_____________________________________________________________________________________________________ *Corresponding author: E-mail: ezenelson24@gmail.com; Asian Journal of Immunology 1(1): 14-19, 2018; Article no.AJI.44952 Missed Immunisation and Immunisation Drop-outs among Infants in Rural Health Facilities in Abakaliki, Nigeria N. C. Eze1* 1 Department of Community Medicine, Federal Teaching Hospital Abakaliki, Nigeria. Author’s contribution Author NCE designed, analysed, interpreted and prepared the manuscript. Article Information DOI: 10.9734/AJI/2018/44952 Editor(s): (1) Dr. Wagner Loyola, Department of Immunology, Brazilian Agricultural Research Corporation (Embrapa) Concordia, Canada. Reviewers: (1) Abram Wagner, University of Michigan, USA. (2) A. Shaikh Amir, Indira College of Pharmacy, Savitribai Phule Pune University, India. (3) Jose Manuel Jaramillo Ortiz, National University Jauretche, Argentina. Complete Peer review History: http://www.sciencedomain.org/review-history/27207 Received 15 th August 2018 Accepted 5 th November 2018 Published 14 th November 2018 ABSTRACT Background: Missed immunisation, immunisation drop-out and coverage rates at primary health care (PHC) level indicate the level at which communities utilise the preventive services and thus serve as a measure of the strength of the public health system. They also measure the effectiveness of the immunisation programme. The extent of missed immunisation and immunisation drop-out is not well known in the study area. This study, therefore, determined the extent of missed immunisation and immunisation drop-outs in Abakaliki. Materials and Methods: Descriptive cross-sectional analytical study design was used for the survey. Total number of infants in the health facilities was used as a sample size in this study (406 infants at Mile-Four hospital and 281 infants at St. Vincent hospital). Data were extracted from the existing immunisation registers in the two health facilities studied. Statistical Package for Social Sciences (SPSS) version 22 was used for data analysis. Ethical approval for this study was obtained from the Research and Ethics Committee (REC) of the Federal Teaching Hospital Abakaliki (FETHA). Original Research Article Eze; AJI, 1(1): 14-19, 2018; Article no.AJI.44952 15 Results: Showed significant differences in the proportion of missed immunisations (39.7% in Mile- Four and 48.4% in St. Vincent respectively, p=0.02) and immunisation drop-outs (35.7% in Mile- Four and 47.7% in St.Vincent respectively, p=0.02). The drop-out rate is 64.3% in Mile-Four and 52.3% in St. Vincent. It also showed that 36.6% of male infants when compared to 34.8% of female infants dropped-out of the 3 rd dose of pentavalent vaccines in Mile-Four while 44.5% of male infants and 51.1% of female infants dropped-out 3 rd dose of pentavalent vaccines in St.Vincent hospital. There was no significant difference in the immunisation drop-out rates between male and female infants in the study groups (p>0.05). Conclusion: A higher proportion of infants missed immunisation and dropped out of vaccination at St.Vincent than Mile-Four. This calls for an aggressive public campaign on the need to ensure immunisation timeliness for effective immunisation in such rural areas. Keywords: Missed immunisation; immunization drop-out; infants; rural health facilities; Abakaliki. 1. INTRODUCTION Immunisation drop-outs refer to infants who have used or missed immunisation services and do not return for subsequent vaccinations. When drop-outs exceed 10 percent, it indicates a problem of utilisation of services. In most settings where full immunisation coverage is low, most infants receive at least one dose of pentavalent vaccines, but the proportion that receives the needed second and third doses drops significantly. Drop-out rates are calculated as the percentage point difference between successive doses of a vaccine, expressed as a percentage of the first dose [1]. Immunisation coverage which is the indicator of access to the preventive services at PHC level is measured by the percentage of infants who have received the appropriate immunisations. Immunisation coverage is calculated as the total number of infants that have received all their immunisations up to the measles vaccine, divided by the total population of children under one year old in a given area [1]. However, differences in the indicators of access and utilisation of immunisation services exist. Indicators of access to health services among other factors include a level of education, sex, patriarchal social arrangement, rural residence, poverty, religious and cultural beliefs about certain diseases and location of health facilities etc. Indicators of utilisation of immunisation services include quality of staff skills, protocols of treatment, availability of supplies and environment of health facilities, physical and financial accessibility of services, knowledge of which services exist, education about how to best utilise self and practitioner-provided services and cultural norms of treatment [2,3]. Vaccination is typically offered free in Primary health care centres and are usually not compulsory for school enrolment. Childhood vaccines are given at interval of 0, 6 th , 10 th , 14 th week and 9 th month of birth. Immunisation drop-out usually are due to far distance to health facility. The extent of missed immunisation and immunisation drop-out is not well known in the study area. This study, therefore, determined the extent of missed immunisation and immunisation drop-outs in Abakaliki. 