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M Silitongo¹, ML Mazaba², D Mulenga³, M Chirambo-Kalolekesha¹, EM Njunju¹, V Daka³, W Tinago⁴, E Rudatsikira ⁵, PM Syapiila ³, C Banda ³, T Marufu⁶, S Siziya⁷

1. Department of Basic Sciences, Michael Chilufya Sata School of Medicine, Copperbelt University, Ndola, Zambia

2. The Health Press, Zambia National Public Health Institute, Ministry of Health, Lusaka, Zambia

3. Department of Clinical Sciences, Public Health Unit, Michael Chilufya Sata School of Medicine, Copperbelt University, Ndola, Zambia

4. School of Medicine and Medical Science, University College Dublin, Dublin, Ireland

5. Department of Public Health, Nutrition and wellness, School of Health Professionals, Andrews University, Berrien Springs, Michigan, USA

6. Department of Community Medicine, College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe

7. Dean’s Office, Michael Chilufya Sata School of Medicine, Copperbelt University, Ndola, Zambia

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Citation Style For This Article: Silitongo M, Mazaba Ml, Mulenga D, et.al. Cluster Survey Evaluation of Reasons of Vaccination Failure in Measles-Rubella Vaccination Campaign in Zambia, 2016. Health Press Zambia Bull. 2019;3(1); Pp 21-26.

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Abstract

A pool of susceptible children to measles and rubella (MR) may increase partly due to non-vaccination of children and as a result lead to MR epidemics. The objective of this study was to establish reasons for non-vaccination in 2016 Measles-Rubella campaign in Zambia. A country-wide cross sectional study was conducted among children aged 9 months to 14 years of age. A total of 6,490 children participated in the survey with a response rate of 87.3%. The following were the common reasons for non-vaccination of children: Central province (56.8% stated that vaccine was not available); Copperbelt (26.3% reported family problems including illness of mother/care taker); Eastern (26.6% indicated that time for session was inconvenient); Luapula (23.8% were unaware of the need for vaccination); Lusaka (24.9% indicated fear of side effects); Muchinga (22.4% stated that mother/caretaker was too busy); Northern (17.0% reported that mother/caretaker was too busy); North-western (38.1% indicated that the vaccine was not available); Southern (53.0% reported that the vaccine was not available) and Western (26.4% were unaware of the need for vaccination) and National (23.5% indicated that the vaccine was not available). There is need to increase coverage in the distribution of MR vaccine to ensure that all children receive the vaccine. Health education and promotion activities must be conducted in communities to ensure that the concept of immunization is well received so that deliberate efforts will be applied to ensure that children are vaccinated..

Keywords: Measles, Rubella, reasons for non-vaccination, Zambia.

Introduction

Measles and Rubella are highly contagious viral infections [1,2]. Measles is caused by an enveloped ribonucleic acid (RNA) virus of the Morbillivirus genus in the family Paramyxoviridae [2,3] and is characterised by fever cough, running nose conjunctivitis and characteristic erythematous and maculopapular rash [3-5]. Meanwhile, rubella is caused by a single-stranded ribonucleic acid virus of the Togaviridae family and is the only member of the genus Rubivirus. The disease causes mild symptoms in children and adults whilst causing abortions, miscarriages and congenital rubella syndrome [6]. Despite both diseases causing morbidity and mortality in developing countries, they are both vaccine preventable diseases [5]. Developed countries have managed to control and eradicate these diseases by implementing measures such as giving a first dose of MMR at age 12-15 months, giving a second dose of MMR to school-age going children and vaccinating high-risk groups such as infants aged 6 to 11 months [7]. In an effort to control measles and rubella, developing countries have conducted vaccination campaigns [2,8-11]. Strategies implemented in Cuba included vaccinating men and women of childbearing age and developing integrated measles and rubella surveillance systems [12].

The Expanded Programme on Immunization in Zambia is one of the health priorities in addressing and reducing vaccine preventable diseases such as pneumonia, diarrhoea and measles, which have been the leading causes of death in children under the age of five years. The National Immunisation Programme introduced a number of new and underused vaccines between 2004 till 2013 starting with the tetravalent: DTP+Hib and switching to pentavalent DPT-HepB+Hib in 2005. Measles containing vaccine second dose (MCV2) and Pneumonia Conjugate Vaccine (PCV10) were introduced in the national immunisation programme in July 2013 while Rotavirus and Human Papilloma Vaccine (HPV) vaccines were introduced in Lusaka province as a demo project in 2012 and 2013 respectively and there was a Rota vaccine national roll-out was in November 2013. Following documentation of Congenital Rubella Syndrome and the measles case based surveillance, the results of which have shown that up to 30% of suspected measles cases tested positive for Rubella, justification for the introduction of rubella vaccine.

