|Year : 2020 | Volume
| Issue : 3 | Page : 209-214
At-birth vaccination timeliness: An analysis of inborns in the highlands of Jos, North-Central Nigeria
S David Danjuma1, A Ishaya Ibrahim1, Nathan Yakubu Shehu2, M Udochukwu Diala1, C Victor Pam3, Christopher O Ogbodo3
1 Department of Paediatrics, Faculty of Clinical Sciences, College of Health Sciences, University of Jos/ Jos University Teaching Hospital, Jos, Nigeria
2 Department of Internal Medicine, Infectious Diseases Unit, Jos University Teaching Hospital, Jos, Nigeria
3 Department of Obstetrics and Gynaecology, Faculty of Clinical Sciences, College of Health Sciences, University of Jos/ Jos University Teaching Hospital, Jos, Nigeria
|Date of Submission||25-Feb-2020|
|Date of Decision||17-May-2020|
|Date of Acceptance||28-May-2020|
|Date of Web Publication||17-Jul-2020|
Dr. S David Danjuma
Department of Paediatrics, Faculty of Clinical Sciences, College of Health Sciences, University of Jos, P.M.B., 2075, Jos
Source of Support: None, Conflict of Interest: None
Introduction: Immunisation and vaccination programmes are preventive and cost-effective child health interventions for reducing childhood mortality and disability from infectious diseases. Timely administration of these vaccines is important to ensure their effectiveness in disease prevention. Aim: The aim was to determine the timeliness, barriers and predictors of at-birth vaccinations. Materials and Methods: This was a cross-sectional study of 355 mother–newborn pairs using simple random sampling technique by balloting. SPSS version 23.0 was used for data analysis. Crude and adjusted odds ratios (AORs) were used as point estimates in the binary logistic regression model, while 95% confidence interval (CI) was used as the interval estimate. A P < 0.05 was considered statistically significant for the study. Results: The mean age of the mothers was 31.0 ± 6 years. The median age of newborns at vaccination was 18 h (IQR = 1 - 17) h. About 185 (52.1%) of the newborns studied were males. Only 191 (53.8%) newborns received at-birth vaccination within 24 h of life. Weekend delivery, birth outside vaccination days, delivery during public holidays and vaccine stock-outs were barriers to timely vaccinations. Private hospital delivery was an independent predictor of delayed at-birth vaccinations (AOR = 2.616; 95% CI = 1.382–4.951). Conclusions: Our study has identified weekend delivery, preterm birth, delivery outside vaccination days and vaccines stock-outs as barriers to timely at-birth vaccinations. Private hospital delivery is a significant predictor of delayed at-birth vaccinations.
Keywords: At-birth vaccination, barriers, infectious diseases, newborns, timely vaccination
|How to cite this article:|
Danjuma S D, Ibrahim A I, Shehu NY, Diala M U, Pam C V, Ogbodo CO. At-birth vaccination timeliness: An analysis of inborns in the highlands of Jos, North-Central Nigeria. Niger Postgrad Med J 2020;27:209-14
|How to cite this URL:|
Danjuma S D, Ibrahim A I, Shehu NY, Diala M U, Pam C V, Ogbodo CO. At-birth vaccination timeliness: An analysis of inborns in the highlands of Jos, North-Central Nigeria. Niger Postgrad Med J [serial online] 2020 [cited 2020 Nov 24];27:209-14. Available from: https://www.npmj.org/text.asp?2020/27/3/209/289914
| Introduction|| |
Immunisation and vaccination programmes are considered key preventive and cost-effective public health interventions for reducing childhood mortality and disability from infectious diseases.,, The World Health Organization's (WHO) Global Vaccine Action Plan provides an ambitious framework through improving access to vaccines across the world.
The WHO and the Nigerian National Program on Immunization recommended the administration of at-birth doses of Bacillus Calmette-Guérin (BCG), hepatitis B virus (HBV1) and oral polio virus (OPV0) vaccines. The overall goal of this policy recommendation is to reduce the risk of both vertical and horizontal disease transmission. Thus, BCG is administered intradermally, 0.05 ml, left upper-arm at birth or as soon as possible. HBV1 is administered at the same time as BCG, but intramuscularly at 0.5 ml, into the upper outer thigh. OPV0, on the other hand, is given per oral at two drops, at the same time with BCG and HBV1.,
Of crucial importance is the timely administration of these vaccines to ensure their effectiveness in disease and disability prevention. This is particularly so in our clinical setting where vaccine preventable diseases (VPDs) risks are high. In addition, poor adherence to recommended age at vaccination can potentially prolong the newborn's time to disease risk exposure and their susceptibility to infections.,
Two community-based studies on routine immunisation activities in the study area have been reported in the literature. The first one examined the timeliness and completeness of routine immunisation, whereas the second assessed immunisation coverage alone. However, timeliness and predictors of at-birth doses of vaccination have not been well studied in the Highlands of Jos, North-Central Nigeria. Similarly, previous studies conducted remote from study area on the determinants of delayed at-birth vaccinations were public hospital-based studies, and none examined the performance of private hospital vaccination services., To the best of our knowledge, our study is the first to do so.
