Measles Second Dose Vaccine Uptake and Determinants among 15–23 Month Old Children at Bahir Dar, Northwest Ethiopia

Document Type : Original Research Article

Authors

1 Lecturer, Department Midwifery, Tedda Health Science College, Gondar, Ethiopia

2 Lecturer, Department of Midwifery, Debark University, Debark, Ethiopia

3 Lecturer, Department of Nursing, Tedda Health Science College, Gondar, Ethiopia

10.22038/jmrh.2024.71216.2089

Abstract

Background & aim: Measles is a highly infectious disease and can cause lifelong complications and death. Most studies focused on children who received a first dose measles vaccine rather than second doses. Therefore, this study aimed to determine second dose measles vaccine uptake proportion and its associated factors among children aged 15–23 months in Bahir Dar, Northwest Ethiopia.
Methods: A community-based cross-sectional study was employed from September 20 to November 25, 2022. A multi-stage cluster sampling technique was applied to select 633 children aged 15 to 23 months. Data were collected through face-to-face interviews using a structured questionnaires. Data were entered into Epidata version 3.1 and univariate and multivariate binary logistic regressions were carried out.
Results: The study revealed that the proportion of second dose measles vaccine uptake was 53.08%. Having parents who were primary guardians (AOR=1.54,CI,95%(1.05, 2.27), antenatal care visit (AOR=1.97 CI, 95%(1.26, 3.07), child delivery at health facility (AOR=1.66, 95%CI: 1.14, 2.42), no child illness in previous vaccination time (AOR=1.53, 95%CI: 1.07, 2.18), and no long waiting time at the vaccination site (AOR= 2.54, 95%CI: 1.05, 2.21) were identified as determinants of measles second dose vaccine uptake. 
Conclusion: The measles-containing second-dose vaccine uptake was low. Children with parents as primary guardians, having antenatal care follow-up, health facility child delivery, absence of child illness during previous vaccination, and short waiting time were determinants. The findings suggests that increasing maternal antenatal care visits and encouraging women to give birth in a health institution would increase MCV2 vaccine uptake.

Keywords

Main Subjects

Full Text

Introduction

Measles is a highly infectious disease and can cause lifelong complications and death (1-2) Despite its highly contagious, measles can be prevented by vaccines (1). A vaccine is a biological substance intended to stimulate the body to produce antibodies against specific infectious diseases by activating changes in the immune system (3).

Globally, due to measles infections annually, 60,000 were causes blindness and more than two million deaths (4). According to reports children mortality due to measles has increased from 89,780 in 2016 to 207,500 in 2019 (5) and case fatality in low-income countries range case fatality rate between 0.05% and 6% (6). It has lifelong complications and illness (7). The illness presents with fever, cough, and conjunctivitis before progressing to the classic rash after 2–4 days (8). Complications are more common in the very young and include otitis media, pneumonia, diarrhea, keratitis, and encephalitis (8, 9). To avert this high child mortality due to measles, the plan stresses the importance of strong routine immunization systems that provide whole doses of measles vaccine, supplemented by campaigns, laboratory-backed surveillance, outbreak preparedness, and case management, as well as research development (10).  

Although national immunization programs has recommended to routine immunization schedule (11), national immunization MCV1 has been achieved (80%) and MCV2 (67.8%) in 2019 in globally (12). According African study, the prevalence of MCV2 coverage varied from 36% to 94% (13) due to high dropout rates (14). Even though, strong routine immunization systems plan, estimating the magnitude of measles deaths is problematic (15) and large drop-out rates in most countries (16) which showed that ranging from 2.9% to 52.9% in Ethiopia (17). For measles elimination, vaccination coverage needs to reach at or exceed 95% with each of the two doses of MCV at the district and national levels (18). To eliminate this vaccine-preventable disease reaching every district strategic approach is recast as the "reaching every child or community strategic approach were adopted (19). National immunization programs must improve the implementation of MCV2 using the standard introduction and evaluation guidelines available for EPI program planning (20).

