| Abstract|| |
Introduction: The government of Karnataka has introduced a new vaccine, i.e., pentavalent vaccine (PVV) in the Universal Immunization Programme (UIP) schedule from 1st April, 2013. There are no published studies on vaccination coverage of this new vaccine. Objectives: 1. To assess the coverage of PVV of infants in a rural area. 2. To find out the reasons for immunization failure. 3. To describe the use of Global Positioning System (GPS) technology and Google Earth as new tools for spatial mapping the vaccine coverage. Methodology: This exploratory study was conducted in September, 2014 by covering three rural Primary Health Centers near Bangalore by a team of field investigators. The population studied was children aged between 6 and 23 months at the time of the survey. WHO's standard EPI 30 cluster sampling technique was used for assessing the vaccine coverage. GarminGPS72H, a hand held GPS receiver, and Google Earth were used for spatial mapping the vaccination coverage. Results: A total of 210 children aged 6–23 months were included in the study. It was found that the completely immunized, partially immunized, and unimmunized children were 93.3%, 4.3%, and 2.4%, respectively. The most common cause for partial immunization and non-immunization was child being ill and the lack of information, respectively. Spatial mapping of vaccination coverage described the immunization coverage in the area and also gave insight into the probable reason for partial/non-immunized children. Conclusions: Coverage of PVV was very high and vaccine was well accepted by the community. GPS and Google Earth were useful in spatial mapping of the vaccination coverage.
Keywords: GPS receiver, Google Earth, pentavalent vaccine, coverage evaluation surveys
|How to cite this article:|
Ramesh Masthi N R, Krishna C. Coverage evaluation survey of the pentavalent vaccine using Global Positioning System technology and Google Earth in a rural area near Bangalore. Ann Trop Med Public Health 2017;10:76-81
|How to cite this URL:|
Ramesh Masthi N R, Krishna C. Coverage evaluation survey of the pentavalent vaccine using Global Positioning System technology and Google Earth in a rural area near Bangalore. Ann Trop Med Public Health [serial online] 2017 [cited 2019 Sep 19];10:76-81. Available from: http://www.atmph.org/text.asp?2017/10/1/76/205544
| Introduction|| |
Immunization is one of the major public health interventions for the protection of children from life-threatening conditions, which are preventable. Vaccines have saved the lives of many children in the world, more than any other medical intervention in the last 50 years. The Government of India introduced in 1978 the Expanded Programme of Immunization (EPI). The program gained momentum in 1985 and was expanded as Universal Immunization Programme (UIP) to be implemented in a phased manner to cover all districts in the country by 1989-90. The objective of the program was to fully vaccinate at least 85% of all infants within 1 year. Universal Immunization Program (UIP) initially covered six vaccine-preventable diseases viz. tuberculosis, diphtheria, pertussis, tetanus, poliomyelitis, and Measles in 1985. Hepatitis B was added to the program in 2008. The pentavalent vaccine (PVV) was introduced in the UIP schedule of Kerala and Tamil Nadu on a pilot basis in December 2011. The government of Karnataka introduced this new PVV in the UIP schedule from 1st April, 2013.
PVV is a new combination vaccine against five killer diseases viz. Diphtheria, Pertussis, Tetanus, Hepatitis B, and Hemophilus influenza type b. PVV is to be administered to infants at 6, 10, and 14 weeks of age. However, the PVV had faced hurdles in its implementation because of false propaganda like attributing deaths due to the vaccine.
Vaccination coverage in India is far from complete despite the long-standing commitment to universal coverage. Complete immunization coverage in India has increased from below 20% in the 1980s to nearly 61% at present, but still more than 1/3rd of the children remains un-immunized. The WHO recommends coverage evaluation survey (CES) for estimating immunization coverage among infants, and it has been found to be very useful by the public health administrators in developing countries, because it is rapid, operationally convenient, and cost effective.