Therefore, this study sought to determine the timeliness, barriers and predictors for delayed at-birth vaccinations. The outcome of this study may provide useful insights to preventive health policymakers and programme managers on the performance of immunisation programme in our environment.
| Materials and Methods|| |
Ethical considerations and confidentiality
Application for ethical approval was submitted to the Jos University Teaching Hospital (JUTH) Institutional Health Research Ethics Committee on 10 April 2017. The approval for the study was granted and received on 11 May 2017, with protocol approval no. JUTH/DCS/ADM/127/XXV/162. Written and verbal informed consents were obtained from all the respondents. Confidentiality and anonymity of their responses were maintained in line with good clinical practice regulations and Helsinki declaration. The study was started on 20 July 2017 (Thursday) and ended on 18 May 2018 (Wednesday).
Study design and location
This study was a cross-sectional design used to determine the timeliness, barriers and independent predictors of timely administration of at-birth doses of vaccinations. It was conducted at the lay-in wards of the JUTH and the Fertile Ground Hospital (FGH), which are located in the cosmopolitan city of Jos, Plateau State, Nigeria, both of which provide maternal and newborn health services.
The JUTH is a 500-bed capacity tertiary centre with an average of 2809 deliveries per annum. FGH, on the other hand, is a privately owned 29-bed capacity and multispecialist hospital which, in addition, providesin vitro fertilisation services. It has an average of 296 annual deliveries. In both the study settings, BCG, HBV1 and OPV0 are given predominantly on Tuesdays and Thursdays, except when the number of deliveries is large, they could be administered outside those days. This policy is aimed at minimising vaccine wastages.
This comprised of mothers or legally authorized representative (LAR)of newborns in the lay-in wards of JUTH and FGH, in the highlands of Jos, Plateau State, Nigeria.
Male and female newborns, with written informed consent of parent or legally authorized representative (LAR).
Severe perinatal asphyxia, clinically significant structural birth defects, pre-term's birth weights <1.8 kg and/or newborns with known clinical or laboratory risks for sepsis that could potentially require delayed administration of at-birth doses of vaccinations especially for hospitalisation and lack of immunisation card for verification process.
Sample size estimation
Sample size was determined using the formula for cross-sectional study (Ibrahim 2009):n = Z2qp/d2, where n = minimum sample size, Z = standard normal deviate at 95% confidence interval (CI) (1.96), q = the complementary probability (1 − p), d = the precision of the study set at 0.05 and P = the proportion in the target population estimated to be present for vaccination within 7 days (estimated to be 43.1% from an earlier study in Nigeria). This gives a minimum sample size (n) of 377 mother–infant pairs. Ten percent (38) mother-newborn pair) of the required minimum sample size was added, making a total of 415 to accommodate for poor and incomplete responses.
Selection of health facilities
From the list of two tertiary level health facilities in the Jos Metropolis, the Jos University Teaching Hospital was selected using simple random sampling technique by balloting. Similarly, from the list of four major privately owned hospitals providing maternal and newborn health services, which have at least 290 deliveries per annum, FGH was selected using simple random sampling technique by balloting.
Selection of enrollees
Proportion-to-size technique was used to determine the number of eligible newborns for the study. Thus, 374 (90.3) and 40 (9.7%) mother–newborn pairs were screened for enrolment from JUTH and FGH hospitals, respectively.
Thereafter, the sampling interval was determined by dividing the total number of eligible newborns per facility by the estimated sample size of each of the facilities. Thus, the sampling interval was 3.
From the sample frame in each of the health facilities, the starting point was determined using simple random sampling technique by balloting within the sampling interval of 3 and thereafter, sampling was continued until the sample size of each facility was met.
Determination of socioeconomic status of respondents
Olusanya's scoring of social indices was used to determine the socioeconomic status of the respondents, which was categorised into upper, middle and lower classes.
Data collection technique
Data were collected using a pre-tested interviewer administered semi-structured questionnaire. A minimum sample size of 41 (10%) was pre-tested across the participating health facilities. Minor transcriptional and typographical errors were identified and corrected before the main field work.
The questionnaire comprised the following sections: (a) sociodemographic characteristics of the mother and obstetrics data and (b) demographic characteristics of infants, perinatal information, age and date of receipt of vaccination and reasons for delays in receipt of vaccination, if there were any.