Some factors attributed for low second dose measles vaccine uptake were child illness, waiting time, maternal education, fear of side effects, poor attitude about the potency of the vaccine, and the beliefs and perceptions of healthcare providers (21-23). Most of the studies in developing countries, including Ethiopia, focused on children who had MCV1 but not MCV2 and associated factors. Therefore, this study aimed to determine measles second dose vaccine uptake proportion and associated factors among children aged 15–23 months at Bahir Dar, Northwest Ethiopia.

Materials and Methods

A community-based cross-sectional study was conducted from September 20 to November 25, 2022 in Bahir Dar City. The city is the administrative center of Amhara Regional State and is 560 kilometers away from Addis Ababa, the capital city of Ethiopia. It has nine sub-cities and 22 kebele (the lowest administrative units in Ethiopia), ten public health facilities and three public hospitals. All these health facilities offer immunization services. According to Bahir Dar city health office administration, in the catchment population, there are currently 332,856 children aged less than 2 years.

The source of population was all children aged 15 to 23 months who lived in Bahir Dar city, while all children aged 15 to 23 months who lived in the selected kebeles in Bahir Dar city during the data collection period were study populations.  Children who aged 15–23 months and permanently resided in the Bahir Dar city were included and children aged 15–23 months who didn’t get their first dose of MCV1 vaccine were excluded.

The study participants were determined by taking 50% proportions. The percentage of the second dose is 50% the confidence level was 95%, Za/2 is 1.96, margin of error is 5%, non-response rate was10%, and design effect was 1.5. n = (za/2)2/d2=384. Adding a 10% non-responder rate and multiplying by 1.5, final sample size was 633.

A multi-stage cluster sampling method was used to select sub-cities and households in the selected sub-cities. From a total of nine sub-cities, three (Belayzeleke, Tana, and Fasilo) was selected randomly using a lottery method, considering the representativeness of the sample and logistical considerations. Then respondents in each of the sub-cities were allocated proportionally. Lastly, study participants selected using a simple random sampling technique. Study participants were interviewed until the allocated sample was reached.

Data collection tools were adopted from different related literatures (24-25). The questionnaire consisted of two parts: (1) Socio-demographic variables, institutional-related, and child vaccination status data variables, 2) vaccination caregivers’ vaccination cards, (3) MCV2 status and related questions were asked to parents/caretakers and then confirmed with the record in their vaccination card. Only written vaccination records were included in the data collection. Four bachelor degree holders in midwifery for data collection and one master's degree older in clinical midwifery for supervisor were engaged in the data collection process. To ensure a common understanding, one-day training was given to both the data collectors and the supervisor regarding the objective of the study, the data collection process, and how to maintain confidentiality.  Children’s age were confirmed with the mother and child health book. Other variables were asked of parents/caregivers, thus there might have been recall bias in the survey. All processes involved in the study strictly followed standard operating procedures. A pretest was done on 5% of the questionnaires at Zenzelima Town by the principal investigator, supervisors, and data collectors before real data collection. Appropriate measures and corrections were taken on time by supervisors and investigators. Moreover, the tool’s reliability was checked for its internal consistency with a Cronbach’s (α) test, 0.802 for proportion of knowledge and practice, respectively.  Multicollinearity was also checked by using a standard error and variance inflation factor to see the linear correlation between the independent variables. Variables with a standard error of >2 and a variance inflation factor (VIF) with a Cronbach’s (α) test, 0.802 for proportion of MCV2. Moreover, Hosmer Lemeshow goodness of fit test was used to check for model fitness by looking at the cut point p-value > 0.05.

Data completeness checked and cleaned up manually before being entered into the software. Then, data entered into the software Epidata version 3.1 and exported to univariate and multivariate binary logistic regressions analyses for further analysis. Descriptive statistics presented like texts and tables. The proportion of MCV2 vaccination uptake among children aged 15–23 months was determined by categorical variables. A binary logistic regression was fitted to determine the association between dependent and independent variables. Variables with a p-value of <0.2 during univariate analysis were included in multivariable regression to assess the effect of independent variables on dependent variables. Finally, in the multivariable analysis, variables with a p-value less than 0.05 were considered statistically significant.

