Expanded programme on immunization: study of immunization status and reasons for postponing immunizations: protocol

WORLD HEALTH ORGANIZATION EPI/GEN/84/4 ORGANISATION MONDIALE DE LA SANTE 1 I · 'u /! ORIGINAL: ENGLISH Expanded Programme on Immunization STUDY OF IMMUNIZATION STATUS AND REASONS FOR POSTPONING IMMUNIZATIONS: PROTOCOL Contents Introduction e • e e • • • • e e • e e • e e • • • e e • e • e e e e e e e e • e e e • e e e e e e e e $ e e e e C e e e • IP e e • • • • • • • e • • • e 1 Principal Questions to be Answered ••..••••.•••.•••.•••.•••••...••...••••••.•.••••• 1 Methods ••••••••••••.•••..•••••••••••.•.•••••••••..••••••.••••••••••••••••••.• • • • • • 2 Analysis of Data • • • • • • • • • • . . • • • • • • • • • • • • • • • . . • • • • • • • • • • • • • • • • • • • • • • • . • • • • • • • • . • • • • 3 Annex 1: Study of Immunization Status and Reasons for Postponing Needed Immunizations (Blank Form) . . • • • • • • • • • • • • • • • . . . . . . • • • . • • • • • • • • • • • • . • • . • • • • • • • . . • • 4 Annex 2: Study of Immunization Status and Reasons for Postponing Needed Immunizations (Completed Form) • • • • • • • • • • • • • • • • • • • • • • . • . • • • • • • • • . • • • • • • • • . • • • • • • • 5 Annex 3: Study of Immunization Status and Reasons for Postponing Needed Immunizations: Master Tally Sheet • • • . • . • • • • • • • • • • . . . • • • • . • • • • • • • • • • • . • • • • • • . • • • • 6 Annex 4: Basic Tabulations • . . • • • • • . . • . . • • • • • • • • • • • • • • • • • • • • • • • • • • • • • . . • • • • • • • • • • . • 8 INTRODUCTION Many children visiting health facilities are not fully immunized, but for one reason or another the opportunity to immunize them at that visit is not seized. During visits to curative care clinics and hospitals, children may not be screened to determine their immunization status and eligibility, or the particular health facility may not offer immunizations. If the children are ill, they may not be-immunized because it is believed that their illness is a contraindication to immunization. In areas where access to health services is limited and morbidity and mortality from the EPI target diseases are high, these lost opportunities to administer immunizations can result in unnecessary morbidity and mortality. This paper presents a short study protocol which provides one approach for immunization programmes and health facilities to assess the magnitude of this problem locally. The protocol is simple, can be rapidly carried out and easily adapted for use in a variety of countries and settings. It should be modified to fit local interests and conditions. Since very little information is available about this aspect of immunization services, it would be of great interest to perform studies such as these, even on a small scale, in many different countries. PRINCIPAL QUESTIONS TO BE ANSWERED 1. What proportion of children visiting a variety of health facilities are not fully immunized, are eligible for immunization and, at least theoretically, could be immunized at that visit? 2. What proportion of eligible children visiting immunization clinics or other facilities where immunizations are offered are not immunized at that visit, and for what reasons? The issue of this document does not constitute formal publication. It should not be reviewed, abstracted or quoted without the agreement of the World Health Organization. Authors alone are responsible for views expressed in signed articles. document ne constitue pas une publication. EPI/GEN/84/4 page 2 METHODS Study population Place of residence Children 3-11, 3-23 or 3-35 months old may be included depending on local definitions of target age groups. Generally all children of appropriate age visiting the health facility should be included regardless of place of residence. However, in areas with much immigration, the investigators may prefer to include only those children living within a defined geographic area for a defined period of time prior to the visit. Study sites Useful information can be obtained by studying a variety of different types of health facilities attended by children in the target age group, including facilities where immunizations are routinely given and facilities where immunizations are not routinely given. Studies of facilities where immunizations are not offered allow a~ssessment to be made whether or not a sufficient number of eligible children are present to justify introducing routine immunization and an estimate of the potential impact of the policy change on overall coverage rates. Health facilities that should be considered for study include immunization clinics, immunization outreach posts, well-baby clinics, curative care clinics and hospitals for children or hospitals with large paediatric wards. The sites could be chosen randomly from lists of facilities of each type, in order to avoid bias in the selection process. Data collection form A sample standardized data form (Annex 1) is attached; a completed form (Annex 2) shows how it is to be completed. Modifications will probably be necessary, depending upon the sites that are chosen for study and other considerations. For example, for studies in curative care clinics and hospitals, Part B will require modification; the columns under "Current illness" might be replaced by one headed "Chief complaint" or "Discharge diagnosis". If a determination of the severity of the illness that led to withholding immunization is desired, categories under the heading "Current illness" could be added or some of the present categories sub-divided. Procedure Two methods might be used to collect data: direct observation of encounters in the clinic, or interviews with the mothers on leaving the health facility. In some cases it may be best to combine observation of encounters with interviews of mothers in order to obtain the most complete data possible or to accomplish a special purpose. Both methods of data collection have advantages and disadvantages. The same data sheet may be used with both methods. 