IMMUNIZATION OF CHILDREN

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1 IMMUNIZATION OF CHILDREN 12 The Expanded Program of Immunization, launched by the Indonesian Ministry of Health (MOH) in 1977, recommended that all children receive immunization against the six major preventable childhood diseases: a BCG vaccination against tuberculosis; three doses of DPT vaccine to prevent diphtheria, pertussis, and tetanus; four doses of polio vaccine; and a measles vaccination. In 1997, the immunization program was expanded to include three doses of hepatitis B (HB) vaccine. All of the recommended vaccinations should be given before children are 12 months of age (MOH, 2000). In the sixth Five-Year Development Plan ( to ), efforts to reduce childhood morbidity and mortality by improving the immunization coverage among children continued; this period included the National Mass Immunization Campaigns in 1996 and Infants brought to health centers or health posts for postnatal care are provided with a health card on which feeding, growth, and immunization information can be recorded. The type and date of vaccinations are recorded in a registration book maintained by the field vaccinators. While it is important that cards be kept by the mothers to enable them to monitor their children s growth and to keep a record of immunization schedules, not all mothers have kept the cards. Furthermore, not all infants receive postnatal care and therefore have never received a health card. In this survey, immunization information was collected for children born in the five years before the survey. For children with a health card, the interviewer asked to see the card, then copied the vaccination dates onto the questionnaire. If the child had never received a health card or if the mother was unable to show the card to the interviewer, the mother was asked questions about the types of immunizations her children received (specifically, BCG, DPT, polio, measles, and HB). The recording of polio immunizations in the Indonesia Demographic and Health Survey (IDHS) was different from that in the 1994 and 1997 IDHS surveys because it included polio 1 through 4, while the earlier surveys recorded polio 0 to IMMUNIZATION COVERAGE Figure 12.1 shows the percentage of children age months who had received vaccinations against the six major preventable childhood diseases by one year of age, as recommended by the government. Overall, 44 percent of children age months were fully immunized against these diseases before they reached their first birthday. The highest coverage is for BCG, DPT 1, and polio1, ranging from 80 to 86 percent. Children are least likely to be fully immunized against polio by age one (43 percent of children age months have had all four doses). Sixty-three percent of children age months received measles vaccine. Eleven percent of children age months have not received any of the recommended vaccines. Another way to evaluate the success of an immunization program is to calculate the percentage of children who started but did not complete all of the doses of DPT and polio vaccine to achieve immunity. In this report, the dropout rate is defined as the percentage of children who received the first dose but did not receive the third dose of the series. The percentages of children who dropped out before receiving all doses of DPT and polio are 31 and 29 percent, respectively. Immunization of Children 141

2 Figure 12.1 Percentage of Children Age Months Vaccinated by 12 Months of Age (Based on Information from Health Cards and Mother s Reports) BCG DPT DPT22 69 DPT33 55 Polio 1 86 Polio 2 76 Polio 3 61 Polio 4 43 Measles 63 All All 1 44 No vaccination Percent Note: For children whose information was based on the mother s report, the proportion of vaccinations given during the first year of life was assumed to be the same as for children with a written record of vaccination. 1 BCG, measles and three doses each of DPT and polio vaccine (excluding polio 4) IDHS IMMUNIZATION BY BACKGROUND CHARACTERISTICS Table 12.1 shows vaccination coverage for the six major preventable childhood illnesses according to information recorded on health cards (top panel), information from mothers reports (middle panel), and information from both sources (bottom panel). The table shows that only 31 percent of children age months had their health cards available at the time of interview. This finding is similar to that of the 1997 IDHS, where 31 percent of children age months had health cards, suggesting that the proportion of health cards kept by mothers has remained the same. Among children whose health cards were seen (Table 12.1, top panel), 71 percent were fully immunized. Comparison with the levels reported in the 1997 IDHS indicates that immunization coverage for specific vaccines, as recorded on health cards, has remained the same. The highest vaccine coverage, as seen from health cards, is for BCG, DPT 1, polio 1, and polio 2 (all 90 percent or more). Immunization coverage based on mothers reports is considerably lower than that based on observation of health cards (Table 12.1, middle panel). For example, the percentage of children who are completely immunized is 43 percent, 28 percentage points lower than that recorded on the health card. The highest coverage of individual vaccine doses, according to mothers reports, was for polio 1 (84 percent), BCG (78 percent), and DPT 1 (76 percent). 142 Immunization of Children

3 Table 12.1 Vaccinations by background characteristics Percentage of children age months who received specific vaccines at any time before the survey (according to health card or mother s report), and percentage with a vaccination card, by background characteristics, Indonesia Percentage of children who received: Percentge DPT Polio No with a Number Background vaccina- health of characteristic BCG Measles All 1 tions card seen children HEALTH CARD Male Female (68.8) (58.9) (39.5) (34.9) (76.9) (54.3) (53.3) (36.5) (44.8) (31.9) Urban Rural No education * * * * * * * * * * * Some primary Completed primary Some secondary Secondary Total MOTHER S REPORT Male ,033 Female Urban Rural ,052 No education Some primary Completed primary Some secondary Secondary Total ,954 Continued... Immunization of Children 143

