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ORIGINAL ARTICLE
Year : 2020  |  Volume : 64  |  Issue : 2  |  Page : 173-177  

Evaluation of vaccination coverage of measles-rubella campaign in Imphal East District, Manipur: A cross-sectional study


1 Associate Professor, Department of Community Medicine, Jawaharlal Nehru Institute of Medical Sciences, Imphal, Manipur, India
2 Assistant Professor, Department of Community Medicine, Jawaharlal Nehru Institute of Medical Sciences, Imphal, Manipur, India
3 Tutor, Department of Community Medicine, Jawaharlal Nehru Institute of Medical Sciences, Imphal, Manipur, India
4 PGT, Department of Community Medicine, Jawaharlal Nehru Institute of Medical Sciences, Imphal, Manipur, India

Date of Submission03-Aug-2019
Date of Decision14-Oct-2019
Date of Acceptance02-May-2020
Date of Web Publication16-Jun-2020

Correspondence Address:
Avinash Keisam
Keisampat Aheibam Leikai, Imphal - 795 001, Manipur
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijph.IJPH_361_19

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   Abstract 


Background: In India, the measles-rubella (MR) vaccination campaign was conducted with the purpose of vaccinating all children of 9 months–15 years of age with a single dose of MR vaccine. However, it encountered various challenges which may hamper with the coverage. Objectives: This study was conducted to evaluate the recently conducted MR campaign in Manipur pertaining to its coverage and factors for not vaccinating. Methods: The cross-sectional study was conducted in Imphal East district of Manipur during May and June 2018 among 1551 children from two communities. The study tool was adapted from the rapid convenience monitoring tool of the WHO. Descriptive statistics were generated, and multivariable logistic regression analysis was performed with vaccination status as dependent with selected independent variables. Results: Among the study children, 38% were in the age group of 5–10 years, males constituting 51.3%. Only two-third (68.8%) of the children had received the MR vaccine, coverage among Muslim children was 40.4% only, and 6.5% of the respondents reported some forms of adverse events following immunization. Children from the Meitei community were (odds ratio: 14.35, 95% confidence interval: 10.22–20.16) significantly more likely to receive the MR vaccination as compared to children belonging to the Muslim community (P = 0.001). Conclusion: Vaccination coverage of only 68.8% highlighted the need for increased sensitization and involvement of local and religious leaders in generating necessary awareness for improved coverage of the campaign.

Keywords: Evaluation, measles-rubella campaign, vaccination


How to cite this article:
Rajkumari B, Keisam A, Haobam DS, Thounaojam T. Evaluation of vaccination coverage of measles-rubella campaign in Imphal East District, Manipur: A cross-sectional study. Indian J Public Health 2020;64:173-7

How to cite this URL:
Rajkumari B, Keisam A, Haobam DS, Thounaojam T. Evaluation of vaccination coverage of measles-rubella campaign in Imphal East District, Manipur: A cross-sectional study. Indian J Public Health [serial online] 2020 [cited 2020 Jul 2];64:173-7. Available from: http://www.ijph.in/text.asp?2020/64/2/173/286814




   Introduction Top


Measles and rubella are viral diseases which are highly contagious and mostly affect the younger age groups. In 2015, there were 83,026 cases of measles and 3265 cases of rubella recorded in India.[1] Unimmunized individuals, often comprising very young children, form a subgroup of susceptible population for the infections causing a high mortality burden. Herd immunity plays an important role as those unimmunized will not only be susceptible to the disease but also act as carriers. Globally, mortality due to measles has reduced from 546,800 in 2000 to 114,900 in 2014 (79% reduction) due to worldwide immunization efforts, which is funded and carried out by different institutions and organizations.[2] In India, measles accounts for 2% of all under-five mortalities.

