Background: Bellary district of India had highest number of Polio cases in the world during the year 2003. This is mainly because of low level of routine immunization coverage. Successful implementation of supplementary immunization activities interrupted Polio transmission in 2003. It is important to sustain the gains made in polio immunization as well as make attempts to improve the immunization coverage against other vaccine preventable diseases. We wanted to look at the immunization coverage rates before and after the catch up campaigns to strengthen routine immunization services in this high-risk district. Aims: Our objective was to evaluate the impact of catch up campaign through estimation of immunization coverage after conclusion of catch-up campaigns in the district of Bellary. Settings and Design: The evaluation data is from a cross sectional study done in Bellary district, India by following multi stage and systematic random sampling. Materials and Methods: The study was done in three stages; In stage one, the district specific DLHS data was analyzed. In stage two; systemic issues were identified by going through immunization registers, records and identified key reasons for low vaccination coverage. In stage three, immediately after catch up immunization sessions, the coverage rates were captured using simple random sampling, and compared with DLHS data. Statistical Analysis: Data analysis was performed using SPSS Statistics 17.0 (Rel. 11.0.1 2001-SPSS Inc), R 2.11, Microsoft Excel (MS office, Version 2007, Microsoft Corporation, USA). Results: The results demonstrate that the coverage for all antigens improved due to the conduct of catch-up campaigns. Conclusions: This study compares estimates of the age-specific population immunization coverage against BCG, OPV, DPT, TT, and Measles before and after the catch up campaigns. Catch-up sessions help to address systemic issues related to routine immunization, and sustain high immunization coverage in developing countries like India.
Keywords: Catch-up campaigns, developing countries, evaluation of immunization
|How to cite this article:
Babu GR, Sathyanarayana T N, Jana S, Nandy S, Farid MN, Sadhana S M. Role of catch-up campaigns in improving immunization services in a developing country. Ann Trop Med Public Health 2012;5:441-6
|How to cite this URL:
Babu GR, Sathyanarayana T N, Jana S, Nandy S, Farid MN, Sadhana S M. Role of catch-up campaigns in improving immunization services in a developing country. Ann Trop Med Public Health [serial online] 2012 [cited 2020 Nov 26];5:441-6. Available from: https://www.atmph.org/text.asp?2012/5/5/441/105127
The success of Smallpox eradication program led to launching of the Expanded Programme on Immunization (EPI) in India to control other Vaccine Preventable Diseases (VPD). In 1978, EPI coverage was included for six diseases: diphtheria, pertussis, tetanus, poliomyelitis, typhoid and childhood tuberculosis. The aim of EPI was to cover 80% of all infants. Subsequently, the programme was universalized and renamed as Universal Immunization Programme (UIP) in 1985. Measles vaccine was included in the programme and typhoid vaccine was discontinued [Table 1].
|Table 1: National immunization schedule-India
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The UIP was phased in from 1985 to cover all districts in the country by 1990, targeting all infants with the primary immunization schedule and all pregnant women with Tetanus Toxoid immunization. ,
We carried out the current study in the district of Bellary, in the state of Karnataka that had 18 confirmed cases of Poliomyelitis in the year 2003 making it the district with highest cases of wild Poliovirus isolation in 2003. Failure to implement routine immunization services has been given as the main reason for the resurgence of Polio transmission in this district. Efforts led by Government of Karnataka with collaboration from WHO and UNICEF interrupted polio transmission in Bellary district in 2003. Further, a state core group on routine immunization was formed to sustain the gains made in polio immunization and to improve the immunization coverage against other vaccine preventable diseases. At the initiation of this group, the district core group implemented catch-up immunization sessions to ensure universal coverage for all antigens in Bellary district. The micro planning done by the district was approved by the state core group, which in return made special logistical and vaccine arrangements for the conduct of these special immunization sessions against all the childhood vaccine preventable diseases.
The impact of catch up immunizations is not documented very well in developing countries. Our study aims at estimating the role of catch up campaigns in improving immunization coverage conducted in Bellary district. Our objective is to study the immunization coverage after the catch up campaign and compare with that of the before catch up campaign in Bellary district of India. In effect, we wanted to estimate whether this catch-up campaign initiative taken was successful or not.
|Materials and Methods|
The catch up immunization session study was carried out in three stages.
