RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCIES,
BANGALORE, KARNATAKA
PROFORMA FOR REGISTRATIONOF SUBJECTS FOR DISSERTATION
1 / NAME OF THE CANDIDATE AND ADDRESS / MRS.USHA RANI.M.CIST YEAR M.SC NURSING
SRI LAKSHMI COLLEGE OF
NURSING
#127/1, SRI GANDADA KAVALU, MAGADI MAIN ROAD , VISHWANEEDAM POST
SUNKADAKATTE, BANGALORE-91
2 / NAME OF THE INSTITUTION / SRI LAKSHMI COLLEGE OF
NURSING
#127/1, SRI GANDADA KAVALU, MAGADI MAIN ROAD , VISHWANEEDAM POST
SUNKADAKATTE, BANGALORE-91
3 / COURSEOF THE STUDY AND SUBJECT / M.SC NURSING 1 ST YEAR
CHILD HEALTH NURSING
4 / DATE OF ADMISSION TO COURSE / 15-05-2010
5 / TITLE OF THE TOPIC / A DESCRIPTIVE STUDY TO ASSESS THE KNOWLEDGE ON HIB VACCINATION AMONG THE MOTHERS OF UNDERFIVE CHILDREN IN A SELECTED RURAL COMMUNITY AT BANGALORE WITH A VIEW TO DEVELOP A SELF INSTRUCTIONAL MODULE ON IMPORTANCE OF HIB VACCINATION.
6.0
6.1
6.2
6.2.1
6.2.2
6.2.3
6.2.4
6.2.5 / BRIEF RESUME OF THE INTENDED WORK
INTRODUCTION
“INVISIBLE CAUSE OF FORGOTTEN CHILD KILLERS’’.
Dr. Kent R.Hill
Every child is an individual and should never be considered a typical boy or girl, one unit of a group who are all alike. Children are the major consumers of health care. In India about 35% of total population are children below 15 years of age.1
Children always need special care to survive and thrive. Good health of these precious members of the society should be ensured as prime importance in all countries. As said by Karl Meninger “What is done to children, they will do to the society”2.
Under five children refers to the children between 0-5 years of age. According to, India demographics total under five population is about 126,642 updated up to 2008.3
According to UNICEF , total population of under five updated up to 2 March 2010 is 1181412 ( in thousands )4.
NEED FOR THE STUDY:
Haemophilusinfluenzae type b is a gram-negative bacterium found among the normal flora of the human respiratory tract. HIB is the most virulent, and affects mainly young children, with 80% of cases worldwide occurring in children younger than 5 years of age. HIB is spread by respiratory secretions.HIB causes meningitis and other severe infections (eg; pneumonia, bacteremia, septic arthritis, epiglottises).5
Immunization is a process of protecting an individual from a disease through introduction of a live, killed or partial component of the living organism into the individual system. Immunization is to produce a degree of resistance sufficient to prevent a clinical attack of the natural infection. It may be active or passive immunization.6
HIB vaccine protects against haemophilusinfluenzae type B infection, all infants should receive a primary series of conjugate HIB vaccine beginning at the age 2, 4, 6 months and booster or dose 12-15 months. The number of doses in the primary depends on the type of vaccine used. The optimal interval between doses is 2 months, with a minimum interval of 1 month. At least 2 months should separate the booster dose from the previous dose. HIB vaccines may be given simultaneously with all other vaccines. Unvaccinated infants and children ages 7 month and older might not require a full series of 3 or 4 doses. Previously unvaccinated children 15-59 months of age should receive a single dose of any conjugate HIB vaccine.7
In worldwide HIBcaused about 8.13 million serious illnesses in 2000, and estimated that HIB caused 37100 deaths (247000-527000) in children aged 1-59 months.8According to 2008 estimates , about 177,000 children under the age of five died of pneumonia in Nigeria. Worldwide nearly 1.6 million children under the age of 5 years die of pneumonia live in developing countries.9
A recent Study in India shows the incidence of HIB meningitis, that 97 cases of possible meningitis were reported an annual incidence of 86 per 100,000 in 0-4 year old children and 356 per 100,000 in 0-11 month infants. In infants 0-11 months of age, the incidence of HIB meningitis was 32 per 100,000 and in the 0-23 month group it was 19. 18 had proven bacterial meningitis an annual incidence of 15.9 per 100,000.10
According to the World Health Organization (WHO) estimated , 3 million cases of HIB infection occur every year in children underfive resulting in approximately 400,000 deaths.11
According to UNICEF, four countries of West Africa are affected with a total of 13,516 cases and 931 deaths. Nigeria is most affected with 9,086 cases and 562 deaths. Mali reports 54 cases and 6 deaths. Burkina Faso reports 1,756 cases and 250 deaths.12
The global estimates the burden of disease caused by haemophilus influenza type b in children younger than 5 years and showed that 8-3 million serious illnesses caused by HIB, in that 371000 deaths in children aged 1-59 months, of which 8100 were in HIV positive.13