In 2017, India conducted a measles-rubella (MR) vaccination campaign with the purpose of vaccinating all children of 9 months–15 years of age with a single dose of MR vaccine. The campaign was conducted within a period of 3–4 weeks. In the initial 2 weeks, vaccination was done in schools and later on in the community through outreach sessions.[2]

The campaign, however, encountered various challenges. Some of the critical challenges included: inadequate preparation to handle negative messages on social media, lack of communication materials for parents, lack of interdepartmental coordination, especially education and health, and issues on acceptance of the vaccination due to inadequate sensitization of private and government school principals.[3],[4]

In Manipur, the campaign had a tardy arrival, delayed by several months, on March 26, 2018, and lasted until April 30, 2018. Vaccines had been sent to 242 primary health subcenters, 7 district hospitals, 2 subdistrict hospitals, 85 primary health centers, 17 community health centers, and schools as well. Altogether 4900 accredited social health activists, 11,000 Anganwadi workers, and 6000 teachers were mobilized. The ambitious project targeted 850,000 children in the state.[3]

Unfortunately, the ambitious campaign was marred by baseless rumors among some communities about the vaccination. The health authorities clarified that the vaccination was not categorized on the grounds of community or religion. They had also clarified that the rumors and stigma against the vaccination that it was given to decrease the population of a particular community or it was given to prevent pregnancy in women of a particular community were unsubstantiated and false.[4] There was also an incident which claimed that a child died after MR vaccination, to which the health authorities clarified that she died from some diseases not related to vaccination.

Various follow-up evaluations pertaining to coverage of MR vaccination in several states of India were conducted by the institutes and local governments alike. However, no such event was carried out in the north-eastern portion of India, which accounts for almost 20% of all cases of measles and rubella[5] despite accounting for only 3.45% of India's population.[6] Furthermore, Manipur was one of the only regions in the country heavily blemished by unsubstantiated rumors regarding the campaign, instigating a stigmatized opinion regarding the vaccination among members of some communities.

Because of all these reasons, it is imperative to conduct an evaluation of the MR campaign pertaining to its coverage and factors for not vaccinating as it will impair the objectives of the campaign.


   Materials and Methods Top


The study was a cross-sectional study conducted in Imphal East district of Manipur. Manipur is a small border state in the north-eastern part of India with a population of 28.56 Lakhs according to the census 2011.[7],[8],[9] Some of the major communities residing in the state are the Meiteis, Nagas, Kukis, and Meitei Pangals (Manipuri Muslims).[10],[11],[12] This study was conducted among the Meiteis and Muslim communities of Kongba and Khetrigao areas, Imphal East district, during May and June 2018. Our study population constituted children in the age group of 9 months–15 years and their caregivers. Interviews were taken from the caregivers and refusal to consent, and those who could not be contacted on two visits were excluded from the study.

The sample size was calculated based on a prevalence of 80% coverage of MR vaccination,[13] 5% significance level, and precision of 2.5% after adding a design effect of 1.5 by using the formula for a single proportion (n = 4 pq/d2). The calculated sample size was found to be 1475 and rounded off to 1500.

Out of total 13 villages in Khetrigao area, two villages were selected using lottery method and all eligible children in the selected villages were included in the study. Similarly, in Kongba area out of five villages, two villages were selected randomly and all eligible children were included.

A pretested questionnaire adapted from the rapid convenience monitoring tool of the WHO[2] was used which consisted of the sociodemographic profile as well as the MR vaccination status of the children and awareness and myths/disbeliefs of the caregivers. A house-to-house survey was conducted, and interviews were taken after obtaining informed consent. Vaccination status of all eligible children in selected households was assessed as well as the awareness of the caregivers about the campaign. Immunization cards/vaccination certificates wherever available were cross-checked. A brief interactive health talk about the MR campaign was given to each household after the collection of information.

Data were entered in MS Excel spreadsheet and checked for consistency. Analysis was performed using IBM SPSS version 22 (IBM company, Chicago, Illinois, United States). Descriptive statistics such as mean, standard deviation, and proportion were calculated. Univariate and multivariable logistic regression analyses were performed to test for association between vaccination status and selected variables. P ≤ 0.05 was taken as statistically significant.

