(Acta Paediatr Jpn 1992; 34: 290
- 294)
Epidemiological Studies on Measles in Karachi, Pakistan -Mothers' Knowledge, Attitude and Beliefs about Measles and Measles Vaccine Shin Isomura, M.D., D.M.S.', Akhtar Ahmed M.B.B.S., F.R.C.P.', Akram Dure-Samin, M.B.B.S., M.D.M.P.H.3, Agboatwalla Mubina, M.B . S ., D.C.H., M.C.PS3 and Toshiaki Takasu, M.D., D.M.S.4
'Aichi Prejecrural Institute of' Public Health, Aichi;
Department of Neurology, Civil Hospital Karachi and Dow Medical College, Karachi; Department of Paediatrics II, Civil Hospital Karachi and DON'Medical College, Karachi; Department of Neurology, Nippon University School of Medicine, Tokyo In order to gather information on the factors affecting the spread of measles vaccine in Pakistan, 287 mothers living in Karachi were interviewed concerning their knowledge, attitude and beliefs about measles and measles vaccine. Measles had been highly prevalent, mainly among infants between 9 and 18 months of age. The seventy of the illness and the frequency of complications were well known and the importance of immunizations was well recognized. In traditional combined families grandparents had made the decision to take children for immunization, but many mothers had begun to feel that they were responsible for participation in the programme. The vaccine acceptance rate had increased sharply in recent years, primarily due to local health educators' activities and mass media such as TV programmes. The present findings confirm the importance of continuous effort toward promotion of primary health care by collaboration of motivated mothers and community health workers. Key Words
Measles, Immunization, Measles vaccine, EPI, Pakistan
Introduction In spite of the worldwide effort towards global eradication of measles conducted by the WHO in The Expanded Programme on
Received September 9, 1991 Revised November I I . 1991 Accepted November 22. 1991 Correspondence address: Shin Isarnura, M.D.,Aichi Prefectural lnstitute of Public Health, 1-214, Yagoto. Kasugai. Aichi 486. Japan
Immunization (EPI), the disease is far from eradicated and still remains as one of the most important vaccine-preventable diseases in the world. This is clearly related to an insufficient vaccine acceptance rate in children among whom measles has been mainly prevalent. Several factors are known with regard to the insufficient acceptance of measles vaccine, such as lack of information [I], mothers' unawareness of the severity and complications of the disease [2], and ignorance about the vaccine [3, 41. Since these factors may be
Measles in Pakistan (33) 291 different from community to community, an active survey should be conducted in each one on mothers’ concepts of measles and measles vaccine, along with the campaign for promotion of immunization. In Pakistan, the “Accelerated Health Programme” has greatly improved the immunization coverage rates, and an active data collection method called “Local Area Monitoring” disclosed a marked decrease of measles between 1974 and 1984 [5]. Detailed epidemiological studies on measles and measles vaccine are now needed for complete control of the disease in the country. The objects of this study are related to a community-based epidemiological study of measles, including the prevalence of the disease, vaccine acceptance rate, clinical efficacy of the vaccine and other factors which affect immunization coverage.
Study Design In October 1988, we started interviews with randomly selected mothers who took their children to the Civil Hospital, Karachi, or to the Abbasi Shahid Civil Hospital, Karachi, aiming to gather information on measles and measles vaccine. Using a simple questionnaire sheet (Table l), the interviewees were asked about their knowledge of the clinical manifestations and complications of measles, their own children’s history, if any, of morbidity and mortality, and any history of immunizations. In 1989 and 1990, a community-based survey was added to the study. Door-to-door visits were conducted in Neelam Colony, Karachi, in the context of a community health survey. According to a census and survey conducted in 1988 [6], the Colony had a population of about 3,000, the infantile mortality rate was 153 per 1,000 births, and the immunization acceptance rate up to one year of age was about 35%. The interviewees were asked about their family structure, the decision-maker for the immunization of their babies, the sources of information on immunizations and the reasons for non-acceptance;
Vol. 34 No. 3 June 1992
they were also asked to fill in the questionnaires used for the patients of the Civil Hospitals. The periods and numbers of interviewees are listed in Table 2. All the interviews were carried out by one person (S.I.) with the assistance of the house staff of the hospitals and community health workers.