The study was conducted to assess the impact of HIB conjugate vaccine in reducing the incidence of meningitis among children less than five years old .This study shows that 979 children with acute bacterial meningitis were detected throughout the entire period. The incidence rate of HIB meningitis decreased from 10.8(X105) in the prevaccine period to 2.3(X105 ) in the 2nd year post vaccination, leading to a risk reduction of 78% targeted to the 7-23 months age group (p<0.05). A total of 65 cases of HIB meningitis were prevented. This study suggests that through proper HIB routine immunization can reduce the incidence of HIB meningitis. 14
A study was conducted to evaluate the reduction of oropharyngeal carriage of haemophilusinfluenzae type b(HIB) in children immunized with an HIB conjugate vaccine and showed among 725 healthy 3 year old children who had or had not been immunized with an HIB conjugate vaccine .Oropharyngeal swabs were collected during the children’s well child visit to their local child health care center 14(3.5%) of the 398 unvaccinated children were oropharyngeal carriers of HIB, whereas none of the 327 children who had received HIB conjugate vaccine carried HIB (p<.001),carriage rates of non type haemophilusinfluenzae (19%) or streptococcouspneumoniae (18%) were the same irrespective of HIB vaccination status of children. This study revealsHIB conjugate vaccine, unlike HIB polysaccharide vaccine, seems to be able to prevent oropharyngeal colonization by HIB.15
A study was conducted to understand the potential risk factors and protective factors for invasive HIB disease among children than 2 years of age and showed that risk factors determined to be important were never breast fed (odds ratio [OR]=3.55, 95% confidence interval [CI]=1.52,8.26) shared care with more than one child less than 2 years (OR=2.32,95%CI=0.91,5.96),wood heating (OR=2.14,95%CI=0.91,5.05),rodents in the home (OR=8.18,95%CI=0.83,80.7)and livestock near the home (OR=2.18,95%CI=0.94,5.04).16
A study was conducted to assess the knowledge attitude about vaccination in post partum mothers and study showed that 228 mothers who were participated in the study, 29%of mothers worried about vaccinating their infants, 23% the vaccines would not at work ,11% were worried that the doctor would give the wrong vaccine and 8% were worried “they” are experimenting when they give vaccines .The mothers reported that most important reasons to vaccinate were to prevent disease in baby (74%) and in society (11%) knowledge about vaccination was poor.70% wanted information about vaccines during pregnancy. Mothers would benefit from additional knowledge regarding the risks and benefits of vaccines particularly during prenatal care. This study suggest that mothers should need more information regarding vaccinating their infants in order to improve their knowledge.17
A study was conducted to identify interventions that can increase timely vaccination by overcoming operational barriers to providing age appropriate immunization and the study was conducted in rural community development block and showed the pre-intervention cohort comprised 4336 children aged less than 18 months who at the time of enrolment in the study had started or completed their immunization schedule, the post intervention cohort comprised 5213 children who were registered prospectively at birth during the study .The majority(99.3%) of mothers consented to participation .The 1st ,2ndand 3rd DPT dose were administered during the study to 4810,4775and 4730 children were admitted to the study hospitals from other blocks. According to their parents report first,2ndand 3rd DPT doses were administered to 477(58.6%) 377(46%) and 294(36%) children respectively. Although nearly 92% of the children in the pre-intervention cohort had received a third DPT dose by the age of 12months, only 19% had received it by the age of 4 months, the age by which they should have received it accordingly to the Indian national immunization schedule. This study reveals mothers had inadequate knowledge regarding immunization schedule.18
HIB disease is considered invasive when it results in significant morbidity and mortality. Before the introduction of national vaccination program, it was estimated that there were at least500 cases of HIB in children under the age of 6, resulting in 10-15 deaths, Vaccination drastically reduced the incidence of HIB in both indigenous and non-indigenous children. Almost 60% of HIB cases are preventable through vaccination.Vaccination play important role in reducing the incidence of HIB diseases. 19 Since HIB Vaccination is expensive and it is not given to the children in government hospitals as a part of routine immunization. The recent studies show mothers having inadequate knowledge regarding HIB vaccination and consequences of HIB causing infections. Hence the investigator want to assess the knowledge of mothers of under five children on HIB vaccination and felt that Self instructional module is an effective teaching strategy which helps the mothers to gain more awareness on HIB vaccination.
