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Child Immunization Coverage – A Critical Review

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IOSR Journal of Computer Engineering (IOSR-JCE)
e-ISSN: 2278-0661,p-ISSN: 2278-8727, Volume 18, Issue 5, Ver. IV (Sep. - Oct. 2016), PP 48-53
www.iosrjournals.org

Child Immunization Coverage – A Critical Review

1
Sourabh Shastri* 2Anand Sharma 3Prof. Vibhakar Mansotra
1
Department of Computer Science & IT, Bhaderwah Campus, University of Jammu, J&K, India
2,3
Department of Computer Science & IT, University of Jammu, J&K, India

Abstract: Immunization plays a vital role in the lives of children by protecting them against infectious diseases
such as Measles, Polio, Tuberculosis, Hepatitis B, Diphtheria, whopping cough, Tetanus etc. There are different
programmes and facilities for newborn and child health under National Health Mission (NHM). However,
despite these schemes and programmes, India fares poorly when compared to other countries. In this research
paper, we present a critical review of the various programmes, schemes and research currently being
undergoing in child immunization.
Keywords: Immunization, Measles, Polio, Tuberculosis, Hepatitis B, Diphtheria, Tetanus etc.

I. Introduction
Children are the future of any country so their development is as significant as the development of
other assets. Immunization is a vital part for the proper development of the children. Immunization is an easy,
secure and efficient process of protecting individuals against the world’s most infectious diseases by
administering vaccines. Immunization reduces the spreading of diseases thus protects the society from harmful
diseases. Immunization plays an essential role in the children’s lives as a preventive health action because it
protects them from most dangerous childhood diseases [1]. Immunization process will become more successful
if the child receives full course of recommended immunization doses [2]. According to World Health
Organization (WHO), Immunization currently averts an estimated 2 to 3 million deaths every year but an
estimated 18.7 million infants worldwide are still missing out on basic vaccines [3]. Around the world, UNICEF
and its partners like WHO, GAVI, the Vaccine Alliance, the US centres for Disease Control, the Bill & Melinda
Gates Foundation and others including numerous non-governmental organizations jointly act to ensure that
vaccines protect all children, especially those hardest to reach and most in need [4].
Attention was given to immunization programme in India after the successful eradication of smallpox
in mid 1970s. India has launched Expanded Programme on Immunization (EPI) for immunizing children against
diphtheria, pertussis, tetanus and typhoid in 1978 mainly for the urban areas. Oral Polio Vaccine against polio,
BCG against tuberculosis and vaccination against measles were included in 1979-80, 1981-82 and 1985-86
respectively [5].
The programme was revised in 1985 and renamed as Universal Immunization Programme (UIP) to
protect all infants (0-12 months) against six diseases namely tuberculosis, diphtheria, pertussis, tetanus,
poliomyelitis, and measles. In 1986, UIP was given the status of National Technology Mission. UIP became a
part of Child Survival and Safe Motherhood (CSSM) programme in 1992. CSSM includes both UIP and Safe
motherhood program. The UIP was integrated with Reproductive Child Health (RCH) programme in 1997 and
became a key area under NRHM in 2005 [6]. Hepatitis B was added to the UIP in 2007. The details of
vaccination under UIP are shown in table 1.

TABLE 1: Details of vaccination under UIP [6]

Vaccine and Presentation Protection Route No. of Vaccination Schedule
doses
BCG (Lyophilized vaccine) Tuberculosis Intradermal 1 At birth (upto 1 year if not given
earlier).
OPV Poliomyelitis Oral 5 Birth dose for institutional deliveries,
(Liquid vaccine) Primary three doses at 6, 10 & 14 week
and one booster dose at 16-24 month of
age. Given orally.
Hepatitis B (Liquid vaccine) Hepatitis B Intramuscular 4 Birth dose (within 24 hours) for
institutional deliveries, Primary three
doses at 6, 10 & 14 week.
DPT Diphtheria, Intramuscular 5 Three doses at 6, 10 & 14 week and two
(Liquid vaccine) Pertussis and booster doses at 16-24 month and 5-6
Tetanus years of age.
Measles (Lyophilized Measles Subcutaneous 2 9-12 months of age and 2nd dose at 16-
vaccine) 24 months.
TT Tetanus Intramuscular 2 10 years and 16 years of age.
(Liquid vaccine) 2 For pregnant women, two doses given

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 Child Immunization Coverage – A Critical Review
(one dose if previously vaccinated
within three year).