Results Knowledge of the clinical picture of measles There was no relation between the answers and the interviewees’ age, occupation, educational background or experience of taking care of measles patients. There was also no difference between the hospital group and the community families. The answers were thus summarized together. Although some of the interviewees answered “not sure/ don’t know” to questions about the clinical picture of measles, most of them replied that the disease, “khasera” in Urdu, usually caused high fever for more than seven days with generalized exanthem and cough (Table 3). More than half of the interviewees talked of many serious complications of measles, Table 1. Questionnaire for interviewees ~~
~~
~
Area of residence. age Occupation, educational background No. of children (both alive and dead) List of children in order of birth: -Live/dead, age, sex -History of measles, history of immunization Knowledge about measles: -Fever, cough, exanthem -Complications, immunity
Table 2. Study periods and numbers of interviewees
November, 1988 November, 1989 October. 1990 Total
Hospital group
Community group
81 45 21
-
90
147
140
50
292 (34) Isomura er ul. including diarrhea and malnutrition (Table 4). Many interviewees replied that once a child was attacked by measles, hejshe developed a long-lasting immunity against the disease (Table 5).
Incidence of measles in children in Karachi Of 1,076 children whose parents gave usable answers. only a few had repeated episodes of measles. The age of contraction of measles varied widely from 4 months to 12 years, but 89% of them were attacked before 6 years, primarily between 9 and 18 months of age (Table 6).
spite of a history of measles vaccine. The vaccine efficacy was 72% (Table 7).
Factors aflecting measles vaccine coverage I ) Decision-maker Jbr participation in the ininiunization schedule in the families of interviewees Usable answers were obtained from 115 families in the community. As the family structure was getting smaller, mothers were taking the place of grandparents, who had formerly been the decision-makers (Table 8).
Clinical ejjcucj. of meusles vaccination The relation between measles vaccination and measles attack was investigated in children in the community group whose immunization histories were precisely reported. A certain number had had a measles attack in
Table 5. Knowledge of frequency of measles attacks
Table 3. Knowledge of clinical manifestations of measles
Table 6. Frequency of measles and age at attack in interviewees’ children
~
Fever
Cough
Rash
In all cases. > 7 days On and off Don’t hnon
93% 16
Selere M ild-moderate Don’t Lnou
85%
Generahied Locallied Don’t hnou
91%
~
~~
Only once Several times Don’t know
91% 2% 7%
Case tf
250
Attacked once
765
35 1-2y 3-4y 5-6y 7y 5
11%
37; 05 9s
Caw #
250
62 84
4 269 38
Attacked twice No history of measles Don’t know
1,076
Total Mortality of measles: 6.5%
lable 4. Knowledge of complicatlons of measles ~
~~
Complicated. sometime5 fatal
88%
Dldrrhea Mdnutrition Pneumonia Brain damage Other5
53% 72cc 22q
Attack of measles Total
+
Vaccine ( ) Vaccine ( - )
Uot complicated
65
Don’t knon
6r;
Case d
Table 7. Efficacy of measles vaccine
250
(+)
(-)
42 I96
190 40
232 236
Vaccine Efficacy; Attack rate in vaccinated ) X lOO==72%, (I - Attack rate in not vaccinated Children of I 6y of age were studied.
Acta Paediatr Jpn
Measles in Pakistan (35) 293 2) Measles vaccine coverage according to age The covera.ge was getting better recently, especially in younger children, but remained low in elder girls (Table 9).
3) Motivation and information sources on immunization The community survey disclosed that recently developed mass media, especially TV broadcasting, were widely used as information sources on public health, as well as clinics and regular health checks. However, more mothers were motivated by the visits of local health educators (Table 10). 4) Reasons wh-y children could not receive immunization Mothers who had moved in from rural areas outside Karachi replied that they had had no medical facilities in their village life. Others gave various kinds of reasons: many replied “Too busy” or “Forgot,” but “Didn’t know” was the most frequent reason among older mothers and grandmothers (Table 11). 5) Opinions of fathers and grandfathers on
the spread of immunization During the community survey, some fathers and grandfathers were asked their opinion about measles vaccine. Many talked of the importance of education and public health activities (Table 12).