Zambia conducted two under 15 years integrated measles supplemental immunisation campaigns between 2003 and 2012. The measles-only supplemental immunisation activities (SIAs) offered a second opportunity for vaccination against measles through a mass vaccination campaign. Additionally, the country conducted countrywide follow-up mass measles vaccinations in 2007 and 2010, and a measles-rubella SIA was conducted in September 2016. The introduction of the measles-rubella combined vaccine and a two dose vaccination schedule is important in maintaining adequate vaccination coverage and keeping antibody levels against measles and rubella sufficiently high [1,11]. Failure to be vaccinated contributes to increasing a pool of susceptible children that may lead to epidemics. The objective of this study was to establish reasons for non-vaccination in 2016 Measles-Rubella campaign in Zambia.

Methods

Study area

A study was conducted in all 10 provinces of Zambia (Central, Copperbelt, Eastern, Luapula, Lusaka, Muchinga, Northern, North Western, Southern and Western). Zambia shares borders with the following countries: Malawi and Mozambique in the east, Democratic Republic of Congo and Tanzania in the north, Angola in the west, and Zimbabwe and Namibia in the south (Figure 1). The 10 province are further subdivide into districts, constituencies and wards. In 2010, there were 74 districts, 150 constituencies and 1,430 wards [13]. The number of districts in Zambia has since been increasing.

Zambia has a population of 13,092,666 with a population density of 17.4 persons per square kilometer [13]. About half (50.7%) of the population is male. Zambia has a young population with 45.4% of its population aged below 15 years. Officially, children start schooling at the age of seven years. They would be of age 7-13 years in Grades 1-7 (primary education) and 14 or 15 years in Grades 8 or 9 (lower secondary education). The overall net primary school attendance rate is 71.6% (72.2% of females and 70.9% of males; 79.6% in urban and 66.9% in rural areas). The under-five mortality rate stood at 75 deaths per 1000 live births in 2013/14 [14].

Study design, target population, sample size and sampling.

A cross sectional study was conducted among children aged 9 to 179 months. The required sample size for the number of clusters was determined using a method proposed by the World Health Organization [15] and considering a desired precision of +5%, expected immunization coverage of 95%, effective sample size of 162 in each province, a design effect for each province varied from 1.04 to 2.29 and a 10 percent non response rate. The required sample size of 228 clusters was obtained, giving 2736 households (12 households in each cluster).

A two-stage cluster sampling method was used to draw the sample. At the first sampling stage, the sampled Standard Enumeration Area(s) (SEAs) were selected within the provinces systematically with probability proportional to size (PPS) from the ordered list of SEAs on the census 2010 sampling frame. The measure of size for each (Enumeration Area) EA was based on the household size identified in the 2010 Census [13]. In order to ensure representation from the whole target area, the frame was sorted by district, constituency, ward, rural/urban, (Census Supervisory Area (CSA) and SEA. A systematic random sampling method was used to select households in the second stage of sampling.

Training and data quality

Training of research assistants was facilitated by national supervisors, statistician and local consultant. External Consultants from WHO IST AFRO and UNICEF ESARO provided technical support during training in addition to quality control during field work. The questionnaire was interviewer administered to the respondents. Data quality team consisting of WHO, UNICEF, MoH and the local consultant visited the survey teams in the field to check on the work conducted and the quality of data. During the visit, the team reviewed the completed questionnaires with the supervisors and interviewing teams for any errors or missing information and corrective measures were immediately taken. The quality control team ensured that they observed the process of one household being interviewed from the beginning to the end of the interview as means of verifying adherence to survey protocol.

Data Management and analysis

Household data were computerized using the Coverage Survey Analysis System (WIN-COSAS) software.  Double entry was done on all data sets to control for and correct any entry errors. Data analysis was conducted using SPSS. All analyses were weighted to adjust for varying response rates according to proportions of clusters and households that were selected in the stratum.