Results

Socio-demographic variables revealed that 633 children participated in the study, with a response rate of 100%. The mean age of participants was 20.69 months ± 1.70(SD). More than half (52.4%) of the children were male. Among the study participants, almost two-thirds (75.67%) were orthodox. Most of the children (75.51%) had parents as primary guardians, and most of their mothers (80.25%) were married. About 43.13% of their mothers were employed and 36.02% of the study participants attended primary school (Table 1).

Access to health facility

Among all study participants, 81.99% of them had an ANC contact, 81.36% had a travel distance between 30 and 90 minutes from a nearby health institution, and 70.77% had delivered their children in a health facility (Table 2).

Proportion of MCV2 coverage

The proportion of MCV2 vaccination uptake among children aged 15–23 months was found to be 53.08 % (95% CI: 49.3%–57.2%). Among (633) study participants, 58.93% of them had information about MCV2, and 63.28% of study participants had vaccinated their children below the age of 18 months. About 57.19% of the study participants believed that immunization was safe for children (Table 3).

Factors associated with the proportion of MCV2

Variables were computed in univariate and multivariable logistic regression analysis to identify association. In univariate analysis, maternal age, primary guardians, prenatal care visit (PNC) visit, information about the second dose of measles vaccine, place of child delivery, fear of side effects of the vaccine, lack of awareness about contraindications, vaccine availability, child illness during previous vaccination, and waiting time were associated with a proportion of MCV2 coverage.

After controlling the confounding effect of the variables in the multivariable analysis guardians of the child, ANC contacts, delivery place of the index child, illness during previous vaccination, and waiting time for vaccine were significantly associated with MCV2 with a p- value of less than 0.05. According to this, children who had parents as primary guardians were 1.54 times more likely to have MCV2 coverage as compared to children who had grandparents as primary guardians (AOR=1.54, 95% (1.05, 2.27). Children who had antenatal care follow-up were 1.97 times more likely to have MCV2 vaccine uptake (AOR = 1.97, 95 %( 1.26, 3.07)).  Similarly, children who had a history of child delivery at health facility were 1.66 times more likely to have MCV2 vaccine uptake (AOR = 1.66, 95% CI; 1.14,2.42), children who had not been ill during previous vaccination were 1.53 times more likely to have MCV2 vaccine uptake (AOR = 1.53, 95% CI; 1.07,2.18), and children who had no long waiting time were 2.54 times more likely to have it (AOR = 2.54, 95%1.05,2.21) (Table 4).

Discussion

This study aimed to determine the proportion of MCV2 vaccine uptake and its predictors among children aged 18–23 months in Bahir Dar, Northwest Ethiopia. The findings showed that the proportion of MCV2 vaccine uptake among children aged 18–23 months was 53.08%. This study is in line with the studies conducted in Kenya (56.2%) (26), Ethiopia (58.5%) (27) and Tanzania (55.8%) (28). However, the finding of this study was higher than other studies conducted in Kenya (22.1% to 45%) (29-30)  . This discrepancy might be due to the difference in sampling technique (multistage cluster sampling), the difference in study setting (community-based study), difference in sociocultural issues and differences in the health care system. Also, this improvement is likely a result of implementing routine vaccination practice and may result from carrying out outreach vaccination activities in coordination with the local community in areas with topography difficulties and long distance (take > 30 minutes to the health facilities.

This result is also lower than the studies done in Algeria (95%) (17), Malawi (81% (29), China (68.2%) (31), and from the WHO recommendation for MCV2 (>95%) coverage to eliminate measles. These discrepancies might be due to the difference in study setting (community-based), caregiver negligence, logistical problems, and a low level of mothers’ knowledge towards important of vaccination.