The study was granted an exempt review by the institutional ethics committee vide letter IEC no. Ac/04/IEC/JNIMS/2018 (106) dated August 21, 2018, for study protocol no. 106/16/2018 submitted on May 20, 2018. Verbal informed consent was obtained from the respondents before the interviews. All identifiers were removed, and strict confidentiality was maintained for all collected data.


   Results Top


A total of 814 households were approached, out of which 771 responded. In 32 of the houses, there were locked doors or no one available, and in 11 houses, there was refusal. The total number of children assessed was 1551, out of which males constituted 795 (51.3%). Fifty-five percent (853) of the respondents belonged to the Meetei community, whereas the remaining belonged to the Muslim community. Around 18% (278) of the households had one eligible child, 40.6% (630) had two, 26.2% (406) had three, and 15.3% (237) households had more than three eligible children. Majority of the children (38.4%, 595) belonged to the age group of 5–10 years. Around 20% (309) of the children had not attended any school. The proportion of mothers and fathers who were illiterate were 12.4% (192) and 6.1% (95), respectively. Majority of the informants (63.8%, 990) were mothers.

Only a small proportion (94, 6.1%) of the respondents were not aware of the MR vaccination campaign. Schools were the major source of information regarding the campaign (52.7%), followed by health-care providers (21.6%), whereas mass media was cited by 18.1% only.

Out of 1551 children assessed for MR vaccination, only 1067 (68.6%) had received the vaccine during the campaign. Coverage among children belonging to the Meitei community (785/853, 92.0%) was found to be significantly higher as compared to children from the Muslim community (282/698, 40.4%) (P = 0.0001) [Table 1].
Table 1: Measles-rubella vaccination status by sociodemographic characteristics and community (n=1551)

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Schools were the most common site of receiving the vaccination (767, 71.9%). Some forms of adverse events following immunization (AEFIs) were reported by 69 (6.5%) of the respondents. Fever (43, 62.3%) was the most common AEFI reported, followed by injection site abscess (9, 13.0%).

Among the 484 (31.2%) unimmunized children, some of the most common reasons stated for not immunizing were as follows: “child was sick” (195, 40.3%), “afraid of myths/rumors” was stated by 107 (22.1%) respondents, and a few (47, 9.7%) stated “negative media report” [Table 2].
Table 2: Reasons for nonvaccination during the campaign (n=484)

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[Table 3] shows the logistic regression analysis with MR vaccination status as a dependent variable with selected independent variables. The adjusted analysis shows that children from the Meitei community were 14.359 (95% confidence interval [CI]: 10.226–20.161) times more likely to receive the MR vaccination as compared to children belonging to the Muslim community (P = 0.001) and also children whose mothers are graduates were 2.263 (95% CI: 1.159–4.422) times significantly more likely to get vaccinated (P = 0.017). For every unit increase in the age of the child, the odds of receiving vaccination increase significantly (odds ratio: 1.164, 95% CI: 1.124–1.205) (P = 0.001). The pseudo R2 value (Cox and Snell R2 = 0.321 and Nagelkerke R2 = 0.451) shows that roughly 45% of the variability in the dependent variable is explained by the predictors in the model. The classification table shows that the model could correctly predict 84.2% (898/1097) of those who received vaccination and only 69.0% (334/484) of the unvaccinated.
Table 3: Crude and adjusted odds ratio with measles-rubella vaccination status as a dependent variable and selected independent variables