Table 1. Household response rates at provincial and national levels

Province	Sampled Clusters	Clusters Interviewed	Number of households		Household Response rate (%)
			Sampled	Interviewed
Central	30	30	360	317	88.1
Copperbelt	18	17	216	163	75.5
Eastern	18	18	216	216	100.0
Luapula	26	24	312	288	92.3
Lusaka	24	24	288	250	86.8
Muchinga	18	18	216	206	95.4
Northern	26	26	312	270	86.5
North western	14	14	168	154	91.7
Southern	26	26	312	237	76.0
Western	28	27	336	288	85.7
National	228	224	2,736	2,389	87.3

Results

Totals of 2,389 households and 6,490 children were enrolled into the survey.  Table 1 shows response rate at provincial and national levels.  Response rates of above 85% were achieved in all the provinces except Copperbelt (75.5%) and Southern (76.0%) province. The national response rate was recorded at 87.3%. Overall, 5.0% (5.5% of males and 4.6% of females) of children were not vaccinated.

Reasons for non-vaccination of children are shown in Table 2.  Overall, in all the provinces except Lusaka and Western provinces, obstacles were the main reasons for non-vaccination of children.  In Lusaka province, the main reason for non-vaccination of children was fear of side reaction (24.9%). Meanwhile, in Western province the main reasons for non-vaccination was luck of availability of the vaccine (23.6%) and  unawareness of the  need for immunization (26.4%).  Specifically, the following were the common reasons for non-vaccination of children: Central province (56.8% stated that vaccine was not available); Copperbelt (26.3% stated family problems including illness of mother/care taker); Eastern (26.6% indicated that time for session was inconvenient and 20.4% were unaware of the need for vaccination); Luapula (23.8% were unaware of the need for vaccination); Lusaka (24.9% indicated fear of side effects); Muchinga (22.4% stated that mother/caretaker was too busy); Northern (17.0% reported that mother/caretaker was too busy and 16.5% decided to postpone until another time); North-western (38.1% indicated that the vaccine was not available and 19.4% said that the health worker was absent); Southern (53.0% said that the vaccine was not available) and Western (26.4% were unaware of the need for vaccination while 23.6% said the vaccine was not available).  Nationally, 23.5% said that the vaccine was not available while 13.0% were unaware of the need for immunization.

Source: https://zambiareports.com/wp-content/uploads/2015/11/Zambian-Map.jpg

Figure 1: Map of Zambia showing its provinces and neighbouring countries

 
 

Table 1: Reasons for child not being vaccinated by province in percentages

Reason for non-vaccination	Central	Copperbelt	Eastern	Luapula	Lusaka	Muchinga	Northern	North- Western	Southern	Western	National
Vaccine not available	56.8	2.8	0.5	14.3	1.0	11.2	2.5	38.1	53.0	23.6	23.5
Unaware of need for immunization	11.1	3.0	20.4	23.8	11.6	1.3	8.0	0.0	1.9	26.4	13.0
Unaware of time for session	1.5	11.0	7.2	11.8	16.3	1.8	3.5	6.0	1.4	7.2	7.9
Mother/care taker to busy	1.1	5.5	11.8	9.7	3.3	22.4	17.0	10.3	0.5	2.5	7.1
Time of session inconvenient	0.8	7.7	26.6	11.4	9.5	3.5	1.0	2.6	0.0	2.7	6.9
Decided to post pone until another time	2.2	4.2	7.6	6.7	7.3	12.9	16.5	1.2	0.0	4.7	5.5
Fear of side reactions	0.6	5.3	0.0	0.3	24.9	0.0	3.4	1.5	0.3	6.9	5.1
Family problem including illness of mother/care taker	0.0	26.3	7.9	3.0	1.1	0.0	9.5	7.2	6.4	8.8	4.8
Place of session too far	7.4	6.1	3.3	6.4	0.3	0.0	1.0	1.2	4.1	3.8	3.8
Health worker absent	0.0	4.3	1.9	0.0	0.0	0.0	9.4	19.4	1.8	0.5	3.8
Child ill, not brought	0.4	7.4	1.7	0.9	1.6	2.2	4.7	2.6	0.9	1.3	1.7
Place of immunisation unknown	0.4	0.0	0.0	0.0	4.8	0.0	3.2	0.0	5.8	0.0	1.5
Wrong ideas about contra-indications	2.9	0.0	0.0	0.4	1.9	3.3	5.5	0.3	0.0	2.6	1.5
No faith immunisation	0.0	0.0	0.0	0.0	5.8	0.0	0.0	0.0	0.0	8.0	1.4
Religious reasons	1.5	0.0	0.0	0.8	1.5	0.0	0.0	0.0	0.5	0.0	0.7
Rumours	0.0	4.5	5.0	0.0	0.3	2.7	0.0	0.0	0.0	0.0	0.5
Long waiting time	0.0	1.5	1.2	0.0	0.0	0.0	3.4	0.0	0.0	0.0	0.4
Child ill brought but not given immunisation	0.0	0.0	0.5	0.0	0.3	0.0	0.0	0.0	0.0	0.0	0.1
Other	13.3	10.1	4.4	10.6	8.6	38.7	11.4	9.6	18.8	1.0	10.6