REVIEW OF LITERATURE:
The review of literature is an extensive systematic selection of potential sources of previous work , which acquaints the investigator with fact finding work after scrutinization.
Polit and Hugler state the review of literature provides the readers with a background for understanding the significance of the study ,20
Review of Literature for the present study has been divided into following headings:
6.2.1.Studies related to infectious diseases due to HIB organisms (Haemophilusinfluenzae type b)
6.2.2.Studies related to Vaccination.
6.2.3.Studies related to HIB Vaccination.
6.2.4.Studies related to Mothers Knowledge on HIB vaccination.
6.2.5.Studies related to self instructional module among mothers of underfive Children.
Studies related to infectious diseases due to HIB Organisms (Haemophilusinfluenzae type b):
A study was conducted regarding bacterial meningitis and showed that data from six institutions were analyzed, in these 6 institutions there were 56338 admissions in pediatric wards of these 852 patients were diagnosed as bacterial meningitis among the admitted patients varied from 0.5% to 2.6% with a mean of 1.5%. Distribution according to age showed that more than 50% of patients were below 1 year of the age. Out of 852 cases the causative organism could be isolated only in 135 (15.8%) patients. The presumptive first line drugs in use at present were more or less. In the first 3 months of life ampicillin with one amino glycosidewas the commonly used regimen. For the age group between 3 months to 1 year chloramphenciol with ampicillin are used. In age group 1-5 years same therapy as in the preeding age group was used. For 5-12 years the same combination as that for 1-5 years age. Experts preferred cefotaxime with amikacinasempirical treatment of bacterial meningitis in the first months of life. The case fatality rate was highest among infants belonging to the age group 0-3 months and was lowest in children above 5 years of age. The mean fatality rate was 16%.21
A population-based study of haemophilusinfluenzae type b (HIB) meningitis was conducted among children less than 5 years of age. Children suspected bacterial meningitis were referred to hospitals and each microbiologic testing. 580 children were evaluated for bacterial meningitis and 23(4%) had confirmed or probable HIB meningitis. The incidence of all HIB meningitis was 12/100000 child-years less than 5 years of age and 26/100000 child-years less than 2 years of age. Nationally, an estimated 1005 children less than 5 years of age are hospitalized for HIB meningitis and 5107 are hospitalized for HIB meningitis, at least 100 will develop severe neurological sequence and 40 will die. These data suggest there is a substantial burden of HIB disease. National leader will provided with these data to facilitate development of national vaccination policies for children. 22
Studies Related to vaccination:
A study was conducted to estimate the vaccination coverage levels in children living in rural areas and identifying statistically significant differences in coverage between children living in rural areas and their sub urban and urban counter parts and showed overall 18%of the children included lived in a rural area, 46%lived in sub urban area and 36% lived in an urban area. The characteristics of the rural population were 72% were white, 24% were below poverty level, 16% had a mother with less than 12 years of education, 30% received vaccinations from public providers. 80% of the rural children, 79% of sub urban children and 77% urban children completed the 4:3:1:3 series. The rural population had statistically significant lower (p<0.01) varicella coverage’s levels than their sub urban and urban counter parts. This study suggest that children living in rural areas are just as likely to receive the basic 4:3:1:3 vaccination series as their suburban and urban counterparts.23
A study was conducted to assess the knowledge about routine immunization among caretakers of young children and 682 caretakers accompanying children under 5years were selected and shows that the propositions of respondents who had awareness about different aspects of routine immunization, such as weekday routine immunization (37%), age group of routine immunization (49%) number of visits required in the first year of life(27%), were all low. When asked to name the four diseases covered under the routine immunization programme only 268(39.3%) could name at least 3. The education level of respondents was strongly associated with their knowledge about routine immunization. The need of hour is to make routine immunization a ‘felt need’ of the community. This study suggest making caretakers more aware about routine immunization is a vital step in achieving this goal.24
Studies related to HIB vaccination:
