Sarab K. Abedalrahman (1) , Ashoor R. Sarhat (2) , Ruqiya S.Tawfeek (3)

1. M. B. Ch. B. , M. Sc in community medicine. community medicine specialist,
   Salah - Al- Deen Health Directorate
   
2. C. A. B. Pediatrics,D.C.H, M.B.Ch.B. Dep. of Pediatrics, Tikrit College of Medicine.
   
3. M.B.Ch.B, F.I.C.M.S. Dep. of community medicine, Tikrit College of Medicine.

Key words: immunization coverage, immunization in Tikrit city
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It is the right of every child to be immunized and the duty of every parent to ensure this[1]. Child immunization is one of the most cost effective public health interventions for reducing child morbidity and mortality, and attaining high levels of coverage with potent vaccines administered at the appropriate ages[2]. Immunization program managers and service providers need continuous information to know of the immunization services accessible to the target population. How many individuals in the target population are being vaccinated? Who is not being vaccinated and why?[3].

The EPI Programme was initiated in Iraq in the early 1980s, and expanding to national coverage in the mid-1980s. Coverage increases steeply but after 1990 coverage declines gradually due to international sanctions. Estimates since 1999 are based on 1999 survey data point. No reliable data are available to show current level of immunization coverage. Officially reported data in the 1990s tends to overestimate coverage[4]. Therfore this study was done to evaluate the coverage rate of vaccination and the factors predicting vaccination delay, in order to find the risk groups in need of comperhensive interferance.

A cross sectional study was done in Tikrit teaching hospital by pediatric consultants, during the period between 15th February to 30th May. A sample of 282 children aged (0-23) months were chosen randomly, and the data collected by face to face interview using a standard questionnaire containing questions about child age, sex, vaccination schedule, mother's job, education, and residence area. The information on vaccination received by the child was collected depending on the child immunization card, and if not present on the history, taken from the mother, depending on her recall.

Fully immunized child is defined as a child of age 12-23 months who received three doses of Oral Polio Vaccine (OPV), three doses of DTP, and one dose each of Bacille Calmette-Guerin (BCG) and measles vaccines before age 12 months, and considered partially immunized if he/she received fewer than these immunizations doses, and considered "not immunized" if he/she did not receive any vaccine. Mothers were considered illiterate if she could not read or write and literate if she could.

Data were entered and analyzed in SPSS Version 7.5 statistical program. Immunization differences were reported as statistically significant when Chi square P value is less than 0.05 simple linear regression, multiple regression and logistic regression (by Enter method) was performed to analyze which factors predicted mothers compliance with childhood immunization.

About 62 (22%) of mothers were illiterate and 220 (78%) literate, the majority of mothers were aged 15-25 years old, 148 (52.5%), did not work 192 (68.1%), were from urban areas 159 (56.4%), and those who had 1-2 child under 5 years old 215 (76.2%).

Among children aged 12-23 months, 24 (12.5%) were not vaccinated, 77 (40.1%) had not completed their vaccination, and only 91 (47.4) were fully immunized, while among children aged 0-11 months was 29 (32.2 %) who had completed vaccination , and 37 (41.1%) of them were not vaccinated as shown in Table 1.

The vaccination coverage among children aged 12-23 months old for BCG was 83.9%, DPT1/POV 74%, DPT2/POV 69.8%, DPT3/POV 65.1%, Measles 58.3%, MMR35.4%, Booster 14.6% as shown in Table 2.

The dropout from DPT1to DPT3 was 11.9%, from BCG to DPT3 was 11.8, and from DPT3 to measles vaccine was 10.4%.

The BCG coverage for children with urban literate mothers was 92.9% and 68.8% for children with rural literate mothers, 92.3% for those with urban ilitrate and 16.9%and 16.9% for children with rural illiterate mothers. The MMR coverage for children with urban literate mothers was 44.4% and 24.4% for children with rural literate mothers, 30.8% for those with urban illiterate and 14.3% for rural illiterate mothers (P value= 0.03)as shown in Figure.1.

The univariate analysis showed that the number of children and the residence independently associated with vaccination coverage and multiple logistic regreression analysis showed that number of children and the residence significantly predicted vaccination compliance among children aged 12-23 monthes old (Table 3).

The multiple regression equation for the factors predicting fully vaccinated status of 12-23 months old children was significant for mother education, number of children, residence, child sex, mother age, mother job (p =0.017) and highly significant for mother education, number of children, residence (p =0.002) as shown in (Table 4).

The information on vaccination was taken from the child immunization card, and immunization history taken from the mother depending on her recall as it is reliable[5,6]. In this study the vaccination coverage for the first year of life is: BCG 57.8%, DPT1 46.7%, DPT2 27.8%, DPT3 11.1%; and these were lower than previous results in Tikrit; BCG 96%, DPT1 89%, DPT2 80%, DPT3 75%[7]. The vaccination coverage for the second year of life was lower than the estimated levels by UNICEF and WHO reports (BCG 93%, DPT1 93% DPT3 81%, MCV 90%) and the government official reports (BCG 95%, DPT1 96% DPT3 84%, MCV 85%). This difference may be due to difficult access to populations as well as a likely underestimation of the denominator[4]. The vaccination coverage for all vaccines was lower than that found in Ethiopia, and Istanbul[8,9]. In this study, fully-vaccinated children aged 0-11 months was 32.2% in comparison to 57% of that found by Mohammed. M et al, and was 47.4% for children aged 12-23 months in comparison to that found by Takelay Kidance and Michael Tekie and Topuzoglu A et al 75.5%, 68.3% respectively[7,8, 9]. But these results are higher than that found in Delhi 41.4%[10].