This study showed that a child who had a parent as a primary guardian was 1.54 times more likely to have MCV2 coverage as compared to a child who had grandparents as a primary guardian. This association is supported with the study conducted in Kenya (32). This might be due to grandparents being less likely to make informed decisions regarding the vaccination of their children due to the fear of side effects. The finding of this study revealed that children who had ANC contact were 1.97 times more likely to have high MCV2 vaccine uptake coverage as compared to children who had no ANC contact. This association is complemented with the study conducted in Afar, Ethiopia (33). It might be when study participants have ANC contact; they got more information about the importance of vaccination during care. It might also represent health- seeking behavior, and women who seek to see a healthcare professional for follow-up might be more likely to seek care for their child later. Children who had a maternal health facility delivery history were 1.66 times more likely to have high MCV2 vaccine coverage as compared to who had history of home. This association in line with the study conducted in the Somali National Regional State, Ethiopia (34) and Abobo District, South West Ethiopia(35) . A possible explanation for this finding might be that mothers who gave birth in health facilities would have communication with health professionals and contacts to know about next immunization schedule at postnatal periods.

According to illness status, children who had not been ill during previous vaccination coverage were 1.53 times more likely to have MCV2 uptake as compared to children who had been ill during previous vaccination. This is in line with the study done in Abobo District, Southwest, Ethiopia (35) and Minjar-Shenkora District, Ethiopia (36). This might be the viral containing vaccine like measles has more side effects and they considered as child illness. For this reason, mothers were postponed on the schedule of their last immunization date by the service provider and were more likely to drop out.

Finally, finding of this study revealed that mothers who had not long waiting time at health facility were 2.54 times more likely to have high MCV2 vaccine coverage as compared to mothers who had a long waiting time during vaccination This is in line with the study done in Abobo District, Southwest Ethiopia (35). This might be because if mothers wait for a short time, it motivates the accumulation of the last immunization schedule next time and healthcare providers may not postpone the immunization schedule and decrease the MCV2 dropout rate.

The study included a report on vaccination status based on the presence of the maternal and child healthcare booklet or vaccination card and a verbal report by the caregiver, which may have introduced recall bias.

Conclusion

MCV2 vaccine uptake among children aged 18–23 months was low. Parents being primary guardians, having ANC contact, health facility delivery of the index child, absence of a child illness during previous vaccination, and no long waiting time were positively associated with the proportion of MCV2 vaccine uptake. The finding suggests increasing maternal ANC contact and encouraging women to give birth in a health institution would increase MCV2 vaccine uptake.

Declarations

Acknowledgments

We acknowledge participants, data collectors, supervisors, and health facility manager of health centers.

Conflicts of interest

     The authors declared no conflicts of interest.

Ethical Considerations

Ethical clearance was obtained from the ethical review committee University of Gondar (IPH/2275/2014). In order to obtain a permission letter, we contacted the head of Bahir Dar city health office administration. Then the health office was informed about the purpose of the study, the importance of their participation, and that they could withdraw at any time. Written consent was obtained from study subjects prior to data collection.

Code of Ethics

The privacy and confidentiality of the information given by each respondent were maintained properly, and names were not recorded.

Funding

The authors received no financial support for the research, authorship, or publication of this article.

Authors' contribution

   AMZ and YAF contributed substantially in the conception and design of the study. YAG and GWA carried out the data collection. AMZ, YAF AND YAF analysed and interpreted the data. AMZ drafted the manuscript. WCT reviewed the manuscript critically for important intellectual content. All authors read and approved the final manuscript and agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