A study was conducted to evaluate the impact of vaccination against HIB on meningitis and it was evaluated through time series analysis using regression forecasting by dividing the time series into 2periods (a) historical (b) validation, after vaccination was introduced into routine immunization schedule, the significant decrease in incidence and mortality rates indicates the vaccine impact with the levels of >90% after its introduction of vaccination on a decrease of 52% in the number of expected HIB cases(2363 prevented cases) and 63% expected deaths (525 prevented deaths) since introduction of the vaccine, related to unspecific bacterial meningitis, the number of expected cases increased by 42% and the number of expected death 6%. This study reveals after HIB vaccination was introduced into routine immunization the incidence rate of HIB meningitis was decreased. 25
A study was conducted to evaluate the effectiveness of conjugate vaccine in the reduction of community acquired pneumonia among infants enrolling 1293 participants. This shows the greatest risk factor of pneumonia among children <2years of age was day-care centre attendance (p<0.001) of the study participants, 83.3%(1072/1287) were classified as vaccinated according to immunization card and 16.7%(218/1287) were considered unvaccinated. By using conditional logistic regression the vaccine effectiveness was estimated at 31.0 (95% CI:-9.0%, 57%.0) after adjusting for sex, previous flu –like illness, day car attendance, smokers at home, house ownership, mothers education and age as continuous variable. Under programmeconditions the effectiveness of HIB conjugate vaccine in infants with radiologically confirmed pneumonia was 31% showing the potential benefit of immunization in prevention of pneumonia. This study suggests that proper routine HIB immunization can prevent pneumonia among infants. 26
A study was conducted to determine the effects of conjugate HIB vaccine in preventing HIB disease or death in children under five years and to determine any serious adverse outcomes it shows that 5 studies were included in the review and 4 in meta-analysis. The overall quality of the trials was good. The relative risk for invasive HIB disease was 0.50(95%CI 0.07 to 0.54, random effects model), but there was statistically significant unexplained variation in the effects of the 4 trials in the meta-analysis (p=0.002) the size of effects found in the trials did not appear to differ consistently with different vaccine types, the number of vaccine doses, age at first vaccination or use in developed vs developing countries, but the CI for the effect estimates were wide. HIB related mortality data showed a non-significant trend towards benefit (relative risk was 0.29, 95%CI 0.07=1.20, random effects model). The relative risk for all cause mortality in the single trial from which data were available was 1.01 (95%CI 0.38 to 2.67 random effects model). No serious adverse effects were reported in any of the trials, involving a total of 257000 infants. This study reveals HIB vaccine is more effective and there was no serious adverse effects on infants. 27
A study was conducted to evaluate the immunogenicity of hepatitis B and haemophilusinfluenzae type b components and reactogenicity of the DTPw– HBV / HIB vaccine when given as primary vaccination to infants and showed a total of 219 subjects completed the study , 2.7% and 11.5% of all administered doses led to redness and swelling >20mm ,only 36% of doses were followed by severe pain within 4 days after vaccination. Fever exceeding 39.5’c was recorded following only one dose in subject. One month post dose 3, all subjects had seroprotective anti-PRP antibody concentrations (≥ 0.5µg/ml) and 98.6% had concentrations (≥1µ/ml) , 99% were seropositive for anti-HBs and 99% were seroprotected. This study revealed the combination DTPW –HBV/HIB vaccine is immunogenic, safe and well tolerated in infants and this combination of vaccination is available in the form of single dose.2
Studies related to mother’s knowledge on HIB vaccination.
A study was conducted to identify reservoirs of HIB pharyngeal carriage and assess barriers to vaccination among 2 communities and it showed among children who were 5 years of age or younger. HIB vaccine coverage was low in the 2 communities. A [9(28%)of 32] and B[3(95%) of 20]. Among parents who did not vaccinate their religious or philosophical objections as a factor. 73% (36 of 49) would vaccinate their children if vaccination were offered locally 51% (26 of 51) reported that vaccinating was not a priority compared with other activities of daily life. 73% (36 of 49) would vaccinate their children if vaccination were offered locally. This study suggests identification of unvaccinated populations and targeted education and vaccination campaigns are essential to achieving elimination of HIB disease.29