4 Table 12.1 Continued Percentage of children who received: Percentage DPT Polio No with a Number Background vaccina- health of characteristic BCG Measles All 1 tions card seen children HEALTH CARD AND MOTHER S REPORT Male ,465 Female , , Urban ,326 Rural ,493 No education Some primary Completed primary Some secondary Secondary Total ,819 Note: Two National Immunization Days took place in 2002, in September for polio vaccine and in October for polio and measles vaccines. Figures in parentheses are based on unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 1 BCG, measles, and three doses each of DPT and polio vaccine Information from both health cards and mothers reports (Figure 12.2) shows that 52 percent of children age months were fully immunized at some time before the interview. This percentage is lower than the 55 percent reported in the 1997 IDHS but higher than that reported in the 1994 IDHS and 1991 IDHS (50 and 48 percent, respectively). Caution should be exercised in comparing data from the IDHS with that from the past because the household sample to be surveyed was drawn from a slightly different set of provinces/regions. The current survey excludes Nanggroe Aceh Darussalam, Maluku, and Papua, as well as the former East Timor province. 144 Immunization of Children

5 Figure 12.2 Children Age Months Who Are Fully Immunized (Based on Information from Health Cards and Mother s Reports) Percent 20 0 IDHS 1991 IDHS 1994 IDHS 1997 IDHS Note: The IDHS excludes Naggroe Aceh Darussalam, Maluku, Papua, and the former East Timor provinces. Children are fully immunized if they have received BCG, measles, and three doses each of DPT and polio vaccine (excluding polio 4). IDHS According to the data recorded in Table 12.1, girls are just as likely as boys to have been fully immunized against the six preventable childhood diseases. Immunization coverage varies across background characteristics of children, other than sex. For example, the percentage of children who have been fully immunized decreases with increasing birth order, ranging from 59 percent for first borns to 17 percent for sixth or higher children. Children in urban areas are more likely than rural children to have completed the vaccination schedule (56 and 47 percent, respectively). Similarly, children whose mothers have had no education are less likely to have been fully immunized against the six preventable childhood diseases than children whose mothers have had higher education (16 percent and 69 percent, respectively). The percentage of children who have received no vaccinations also varies widely by demographic and socioeconomic background characteristics. High-order births and children whose mothers have had no education are the most likely to have missed immunizations. As much as 35 percent of children of sixth or higher birth order and 37 percent of children whose mothers have had no formal education have not received any vaccinations (Table 12.1, bottom panel). The immunization coverage varies substantially across province. Provinces with the highest coverage include DI Yogyakarta (84 percent) and Bali (80 percent), while Banten has the lowest level of full immunization coverage (25 percent). Health card coverage also varies across provinces, ranging from 13 percent in South Sumatera to 54 percent in Bali (Appendix Table A.12.1) HEPATITIS B IMMUNIZATION As mentioned earlier, in 1997, the government of Indonesia expanded the immunization program to include three doses of hepatitis B (HB) vaccine. The government also stated that all of the vaccinations should be given before the child reaches one year of age (MOH, 2000). Immunization coverage for HB is presented in Table 12.2 and Appendix Table A.12.2 and is based on both vaccination cards and mothers reports. Although HB vaccination was only initiated in 1997, 71 percent of children age months have received at least one dose of the vaccine, and 45 percent have completed the HB series. Immunization of Children 145

6 Table 12.2 Hepatitis B vaccination coverage Percentage of children age months who received hepatitis B vaccinations at any time before the survey (according to vaccination card or mother s report), by background characteristics, Indonesia Hepatitis B vaccination Background Number characteristic HB1 HB2 HB3 of children Male ,465 Female , , Urban ,326 Rural ,493 No education Some primary Completed primary Some secondary Secondary Total ,819 Table 12.2 shows that girls are slightly more likely than boys to have been immunized against HB. Immunization coverage for other background characteristics shows the same pattern as that for immunization against other diseases. For example, the percentage of children who have completed the three doses decreases with increasing birth order, ranging from 51 percent for first born to 14 percent for children of birth order six or higher. Children in urban areas are more likely than rural children to have completed the vaccination schedule (52 and 40 percent, respectively). Similarly, children whose mothers have had no education are less likely to have been fully immunized against all of the preventable childhood diseases than children whose mothers have had higher education (13 and 62 percent, respectively). HB immunization coverage varies substantially by province. Provinces with the highest coverage for the three-dose series include DI Yogyakarta (91 percent) and Bali (82 percent), while Banten has the lowest level of coverage (28 percent) (Appendix Table A.12.2). 146 Immunization of Children

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