References

  1. Kemenkes R. Program Pengendalian HIV AIDS dan PIMS di Fasilitas Kesehatan Tingkat Pertama: Petunjuk Teknis di Rektorat Jendral Pencegahan dan Pengendalian Penyakit. Indonesia: Kemenkes RI. 2016.
  2. Tulchinsky TH. Maurice Hilleman: Creator of Vaccines That Changed the World. Case Studies in Public Health. 2018: 443-470.
  3. Keja K, Chan C, Hayden G, Henderson RH. Expanded programme on immunization. World Health Statistics Quarterly Rapport Trimestriel de Statistiques Sanitaires Mondiales. 1988; 41(2) :59-63.
  4. Hussein Musa T, Hussein Musa H, Mohammed LA, Ahmed AA, Kambo RI, Musa IH, et al. Epidemiology of Measles in Sudan. Journal of Advances in Medicine and Medical Research. 2019; 30(11): 1-9.
  5. Colizza V, Grill E, Mikolajczyk R, Cattuto C, Kucharski A, Riley S, et al. Time to evaluate COVID-19 contact-tracing apps. Nature Medicine. 2021; 27(3): 361-362.
  6. Skwarczynski M, Toth I. Peptide-based synthetic vaccines. Chemical Science. 2016; 7(2): 842-854.
  7. Holzmann H, Hengel H, Tenbusch M, Doerr H. Eradication of measles: remaining challenges. Medical Microbiology and Immunology. 2016; 205(3): 201-208.
  8. Ramsay ME. Measles: the legacy of low vaccine coverage. Archives of disease in childhood. 2013;98(10):752-4.
  9. Fields R, Dabbagh A, Jain M, Sagar KS. Moving forward with strengthening routine immunization delivery as part of measles and rubella elimination activities. Vaccine. 2013; 31: B115-B121.
  10. Goodson JL, Alexander JP, Linkins RW, Orenstein WA. Measles and rubella elimination: learning from polio eradication and moving forward with a diagonal approach. Expert Review of Vaccines. 2017;16(12):1203-16.
  11. WHO. Weekly epidemiological record. Weekly Epidemiological Record= Relevé épidémiologique hebdomadaire. Available from: https:// policycommons.net/ artifacts/602014/weekly-epidemiological-record-releve-epidemiologique-he bd om ad aire/1581569/
  12. Muhoza P, Danovaro-Holliday MC, Diallo MS, Murphy P, Sodha SV, Requejo JH, et al. Routine vaccination coverage—Worldwide, 2020. Morbidity and Mortality Weekly Report. 2021; 70(43): 1495.
  13. Aborode AT, Babatunde AO, Osayomwanbor B-AS, Fajemisin EA, Inya OC, Olajiga O, et al. Measles outbreak amidst COVID-19 pandemic in Africa: grappling with looming crises. Tropical Medicine and Health. 2021; 49(1): 1-3.
  14. Lim SS, Stein DB, Charrow A, Murray CJ. Tracking progress towards universal childhood immunisation and the impact of global initiatives: a systematic analysis of three-dose diphtheria, tetanus, and pertussis immunisation coverage. The Lancet. 2008; 372(9655): 2031-2046.
  15. Desta T, Lemango E, Wayessa D, Wondowossen L, Kerie M, Masresha B. Invalid measles vaccine dose administration and vaccine effectiveness in Ethiopia. Pan African Medical Journal. 2021;40(1): 1-14.
  16. Salmon DA, Dudley MZ. It is time to get serious about vaccine confidence. The Lancet. 2020; 396(10255): 870-871.
  17. Masresha BG, Luce R, Okeibunor J, Shibeshi ME, Kamadjeu R, Fall A. Introduction of the second dose of measles containing vaccine in the childhood vaccination programs within the WHO Africa Region–lessons learnt. Journal of Immunological Sciences. 2018: 113-121.
  18. Patel MK, Dumolard L, Nedelec Y, Sodha SV, Steulet C, Gacic-Dobo M, et al. Progress toward regional measles elimination worldwide, 2000–2018. Morbidity and Mortality Weekly Report. 2019; 68(48): 1105.
  19. Wolfson LJ, Grais RF, Luquero FJ, Birmingham ME, Strebel PM. Estimates of measles case fatality ratios: a comprehensive review of community-based studies. International Journal of Epidemiology. 2009; 38(1): 192-205.
  20. Plans-Rubió P. Vaccination coverage for routine vaccines and herd immunity levels against measles and pertussis in the world in 2019. Vaccines. 2021; 9(3): 256.
  21. Syakantu MC. Factors influencing uptake of measles booster vaccine among under-five children at selected clinics in Lusaka, Zambia. 2017.