1. Observation of encounters. Observe the outcome of 50 to 100 or more consecutive encounters in each clinic. Preferably, data should be recorded for all encounters, not just for incompletely immunized children or for children who are rescheduled. Ideally, to reduce bias, an independent observer or supervisor would attend the clinic, witness each encounter and record the results without suggesting changes or influencing the immunization practices of the clinic. The mere presence of an observer, however, will at times be sufficient to cause the clinic staff to change their routine, thereby limiting the usefulness of the study. The clinic staff could be asked to collect the data themselves, but this is much less desirable. If this method is used, the staff should be certain to record the results of eachlencounter immediately and not try to complete the data sheet from memory at the end of the clinic session. Routine clinic records, in most cases, will not be complete enough to provide meaningful data. · 2. Interviews with mothers. EPI/GEN/84/4 page 3 Similar data might be collected by interviewing a sample of mothers as they leave the health facility. Since the clinic staff would not be observed directly, they would be less likely to change their immunization practices. Therefore, this method has the advantage of introducing less bias. The main disadvantage of this approach is that there is less opportunity for the investigator to verify the information; the quality of the data will depend primarily on the mothers' recollections and understanding of events. ANALYSIS OF DATA From a study of this sort, the following information may be learned: 1. Age and sex distribution of the children visiting the clinic(s). 2. Total number of children seen during the session(s). 3. Immunization coverage rates by age group. (Note that the children visiting the clinic may not be a representative sample of children in the area). 4. Number and percent of children already fully immunized, immunized at that visit, not immunized (regardless of reason) and rescheduled. 5. Reasons for not immunizing those in need. A suggested tally sheet (Annex 3) and a sheet showing basic tabulations (Annex 4) are attached. 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ST UD Y OF I M M UN IZ AT IO N ST AT US A ND R EA SO NS F OR P OS TP ON IN G NE ED ED IM M UN IZ AT IO NS NA ME O F HE AL TH F A CI LI TY : - - - - - - - - TY PE O F FA CI LI TY : IM M UN IZ AT IO N CL IN IC O R PO ST CU RA TI VE C AR E CL IN IC HO SP IT AL OT HE R (SP EC IFY ) PA RT A (A LL F A CI LI TI ES ) D D 0 Im m un iz at io n St at us - A lr ea dy g iv en { tic kv ) - G iv en t hi s v is it ( w ri te ~) L OC AT IO N: UR BA N D R UR AL D IM M UN IZ AT IO N SE RV IC ES YE S r:= :] RO UT IN EL Y AV AI LA BL E: N O [:: ] AG E GR OU P (M ON TH S) : 3 -1 1 0 3- 3 5 0 3- 23 O oT H E R DA TE - - - - - - - IN VE ST IG AT OR ST AT E OR R EG IO N D IS TR IC T - - - - PA RT B (F AC IL IT IE S W IT H IM M UN IZ AT IO N SE RV IC ES ) If i m m un iz at io n n o t gi ve n, ti ck V m o st im po rt an t re a s o n (s ) - N ee de d bu t n o t gi ve n th is v is it (w rit e 0) CU RR EN T IL LN ES S HI ST OR Y PO LI CY /L OG IS TI CS Na me ,- .. . i:: . . H O th er O th er O th er O S ,, .. .. ,, g (s pe ci fy ) (s pe ci fy ) Q) Q) DP T OP V • .. . , 0 ::c: i:: Q) i:: (.) (s pe ci fy ) ,, .. .. ,, . µ H ' - ' Cl ) '" Cl i:: . .. . , i:: Cl ) cu 4-< , - . . , 0 Cl ) 0 0 Q) 4 -< 0 >- . (.) . .. . , . . c: N u >- . . . c: • .- 1 i:: . µ '" Cl i:;: O •.. -l . . . . . . (.) Cl ) . µ • . . . , C/l ' - ' H bO .,, µ 0 Q) . µ • ... , cu Q) . µ i:: i:: ;::l 0 ;:l Q) b ( • .- 1 • .- 1 i:: Cl ) Q) '" Cl cu H :> '" " " C ll H 0 :>< Cl ) ;::l . µ '" Cl . µ 0 0 i:: . . . Cl ) 0 ;::l H Q) N cu cu o o s Q) Q) ~ CU H Cll u . . c: • .- 1 µ . . . . . . • .. . , 0 (.) Q)• ..-l H 4-< :> '" Cl . . c: ' - ' U l . . . . . . . µ cu · . - 1 . . . ~ .. . µ ;:l ;::l . µ • .. . , Cl ) c c 0 0 H Ul Ul H Ul (.) ,. C: Q) " d . . . • .- 1 i:: :> (.) :> ;::l p. Q) . µ Q) c. , 1 2 3 1 2 3 cu ~ . . . . . . . ,, ~ . . . . . . i:: cu Q) . µ H ~ s . µ . µ Cl ) 0 bO M F u Q) H 0 • .- 1 ~ 0 Q) H 0 0 Q) ;::l i:;: cu O - 0:: i:Q ~ c "" u A :> u r:,: : P- z 4- <• ..- l E-< 0 H '" "" . µ ,, .. .. ,, '" Cl t" l :i> "' ' 1 j ;::l O' l H ;::! (1) . . . . . _ (1) G ) x . . . _ , t" l z w . . . . . _ ' - ' 00 + ' . . . . . _ + ' EPI/GEN/84/4 page 8 ANNEX 4 BASIC TABULATIONS 1. Types of facilities studied by numbers of children. Type of facility Immunization clinic Curative clinic Hospital Other Total No. (%) of facilities 2. Age distribution of children. Age group (months) No. (%) of children 3-5 6-11 12-17 18-23 Total 3. Sex distribution of children. Male:Female ratio 4. Source of information about immunization status. Source No. (%) of children Card (or register) History Total 5. Immunization status by age prior to visit. No. (%) of children Type of vaccine No. of children in each age group (months) 3-5 6-11 12-17 18-23 BCG DPT-1 DPT-2 DPT-3 OPV-1 OPV-2 OPV-3 MEASLES