In this study, the not vaccinated children among all children was 21.6% in comparison to 4%, that found by Al Hilfy T.K and Essa A, and this difference may be due to the fact that their data was collected in the PHCCs and this gives the high coverage rate[11]. Access to immunization services was 83.9% (BCG) and 74% (DPT1/pov), but fully vaccinated children was 47.4%, which means a default in the programe success[2]. These results differ from that found by Al-Sheikh OG, et al; that access to immunization services were BCG 97% in urban and 92% in rural areas in comparison to 60% of urban children, and 28% of rural children being fully immunized[12]. The drop out of BCG to DPT3-OPV was 11.8%, DPT1-OPV to DPT3-OPV was 11.9%, DPT3-OPV to measles was 10.4%, which indicates a default in programme performance and poor communication between health worker and parents[2]. The drop out from vaccination gives the impression that with increasing child age the coverage will decrease and this is what wasv found by Al-Sheikh OG. et al [12], and Farizo et al[13].

In this study the drop out rate of DPT1/pov to DPT3/pov was lower than that in Delhi 18%[10].

These results may be explained by the delivery system of immunization which has many inherent problems to which an addition may be made by the people themselves, with their prejudices, carelessness and apathy[14]. Other national factors can be added; overloading as the city loaded with thousands of families coming from other governorates, or to lack of some vaccines in the primary health care centers, difficult transportation due to insecurity and lack of fuel, or to lack of awareness of the importance of immunization and the need for continuingdoses, and lastly the idea that the vaccines may be unhealthy or toxic and may kill their children, as a part of civil war, as it noticed that multiple families refuse vaccination, as found by Mohammed. M et al that 28.7% of mothers fear side effects of the vaccine, and 43% of mothers lack of awareness [7].

In this study, the children of literate-urban mothers are more likely to have completed vaccination, than the children of literate rural mothers. This finding is supported by researchers, who found that vaccination coverage was higher in urban than in rural areas[12,15,16]. In contrast, Takelay Kidance and Michael Tekie found the opposite[8].

n this study, the univariate and multivariate analysis shows that the vaccination status was significantly associated with residence and number of children >5 years old in the family. This is supported by Takelay Kidance and Michael Tekie,[8] who found that there is a significant association between the residence and mother's education and vaccination status of the children by using the multiple logistic regrression analysis, and that found by Cutts FT.[17] et al and Diaz T. et al[18] that the vaccination completion was determined by the mother's experience with vaccination services.

The multiple linear regression highly associated with mother's education, number of children, residence (p value 0.002), gives a view about the risk groups which the programme efforts must concentrate on. This finding was supported by Cutts FT.[17] et al and Diaz T. et al[18] who found that vaccination completion was determined by the mother's educational level, employment status and experience with vaccination services, and by Takelay Kidance and Michael Tekie,[8] who found it significantly associated with residence and mother education, while, Topuzoglu A etal and Simonetti A. et al found a significant association between high socio-economic status and coverage level[9,19].

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Table 2. The vaccination coverage according to the child’s age.

Type of vaccine	0-11 month N (%) denominator=90	12-23 month N(%) denominator=192
BCG	52 (57.8%)	161 (83.9%)
DPT1/POV	42 (46.7%)	142 (74%)
DPT2/POV	25 (27.8%)	134 (69.8%)
DPT3/POV	10(11.1%)	125(65.1%)
Measles	4(4.4%)	112(58.3%)
MMR	0(0%)	68(35.4%)
Booster 1	0(0%)	28(14.6%)

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Figure 1. Immunization coverage (%) of 12-23 months old children by residence and maternal education.

BCG     p=0.2 , DPT₁    p=0.3, DPT₂    p=0.3, DPT3       p=0.4, Measles p=0.4   MMR    p=0.03, Booster  p=0.07

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Table 3. Factors predicting fully vaccinated status of 12-23 months old children.

Risk factor	not fully	Univariate	multivariate	95% CI	P-value
	vaccinated/total	OR	OR
Mother literacy
illiterate	21/34	0.68	0.635	0.2-1.3	0.1
Literate	80/158	1.08
Residance
Rural	44/66	0.55	2.4	1.3-4.5	0.004
urban	57/126	1.34
NO. of children
1-2 child	67/145	1.29	3.04	1.48-6.2	0.001
> 2 child	34/47	0.42
sex
Male	56/104	0.95	0.89	0.5-1.5	0.4
Femal	45/88	1.06

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Table 4. Multiple regression equation for the factors predicting fully vaccinated status of 12-23 months old children.

Model	R	R square	Adjusted R Square	Std. Error of the Estimate	Sig*.
1	0.085a	0.007	0.002	0.5001	0.240a
2	0.23b	0.055	0.045	0.4892	0.004b
3	0.271c	0.073	0.058	0.4858	0.002c
4	0.273d	0.074	0.055	0.4867	0.006d
5	0.276e	0.076	0.052	0.4875	0.011e
6	0.281f	0.079	0.050	0.4881	0.017f

*significant tested by ANOVA

a. Predictors: (Constant), mother education
b. Predictors: (Constant), mother education, number of children
c. Predictors: (Constant), mother education, number of children, residence
d. Predictors: (Constant), mother education, number of children, residence, child sex
e. Predictors: (Constant), mother education, number of children, residence, child sex, mother age
f. Predictors: (Constant), mother education, number of children, residence, child sex, mother age, mother jobe

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