JE (Lyophilized vaccine) Japanese Subcutaneous 2 9-12 months of age and 2nd dose at 16-
Encephalitis 24 months (6 months after vaccination
(Brain Fever) drive).
Hib Hib Pneumonia Intramuscular 3 6, 10 & 14 week of age.
(Liquid vaccine) and Hib
meningitis

Immunization division at Ministry of Health and Family Welfare (MoHFW) provides all the technical
assistance required to undertake the activities under UIP. The primary responsibility of this unit comprise
actions connected to Routine Immunization, Campaigns (SIAs) such as Polio, Measles, and Japanese
Encephalitis, Monitoring Adverse Events Following Immunization (AEFI), Vaccine and Cold Chain Logistics,
Strategic communication related to immunization program and trainings related to Immunization Program [6].
Adverse Events Following Immunization (AEFI) surveillance system was initiated in 1988 in India. It
monitors immunization safety, detects and responds to any adverse events and improves the quality of
immunization in India. The national AEFI guidelines were published in 2005 which have then been revised in
2010 and then these guidelines have been disseminated all over the country to medical officers.
According to National Health Mission, Ministry of Health & Family Welfare, Government of India, the
total financial expenditure for routine immunization for 2014-15 was Rs 1068.10 crore as budget estimate and
Rs. 740 crore as revised estimate. The budget estimate for the year 2015-16 is Rs. 700 cr. This includes the cost
for the vaccine, syringes, cold chain and operational cost provided to the states/UTs under Program
Implementation Plans (PIP) [7]. The full immunization coverage as assessed by various surveys is shown in
table 2.

TABLE 2: Different Surveys [7]

Source Coverage Evaluation Survey (CES 2009) Rapid Survey on Children (RSOC 2013-14)
Full Immunization 61.0 65.3
BCG 86.9 -
OPV3 70.4 -
DPT3 71.5 74.7
Measles 74.1 78.8
No Immunization 7.6 6.7

Mission Indradhanush was launched by Ministry of Health and Family Welfare (MoHFW) on
December 25, 2014 as a programme all over the country to vaccinate all unimmunized and partially immunized
children and pregnant women by 2020 under the UIP that are missing during the schedule immunization
programmes. The main objective of the mission is to fully immunized all children under the age of two years
against seven life-threatening but vaccine-preventable diseases namely: Diphtheria, Pertussis (Whooping
Cough), Tetanus, Tuberculosis, Polio, Hepatitis B and Measles which increased by only 1% a year from 2009 to
2013, from 61% to 65%. Besides, vaccines for Japanese Encephalitis (JE) and Haemophilus influenzae type B
(HIB) are also being provided in selected states. The motive of mission Indradhanush is to increase full
immunization coverage from 65% in 2013 to 90% children of the country in next five years. Initially, 201 High
Focus Districts were selected for the first phase that has utmost number of unimmunized and partially
immunized children. There were total four rounds and 9.4 lakh sessions in the first phase where about 2 crore
vaccines were given to the children and pregnant women. 352 districts have been selected for the second phase
of mission Indradhanush including 279 mid-priority districts, 33 from North-East states and 40 districts from the
phase one, where large number of missed-out children was selected [8].
A nation with healthy children is more capable of achieving goals because today’s children are nation
builders of tomorrow for making the country vibrant and flourishing. So the health of the children should be
given priority in the policies of the government. In this way, Immunization is one of the powerful tool and basic
need in the lives of children.

II. Review Analysis

India is the country that accommodates the maximum number of children in the world. India itself
contributes to more than 20 percent of the world’s child deaths, with approximately 1.73 million children dying
annually before completing their fifth birthday [9]. The main purpose of this research paper is to present a
survey on the research performed in the field of child immunization. The research papers were thoroughly
reviewed and we extracted the goals achieved, schemes implemented and various techniques applied in child
immunization databases.