One of the main concerns in country like India is the validity of the data collection and documentation of the information. The advent of new technology has revolutionized ways in which information on problems of health is collected and disseminated. Global Positioning System (GPS) and Google Earth are the tools that can be used to measure health events. The GPS technology is a satellite-based navigation system that sends and receives radio signals and then uses the information to determine and display the location, speed, time and distance, etc., anywhere in the world. GPS provides much needed contextual information (e.g., location), and thereby explores potential associations of how people are influenced by environmental factors. Google Earth is a free software that can be downloaded onto a computer or to any compatible gadgets such as smart phones, tablets, and so on.
There are no published studies available on pentavalent vaccination coverage in India, and also evaluation surveys have never been mapped using GPS and Google Earth. Hence, the present study was taken up to assess the coverage of PVV in infants in a rural area, to find out the reasons for immunization failure, to describe the use of GPS technology and Google Earth as tools for spatial mapping the vaccine coverage, and to assess the awareness of mothers about PVV.
| Materials and Methods|| |
This exploratory study was undertaken in a rural area near Bangalore in the month of September 2014. The study subjects were children aged between 6 and 23 months at the time of the survey. WHO's standard EPI 30 cluster sampling technique was used for assessing the vaccine coverage. Selection of clusters: All the villages in the area were line listed along with their population, and cumulative population was calculated for each village. Sampling interval was calculated by dividing the total cumulative population by 30(clusters). First cluster was selected by a random number using a currency note, and the remaining clusters were selected by adding the sampling interval. Selection of household: Selection of household was done till seven children were found in each cluster. Subjects who fulfilled the inclusion and exclusion criteria were interviewed using a pretested, semi-structured questioner. The socio-demographic details of all the family members, details about PVV immunization, reasons for not immunizing child, and awareness of mothers about PVV were recorded. Confirmation of vaccination coverage was done by immunization card/Mother and Child Health (MCH) card.
Under UIP, the vaccination schedule for PVV is at the age of 6, 10, and 14 weeks. A fully immunized child was one who had received all three doses of PVV at the time of survey. A partially immunized child was one who had received one or two doses of PVV. An unimmunized child was one who had not received any dose of PVV. According to the PVV schedule, the children should have completed the course at 14 weeks of age. As the present study was focused only on PVV coverage, children aged 6 months and above were included. The data were analyzed in MS excel, and simple proportions were calculated.
Spatial mapping using a GPS receiver and Google Earth: A handheld GPS receiver (Garmin GPS 72H) was switched on, in front of the household of subject. A GPS receiver displayed the information regarding elevation, time, and receiver's current location, i.e., latitude and longitude in terms of degrees and minutes (North .o.' and East .o.'). These values were recorded in the standard questionnaire. On entering the GPS coordinates in a computer with Google Earth, the households of study subjects were spatially mapped. The data were analyzed using MS excel. Proportions and descriptive statistics were applied.
| Results|| |
The present study included 210 children with 110 (53.4%) girls and 100 (47.6%) boys. The age of the study subjects ranged from 6 to 23 months with mean ± standard deviation of age 9.72 ± 3.33 months. A total of 190 (90.5%) children were Hindus, 16 (7.6%) were Muslims, and 4 (1.9%) were Christians by religion. A total of 161 (76.6%) children had MCH card given by the government health care provider and 49 (23.3%) had private immunization card. A total of 119 (56.7%) subjects belonged to high socio-economic status followed by 80 (38.1%) medium and 11(5.2%) low according to the Standard of living Index. 71%, 8%, and 21% belonged to nuclear, joint, and three generation families, respectively.
Total 196 (93.3%, 95% CI [89.8%-96.8%]) subjects were fully immunized, 9(4.3%, 95% CI [2.9%-5.7%]) partially immunized, and 5(2.4%, 95% CI [1.3%-3.5%]) unimmunized [Table 1]. The fully immunized subjects were more among girls (95.5%) compared to boys (91.0%). However, the difference between them was not statistically significant (Z = 1.29, p = 0.98). Partially immunized subjects were distributed equally and unimmunized were more among boys.
