Tetanus Immunization Among Adolescent Girls in Rural Haryana Amarjeet S i n g h and Arvinder Kaur A r o r a

Department of Community Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh Abstract. This survey was undertaken to estimate tetanus immunization coverage of adolescent girls in a selected rural community of Haryana and to ascertain the knowledge of these girls and their mothers abou( tetanus. The study period was between April 1996-March 1997. A 30-cluster immunization coverage house to house survey was carded out by a female social worker. The total population covered was 30448. Twelve roadside villages were selectively chosen. Eleven year and 17 year old girls (210 in each group) were surveyed for coverage evaluation. For K.A.P. survey 114 grils (aged 17 years) and 98 mothers (of 11 year old girls) were interviewed. Chi square, percentage and 95% confidence interval were used for statistical analysis. Coverage for tetanus immunization was 44.3% among 17 year old girls and 26.7% among 11 year old girls. The coverage was better (35%) among school going girls as compared to non-school going girls (13%). Correct immunization schedule of pregnant women was told by 16 (7,5%) respondents. None of them told the correct immunization schedule for children. Death was told as the main danger from tetanus by 172 (81%) respondents. Most (98%) were aware of the role of clean-stump (umbilical cord) at the time of delivery in the etiology of tetanus neonatorum. Tetanus immunization coverage needs to be improved among adolescents. They also need to be educated on various aspects of tetanus. [Indian J Pediatr 2000; 67(4) : 255-258]

Key words : Immunization; Tetanus (neonatorum); Adolescent health.

World Health Organization (WHO) had envisaged global elimination of neonatal tetanus (NT) by 1995L However, as of 1994, globally, 4,90,000 cases of NT deaths were reported, including an estimate of more than 1,00,000 deaths from India 2-3. NT is reported to be endemic in 90 countriesL Global coverage of TF (tetanus toxoid) in pregnancy was 45% in 1993. In India, this coverage was reported to be 78% in 199323. Besides administration of 3 primary doses and a booster of DPT (diphtheria-pertussis-tetanus) vaccine to the underfives, the immunization programme in India involves administration of DT (diphtheria-tetanus) vaccine to children at 5 years and T r at 10 years and 16 years ageL thus, every woman is likely to receive 7 doses of T r in her life prior to conception. But the c o v e r a g e by TT in adolescent girls is low in India. Keeping this in view, the present study was conducted to estimate the TF coverage of girls-11 and 17 years old-and to study the knowledge of girls and their mothers regarding TT vaccination and tetanus. MATERIALS AND METHODS 1he study was conducted during 1996-97 in a rural area of Reprint requests : Amarjeet Singh, Additional Professor Community Medicine PGI, Chandigarh, India-160 012. E-mail : [email protected] Indian Journal of Pediatrics, 2000; 67 (4) : 255

Haryana. Immunization coverage of the area is more than 90% (for infants and pregnant women). Infant mortality rate is 54/1000 live'births and maternal mortality rate is 320/100000 live births. More than 90% of the babies are delivered at home. More than 80% deliveries are conducted by traditional birth attendants. Female literacy rate of the study area is 41%6. Tetanus immunization to adolescents is administered at schools. Usually, it is done for students of classes 5 and 10 only in the study area. A female social worker was recruited for the study and was trained in interviewing techniques. An interview schedule was developed and was pretested/pilot tested. Overall, a population of 30448 was covered in 12 selectively chosen roadside villages of district Ambala. Thirty cluster immunization coverage survey technique was usedL In each cluster, a house to house survey was done by the social worker starting with a randomly chosen house. Presence or absence of 11 and 17 year old girls was ascertained in each house. The survey continued till each cluster yielded 7 eligible girls of both the age groups. Thus 210 girls each from 11 years and 17 years age group were surveyed. This i n c l u d e d b o t h school g o i n g and n o n - s c h o o l g o i n g adolescent girls. In bigger villages more than one clusters were surveyed. All such villages had more than one "anganwadis"(AW). Each AW had well demarcated area. Required number of AWs were randomly selected from each village to provide required number of clusters.

A. Slngh and A.K. Arora Each eligible girl was asked if she had received any TT (tetanus injection) during last year. Their T1~immunization status was noted verbatim. Records, if any, were also checked. For a s s e s s m e n t of the k n o w l e d g e of the TABLE1. TT h n m u n i z a t i o n Status A m o n g School G o i n g and Non-school going Adolescent Girls TT immunization status

School g o i n g Yes

No

93 (44.7%) 115 (55.3%)

17 year olds

X2

Received TI"

46 (35.1%)

Did not receive

85 (64.9%)

RESULTS

X2

1I year olds

Received TT Did not receive

respondents about tetanus it was planned to interview at least 100 girls aged 17 years and mothers of 100 girls aged 11 years. Every alternate respondent was proposed for interview. The data was recorded on the interview schedule. Manual analysis of the data was done using percentages and Chi square test with 95% confidence intervals.