Table 8. Who is the person who decides to take a child to immunization?
Table 9. Vaccine acceptance rate according to age Fully immunized
Not immunized*
Total
* Including partially immunized children Table 10. Motivation and information sources on immunization ~~
Clinic/ health check Health educator/ nurse TV and other media Taught by neighbows/ friends Taught by relatives Others Case #
~
-~
52% 82% 75% 32% 8% 4% 450
Some families used multiple sources. Table 11. Reason for nonattendance at immunization Because of illness/ too small No medical facility Too busy/forgot Afraid of side-effects Didn’t knowinot informed Thought unnecessary Case #
13% 30% 32% 1% 11%
3% 250
-~
~~
Some families gave multiple reasons.
-
Combined family* No, of family members
Key person: Grandfather Grandmother Father Mother Other
11-20
5-10
3 6 2 5 I
4 9 7 9 0
Simple family** 115
5--10
0 0 0 0 3 5 5 4 5 0 0
Table 12. Fathers’ opinion on problems in spread of immunization
1 4
0 0 4 7 0
Education of mothers Ignorance Lack of medical facility Thought unnecessary Afraid of side-effects Opposition to vaccine
53% 40% 27% 10% 10% 7%
Case #
30
-
* Three or more generations live together. parents and children only.
Vol. 34 No. 3 June 1992
** Families of
Some fathers gave multiple answers.
294 (36) lsomura et al.
Discussion The results obtained through the interviews with mothers indicate that “khasera” is an entity very similar to measles and has not been confused with other viral exanthematous diseases such as rubella and enterovirus infections. The results also indicate that the disease is in good agreement with the criteria for notification of measles to the Center for Disease Control, USA 171. Among the children whose parent’s gave usable answers, only a few had repeated episodes of measles. This supports the idea that “knasera” gives a long-lasting immunity, and is the same as measles. Taking histories on cases of measles thus ma): give sufficient information on its epidemiology. The awareness of the severity and complications of measles among the interviewees suggests that there is a high intrinsic need for immunization against the disease. Through community study it was clarified that in Karachi, where rapid urbanization had been in progress, mothers were now playing the role of decision-makers for participation in immunization. The EPI campaign therefore should be continued through efforts toward the education of mothers in each community. The vaccine acceptance rate in the community was increasing sharply in recent years. This rapid increase might primarily be due to the activities of local health workers, since many mothers answered that they were motivated to accept immunization by the visits of health educators.
An excellent seroconversion rate after measles vaccine was reported recently in a quick survey in Pakistan [8]. However, the clinical efficacy of measles vaccine obtained in the community (72%) was relatively lower than that in developed countries (around 95 to 97%). A more detailed survey associated with serological examinations to clarify the seroconversion after immunization in the studied area is now in progress. (This study was supported partially by the Ministry of Culture and Education, Japanese Government.) Acknowledgements We thank Dr. F. Habib, Dr. R. Naseem, Ms. F. Farzana and Mr. 2. Haq for their assistance.
References I.
2.
3. 4. 5. 6.
7. 8.
Belcher D.W., Nicholas D. et al. A mass immunization campaign in rural Ghana. Public. Health. Rep. 1978; 93: 170-6. Blair S., Shave N . et al. Measles matters, but d o parents know? Brit. Med. J. 1985; 290: 623 4. Profeta M.L., Ferrante P. et al. A survey on factors affecting acceptance of measles vaccine. Eur. J. Epidemiol. 1986: 2: 128 33, Dutta P.K.. Vaz L.S. et al. Knowiedge. attitude and beliefs about measles and vaccination coverage in a rural area. J. Corn. Dis. 1989; 21: 285 9. WHO. Expanded Programme OR Immunkatioii. W H O Wkly. Epid. Rec. 1986; 61: 142-5. Agboatwalla M. & lmran K. Vital statistics and immunization. In: Akram. D.S. (ed) Health education and literacy project. Karachi. 1990, CHK and DMC, p19-26. CDC. Measles -United States, 1988. MMWR 1989; 38: 601 4. WHO. Expanded Programme on Immunization. WHO Wkly. Epid. Rec. 1990: 65: 34-5.