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 Child Immunization Coverage – A Critical Review

Farha Azmi and Dr. Ratna Prakash [10] in their study assessed the knowledge of immunization among
mothers of under-5 children of Uttar Pradesh state. They have concluded according to their research approach
that most of the mothers of under-5 children have poor knowledge of immunization.
PCTS (Pregnancy, Child Tracking & Health Services Management System) [11] is an online web
based service provided by the Government of Rajasthan for facilitating the citizens. The system tracks pregnant
women, infants and children online for providing the proper services and monitoring the immunization
programme to reduce maternal and infant mortality. Swasthya Sandesh Seva is used to send sms alerts to the
citizens and health workers.
Government of India [6] has launched mission Indradhanush on 25th December 2014 as a particular
drive to immunize all children and pregnant women who have either not received any vaccination or partially
vaccinated under Universal Immunization Programme by 2020.
Puneet Kumar and Dharminder Kumar [12] proposed a conceptual model using ICT to improve the
process of child immunization in India. Aadhar is used to register the infants and every health centre should be
equipped with a child registration unit to register the children for immunization. They have also compared their
framework with PCTS service provided by the Government of Rajasthan.
Debjani Barman and Arijita Dutta [13] examined the month-specific immunization coverage in West
Bengal by using DLHS-3 2007-08 data and concluded that only 20% month-specific coverage stands but the
non-month specific coverage is 75%. Thus more determined preparation is required for the enhancement of
month-specific coverage in West Bengal.
Dr. M. Hemalatha and S. Megala [14] examined immunization data of children by applying decision
tree and Artificial Neural Network. In their study, for the doses of OPV2, OPV3, DPT3 and MCV, uptake in
male’s children is approximately 1% higher than in females children and in DPT1, females children have higher
uptake of 41.4 % than males children of 39.2%.
Mohitulameen Ahmed Mustafi and Dr. Mir Mohammad Azad [2] examined the factors like socio-
economic, demographic, cultural, community and behavioural affecting the status of immunization of children
under five in Bangladesh. They have developed a conceptual framework having three sets of factors i.e. factors
associated with clients, health care providers and demographic, socio-cultural and community variables having
relationship with acceptance of immunization. Their analysis resulted that the children who have chances of
getting full immunization are the children whose parents are educated, service holders, children of respondents
who had no work, current age of respondents whose age is 21-30 years , highest education level of respondent,
the respondents who had used tube well water and children who come from better economic status households.
Abhishek Kumar and Sanjay K. Mohanty [15] examined the socio-economic differentials in coverage
of basic childhood immunization in India. They have used bivariate, multivariate and progression rate to
understand the differentials and changes in child immunization. Data for the survey has been taken from three
rounds of NFHS conducted during 1992-2006. All three rounds have covered 99% of India’s population. Full
immunization increased from 35% in 1992-93 to 44% in 2005-06, partial immunization increased from 35% to
51 % and a decline in no immunization from 30% in 1992-93 to 14% in 1998-99 and 5% in 2005-06. Special
effort is needed for the coverage of DPT and measles vaccines as coverage of these vaccines is lower as
compared to polio.
A M Kadri et. al. [16] studied the immunization coverage among children aged 12-23 months in urban
slums of Ahmedabad city. Cross-sectional study was conducted that included 138 children from 1800
households. Children who have received 1 dose of BCG, 3 doses of DPT and OPV and 1 dose of measles were
considered full immunized. The children who have missed 1 or more doses from these is considered as partially
immunized and the children who did not receive even a single dose of vaccine are considered as no immunized.
They have found that the coverage of vaccines was high for BCG, DPT-1 and OPV-1 i.e. 83.3 % and low for
measles i.e. 71.7 %. The coverage rate was slightly high among male children than female children for all the
vaccines. Full immunization coverage is low due to not immunize with measles vaccination.
Adebayo Peter Idowu et. al. [17] presented a mathematical model for predicting immunizable diseases
in Nigeria that affect children between age 0-5 years. They have applied three data mining techniques namely
ANN, Decision tree and Naïve Bayes Classifier to uncover hidden information. Their study collected data from
six immunizable diseases namely: Measles, Tuberculosis, Polio, Yellow Fever, Pertussis and Hepatitis B. They
also argued that if a predictive model is introduced, the programme of immunization will be strengthened.
M. Mamatha and V. Nageswara Rao [18] explored the vaccination coverage among children aged 0-9
months using NFHS- III data and analyzed by chi-square test to find out the results using SPSS. Out of total
population, 12.4 % are still not been vaccinated. Non-utilization of vaccines is found to be 9.1 % among the
total urban and 14.2 % among the total rural population. The non-coverage rate of vaccines is observed to be
slightly high in female children i.e. 12.9 % than their male counterparts i.e. 12 %.
Dr. Lokesh Kumar Sonkaria et. al. [19] examined the immunization status of 1 to 5 years children of a
rural area of Rajasthan. They have carried out a community based cross-sectional descriptive study of 330

