December 1997 was 53%; for children born between April 1996 to March 1997 was 61%; and for those born between January 1997 to October 1998 was 63%. Thus, there has been improvement in the immunization coverage levels in the recent years.

The following suggestions emerge from this survey for improving the immunization coverage in the country. Literacy of mother is the key to the success of the Universal Immunization Programme (UIP). Hence, efforts should be made to have Information, Education and Communication (IEC) activities targeted to educate the mother especially in rural areas. The tribal, small and inaccessible villages and the states of Bihar, Rajasthan, Uttar Pradesh, Madhya Pradesh and North Eastern states (combined) should be especially focussed on.

The authors are grateful to Shri A.R. Nanda, Secretary, Department of Family Welfare, Ministry of Health and Family Welfare, Government of India for sponsoring the study. Authors are also indebted to Shri Gautam Basu and Dr. (Ms.) Meenakashi Dutta Ghosh, Joint Secretaries, Dr. V.K. Manchanda, Dy. Director (CH) and Dr. S. Sarkar, AC (Immmunization) for their keen interest and encouragement throughout the course of investigation.

The authors are grateful to Prof. N.K. Ganguly, Director General, Indian Council of Medical Research for granting permission to the Institute to undertake the study. The authors are thankful to the Chief (RHN) ICMR, Officers-in-Charge, HRRCs, Director of ICMR Institutes/Center viz., TRC, Chennai, CJIL, Agra, RMRCs Dibrugarh, Jabalpur and Port Blair as well as Principals of Medical College of Kota and Dibrugarh for sharing the responsibility of survey work.

The authors are thankful to the Chief Secretaries and Secretaries of the Department of Health as well as District Authorities of the states for providing logistic support and extending assistance in the conduct of the study.

The officers and staff of the Division of Training and Field Survey and other divisions of the institute shared the responsibilities of data collection and timely completion of work relating to the project. The entire responsibility of data processing of the project was shouldered by Mr. Anil Kumar, Senior Research Officer.

Contributors: PS was the Project Director. He was responsible for overall study design, analysis of data and manuscript drafting and will act as the guarantor for the study. RJY was the project co-ordinator. He coordinated data collection, data management, analysis and helped in manuscript drafting.

Funding: Department of Family Welfare, Ministry of Health and Family Welfare, Government of India.
Competing interests: None stated.

1. Ministry of Health and Family Welfare, India. Evaluation of Routine Immunization, 1997-1998.

2.  Ministry of Health and Family Welfare, India. Rapid Household Survey Reproductive and Child Health Project, 1999.