Acta Paediatr Jpn
- 294)
Epidemiological Studies on Measles in Karachi, Pakistan -Mothers' Knowledge, Attitude and Beliefs about Measles and Measles Vaccine Shin Isomura, M.D., D.M.S.', Akhtar Ahmed M.B.B.S., F.R.C.P.', Akram Dure-Samin, M.B.B.S., M.D.M.P.H.3, Agboatwalla Mubina, M.B . S ., D.C.H., M.C.PS3 and Toshiaki Takasu, M.D., D.M.S.4
'Aichi Prejecrural Institute of' Public Health, Aichi;
Department of Neurology, Civil Hospital Karachi and Dow Medical College, Karachi; Department of Paediatrics II, Civil Hospital Karachi and DON'Medical College, Karachi; Department of Neurology, Nippon University School of Medicine, Tokyo In order to gather information on the factors affecting the spread of measles vaccine in Pakistan, 287 mothers living in Karachi were interviewed concerning their knowledge, attitude and beliefs about measles and measles vaccine. Measles had been highly prevalent, mainly among infants between 9 and 18 months of age. The seventy of the illness and the frequency of complications were well known and the importance of immunizations was well recognized. In traditional combined families grandparents had made the decision to take children for immunization, but many mothers had begun to feel that they were responsible for participation in the programme. The vaccine acceptance rate had increased sharply in recent years, primarily due to local health educators' activities and mass media such as TV programmes. The present findings confirm the importance of continuous effort toward promotion of primary health care by collaboration of motivated mothers and community health workers. Key Words
Measles, Immunization, Measles vaccine, EPI, Pakistan
Introduction In spite of the worldwide effort towards global eradication of measles conducted by the WHO in The Expanded Programme on
Received September 9, 1991 Revised November I I . 1991 Accepted November 22. 1991 Correspondence address: Shin Isarnura, M.D.,Aichi Prefectural lnstitute of Public Health, 1-214, Yagoto. Kasugai. Aichi 486. Japan
Immunization (EPI), the disease is far from eradicated and still remains as one of the most important vaccine-preventable diseases in the world. This is clearly related to an insufficient vaccine acceptance rate in children among whom measles has been mainly prevalent. Several factors are known with regard to the insufficient acceptance of measles vaccine, such as lack of information [I], mothers' unawareness of the severity and complications of the disease [2], and ignorance about the vaccine [3, 41. Since these factors may be
Measles in Pakistan (33) 291 different from community to community, an active survey should be conducted in each one on mothers’ concepts of measles and measles vaccine, along with the campaign for promotion of immunization. In Pakistan, the “Accelerated Health Programme” has greatly improved the immunization coverage rates, and an active data collection method called “Local Area Monitoring” disclosed a marked decrease of measles between 1974 and 1984 [5]. Detailed epidemiological studies on measles and measles vaccine are now needed for complete control of the disease in the country. The objects of this study are related to a community-based epidemiological study of measles, including the prevalence of the disease, vaccine acceptance rate, clinical efficacy of the vaccine and other factors which affect immunization coverage.
Study Design In October 1988, we started interviews with randomly selected mothers who took their children to the Civil Hospital, Karachi, or to the Abbasi Shahid Civil Hospital, Karachi, aiming to gather information on measles and measles vaccine. Using a simple questionnaire sheet (Table l), the interviewees were asked about their knowledge of the clinical manifestations and complications of measles, their own children’s history, if any, of morbidity and mortality, and any history of immunizations. In 1989 and 1990, a community-based survey was added to the study. Door-to-door visits were conducted in Neelam Colony, Karachi, in the context of a community health survey. According to a census and survey conducted in 1988 [6], the Colony had a population of about 3,000, the infantile mortality rate was 153 per 1,000 births, and the immunization acceptance rate up to one year of age was about 35%. The interviewees were asked about their family structure, the decision-maker for the immunization of their babies, the sources of information on immunizations and the reasons for non-acceptance;
Vol. 34 No. 3 June 1992
they were also asked to fill in the questionnaires used for the patients of the Civil Hospitals. The periods and numbers of interviewees are listed in Table 2. All the interviews were carried out by one person (S.I.) with the assistance of the house staff of the hospitals and community health workers.