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 Child Immunization Coverage – A Critical Review

sample size. They have founded that out of 330 children, 248 (75.15 %) children were fully immunized i.e.
those children who receive one dose of BCG, one dose of Measles, three doses of OPV and three doses of DPT
vaccines up to 1 year of age, 60 (18.18 %) were partially immunized i.e. those who have missed any one of the
doses and 22 (6.67 %) were unimmunized i.e. those who have not received any type of vaccination.
Bhuwan Sharma et. al. [20] examined the role of socio demographic variables on immunization
coverage. They have used WHO’s 30 cluster sampling method for the evaluation of immunization coverage and
selected seven subjects between age group of 12-23 months from each of 30 clusters so therefore final sample
size consists of 210 children. In their study area, 170 (81 %) children received complete immunization, 37 (17.6
%) children received partially immunization and 3 (1.4 %) children did not receive any type of immunization.
The coverage of BCG dose was found highest (97.1 %) while Hepatitis was lower than that of OPV and DPT.
Measles coverage is also less than 90 %. The major reasons of low vaccination coverage were children illness,
lack of knowledge, low education of mother, high birth order and place of delivery.
Danish and Ayaz Muhammad [21] examined the relationship between child immunization of children
aged 12-23 months and household socio-demographic characteristics in Pakistan. They have applied chi-square
test and logistic regression on the household level data from Pakistan Social and Living Standard Measurement
Survey. In their conceptual framework, child immunization is considered as dependent variable while the
gender, parents education, area and province or region are taken as independent variables. The sample size for
all provinces has been fixed at 76546 households selected from 5413 sample villages or enumerated blocks.
Their results showed that the male children are more immunized as compare to female children, people in urban
area more likely to immunize their children as compare to people in rural area. In case of child immunization,
not only child’s age but also child’s gender, resident of the child, parents education, household income, family
size plays a vital role.
Rachna Kapoor and Sheetal Vyas [22] examined the awareness and knowledge of mothers of under
five children regarding immunization in Ahmedabad. The primary sources of knowledge of mothers about
vaccine preventable diseases were anganwadi workers and television. In their cross sectional descriptive study,
85% of the women were aware of poliomyelitis, 15% women were aware of Hepatitis B and 10% women were
aware of pertusis as a vaccine preventable disease. Even 80% women had no knowledge of vitamin A.
Jisy Jose et. al. [23] observed the awareness on immunization among mothers of under five children
with non-experimental exploratory survey. They have collected the data by using base line performa and
structured knowledge questionnaire. In their survey they have found that 30% of mothers have poor knowledge
of immunization while 43.4 % had average knowledge, 23.4 % had good knowledge and 3.33 % mothers had
excellent knowledge of immunization. They have concluded on the basis of their result that there was a
significant association between knowledge and exposure to mass media in relation to immunization among
mothers of under five children.
Tufeel Ahad Baba et. al. [24] examined the utilization of maternal and child health services at sub
centre level by target population in a sub centre area. They have found in their survey of 671 cases that 40.5 %
mothers had taken their children at sub centre for immunization. 67.66 % children received complete
immunization at sub centre and 32.33 % children received incomplete immunization at sub centre.
Rahul Sharma and Sanjiv K Bhasin [25] assessed the knowledge about routine immunization among
caretakers of young children. In their cross-sectional study, 682 caretakers accompanying children under 5 years
were considered and proportions and chi-square test have been applied for the results. Out of 682 caretakers,
only 268 caretakers were aware of three diseases covered under routine immunization. They concluded that
there is an urgent need to aware caretakers about routine immunization.
Payyappat Sabin Shivan et. al. [26] worked on a project named as Pre-Baby vaccination to provide
vaccination notifications and reminders as SMS to the families of newborn and pregnant women at regular
intervals by using their registered id. In the proposed system K-means clustering algorithm has been used and
the families can access the static information send by the system as a notification periodically.

