A COMPARATIVE STUDY OF IMMUNIZATION AND NUTRITIONAL STATUS OF CHILDREN AGED BELOW TWO YEARS IN RURAL AND URBAN COMMUNITIES IN BAYELSA STATE

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A COMPARATIVE STUDY OF IMMUNIZATION AND NUTRITIONAL STATUS OF CHILDREN AGED BELOW TWO YEARS IN RURAL AND URBAN COMMUNITIES IN BAYELSA STATE

TABLE OF CONTENTS  

Title                                                                                                                         Page

Title page                                                                                                                          i Certification                                                                                                                      ii Declaration                                                                                                                      iii

Dedication                                                                                                                       iv

Acknowledgement                                                                                                           v

Table of content page                                                                                                  vi-vii

Acronyms/Abbreviations used                                                                                       viii

List of Tables                                                                                                                  ix

Definition of Terms used                                                                                                 x

Formulae used                                                                                                               xi

Summary                                                                                                                      1-2

CHAPTER ONE                                                                                                           3-10

Introduction                                                                                                                   3-7

    Immunization Status                                                                                                 3-4

Immunization in Nigeria                                                                                            4-6

Nutritional Status                                                                                                      6-7

Objectives of the study                                                                                             7-8

Statement of the problem                                                                                         8-9

Relevance of the study                                                                                              10

CHAPTER TWO                                                                                                       11-61

Literature Review                                                                                                     11-61

Background to the reaching every district strategy and evaluation objectives     14-34

Target diseases of immunization                                                                          34-50

Nutritional status in Children                                                                               50-61

CHAPTER THREE                                                                                                    62-71

Materials and Methodology                                                                                 62-71

  

Background Information on the study centres                                                           62-63

Sample Size                                                                                                              64-68

Inclusion/Exclusion Criteria                                                                                       68-69

Study Instrument                                                                                                             69

Duration of the study                                                                                                       69

Data Collection                                                                                                          69-70

Analysis                                                                                                                          70

Ethical Consideration                                                                                                 70-71

CHAPTER FOUR                                                                                                      72-80

Results                                                                                                                       72-80

CHAPTER FIVE                                                                                                        81-86

Discussion                                                                                                                 81-86

Conclusion                                                                                                                      87

 

CHAPTER ONE

INTRODUCTION

  IMMUNIZATION STATUS

Diphtheria, measles, pertussis (whooping cough), poliomyelitis, tetanus, tuberculosis, yellow fever, Hepatitis B, and cerebrospinal meningitis (in endemic areas) which still plague mainly the world’s under-five population are the target diseases against which vaccination is given by the Expanded Programme on Immunization (National Programme on Immunization in Nigeria). In Nigeria, about one child in five dies before its fifth birthday; this represented about 191 deaths per 1000 live births of under-five and 99 deaths per 1000 live infant births1. Vaccine-preventable diseases (VPDs) account for about 22% of these deaths. Therefore over 200,000 children a year are dying needlessly of VPDs 2. Out of the 10 million children dying in the world every year, up to 1.6 million could be saved with currently available vaccines and another 1.5 million with vaccines that are expected to be available for introduction over the next few years. According to conservative estimates, current efforts save 3 million children’s lives 3. Also several children who would otherwise have been crippled by polio are now walking and running about as a result of the protection from immunization. Immunization coverage survey is a survey of a small number of individuals to determine their immunization status. It involves visiting a small sample of homes and systematically recording the immunization data to get the required information needed by managers and planners to evaluate reduction in morbidity and mortality from vaccine preventable diseases as coverage increases 4.  Following an existing poor utilization of immunization services in the years before, the Universal Child Immunization (UCI) sought to reverse that trend. This resulted in the attainment of 80% minimum immunization coverage by December 1990 in all countries   even though, there were pockets of inadequately covered areas especially in less developed countries of the world.  As a result of this, the World Health

Organization (WHO)/ Expanded Programme on Immunization’s (EPI’s) Global Action Group (GAG) decided in October 1990 in Egypt to unmask such areas by the analysis of immunization coverage data at a provincial or district or health service level 5

 

IMMUNIZATION IN NIGERIA

With the control of epidemic diseases-yellow fever and smallpox and as a step towards implementing EPI on State basis, a pilot project on immunization was carried out at Ikire health centre in May 1975 in Oshun Southern Local Government Area (LGA) in the defunct Western State of Nigeria. The result was an increase in immunization coverage to 72.4% children in the LGA which contrasted with 14.1% coverage in the State6. Every State was then required to carry out similar pilot projects, and by 1979 the EPI was started nationally. However, low coverage rates of 15-25% as against 80% national target necessitated a review in the period 1979-1983 leading to Owo pilot project formation that resulted in an increase from 9% to 83% in the LGAs involved6. Several measures such as regular vaccine supply, storage, transport, greater use of static facilities for immunization and improved management were put in place to increase immunization coverage of children aged 0-2 years against the six killer diseases 5,6. 