10 (13%)

12.73 d.f. = 1 69 (87%) p<0.001 95% C.I. 10.97-33.03

X' = 14.14, d.f. = 1, p<0.01 (for overall difference between T1~coverage levels among 11 year old and 17 year old girls; 95% confidence interval 7.99 -26.01).

The TF immunization coverage rate as estimated by 30 cluster house-to-house survey in the present study was 44.3% (93/210) and 26.7% (56/210) in the adolescent girls aged 11 years and 17 years respectively. The difference was statistically significant (x2 = 14.24, d.f. = 1, p < 0.001) (Table 1). Significantly, more of school going 17 year old girls had received TT during last year (35%) as compared to 13% non-school going girls. In all, 114 girls aged 17 years and 98 mothers of 11 year old girls were interviewed. Almost all respondents (except 3 school girls) were aware that there were some injections (vaccines) which prevent the disease occurrence. Except for one s ~ o o l girl, all the respondents had heard of tetanus disease and tetanus toxoid. Death was the main danger of tetanus as told b y m a j o r i t y of r e s p o n d e n t s (172; 81%). O t h e r c o m p l i c a t i o n s told w e r e w e a k n e s s / p a r a l y s i s (17), infection/suppuration (4), madness (1), and septicemia (1).

TASTE2. Knowledge of the Respondents about Tetanus and its Prevention* Respondents Response

Mothers n = 98 (%)

17 year old girls n = 114 (%)

Which category of people are more prone to get tetanus

Children/women All/anyone Don't know

32 (33) 65 (66) 1 (1)

72 (63) 27 (24) 15 (13)

66 29 6 3

(67) (30) (6) (3)

64 (56) 17 (15) 18 (16) 30 (26)

65 (66) 29 (30) 4 (4)

84 (74) 13 (11) 17 (15)

22 (22)

28 (25)

80 (82) 16 (16) 2 (2)

100 (88) 3 (3) 11 (10)

What should be applied on the umbilical stump after delivery of the baby

Spirit/antiseptic lotion Clarified butter/turmeric Cowdung/ash/soii Don't know What proportion of tetanus patients can be saved.

Some die, most can be saved Half or more die, few can be saved Don't know Have you ever seen a patient of tetanus.

Yes How should the umbilical cord be cut at delivery

By clean blade Knife, sickle, other domestic appliances Don't know * Some respondents gave multiple responses. 256

Indian Journal of Pediatrics, 2000; 67 (4)

Tetanus Immunization Among Adolescent Girls

All except 5 respondents said that ff cleanliness was not maintained while cutting the umbilical cord at the time of delivery it would lead to tetanus a n d / o r i n f e c t i o n / suppuration of the stump wound. Various symptoms of tetanus as told by the respondents included stiffness of body (84; 40%), refusal of feeds (40; 19%), unconsciousness/drowsiness (10; 5%), weakness (18; 9%), frothing at mouth/clenching of teeth (8; 4%), difficulty in breathing, fever, swelling, pain and diarrhea. More girls (63%) than mothers (33%) said that children and women were more prone to tetanus. Majority of mothers (66%) told that people of all age/sex group may get tetanus. Majority of respondents (130; 61%) said that spirit or antiseptic lotion should be applied at umbilical stump of the baby after d e l i v e r y . Majority of the respondents (149; 70%) said that most of the cases of tetanus could be saved. About one fourth had also seen a case of tetanus. Most of the respondents told that clean blade should be used to cut the umbilical cord of the baby at delivery (Table 2). All the mothers and most of the girls (89%) were aware that tetanus immunization is available at government health facilities. Majority of the respondents (173; 82%) told that XT should be given in cases of dog bite. Majority (175;

83%) also told TF should be given every time an injury is sustained. Immunization schedule of the pregnant women was told correctly by very few respondents (16; 7.5%). None of the respondents gave correct i m m u n i z a t i o n schedule for children. Almost one quarter of the respondents told that 3 doses of TF are given in pregnancy. Majority of the mothers (71; 72%) and 52 (46%) girls told that 1-2 doses are needed. Many girls (34; 30%) did not know the requisite number of T r doses to be given in pregnancy (Table 3). Cleansing of w o u n d and administration of tetanus toxoid were known by most of the respondents as the preventive measures against tetanus. All except seven girls said that tetanus immunization is given during pregnancy to protect both the mother as well as the baby against tetanus. DISCUSSION To combat the problem of neonatal tetanus WHO had envisaged a ,5-dose TI" schedule for women. ~ schedule of 5-doses is not confined to the pregnant wome~ only. These doses include TT given d u r i n g childhood and adolescence too. This gives protection against tetanus to the w o m e n for whole of their reproductive span. Other

TABLE 3. K n o w l e d g e of the Respondents about Tetanus I m m u n i z a t i o n Respondents Response

Mothers n = 98 (%)

17 year old girls n = 114 (%)

Place where TT injections are given/available*

School/home At Anganwadi Hospital/health centre Private clinic

3 (3)

51 (45)

32 (33) 98(100) 53 (54)

47 (41) 101 (89) 48 (42)

15 (15) 75 (77)