In stage one, the immunization coverage earlier to the conduct of catch up campaigns was assessed by analysis of DLHS data for Bellary district [Table 2]. In stage two, based on the results of registers and records of immunization, the district core group analyzed the reasons for poor coverage with the objective of addressing them to improve immunization coverage. As a result, the identified systemic issues were addressed at the district meetings and district core group focused its efforts to improve catch up immunization services.
|Table 2: Comparison of evaluated coverage with present study
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In stage three, the catch up session’s coverage study was conducted in the month of August 2007 immediately after the special “catch-up” immunization sessions that were conducted in Bellary district during the months of July and August of the year 2007. We compared background rates of DLHS immunization data with our study data. This community-based study of children aged 0-2 years was carried out in Bellary district during the month of September 2007. ,
Study design: Multistage cluster sampling was used for the selection of sample, as it assured objectivity of houses selection. ,,,,, The participation in the study was voluntary and informed consent was taken from the subjects. The analysis was done at University of California, Los Angeles with permission of IRB from University of California Los Angeles for data analysis (IRB# 007-06-084-02).
Analysis: All the information obtained was entered in a master sheet corresponding to the village by the interviewer. The coded information was entered village wise in Microsoft excel. The names and all other personal identification measures were removed from the data before data analysis. Data analysis was performed using SPSS Statistics17.0 (Rel. 11.0.1 2001-SPSS Inc), R 2.11, Microsoft Excel (MS office, Version 2007, Microsoft Corporation, USA). Eligibility criterion for the selection of house was that it should have had at least one child-birth in the last two years. Out of the 1630 children were surveyed, we included only 1110 children between 9-24 months of age for our study. This was because we wanted to check complete immunization status in these children and this could have been done only if they have completed nine months of age.
The survey following immunization captured data from 1630 children of whom 830 were girls and 790 were boys (with the gender ratio to be 1.05.) We only included children between 9-24 months of age for our study. This resulted in carrying out further analysis on 1110 children (562 girls and 548 boys and 1.02 being the gender ratio).
Comparison with baseline Coverage:
The District Level Household Survey (DLHS) conducted by National Family Health Survey in 2006 had been taken as background immunization rate in the district. DLHS-1 was conducted in the years 1998-99 and DLHS-2 was conducted in the years 2002-04 [Table 2].
Complete immunization is defined as the completion of BCG dose at birth (or later), three doses of DPT and OPV with four weeks gap in between Measles before the age of one year. Going by this definition, the proportion of completely immunized children in this study is 82.67%.
[Figure 1] shows the baseline immunization coverage as per the immunization records maintained in the district in comparison with post-catch up campaign coverage. To compare with more reliable source of information, we compared the earlier evaluated coverage’s with post-catch up campaigns [Figure 2], [Table 3].
|Figure 1: Comparison of immunuziation before and after catch-up campaigns
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|Figure 2: Comparison of evaluated coverage with present study|
|Table 3: Coverage of VPD antigens before and after supportive supervision
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We fitted a negative binomial model to this overdispersed count data (the overdispersion was confirmed by the log likelihood test for overdispersion which accepted the negative binomial model against the Poisson model). The Wald’s chi-square test statistic comparing the two time points (before and after) for BCG and OPV 0 was 183.24 (p-value less than 0.001). Hence, it can be inferred that the coverage of BCG at birth and OPV 0 after the catch-up campaings have significantly increased. The difference across the Taluks are not significant. These results are same for the rest of the antigens [Table 4].
|Table 4: Comparison of evaluated coverage with present study
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Our results demonstrate that [Table 3] and [Table 4] the conduct of catch-up campaigns did significantly affect the difference in coverage for all antigens across all taluks.
The results from our study indicate that coverage for all antigens under UIP had significantly increased as a result of conducting catch up campaigns compared to DLHS-1 and DLHS-2. The results suggest that catch-up campaign can be used as tool to improve the immunization coverage in high-risk areas, which are prone for high burden of vaccine preventable diseases. Planning catch up campaigns at regular intervals will not only address improving immunization coverage directly but can also will help in strengthening functioning of local health systems.
