62 Malawi Medical Journal Some factors associated with non-acceptance of measles immunization in Chikwawa District: A population with high measles immunization coverage Author: Affi Iiation: Abstract Paul Courtright, DrPH Department of Ophthalmology University of British Columbia St. Paul's Hospital 1081 Burrard Street Vancouver, BC V6Z 1 Y6 CANADA Data from a child health survey in Chikwawa District was used to investigate characteristics of non-acceptance of measles immu- nization. 9.3% of the children with vaccination cards had not been vaccinated. Distance to a static health centre and failure to attend a growth monitoring clinic were predictors of lack of immuniza- iion. There were fewer missed opportunities during mobile clin- ics compared to static clinics. The high cost of mobile clinics does not make expansion of this method attractive. Strengthening educational efforts at the community level regarding measles immunization may be a more reasonable method for improving measles coverage. Introduction Success of measles immunization programmes depend not only on the technical intervention but also on being accepted and used by the target population. Studies evaluating the factors ed with non-acceptance of vaccination in widllow ga:i .. nation coverage suggest that mateJ1l8l tion, socio-economic factOJs,: aqd ,.-.,_s._ .. _ wi'" health staff contribute ;-lMtSfM .... tion.I.2 As immunizaUOII ,... •• 'wf1JI coverage also chanp .. , ....... lor,...,.ill- ing and improving immunization coverage in settings with high immunization coverage it is important to investigate factors asso- ciated with non-acceptance in these settings. Materials & Methods We conducted a child health survey in Chikwawa District, Malawi in 1992; the methods have been described previously.. Briefly, a probability-proportional-to-size sample of children under 6 years was taken to include 50 children each from 66 lages. Mothers or guardians were interviewed regarding various child health issues and immunization records of children 12-23 months of age were reviewed. No measure of socio-economic status was included in the survey. Measles immunization was defined as complete if recorded on the immunization record, regardless of timing of immunization. Children without immu- nization records were excluded from the analysis. Multivariate analyses were used to evaluate the independent contribution of factors to the outcome. Measles immunization in Chikwawa District (population 380,0(0) is carried out as part of an overall immunization pro- .,fWW!h;,;lmmunizations are available at all 14 health centres, at and through mobile growth monitoring/immuniza- monthly at 61 sites. Results There were 634 children between 12-23 months C;r surveyed; 63 children (9.9%) had no vaccination record. Of the 571 chil- dren with vaccination cards, 53 children (9.3 %, 95 % cQnfidence interval: 6.9%, 11.7%) had not been vacCinated against measles. Characteristics associated with vaccination are given in Table 1. All of these parameters, except literacy, whCWmetuded in a logistic regression model, remained independently associated with measles vaccination. Age and sex of the child, mwher'lI age, sub-district of residence, vitamin A capsRle and breast feeding ptactices were not associated wit.h of measles immunization. I .-nll";'l ' .. " Evaluating the relationship bet,*een age revealed that there was a large variarite in the c:oYMgein vil- lages five or more kilolJ1eters from the nearest health centres. (Table 2), Children living far were slightly more likely to have a clinic in the past six months than children living near a health cen- tre. Among this group (living far fromhe.Uth ceotres and more likely to rely on monthly mobile c1imcs ratbctr thaD static health facilities) 99.0% who participated in growth ..,.ntoting were vac- cinated. Among the group of children Iivins,ae., .rlaealth centre (more likely to use the static health facility. fena.muaization and growth monitoring) 92.5 % of tllose participating iltgrowth mon- itoring had received measles corrected chi- who h,.a,'JI8La&leedaG • )lfOWtb, jmbRi .. r ...... was similar * vaccination .. any of , I .... " ... i! If> uL· 'i,·1 "" .!;t' . Discussion High measles immunization coverage can reduce disease inci- dence although it will not eliminate outbreaks; a large outbreak occurred in Chikwawa in 1991. A major concern is the continued occurrence of measles cases in infants under nine months of age. In nearby urban Blantyre, hospital records for 1992 showed that 34% of admitted measles cases were in children under 9 months of age. 4 It has been suggested that in areas where high coverage of infants under 23 months has been attained "catch-up" vaccina- tion of older unvaccinated children and intensified surveillance for prompt action at the onset of an outbreak may reduce the like- lihood of exposure of infants.5 As few Malawian mothers still have immunization records by the time a child reaches school age, identifying older unvaccinated children is problematic. Intensified surveillance may be a more practical approach although it would require additional training and an improved i;lfrastructure. Low educational level of mothers, an important predictor of acceptance in other settings, does not appear to be a predictor in Malawi. Knowledge of the correct measles immunization schedule reflects previous interactions with health personnel; there have been few efforts outside the health structure to educate the rural population regarding immunization. The presence of tetanus toxoid vaccine (TTV) cards and TTV inoculations also indicate interactions with health staff. Mobile growth monitor- ing/immunization clinics appear to generate better measles cover- age than static clinics; it is our impression that mobile clinics are Reproduced by Sabinet Gateway under licence granted by the Publisher ( dated 2012)