11 (10) 98 (86)

8 (8)

5 (4)

15 (15) 83 (85)

22 (19) 92 (81)

71 (72) 26 (27) 1 (1)

52 (46) 29 (25) 33 (29)

9 (9)

7 (6)

70 (71)

64 (56)

Whether 1T should be given in cases of dog-bite

No Yes Don't know Should 1T be given every time one sustains injury No Yes Number of TF injections to be given during pregnancy

1-2 3 Don't know Immunization schedule of pregnant women told correctly Correct response Did anybody receive IT in your family last year

Yes * Some respondents gave multiple responses. Indian Journal of Pediatrics, 2000; 67 (4)

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A. Singh and A.K. Arora researchers have also c a m ~ e n t e d that for i m m u n i z e d adults who have received five doses either in childhood or as an adult, booster doses are not recommended other that at the t i m e of t e t a n u s p r o n e i n j u r y B". Recently, in Bangladesh, a c a m p a i g n was launched to increase the awareness among adolescent girls and young w o m e n of reproductive age, about need to begin their series of five TT i m m u n i z a t i o n s as e a r l y as p o s s i b l e d u r i n g their reproductive lives R. This approach implies that w h e n the current cohort of female underfives (in w h o m the coverage for p r i m a r y immunization is more than 90%) enter the child bearing age in the 21st century, they would have already received at least 3 tetanus toxoid doses (3 primary doses of DPT) in infancy and, presumably, a booster of DPT at 18 months age. Adequate coverage of this cohort of w o m e n in their first p r e g n a n c y will p r o v i d e r e a s o n a b l y satisfactory protection against neonatal tetanus. If simultaneously the coverage of this and the future cohorts of girls at 5, 10 and 16 years age by D T / T T is also improved, the situation will be far more satisfactory. This w a y the neonatal tetanus problem will be under control in the next 10-15 years. In this context, our study reported a coverage of 44% and 27% for TT immunization in 11 year and 17 year old

REFERENCES 1. Silveira CM da and Q u a d r o s CA de. Neonatal tetanus : countdown to 1995. World Health Forum 1991; 12 : 289-296. 2. WHO. Progress towards control of neonatal tetanus. Weekly Epidemiological Report 1996; 71 : 33-40. 3. WHO. Progress towards global elimination of neonatal tetanus (1989-1995). Weekly Epiderniological Report 1995; 70 : 81-88. 4. Whitman C, Belgharbi L, Gasse F, Torel C, Mattei V and Zoffmann H. Progress towards elimination of neonatal tetanus. World Hlth. Statist Quart. 1992; 45 : 248-256. 5. Park K. Park's Textbook of Preventive and Social Medicine. 15th edn., Jabalpur, India, Banarsidas Bhanot Publishers, 1997. 6. Singh AJ. Profile of traditional birth attendants in a rural area of North India. Journal of Nurse Midwifery 1994; 39 : 119-123. 7. Govt. of India. National child survival and safe moth-

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girls respectively. This indicates a definite s c o p e of improvement in coverage levels for TF among adolescent girls. School health programme needs to be strengthened further. Simultaneously, attempts need to be made to cover non-school going a d o l e s c e n t girls also, since the TT coverage was significantly better among school going girls as compared to non-school going girls. The proportion of 11-18 year old girls who never went to school was 14%, and of those who dropped out of school was 26%, as indicated in a previous survey done by the investigators in the study area 13. In the present study also 38% of 17 year old girls were non-school going. Knowledge of the respondents about some aspects of tetanus was deficient. Correct immunization schedule of pregnant women or of children was not known to majority. These issues n e e d to be i n c o r p o r a t e d in a n y h e a l t h education campaign to be devised for the community. The present study results are confined to the immunization history obtained from the respondents for the preceding one year. The details on primaryimmuniza~on during infancy are not reflected in the study.

Acknowledgement The study was funded by Institute Research Scheme Fund of PGIMER, Chandigarh. erhood programme - evaluate service coverage. Ministry of Health and Family Welfare, New Delhi, India, 1992. 8. Basu RN. Elimination of neonatal tetanus. Swasth Hind 1991; 35 : 36-38. 9. Anonymous. Commentary- tetanus toxoid for adults - too m~'ch of a good thing. Lancel 1996; 348 : 1185-1186. 10. John TJ. Immunization dialogue - I.A.P.'s immunization time table in pediatrics. Indian Paediatr1996; 33 : 609-612. 11. Cutts FT. Advances and challenges for the expanded programme on immunization. BrMed Bull 1998; 54 : 445461. 12. Perry H. Weierbach R, Hossain I and Islam R. Tetanus toxoid immunization coverage among women in zone 3 of Dhaka city : the challenge of reaching all women of reproductive age in urban Bangladesh. Bull WHO 1998; 76 : 449-459. 13. Singh AJ, Kaur A and Kaur A. Rural adolescents' attitude towards family life. Indian Medical Gazette 1994; 128 : 242-245.

Indian Journal of Pediatrics, 2000; 67 (4)