Results Knowledge of the clinical picture of measles There was no relation between the answers and the interviewees’ age, occupation, educational background or experience of taking care of measles patients. There was also no difference between the hospital group and the community families. The answers were thus summarized together. Although some of the interviewees answered “not sure/ don’t know” to questions about the clinical picture of measles, most of them replied that the disease, “khasera” in Urdu, usually caused high fever for more than seven days with generalized exanthem and cough (Table 3). More than half of the interviewees talked of many serious complications of measles, Table 1. Questionnaire for interviewees ~~
~~
~
Area of residence. age Occupation, educational background No. of children (both alive and dead) List of children in order of birth: -Live/dead, age, sex -History of measles, history of immunization Knowledge about measles: -Fever, cough, exanthem -Complications, immunity
Table 2. Study periods and numbers of interviewees
November, 1988 November, 1989 October. 1990 Total
Hospital group
Community group
81 45 21
-
90
147
140
50
292 (34) Isomura er ul. including diarrhea and malnutrition (Table 4). Many interviewees replied that once a child was attacked by measles, hejshe developed a long-lasting immunity against the disease (Table 5).
Incidence of measles in children in Karachi Of 1,076 children whose parents gave usable answers. only a few had repeated episodes of measles. The age of contraction of measles varied widely from 4 months to 12 years, but 89% of them were attacked before 6 years, primarily between 9 and 18 months of age (Table 6).
spite of a history of measles vaccine. The vaccine efficacy was 72% (Table 7).
Factors aflecting measles vaccine coverage I ) Decision-maker Jbr participation in the ininiunization schedule in the families of interviewees Usable answers were obtained from 115 families in the community. As the family structure was getting smaller, mothers were taking the place of grandparents, who had formerly been the decision-makers (Table 8).
Clinical ejjcucj. of meusles vaccination The relation between measles vaccination and measles attack was investigated in children in the community group whose immunization histories were precisely reported. A certain number had had a measles attack in
Table 5. Knowledge of frequency of measles attacks
Table 3. Knowledge of clinical manifestations of measles
Table 6. Frequency of measles and age at attack in interviewees’ children
~
Fever
Cough
Rash
In all cases. > 7 days On and off Don’t hnon
93% 16
Selere M ild-moderate Don’t Lnou
85%
Generahied Locallied Don’t hnou
91%
~
~~
Only once Several times Don’t know
91% 2% 7%
Case tf
250
Attacked once
765
35 1-2y 3-4y 5-6y 7y 5
11%
37; 05 9s
Caw #
250
62 84
4 269 38
Attacked twice No history of measles Don’t know
1,076
Total Mortality of measles: 6.5%
lable 4. Knowledge of complicatlons of measles ~
~~
Complicated. sometime5 fatal
88%
Dldrrhea Mdnutrition Pneumonia Brain damage Other5
53% 72cc 22q
Attack of measles Total
+
Vaccine ( ) Vaccine ( - )
Uot complicated
65
Don’t knon
6r;
Case d
Table 7. Efficacy of measles vaccine
250
(+)
(-)
42 I96
190 40
232 236
Vaccine Efficacy; Attack rate in vaccinated ) X lOO==72%, (I - Attack rate in not vaccinated Children of I 6y of age were studied.
Acta Paediatr Jpn
Measles in Pakistan (35) 293 2) Measles vaccine coverage according to age The covera.ge was getting better recently, especially in younger children, but remained low in elder girls (Table 9).
3) Motivation and information sources on immunization The community survey disclosed that recently developed mass media, especially TV broadcasting, were widely used as information sources on public health, as well as clinics and regular health checks. However, more mothers were motivated by the visits of local health educators (Table 10). 4) Reasons wh-y children could not receive immunization Mothers who had moved in from rural areas outside Karachi replied that they had had no medical facilities in their village life. Others gave various kinds of reasons: many replied “Too busy” or “Forgot,” but “Didn’t know” was the most frequent reason among older mothers and grandmothers (Table 11). 5) Opinions of fathers and grandfathers on
the spread of immunization During the community survey, some fathers and grandfathers were asked their opinion about measles vaccine. Many talked of the importance of education and public health activities (Table 12).