III. Tables
Table 3, Table 4, Table 5 and Table 6 depicts the techniques used, areas covered, data used, and socio-
demographic variables/factors used in papers respectively.

TABLE 3: Techniques Used in Papers

Techniques Papers
Non Experimental Survey Method 10, 23
Convenient Sampling Method 10
Decision Tree 14, 17
Artificial Neural Network 14, 17
Chi-Square Test 2, 15, 18, 21, 25
Bivariate, Multivariate and Progression Rate 15
Cluster Survey 16
DOI: 10.9790/0661-1805044853 www.iosrjournals.org 51 | Page
 Child Immunization Coverage – A Critical Review
Naïve Bayes Classifier 17
Thirty Cluster Sampling Technique 19, 20
Multistage Sampling 24

TABLE 4: Coverage Area in India and Other Countries

Area Papers
Uttar Pradesh 10
West Bengal 13
Bangladesh 2
India 15, 18
Bihar 15
Gujrat 15
Ahmedabad 16, 22
Nigeria 17
Rajasthan 19
Pakistan 21
Mangalore 23
Kashmir 24
East Delhi 25

TABLE 5: Data used in Papers

Data Papers
BDHS 2004 2
NFHS 1992-2006 15
Survey Data 10, 16
NFHS -3 18
Household level data (PSLM 2010-11) 21
DLHS- 3 (2007-08) 13

TABLE 6: Socio-Demographic Variables/Factors used in Papers

Socio-Demographic Variables/Factors Papers
Religion 2, 10, 13, 15, 21, 23
Area/Place of Residence 10, 13, 15, 21
Educational Status 10, 13, 21, 22, 23
Monthly Family Income 10, 13, 21, 23
Sex 2, 13, 15, 21
Age 2, 21
Employment/Occupation 13, 22, 23
Age of Mother 15, 22, 23
Family Size 21
Source of Information 23
Exposure to Mass Media 23

IV. Conclusion
Immunization is the most economic and most efficient solution to prevent children from infectious
diseases. This paper aimed to explore the goals achieved, schemes implemented, techniques used, data used,
areas covered, and socio-demographic factors used in the domain of child immunization. The paper explored the
reasons why new born babies missed immunization schedules. In the result, we have reviewed that the reasons
for missing immunization are bad health of children, parent’s knowledge of immunization, family size,
household income, place of delivery, high birth rate, low education status of mother etc. The factors for full
immunization discovered in the papers are children whose parents are educated, children of parents who has a
service holder, current age of respondents whose age is 21-30 years, highest education level, drinking water
from tube well and who comes from better economic status households. Some researchers proposed conceptual
frameworks using ICT to improve the process of child immunization while others examined by applying
statistical and data mining techniques on immunization data to understand the differentials and changes in child
immunization. The Government of India has launched the mission Indradhanush to immunize all children and
pregnant women by 2020 under universal immunization programme. The Government of Rajasthan facilitated
PCTS web based application for tracking pregnant women and children for providing services.

V. Future Scope
There has been enormous progress achieved till now but still there is a need to extract knowledge from
the child immunization data for the improvement of quality. In the future, we shall apply different ICT and data
mining techniques on child immunization data to discover the interesting patterns and knowledge for the welfare
of the society.

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 Child Immunization Coverage – A Critical Review

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