Among nine (4.3%) subjects who were partially immunized, the reasons were illness of the child, lack of awareness among parents regarding need for 2nd and 3rd doses, lack of time, and postponement and refusal by the vaccinator because of ill health of the child at the time of vaccination. Among the five (2.4%) unimmunized subjects, the reasons were the lack of awareness regarding the place and the time of immunization, refusal by the vaccinator because of ill health of the child, and the lack of awareness on the need for immunization.
The overall dropout rate for PVV was 4.39%. The dropout rate from PVV-1 to PVV-2 was observed to be 0.98% and for PVV-2 to PVV-3 was 3.45%. Majority (39%) of the children were vaccinated at the sub-center followed by Primary Health Center (PHC), private hospital, outreach activity, and private clinic [Graph 1].
Spatial mapping of vaccination coverage was done with the GPS receiver and Google Earth using Google Maps on a computer. [Figure 1] describes the spatial map of the study area and 30 clusters surveyed. Yellow pins represent the clusters with fully immunized children, green pins represent the clusters with partially immunized children, and red pins represent clusters with unimmunized children. By zooming in, topography (plain area) of the villages and connectivity by the road of each cluster to the health care provider can be visualized.
|Figure 1: Spatial map showing distribution of clusters in the study area according to immunization status|
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Similarly, for each cluster, special mapping can be done. [Figure 2] describes the spatial map of study subjects in one cluster-12. Yellow pins represent fully immunized, green represents partially immunized, and red pin unimmunized subjects. Each subject is represented as “C” (cluster number) and “S” (subject number). Here, fully immunized children resided at the center of the village, and partially immunized and unimmunized children resided at the periphery.
|Figure 2: Spatial map showing distribution of vaccination status of subjects in cluster-12|
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The spatial relationship between immunization status and proximity of clusters to the health care provider (PHC, SC, and RHTC) is described. It was observed from the spatial maps that the immunization status of the study subjects was neither dependent on the distance of cluster from the health care facility nor on the location of the household in the village. This sort of spatial analysis of immunization coverage is possible through GPS technology and Google Earth.
Only 11(5.2%) of the mothers knew about PVV. However, 195 (92.8%) mothers knew the vaccine by different names like jaundice injection or brain fever injection and not as PVV and that it needs to be taken at 6, 10, and 14 weeks of age. Among them, 63.6% knew about all the five diseases prevented by PVV, and 41% were aware that the vaccine was available in government hospitals, 3% in private hospitals and 56% at both government and private hospitals. The source of information was doctors and Anganwadi workers. Total 68% opined that the vaccine is more painful. Total 85% were aware of the need to complete the full course of vaccination for complete protection and 78% opined that vaccine cannot be given if the infants had mild fever/cough/cold, etc. Total 65% opined that the new vaccine reduced the number of pricks to the child compared to the previous schedule (DPT and Hepatitis B).
| Discussion|| |
India's UIP is one of the largest in the world in terms of quantities of vaccine used, the number of beneficiaries, the number of immunization session organized, the geographical spread, and diversity of areas covered. The government of India plans to introduce the PVV all over the country in a phased manner by 2015. Giving PVV reduced the number of pricks to a child, reduced the number of visit to the health care provider, and provided protection from five diseases.
According to CES of UNICEF in 2009, the percentage of children taking three doses of DPT in India was 71.5% with 69.1% and 77.6% in rural and urban India, respectively. In Karnataka, the percentage of children taking three doses of DPT was 88.2% with 86.8% and 90.7% in rural and urban Karnataka, respectively., The coverage level of DPT may be considered as one of the best indicators of health system performance in any country. Globally, DPT-3 coverage rose from 20% in 1980 to 81% in 2007., The current study had shown that the PVV coverage was higher than the state average and vaccine was well accepted by the community. As more and more immunization sessions are taking place at the sub-center level, this could be the one of reasons for high vaccination coverage and also indicates strong implementation of outreach immunization sessions.