2. MATERIALS AND METHODS This study was carried out at Mile four and St. Vincent hospitals (in Ebonyi and Izzi Local Government Areas respectively) in Ebonyi State. Both private facilities are in the rural area. Descriptive cross- sectional analytical study design was used for the survey. Data were extracted from the existing immunisation registers in the two health facilities studied. A total number of infants in the health facilities was used as sample size for the study (406 infants at Mile-Four hospital and 281 infants at St. Vincent hospital, both in Abakaliki, Ebonyi State). Statistical Package for Social Sciences (SPSS) version 22.0 was used for data analysis. Chi- squared test was to determine association or differences between proportion of the variables and the level of statistical significance was set at p< 0.05 and confidence level at 95%. Ethical approval for this study was obtained from the Research and Ethics Committee (REC), Federal Teaching Hospital Abakaliki (FETHA), Ebonyi State, Nigeria. 3. RESULTS A total of 687 infants were studied, 406 (59%) in Mile-Four and 281 (41%) in St. Vincent. These figures were the number of infants recorded as at Eze; AJI, 1(1): 14-19, 2018; Article no.AJI.44952 16 the time of data extraction. Review of immunisation register showed significant differences in the proportion of missed immunisations (39.7% in Mile four and 48.4% in St. Vincent respectively, p=0.02) and immunisation drop-outs (35.7% in Mile Four and 47.7% in St. Vincent respectively, p=0.02). Table 1 showed that the proportion of infants who missed immunisations was 39.7% in Mile- Four and 48.4% in St. Vincent. The difference in proportion of infants who missed immunisation was statistically significant (p=0.02). Table 2 showed that the proportion of male and female infants who missed penta-valent vaccines. The difference in their proportion was not significant. Table 3 showed that 35.7% of infants dropped out of pentavalent vaccines 3 in Mile-Four when compared with 47.7% who dropped out of pentavalent vaccines 3 in St. Vincent. The difference in their proportions was statistically significant (p=0.02). The drop-out rate is 64.3% in Mile-Four and 52.3% in St.Vincent. Table 4 showed that 36.6% of male infants and 34.8% of female infants dropped-out of 3 rd dose of pentavalent vaccines in St. Vincent while 44.5% of male infants and 51.1% of female infants dropped-out 3 rd dose of pentavalent vaccines in Mile-Four. There was no significant difference in the immunisation drop-out rates between male and female infants in the study groups (p>0.05). 4. DISCUSSION In this study, a significantly lower proportion of infants (39.7%) in Mile Four than St.Vincent (48.4%) missed immunisation. More infants missed immunisations in increasing interval (most commonly missed are 14 th week vaccines compared to 10 th week vaccines and least missed are 6 th week vaccines). This may be due to the fact that as immunisation time intervals increase, caregivers tend to forget the exact date of immunisation of their infants thereby making immunisation timeliness unrealisable and putting such infants temporally at risk of infection by vaccine preventable diseases [4]. This finding is at variance with that found in Nnewi in a study of mother-neonate pairs where most commonly missed immunisations were BCG, OPV0 and OPV1, HBV1and DPT1 compared to the 10 th week and 14 th week vaccines. In that study, mother’s age, education and knowledge of immunisation were not significantly associated with missed immunisation. There was comparable proportion of missed immunisations (pentavalent vaccines 1 and 3) between the male and female infants who were vaccinated three (3) months before the intervention. This may explain the importance attached to both male and female infants now unlike olden days when preference was given to male infants in the African society. A higher proportion of infants missed OPV3, Pentavalent 3 vaccines and PCV3 than the 6 th and 10 th week vaccines. The prevalence of missed immunisation in Mile-Four (39.7%) is higher compared to those reported in Nnewi (17%) [5], Benin City (27.6%) [6] among mothers of infants 6 months to 1 year and consistent with that in Calabar (39.1%) [7] but