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   Discussion Top


In our study, the overall MR campaign coverage was only 68.8% which is comparatively much lower than the studies done elsewhere.[13],[14],[15],[16],[17] Joe et al.[18] reported coverage of 86.4% in a study done in Karnataka in the year 2017. Uddin et al. in a study conducted in Bangladesh found that the coverage rose from 13% before the MR campaign to as high as 90% after the campaign.[19] Another study conducted in rural areas of Tamil Nadu[20] reported a vaccination coverage of 80.2%. In this study, the coverage among the Muslim community (40.4%) was much lower as compared to the Meitei community (90.2%) and needs particular attention. Vaccine hesitancy was common among the Muslim community. Some of the reasons were child being sick (35.81%), afraid of myths/rumors (25.72%), and negative media report (12.39%) as cited by the respondents from the Muslim community who had not received vaccination (416, 59.6%). As such, the campaign was heavily marred by the negative media report of a child death during the campaign linking it to vaccination despite being clarified by the state health department that the death was not related to vaccination.[4] A coordinated effort to raise widespread awareness among all sections as well as mobilization by grass-root level workers is much needed to avoid such low turnout. Active involvement of religious leader like the Imam or Caliph in spreading positive messages about the campaign and refute rumors and myths may help in the long run. The coverage among school-going age group (5–14 years) in this study was relatively higher (78.1%) as compared to another study.[13] The study also shows that only 44.6% of the family ever got visited by a health worker which may relate to the low coverage.

Some of the main reasons cited for not getting vaccinated were as follows: child was sick, myth/rumors, not aware of campaign, and negative media reports which accounted for 40.29%, 22.11%, 10.74%, and 9.71% respectively. Such reasons were also stated by studies done elsewhere.[13],[14] Priyadharshini and Jasmine reported “rumors of adverse effects”(47.5%), fear of adverse effects (53.3%), and no faith in immunization (18.9%) as some of the main reasons cited.[20] In a study done in Bangladesh, “fear of adverse effect” (33%) was the main reason for not getting vaccinated.[15] Meena et al. reported “children away from home” (20%) and “not aware of campaign” (15%) as some of the common reasons cited in a study done in rural areas of Bhopal.[21]

Campaign-associated AEFI was higher in our study (4.5%) as compared to a study by Silvia Bino et al. in Albania which was reported to be 0.26%. This could be due to the lack of proper training and work experience of the nurses involved in the campaign.[16]

A significant association between vaccination status and mother's education was also reported from a study done in urban areas of Mysore city[18] as was observed in our study. These findings were consistent with reports from studies done in other countries,[16],[22],[23],[24],[25] thus highlighting the importance of education and awareness of the care providers for a successful health program.

From a programmatic point of view, the campaign also had various setbacks due to inadequate preparedness, failure to handle negative messages on social media, not involving the local leaders, and inadequate sensitization of the parents, school principals, and teachers. The study's limitations were that the information of the vaccination was obtained through interviews which were taken after 1 month of the campaign and we have to rely on the recall of the caretakers. Only a few could provide the vaccination certificates, so there was no mechanism for confirming the vaccination status for all the children.


   Conclusion Top


The total MR campaign coverage in the study was only 68.8%, with much lower coverage among the Muslim community. This highlights the need for widespread sensitization and involvement of local and religious leaders in spreading awareness for improved coverage of the campaign.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

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World Health Organisation. Measles and Rubella Surveillance Data 2018. Available from: http://www.who.int/immunization/mon itoring_surveillance/burden/vpd/surveillance_type/active/measles_monthlydata/en/. [Last accessed on 2018 May 07].  Back to cited text no. 1
    
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Bino S, Kakarriqi E, Xibinaku M, Ion-Nedelcu N, Bukli M, Emiroglu N, et al. Measles-rubella mass immunization campaign in Albania, November 2000. J Infect Dis 2003;187 Suppl 1:S223-9.  Back to cited text no. 15
    
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[PUBMED]  [Full text]  
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Priyadharshini, Jasmine A. Coverage survey of measles-rubella mass vaccination campaign in a rural area in Tamil Nadu. J Family Med Prim Care 2019;8:1884-8.  Back to cited text no. 20
    
21.
Meena S, Saxena DM, Bankwari V, Meena P. Evaluation of measles immunization coverage in rural area of central India using WHO EPI 30 cluster survey method. Int J Community Med Public Health 2017;4:1668-73.  Back to cited text no. 21
    
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Bosch-Capblanch X, Banerjee K, Burton A. Unvaccinated children in years of increasing coverage: How many and who are they? Evidence from 96 low- and middle-income countries. Trop Med Int Health 2012;17:697-710.  Back to cited text no. 25
    



 
 
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