A national coverage survey to assess the achievement of the revised EPI, in 1988 however failed to show the desired increase hence the introduction of National Immunization Days (NIDs). The first series of National Immunization Days (NIDS) were 3 days each in March, April and May 1988.This helped increase public awareness of immunization, its acceptance and subsequently the coverage rates. In 1989 each State’s Ministry of Health (SMOH) introduced the State Immunization Days (SIDs) and subsequently the Local Government Immunization Days (LIDs) and Village Immunization Days (VIDs) during which vaccinators immunized eligible people from house to house to further increase immunization coverage 5.

Routine immunization against DPT, measles, polio and TB is proven to be most costeffective interventions for reducing childhood illness and mortality, especially with the addition of other vaccines such as cerebrospinal meningitis (CSM) and yellow fever in endemic areas and tetanus toxoid injections for pregnant women. And yet national coverage in Nigeria for full immunization in children aged below 1 year is less than 13%, one of the lowest rates in the World2.  Both the Nigeria Demographic and Health Survey

(NDHS 2003), conducted by the National Population Commission, and the Nigeria

Immunization Coverage Survey (NICS 2003), conducted by the National Programme on Immunization (NPI), provide the same irrefutable evidence. The percentage coverage for the following four (4) vaccines in Nigeria are as follows: BCG 69%; DPT1- 72%, DPT3- 54%; POLIO 61% and measles 62%1,7,8,9. The corresponding results for Bayelsa State are: BCG 37%; DPT 45%; POLIO 44%; Measles 30%10. The national percentage DPT3

coverage for Nigeria is 54% 1,7,8,9.

Nigeria’s performance on routine immunization has continued to decline since the high point achieved around 19902.The implication of this is an attendant rise in vaccine preventable diseases.

It is known from other studies that immunization coverage is lower in rural than urban areas5. This is due to reasons of difficult terrain/inaccessibility as well as their dependence on mobile immunization teams whose services are often intermittent.

 

NUTRITIONAL STATUS

A number of agencies, including UNICEF and WHO, have agreed on certain household practices for neonates and infants that can help to promote child survival, health and nutrition in communities1:

  • Exclusive breastfeeding: Exclusive breastfeeding from birth to six months. (Mothers found to be HIV-positive require counseling about possible alternatives to breastfeeding). In Nigeria, 17% children are on exclusive breastfeeding below 6 months of age, 34% still breast feed at 20-23 months; 29% under 5 children have moderate to severe underweight, 9% are severely wasted and 38% have moderate to severe stunting1. Whereas, 73% receive vitamin supplementation at 6-59 months of age, 97% of households consume iodized salt1.
  • Complementary feeding: Starting at about six months old, feeding children energy- and nutrient-rich complementary foods while continuing to breastfeed for at least two years could prevent more than 10 per cent of deaths from diarrhoea and acute respiratory infections, particularly pneumonia; and increase resistance to measles and other illnesses.
  • Micronutrient supplementation: Improving the intake of vitamin A through diet or supplements in communities where it is deficient could reduce mortality among children aged 6 months to five years by 20 per cent.
  • Hygiene: Better hygiene practices, particularly hand washing with soap (or ashes) and the safe disposal of excreta could reduce the incidence of diarrhoea by 35 per cent.
  • Immunization: Vaccination against measles for children under age one could prevent most of the measles-related deaths each year. Caregivers should make sure children complete a full course of immunizations (Bacille Calmette- Guérin; diphtheria, pertussis and tetanus vaccine; oral polio vaccine; and measles vaccine) before their first birthday. This study is first of its kind in the places intended. Both places are located in the tropical rain forest area of the country with the attendant variations in climatic conditions. Ondewari town, which is reached only by infrequent boat transport also depends on, infrequent mobile immunization teams for the immunization of their children. It is hoped that identifying the deficiencies will help in the improvement of services in the areas.