Commonest reason for child being unimmunized was that they were from migrant families who had come in search of job, and they were not aware about the time and place of vaccination. Even though outreach sessions were held in the village with the help of Anganwadi teacher and ASHA workers, these migrants resided outside the village at construction site/brick factory, farm, etc. Their work schedule made it difficult to access outreach session and also the health workers were not able to track them because of frequent migration. Hence, additional outreach immunization sessions to reach missed out children in hard to reach/left out areas are needed. The results are similar to immunization coverage study in rural Maharashtra and Delhi.,
Traditionally, data collected in epidemiological surveys in India are subject to the integrity and competence of the surveyor. One of the important issues about surveys is the authenticity of the data collected, difficult to evaluate the survey, and CES have never been mapped. Spatial mapping is one such tool available through which coverage surveys can be accurately mapped, and the households can be visually depicted. Independent evaluation of CES is possible using GPS, which was difficult to do previously, and is a huge advantage to ensure the accuracy of data collected. The data are stored permanently and can be retrieved whenever needed at later time for comparison purpose.
In rural areas, where the address of households are not precise, spatial mapping gives the exact location of the household, and also the direction of the survey can be known by waypoints and routes saved in the GPS receiver. The spatial map describes the topography of the village and surrounding areas, latitude, and connectivity by road. The spatial mapping describes the distance of households located in the village from the primary health care provider and also distance to the nearest healthcare provider, i.e., sub-center/PHC.
Spatial mapping of the CES on Google Earth also informs about the other possible reason for unimmunized children such as the location of the household in the village. This helps in planning a better immunization session. Majority of the PHC in India have computers with internet connectivity. GPS technology and Google Earth are free and do not depend on expensive software such as Geographical Information System, and so on. Newer generation smart phones have inbuilt GPS and a separate GPS receiver is not mandatory. Health workers in many states have been provided with mobile phones. Ultimately, this would help to measure the burden of disease, map the distribution accurately and help health workers to reach the households of beneficiaries, especially in rural/remote areas of the country, and provide services effectively.
Google Earth is a great research tool. The imagery itself contains a great deal of information about the natural landscape and human infrastructure on the Earth's surface. It enables users to create and display their own data. Google Earth has various thematic layers that contain information regarding roads, populated places, geographic features, etc. Google Earth presents a great deal of information in a geographic context, is easy to install and use, is an excellent venue for inquiry-based activities, and is appropriate for educational use in a wide range of subject areas. Google Earth allows users to call upon their computer screens for detailed satellite images of most locations on the Earth. These maps can be combined with various overlays such as street names, weather pattern, population densities, and so on.
GPS data were used to study the geographical distribution of HIV-infected patients and to implement the rollout of treatment as prevention in an efficient manner. Another study used GPS for measuring the nutritional status distribution of anemia in a ruralarea. GPS was used for spatial mapping the distribution of malaria vector mosquitoes and also for risk mapping in analyzing the past and present trends in monitoring and evaluation of malaria.
A total of 65% mothers opined that diseases could be prevented by immunization, whereas only 11.61% could name two or more diseases that could be prevented by immunization schedule and 61% could not even name one disease. They also found that the main reason for partial and non-immunization was the lack of information (about the schedule, place of vaccination, need for vaccination, and fear of side effects) and lack of motivation. ANMs and paramedical workers were the major sources of information for the mothers. There is a need to create awareness regarding PVV and its use through mass media as majority of mothers were not aware about the vaccine. A study involving larger samples and covering wide geographical areas is needed for the generalization of the study results.
| Conclusion|| |
Coverage of PVV was very high and vaccine was well accepted by the community. GPS technology and Google Earth were effective in spatial mapping the vaccine coverage.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest
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Dr. N R Ramesh Masthi
Department of Community Medicine, Kempegowda Institute of Medical Sciences, Bangalore
Source of Support: None, Conflict of Interest: None
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