Table 8. Who is the person who decides to take a child to immunization?
Table 9. Vaccine acceptance rate according to age Fully immunized
Not immunized*
Total
* Including partially immunized children Table 10. Motivation and information sources on immunization ~~
Clinic/ health check Health educator/ nurse TV and other media Taught by neighbows/ friends Taught by relatives Others Case #
~
-~
52% 82% 75% 32% 8% 4% 450
Some families used multiple sources. Table 11. Reason for nonattendance at immunization Because of illness/ too small No medical facility Too busy/forgot Afraid of side-effects Didn’t knowinot informed Thought unnecessary Case #
13% 30% 32% 1% 11%
3% 250
-~
~~
Some families gave multiple reasons.
-
Combined family* No, of family members
Key person: Grandfather Grandmother Father Mother Other
11-20
5-10
3 6 2 5 I
4 9 7 9 0
Simple family** 115
5--10
0 0 0 0 3 5 5 4 5 0 0
Table 12. Fathers’ opinion on problems in spread of immunization
1 4
0 0 4 7 0
Education of mothers Ignorance Lack of medical facility Thought unnecessary Afraid of side-effects Opposition to vaccine
53% 40% 27% 10% 10% 7%
Case #
30
-
* Three or more generations live together. parents and children only.
Vol. 34 No. 3 June 1992
** Families of
Some fathers gave multiple answers.
294 (36) lsomura et al.
Discussion The results obtained through the interviews with mothers indicate that “khasera” is an entity very similar to measles and has not been confused with other viral exanthematous diseases such as rubella and enterovirus infections. The results also indicate that the disease is in good agreement with the criteria for notification of measles to the Center for Disease Control, USA 171. Among the children whose parent’s gave usable answers, only a few had repeated episodes of measles. This supports the idea that “knasera” gives a long-lasting immunity, and is the same as measles. Taking histories on cases of measles thus ma): give sufficient information on its epidemiology. The awareness of the severity and complications of measles among the interviewees suggests that there is a high intrinsic need for immunization against the disease. Through community study it was clarified that in Karachi, where rapid urbanization had been in progress, mothers were now playing the role of decision-makers for participation in immunization. The EPI campaign therefore should be continued through efforts toward the education of mothers in each community. The vaccine acceptance rate in the community was increasing sharply in recent years. This rapid increase might primarily be due to the activities of local health workers, since many mothers answered that they were motivated to accept immunization by the visits of health educators.
An excellent seroconversion rate after measles vaccine was reported recently in a quick survey in Pakistan [8]. However, the clinical efficacy of measles vaccine obtained in the community (72%) was relatively lower than that in developed countries (around 95 to 97%). A more detailed survey associated with serological examinations to clarify the seroconversion after immunization in the studied area is now in progress. (This study was supported partially by the Ministry of Culture and Education, Japanese Government.) Acknowledgements We thank Dr. F. Habib, Dr. R. Naseem, Ms. F. Farzana and Mr. 2. Haq for their assistance.
References I.
2.
3. 4. 5. 6.
7. 8.
Belcher D.W., Nicholas D. et al. A mass immunization campaign in rural Ghana. Public. Health. Rep. 1978; 93: 170-6. Blair S., Shave N . et al. Measles matters, but d o parents know? Brit. Med. J. 1985; 290: 623 4. Profeta M.L., Ferrante P. et al. A survey on factors affecting acceptance of measles vaccine. Eur. J. Epidemiol. 1986: 2: 128 33, Dutta P.K.. Vaz L.S. et al. Knowiedge. attitude and beliefs about measles and vaccination coverage in a rural area. J. Corn. Dis. 1989; 21: 285 9. WHO. Expanded Programme OR Immunkatioii. W H O Wkly. Epid. Rec. 1986; 61: 142-5. Agboatwalla M. & lmran K. Vital statistics and immunization. In: Akram. D.S. (ed) Health education and literacy project. Karachi. 1990, CHK and DMC, p19-26. CDC. Measles -United States, 1988. MMWR 1989; 38: 601 4. WHO. Expanded Programme on Immunization. WHO Wkly. Epid. Rec. 1990: 65: 34-5.
Acta Paediatr Jpn