  22. Ibrahim HA, Wariyo A, Asefa EM, Cheru A, Abebe Lonsako A, Dirirsa G. Measles second dose vaccine uptake and associated factors among under-five children in Jigjiga City, Somali Region, Eastern Ethiopia: a community-based cross-sectional study. Frontiers in Public Health. 2024; 12: 1395802.
  23. Adisu MA, Bogale WA, Alemu TG. Second dose of measles-containing vaccine coverage and associated factors among children aged 24–36 months in Gondar city, Central Gondar, Northwest Ethiopia, 2023. Frontiers in Public Health. 2024; 12: 1364865.
  24. Okoro OO, Anoke CI, Olaiya PA, Ogbu MA, Okoro OG. Understanding the Socio-Economic and Demographic Factors Affecting Uptake of Second Dose Measles Vaccination (MCV2) among Children Under 5 in Ebonyi State, South-Eastern Nigeria. Texila International Journal of Academic Research. 2024; 1-14.
  25. Demewoz A, Wubie M, Mengie MG, Kassegn EM, Jara D, Aschale A, et al. Second dose measles vaccination utilization and associated factors in Jabitehnan District, Northwest Ethiopia. Dose-Response. 2023; 21(1): 15593258231164042.
  26. Mamuti S, Tabu C, Marete I, Opili D, Jalang’o R, Abade A. Measles containing vaccine coverage and factors associated with its uptake among children aged 24–59 months in Cherangany Sub County, Trans Nzoia County, Kenya. Plos One. 2022; 17(2): e0263780.
  27. Abebaw E, Tesfa M, Gezimu W, Bekele F, Duguma A. Female healthcare providers’ knowledge, attitude, and practice towards cervical cancer screening and associated factors in public hospitals of Northwest Ethiopia. SAGE Open Medicine. 2022; 10: 20503121221095931.
  28. Magodi R, Mmbaga EJ, Massaga J, Lyimo D, Abade A. Factors associated with non-uptake of measles-rubella vaccine second dose among children under five years in Mtwara district council, Tanzania, 2017. Pan African Medical Journal. 2019; 33(1): 1-7.
  29. Chirwa G, Wilkins KA, Mercer DJ. Descriptive study of measles vaccination second dose reporting and barriers to improving coverage in six districts in Malawi. The Pan African Medical Journal. 2020; 35(Suppl 1).: 1-4
  30. Kisangau Kisangau N, Sergon K, Ibrahim Y, Yonga F, Langat D, Nzunza R, Borus P, Galgalo T, Lowther SA. Progress towards elimination of measles in Kenya, 2003-2016. Pan African Medical Journal. 2018; 31(1): 1-11.
  31. Hu Y, Chen Y, Liang H, Wang Y. An Overview of Coverage of BCG Vaccination and its determinants based on data from the coverage survey in Zhejiang Province. International Journal of Environmental Research and Public Health. 2018; 15(6): 1155.
  32. Shikuku DN, Tanui G, Wabomba M, Wanjala D, Friday J, Peru T, et al. The effect of the community midwifery model on maternal and newborn health service utilization and outcomes in Busia County of Kenya: a quasi-experimental study. BMC Pregnancy and Childbirth. 2020;20:1-15.
  33. Hailu C, Fisseha G, Gebreyesus A. Determinants of measles vaccination dropout among 12− 23 months aged children in pastoralist community of Afar, Ethiopia. BMC Infectious Diseases. 2022; 22(1): 1-9.
  34. Mohamud AN, Feleke A, Worku W, Kifle M, Sharma HR. Immunization coverage of 12–23 months old children and associated factors in Jigjiga District, Somali National Regional State, Ethiopia. BMC Public Health. 2014; 14(1): 1-9.
  35. Abebe AM, Kassaw MW. Assessment of Factors Affecting the Implementation of Integrated Management of Neonatal and Childhood Illness for Treatment of under Five Children by Health Professional in Health Care Facilities in Yifat Cluster in North Shewa Zone, Amhara Region, Ethiopia. International Journal of Pediatrics. 2019; 2019: 9474612.
  36. Mekonnen AG, Bayleyegn AD, Ayele ET. Immunization coverage of 12–23 months old children and its associated factors in Minjar-Shenkora district, Ethiopia: a community-based study. BMC pediatrics. 2019; 19(1): 1-8.
Journal of Midwifery and Reproductive Health
Volume 13, Issue 1
January 2025
Pages 4568-4576

Files

Share

How to cite

Statistics