Discussion

This study investigated the causes of non-vaccination in the 2016 Measles/Rubella vaccination campaign. The main reason for non-vaccination in five of Zambia’s ten provinces was unavailability of vaccine. On the Copperbelt province, the main reason for non-vaccination was family problem including illness of mother/care taker whilst in Lusaka province it was the fear of side reactions. Inconvenient time of vaccination session and mother or caretaker being too busy were the main reasons in the Eastern and Northern provinces respectively. Lack of enough coverage during vaccination has also been cited as a cause of non-vaccination and Measles/Rubella outbreaks [2,16]. The 2010 – 2011 Measles outbreaks in Zambia were attributed to low routine immunisation coverage [17]. In Mozambique, some measles outbreaks have been associated with insufficient vaccine coverage to interrupt measles transmission [18]. In Nigeria where there is perennial, low routine vaccination coverage and where the quality of the mass immunization campaign is not high enough, large and persistent measles outbreaks continue to occur with high morbidity and mortality [19,20].

In Haiti, Tohme et al [16] reported 31% of non-vaccination being due to caregivers not being aware of the vaccination exercise. This was one of the main reasons for measles-rubella non-vaccination in Luapula, Eastern and Western provinces of Zambia. At national level in Zambia, the main reason for non-vaccination was unavailability of vaccine unlike in Haiti where vaccine unavailability was not among the main reasons. World Health Organisation (WHO) Global Burden of Disease (GBD) project indicate that approximately 1.7 million vaccine-preventable childhood deaths occurred in 2000, of which 46% were attributed to measles. The measles deaths occurred overwhelmingly among children living in poor countries with inadequate vaccination services [21]. Failure to control measles has usually been due to a failure to implement planned strategies adequately [22]. For complete elimination of Measles there is the need to raise the visibility of measles elimination and make adequate investments in strengthening health systems [2,23]. Sartorious et al [2] suggested that identifying and targeting emerging high-risk areas in resource-limited settings where vaccine coverage is low or waning appears a more viable strategy for preventing outbreaks in sub-Saharan.

Conclusion

The control and eventual eradication of measles and rubella partly hinge on the ability to vaccinate all children to avoid pool of susceptible children to increase that could lead to epidemics. There is need to increase coverage in the distribution of MR vaccine to ensure that all children receive the vaccine. Health education and promotion activities must be conducted in communities to ensure that the concept of immunization is well received so that deliberate efforts will be applied to ensure that children are vaccinated.

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14. WHO. Vaccination coverage cluster survey: Reference manual Annexes, July 2015. Accessed 2018 July 15. URL: http://www.who.int/immunization/monitoring_surveillance/Vaccination_coverage_cluster_survey_with_annexes.pdf.

15. Tohme RA, François J, Wannemuehler K, Magloire R, Danovaro-Holliday MC, Flannery B, et al. Measles and rubella vaccination coverage in Haiti, 2012: progress towards verifying and challenges to maintaining measles and rubella elimination. Trop Med Int Health. 2014;19:1105-15.

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18. Okonko O, Nkang AO, Udeze AO, Adedeji AO, Ejembi J, Onoja BA, et al. Global eradication of measles: a highly contagious and vaccine preventable disease-What went wrong in Africa? J Cell Animal Biol 2009;3(8):119-40.

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