Apart from directly contributing in coverage of missed children, catch up campaigns in Bellary district provided an opportunity to identify and solve challenges faced by local health system. In Bellary district, analysis from catch up sessions showed that there were several uncovered urban areas due to abolition of a category of health centers, several vacant positions of Auxillary Nurse Midwife (ANM) vacancy for the past 4-5 years, some of the urban areas were severely understaffed (for e.g. only two workers/1.6 lakhs population in one town), identification of several hard to reach areas with inaccessible roads (about 26 villages in one block were not covered for 3-4 years), very poor supervision at all levels and trainings about routine immunization were done long back for example around 20 years back in Childhood survival and safe motherhood scheme (CSSM”). Also, planning and implementation of catch up sessions resulted in conduct of several district meetings and immediate steps to improve the routine immunization coverage were taken. Some of the important reasons for poor immunization coverage were uncovered urban areas due to abolition of urban health centers, unfilled vacancies of nurse midwifes for past 4-5 years, non inclusion of hard to reach areas with inaccessible roads, poor supervision at all levels and poor quality of trainings about routine immunization.
For effective sustenance of coverage’s in universal immunization programs, we infer that catch up sessions should be integrated with regular routine immunizations at primary health care centers. This can be done by integrating strategies to identify all the outreach areas and conducting awareness campaigns. 
In India, the Ministry of health and family welfare has recommended universal vaccination for all children for lifetime protection against specific diseases. Ensuring adequate routine immunization coverage not only reduces the risk of individual acquiring the disease but also lowers the risk of transmitting infections to others, thereby conferring protection to entire community. Catch-up sessions are important to ensure in immunizing missed children often in missed areas and thereby can raise the immunity to selected childhood infections (i.e., BCG, OPV, DPT and Measles). For comprehensive preventive health care program, routine immunization to childhood must be viewed as important integral component. The information regarding proven efficacy and safety of vaccines should be disseminated to parent communities. Effective immunization programs will prevent significant morbidity/mortality and also help in reducing health care expenditure. It is imperative that health care providers need to step up awareness campaigns to inform and educate adult patients and encourage vaccination for their children.
In order to address the sustainable systemic issues related to high immunization coverage, we have carefully addressed in this study such as outreach areas identification, staff limitations, their motivational issues, community awareness, children’s demographic data and community awareness using local and mass media. Alavian et al, also mentions that to improve awareness in the community, media education approach has significantly contributed to achieve acceptable outcomes. In our study we compared demographic profile before and after catch up campaign to assess improvements in coverage rates. Similar observation made in Poland, roma community as well that the used better demographic data to understand barriers for health services to conduct catch up immunization especially for vulnerable children.  Parallel to the above key issues, the activity performance monitoring and feedback may help to expand the immunization coverage. 
Despite of several targeted approaches, central and state Governments have not been able to achieve universal immunization coverage. Earlier evaluations of routine Immunization in India have shown wide differences between reported coverage by local health agencies compared to evaluated coverage by external agencies. ,,, India is facing the re-emergence of childhood vaccine preventable diseases due to varying levels of immunization coverage under UIP. High burden of vaccine preventable diseases affect India as long as the vaccination coverage is not optimal.
Our study had some limitations. Being a cross-sectional evaluation, we cannot make causal claims regarding the association described in the paper. Also, in the absence of other external evaluations, the District Level Household Survey (DLHS) conducted by National Family Health Survey in 2006 had been taken as background immunization rate in the districts.
Conducting catch up immunization sessions can be useful in areas with poor coverage of immunization services. As shown in this paper, catch up sessions are still the best method to step up the immunization coverage to optimal level. However, catch up sessions interval could be extended for a year to cover up the booster doses as well as to address the systemic issues to get improve for long term sustainable routine immunization strengthening.
Every year, cohort of newborn children gets added to target population for meeting with immunization coverage. Hence, we infer that continuous dynamic planning including catch-up sessions are necessary to improve and sustain high immunization coverage in developing countries such as India. Continuing catch up campaigns might be necessary till such time the routine immunization reaches to the acceptable level of immunization coverage. Due consideration of country and context specific issues and resources can help to smoothen the path for sustainable immunization coverage in low and middle-income countries. Conducting catch up sessions are in a way like catalyst in boosting up the immunization coverage in defined geographical area by several ways. ,,,,,,,,, India has made greater progress in provision of health services. The country can gain by incorporating evidence based public health program planning and implementation. ,,,
We want to thank Mr. Shanth Kumar for his help in data entry.
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Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4]