OBJECTIVES OF THE STUDY (SURVEY) General Objective:

To study the immunization/nutritional status of children aged below 2 (two) years in Ondewari, a rural community and compare that with Yenagoa, an urban community.

 

Specific Objectives: 

To determine the following:

  1. Immunization coverage rates for children aged 0-23 months in Ondewari and

Yenagoa communities in Bayelsa State.

  1. The drop-out rates from immunization and reasons for it.
  2. Socio-demographic factors associated with immunization status of children aged 023 months.
  3. Socio-demographic factors associated with nutritional status of these children aged

0-23 months.

 

STATEMENT OF THE PROBLEM

Vaccine preventable childhood diseases have continued to kill a significant percentage of children world-wide but especially in developing countries1-3. This is due to nonvaccination of children against these diseases as a result of ignorance, poverty, religious prohibitions, lack of access to immunization services, poor quality of service, and difficulty maintaining effective cold chain. This has led to a failure to meet immunization target and failure to sustain attained levels. For instance, the World Health Assembly had planned to eradicate poliomyelitis globally by the year 2000, but instead saw a resurgence of wild strain in certain states of Nigeria because of misconceptions

regarding the vaccine in 2005 11,12. The resurgence resulted in the spread of wild polio virus (WPV) into 18 countries that had been polio free for 1 or more years including 3 countries outside Africa 12. Poliomyelitis from Nigeria spread to several nearby countries that had previously been free of the virus, in what WHO experts described as “a grave threat” to public health. A dozen children were paralyzed by wild polio in Ghana, Togo, Burkina Faso, Niger and, most recently, Chad. Among these countries only Niger has had any wild polio virus circulating in the past few years. Public health officials are also worried by the spread of infection within Nigeria, from its epicentre in the north of the country to other cities13. Nigeria, which had long been a reservoir for polio in West Africa, seemed to have overtaken India as the country with the largest number of polio cases worldwide14,15.

The study location with its peculiar Niger Delta terrain is even worse off than other upland areas of the country, in terms of immunization coverage, which itself according to World Health Report, 2000 ranked Nigeria 187th out of 191 countries, in overall health systems performance15,16,17. This was a precipitate of a near collapse of the health care system in Nigeria particularly during the military era, a situation attributable to several factors including poor funding, poor management capacity and poor infrastructure. This situation led to a very difficult setting for achieving public health goals. This could explain to a large extent the delay in reaching the goals for polio eradication and the failure to sustain a strong routine immunization system in the country.

In a special United Nations Session on Children document, “A World fit for children”, the goal, by 2010 in “Ensuring full immunization of children under one year of age at 90% coverage nationally, with at least 80% coverage in every district or equivalent administrative unit” was proposed3. It is therefore important to regularly assess coverage rate to evaluate the progress towards the attainment of this goal particularly in these hard to reach, riverine, rural areas such as Ondewari town, one of the study areas where there are limited health personnel and health facilities to deliver immnunization services.

Finally, a disease prevention-oriented approach is necessary to avoid the need for much curative care, particularly where resources for medical care delivery are limited, as it is, of our society. In this therefore, the family physician being a primary care provider, be well informed and always offer this important component of primary health care, as he/she stands advantageous with the unique role of the Specialists whom patients look up to, for providing this broad range of health promotion and disease prevention activities for the entire family.

 

 RELEVANCE OF THE STUDY

In spite of the availability of vaccines and their usefulness in preventing diseases with the existence of immunization programmes, utilization has not been encouraging – less than 13%

full immunization for Nigeria as at June 20051. Process measures are frequently used as intermediate measures to overcome limitations in study power to detect differences in disease outcomes. The relative ease of demonstrating improvement in the process of health care (compared with outcomes) provides substantial advantage, albeit with the need to infer indirectly from process to outcome. For immunizations, this inference is on solid ground because the process of vaccination is highly associated with both protection from vaccine-preventable disease (VPD) and reduction of VPD rates. This strong link between process and outcome makes immunization status one of the most commonly used measures of child health status and the adequacy of preventive care 18.

This study looked at immunization status and identified factors affecting them as well as indicators of nutritional status in children aged below 2 years in the study places with a view to preparing the primary care physician with a better understanding of the morbidity pattern of these immunizable diseases. It also offered suggestions for improvement as deaths arising from these diseases are avoidable.

A COMPARATIVE STUDY OF IMMUNIZATION AND NUTRITIONAL STATUS OF CHILDREN AGED BELOW TWO YEARS IN RURAL AND URBAN COMMUNITIES IN BAYELSA STATE

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