lower than the 57.1% reported in India [8]. The missed vaccines would invariably reduce herd immunity of such population and consequently make such infants prone to vaccine preventable diseases [4]. The commonest vaccines missed were OPV1, HBV1 and DPT1 (40.38%), followed by BCG and OPV0 (38.46%), and OPV2, HBV2, and DPT2 (11.54%). The finding of higher rate of missed immunisation is in keeping with other study elsewhere [9] suggesting that the reasons for this high level of missed immunisation have not been adequately addressed. These should be addressed through adequate communication between mothers and health workers, training of health workers and policy flexibility [5]. Lower proportion of infants in Mile-Four (35.7%) than St.Vincent (47.7%) dropped-out of vaccination. There was a statistically significant difference in the proportion of infants who dropped-out of vaccination in the groups. This significant dropout rate among the infants would invariably compromise the herd immunity of such population and consequently make such infants prone to vaccine preventable diseases with attendant morbidity and mortality [4]. There was no significant difference in the immunisation drop-out rates between male (36.6%) and female (34.8%) infants in Mile-Four and St.Vincent (male; 44.5% and female; 51.1%). The cumulative drop-out rates were 64.3% in Mile-Four and 52.3% in St.Vincent. This may be due to the fact that most infants were delivered in the facility and as their mother’s postnatal care services ended, they continued the immunisation in a nearby health facility [5]. Eze; AJI, 1(1): 14-19, 2018; Article no.AJI.44952 17 Table 1. Proportion of infants who missed immunisations in both facilities Variables Mile-Four (n=406) Freq. (%) St. Vincent (n=281) Freq. (%) χ 2 (p-value) Number who missed immunisation Yes 161 (39.7) 136 (48.4) 5.17 (0.02)٭ No 245 (60.3) 145 (51.6) Number who missed each vaccine BCG 0 (0.0) 0 (0.0) OPV0 0 (0.0) 0 (0.0) HB0 2 (0.5) 0 (0.0) OPV1 60 (14.8) 22 (7.8) Pentavalent1 11 (2.7) 5 (1.8) PCV1 26 (6.4) 7 (2.5) OPV2 89 (21.9) 57 (20.1) Pentavalent2 80 (19.7) 58 (20.6) PCV2 99 (24.4) 57 (20.3) OPV3 152 (37.4) 136 (48.4) Pentavalent3 146 (36.0) 135 (48.0) PCV3 161 (39.7) 136 (48.4) statistically significant٭ Table 2. Within group comparison between Sex of infants and missed immunisation in both facilities Variables Mile Four (n=406) St.Vincent (n=281) Missed immunisation Missed immunisation Yes Freq. (%) No Freq. (%) Total χ 2 (p-value) Yes Freq. (%) No Freq. (%) Total χ 2 (p-value) Sex of infants Pentavalent vaccines1 Pentavalent vaccines1 Male 4 (2.0) 201 (98.0) 205 (100) 0.90 (0.34) 4 (2.7) 142 (97.3) 146 (100) FT (0.37) Female 7 (3.5) 194 (96.5) 201 (100) 1 (0.7) 134 (99.3) 135 (100) Pentavalent vaccines 3 Pentavalent vaccines 3 Male 76 (37.1) 129 (62.9) 205 (100) 0.22 (0.63) 65 (44.5) 81 (55.5) 146 (100) 1.51 (0.21) Female 70 (34.8) 131 (65.2) 201 (100) 70 (51.9) 65 (48.1) 135 (100) FT=Fisher’s exact test Eze; AJI, 1(1): 14-19, 2018; Article no.AJI.44952 18 Table 3. Proportion of clients who dropped- out of vaccines in both facilities Variables Mile-Four (n=406) Freq. (%) St.Vincent (n=281) Freq. (%) χ 2 (p-value) Number who dropped-out vaccines Yes 145 (35.7) 134 (47.7) 6.10 (0.02)٭ No 251 (64.3) 147 (52.3) Drop-out rate 64.3% 52.3% Number who dropped-out each vaccine OPV3 147 (36.2) 134 (47.7) 9.05 (<0.01)* Pentavalent3 145 (35.7) 134 (47.7) 9.87 (<0.01)* PCV3 152 (37.4) 136 (48.4) 7.11 (0.01)* statistically significant٭ Table 4. Within group comparison between sex of infants and immunisation drop-outs in both facilities (3 rd dose of pentavalent vaccines) Variables Mile Four (n = 406) St.Vincent (n=281) Immunisation drop-out Immunisation drop-out Yes Freq. (%) No Freq. (%) Total χ 2 (p-value) Yes Freq. (%) No Freq. (%) Total χ 2 (p-value) Sex of infants Pentavalent 3 Pentavalent 3 Male 75 (36.6) 130 (63.4) 205 (100) 0.13 (0.71) 65 (44.5) 81 (55.5) 146 (100) 1.22 (0.26) Female 70 (34.8) 131 (65.2) 201 (100) 69 (51.1) 66 (48.9) 135 (100) Eze; AJI, 1(1): 14-19, 2018; Article no.AJI.44952 19 5. CONCLUSION Higher proportion of infants missed immunisation and dropped out of vaccination in St.Vincent than Mile-Four hospital. This finding calls for an aggressive public campaign on need to ensure immunisation timeliness for effective immunisation in such rural areas. CONSENT As per international standard or university standard, patient’s written consent has been collected and preserved by the author(s). 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West African Postgraduate Medical College; 1999. _________________________________________________________________________________ © 2018 Eze; This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Peer-review history: The peer review history for this paper can be accessed here: http://www.sciencedomain.org/review-history/27207 http://creativecommons.org/licenses/by/4.0