Delivery and vaccination dates were used to determine age at vaccination in days. The date of birth of the newborn was taken as day zero (D0). The interval (in days) between the receipts of at-birth doses of vaccinations was obtained by determining the difference between the date of birth and the day of vaccinations. The day (24 h) after D0 was adjudged day (D1). The time to vaccination was categorised into four: within 24 h of life (D0), D1 and D7, D8 and D14 and after D14.,
Two research assistants were trained by the lead investigator on the content, structure and method of administration of the questionnaire prior to the commencement of the study. Both research assistants were university graduates with good and fluent communication skills in both Hausa and English languages which were mostly used in the study area.
Reliability and validity of the study tool
The questionnaire was peer reviewed and validated with the co-authors and colleagues and then pre-tested with 10% of the total questionnaire prior to commencement of the data collection. Typographical errors were corrected and some questions were rephrased.
Study outcome measures
The study outcome measures included age at receipt of at-birth doses of vaccinations, barriers to timely receipt of at-birth vaccination and predictors of delayed administration of at-birth doses of vaccinations.
All questionnaires used to obtain relevant clinical information were serialised by the type of facility codes and double checked for adequacy and completeness. Three hundred and fifty-five (85.7%) questionnaires had complete information and were available for processing and final data analysis. The information was extracted and entered into an excel spread sheet and then exported to Licensed IBM SPSS Inc. Delaware, Chicago, USA, version 23.0. 1989, 2015, for analysis.
Univariate analysis of sociodemographic characteristics of the mother and newborns and perinatal characteristic was done, and the basic descriptive statistics were presented in frequency and percentages. Continuous variables were described using mean ± standard deviation if the data were normally distributed but median and interquartile range (IQR) were used for the data which did not fulfil the assumptions of normality. Qualitative variables were described using frequencies and proportions, and then presented in tables. Crude and adjusted odds ratios (ORs) were used as point estimates in the logistic regression model, while 95% CI was used as the interval estimate. Factors which showed statistical significance on the univariate analysis and those deemed clinically significant were entered as covariates in the multiple regression model to test for suppressor effects of other potential confounders. All tests of significance were two tailed. P < 0.05 was taken to indicate statistically significant difference.
| Results|| |
Out of 415 mother–newborn pairs screened for study eligibility, 355 (85.3%) met the enrolment criteria and were recruited for the study. Majority (320 [90.4%]) of the respondents were from the JUTH. The mean age of the mothers was 31 ± 6 years, with majority (209 [58.9%]) being 30 years of age and above. Because this study was carried out among mothers, 333 (94.7%) were married. The median age of the newborns was 18 (IQR = 1 - 17) h; 185 (52.1%) were males. Most (310 [96%]) of the families were found to be monogamous. The socioeconomic status of the respondents cuts across all levels with the majority (126 [35.5%]) in the upper stratum [Table 1].
Only 191 (53.8%) newborns studied received their at-birth doses of vaccinations within 24 h of life. Nearly one-third of the respondents received their vaccination between D0 and D7 of delivery. The median age at vaccination was 1 (1–14 days) [Table 2].
The barriers to timely administration of at-birth doses of vaccinations cut across various social and medical factors. Weekend's delivery was the most common barrier numbering 56 (32.2%) newborns. Out of a total of 174 (49.0%) that experienced at-birth vaccine administration delays, vaccines stock-outs was the reason in 33 (19.0%) newborns. In addition, prematurity with associated low birthweight below 1.8 kg accounted for as high as 7 (4.0%) out of a total of 174 (49.0%) newborns who had delayed at-birth doses of vaccinations [Table 3].
Private hospitals predict delayed at-birth vaccinations compared to government hospitals (adjusted OR = 2.616; 95% CI = [1.382–4.951]; P = 0.003). Other factors examined did not significantly predict delayed receipt of at-birth vaccinations [Table 4].
|Table 4: The binary logistic regression for predictors of delay in the administration of at-birth vaccines|
Click here to view
| Discussion|| |
This study observed substantial delays in the administration of at-birth doses of BCG, OPV and HBV. Weekend delivery, delivery outside routine vaccination days and on public holidays, vaccine stock-outs and prematurity with associated low birth weight were all barriers to timely administration of vaccines. The findings of our study have significant public health policy and clinical practice implications.
For example, delays in vaccines administration at the time when the newborns are most susceptible to severe infection could potentially increase VPDs' risk exposure with consequent increase in infant and under-5 morbidity and mortality.,
The current recommendations by the WHO that newborns should receive hepatitis B vaccine within 24 h of delivery is to reduce the risk of mothertochild transmission of the virus. This clinical practice recommendation is imperative because of high disease burden (12.2%) in Nigeria. In addition, 90% of perinatally acquired HBV infection go on to develop chronic disease (chronic carriers, cirrhosis and/or hepatocellular carcinoma).,,
Furthermore, a recent study found that, delays at the first visit in fact contribute to incomplete vaccination status by 24 months of age. Association between vaccine delays at the first vaccination visit and later vaccine delays or incomplete vaccination status by 24 months of age has also been clearly demonstrated from earlier studies on vaccine coverage and timeliness.,,
Nigeria has made some gains in reducing under-5 mortality from 193/1000 live births in 1990 to 132/1000 live births in 2018, although unable to meet its Millennium Development Goals of 62/1000 in 2015. Therefore, to attain the Sustainable Development Goals 3, of decreasing the under-5 mortality to 25/1000 live births,, Nigeria will require intentional and sustained increase in the provision of focused child health services including ensuring that every newborn, except medically contraindicated, receives timely administration of all age-appropriate recommended doses of childhood vaccinations within 24 h of life in every hospital providing maternal and newborn services. To achieve these ambitious objectives, trained vaccination staff may need to be included on shift duties in order to reduce the proportion of vaccine administration delays.
The decision of the National Primary Health Care Development Agency, Abuja, Nigeria, to declare on July, 2017, the establishment of the National Emergency Routine Immunization Center is a welcomed innovation, and thus should be supported to improve routine immunisation coverage and timeliness in the country.
We found that a little over half of the newborns studied presented and received BCG, OPV0 and HBV1 vaccinations within 24 h of delivery and nearly one-thirds between day zero (D0) and day eight (D8). This low timeliness figure may be explained partly by the fact that, BCG and HBV1 were only administered on Tuesdays and Thursdays at the Well Child Clinic Department of the study sites. Consequently, mothers had to wait for scheduled BCG and HBV1 vaccination days.
The finding of D0 is consistently higher than 49.8% (Ilorin, Kwara), and much higher than 1.3% (Benin, Edo), States of Nigeria, and 1.1% (The Gambia) West Africa, but significantly lower than 100% (Anna Nagar West, Chennai, Tamil Nadu, India) reported previously. The disparities in the figures cited above could be explained partly by the lack of consensus on what constitutes or defines timeliness in vaccine administration as observed from different studies within and between countries.,,,, For example, timeliness and coverage were calculated at birth (0–1 day), day 7, day 28, 6 months and 1 year of age compared to the current study which used D0, D1 to D7, D8 to D14 and after D14.
Compared to 24-day vaccine delays for BCG and OPV0 in Ethiopia, the current study found a median vaccine administration delay of 2 weeks. However, our finding was higher than 1.3 weeks reported from Benin City but compared favourably to 2.1 weeks observed from low- and middle-income countries. While BCG is administered once a week at some institutions, it is given twice a week at the study area. This observation further highlights the need to provide round-the-clock vaccination services and even more desirably at the delivery rooms. While this idea may sound ambitious, it may be a necessary step to reduce some of the institutional barriers to timely vaccinations in our environment.
Our study identified delivery on weekends, public holidays, vaccine stock-outs and prematurity as barriers to timely at-birth vaccinations. These barriers align with and are corroborated from previous studies from within and outside Nigeria.,,,, These identified factors further reiterates that more deliberate, increased and sustained interventions need to be instituted to ensure on-the-clock availability and accessibility of vaccines globally in order to reduce to the barest minimum VPDs attributable childhood morbidity and mortality.
Private hospital delivery was the only factor that significantly predicted delayed administration of at-birth vaccinations. This finding, however, differs from that of other studies which identified antenatal clinic attendance, maternal educational level, rural dwelling and high socioeconomic status as predictors of delayed at-birth presentation and receipt of vaccinations. This identified predicting factor could be a useful tool to research further in order to minimise vaccine delays in private hospitals providing childhood vaccination services.
Our study has three major limitations. For example, due to its cross-sectional study design, it could not evaluate the impacts of vaccination delays on subsequent doses of vaccinations because of the study design employed. Second, serial serum assays of protective antibodies would provide a better measure of effective immunisation because vaccination does not necessarily confer protection to recipient. We could not evaluate that. And third, test–re-test method for reliability of study tool (questionnaire) should have been done in similar but non-participating health institutions. This study conducted this reliability test in the participating health institutions.
| Conclusions|| |
This study has identified weekend delivery, preterm birth, delivery outside vaccination days and vaccines stock-outs as barriers to timely at-birth administration of vaccines. Private hospital delivery significantly predicted delayed vaccinations. Therefore, this work provides a basis for further operational research to design intervention programmes to improve timely at-birth vaccinations.
We acknowledge Dr Kajo, Kaneng Stephanie Francis and Jane Brown who participated as data clerks.
Financial support and sponsorship
The study was entirely funded by the authors.
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]