Immunization against preventable diseases is a vital component of mother and child health services in India. This paper focuses on various socio-economic variables in likelihood of immunization of infants against the six main vaccine preventable diseases under Universal Immunization Program (UIP). It analyses immunization coverage in India and also its states comparison based on data from NFHS surveys and UNICEF reports. Additionally, it discusses the challenges and reasons for not immunizing children in India. It also assists policy makers to understand the program constraints and needs for identifying the disparities in coverage level between the different sub groups of population and differences in level of performance in India. Thus, creating awareness, increasing literacy, population control, removing barriers to immunization, eliminating racial/ethnic disparities, addressing vaccine safety issues, financing recommended vaccines, and immunizing specific groups, provides direction towards disease prevention through vaccination in multiple population groups while maintaining high levels of safety.
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Chapter 1: Introduction
Immunization is a method to protect body against infectious diseases by providing vaccination. Children are highly susceptible of developing infections. Therefore, immunization becomes crucial to reduce the infant and child mortality. It has revolutionised child health in countries throughout the world, preventing millions of deaths in children and risk of disability caused due to infectious diseases. It is one of the greatest public achievements of the 20th century. Global commitment to immunization has not been sustained in all developing countries and benefits are not reaching children in every part of the world equally. Millennium Development Goal (MDG) on reduction of child mortality has made the world conscious about the prevention of disease and well being of the child.

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Immunization is considered the most cost-effective way to decrease the infant mortality. It is an important intervention to control the major preventable diseases where children are suffering from undernourishment and die due to preventable diseases. (World Bank,1993).  According to World Health Organization (WHO), the basic vaccination schedule recommended is Bacillus Calmette Guerin (BCG) at birth, diphtheria, tetanus and pertussis (DTP) together with oral polio vaccine at 6, 10 and 14 weeks and measles is given at 9 months. A child is considered fully vaccinated if he/she has received all these vaccines. (Pegurri, E., Fox-Rushby,J., Damian,W., 2005).
Vaccine preventable diseases (VPD) are still causing 25% of the 10 million deaths in children below 5 years of age every year. In the year 2005, 58th World Health Assembly (WHA) after recognising that vaccines can decrease the infant mortality embraced the Global Immunization Vision and Strategy (GIVS) 2006-2015 developed by the World Health Organization (WHO) and UNICEF as a framework to strengthen the national immunization programs. The goal of GIVS is to achieve DTP coverage 90% at the national level and 80% at the district level. (Vashishtha, V.M, 2012).
According to provisional population data count, India’s population count in 2011 was 1.21 billion ranking second in the World after China. The country is divided into 29 states having different population count, different religions, languages and culture. In India, delivering vaccinations to children is a component of health services and has been given a top priority. The country adopted the Expanded Program on Immunization (EPI) after the Alma-Ata Declaration in 1978 in which it committed to itself to attaining “Health for All” on the basis of primary health care approach. (Peters et al, 2002). It introduces the basic six vaccines recommended by WHO. (Basu,1985; Kanitkar 1979). The immunization services were given to at all public health centres and sub-centres without any charge. In 1985-86, Government of India then launched UIP for immunizing pregnant women and children by 1990s against six vaccine-preventable diseases. “All the states of India were served by UIP (Sokhey et al, 1993) and it became a part of Child Survival and Safe Motherhood Program in 1992 and Reproductive and Child Health (RCH) in 1997”. (MOHFW, 2003).  
UIP showed a good performance in the first decade with a coverage level of vaccines reaching 70-85% in India in the year 1985-1995 with a decline in the number of new cases of VPDs. Since then, the country showed a downfall in the coverage level by 15-20% of different vaccines. National Family Health Survey (NFHS) I, II and III and UNICEF showed a decline from 15-40% of the coverage level, compared to the reported levels of coverage in UIP. The recent Coverage Evaluation Survey (CES) 2009 by UNICEF during the time period of November 2009 to January 2010 conducted a nationwide survey covering all the states and Union territories. The national fully Immunization (FI) coverage was 61% for the six vaccines included in UIP for children of age group of 1-2 years. District Level Household and Facility Survey (DLHS-3) in 2007-08 and NFHS-III in 2005-06 reported 54.1% and 47.3% respectively. According to CES, coverage of individual antigens in 2009 for age 1-2 years for BCG, OPV, DTP3 and measles first dose 86.9%, 70.4%, 71.5% and 74.1% respectively. India shows a slow progress in performance of routine immunization since last few years. Many of the states show a marginal improvement according to the recent records. Even though India is improving six states with high population have 80% of 8.1 million unimmunized children. Uttar Pradesh and Bihar which are one of the poorest states in India show the highest rate of 52% of the unimmunized children. (Vashishtha,V.M, 2012).
The focus of this paper is to examine performance and coverage of vaccination programs in India during 2000-2010 and its several states like Bihar, Maharashtra, Uttar Pradesh, Karnataka and West Bengal. It describes the socioeconomic differentials, regional variations of the states, challenges and suggests policy and programmes for achieving immunization among the infants of all population groups in India.
The analysis aims to:
• compare inter-state variations of immunization.
• discuss the pattern, trends and reasons of immunization in India.
• examine the immunization coverage in districts of West Bengal.
Chapter 2: Socio-economic Differentials in Immunization
Socioeconomic inequalities in child heath remain a major concern in developing countries to reach MDG. Reducing these inequalities in child health is being stalled by gap in documenting and understanding trends in less developed countries. (Lauridsen, J; Pradhan, J. ,2011).Socio economic development for developing countries remains at a low level with insufficient housing and poor hygiene. Under nutrition for children below 5 years of age is also a problem of concern. In developing countries like India vaccines and medications are present but the delivering of health services are poor and inadequately funded with poor connections, infrastructure and low literacy. Due to lack of economic development in developing countries two independent strategies were formed. Firstly, primary health care (PHC) was designed to maintain a link between the people and health services which can be achieved by recruitment, training, supply and support of village health workers that helped in involvement and communication with people, to learn from people that will improve health care delivery and immunisation coverage. Secondly, effective, sustainable development of healthcare delivery systems to support the government and primary health care workers for immunisation program to succeed. (Poore, P,1988).
In developing countries national government and international donors have played a major role to increase immunization coverage. Therefore, a basic vaccination schedule has been incorporated in health programs to reduce mortality in children. ( Hardon and Bloom, 2005; Jolly 2004; Stephan et al., 2008).  
Data for the study of the socio-economic differentials is taken from the three consecutive rounds of NFHS conducted during 1992-2006. The beginning of the survey (1st) was in 1992-1993,covered a sample of 89,777 ever-married women aged 13-48 years, the second round was conducted in 1998-1999, covered 90,303 ever-married women aged 15-49 years and the third in 2005-2006, covered 124,385 married and unmarried women aged 15-49 years. The data is collected from the Women Questionnaire which includes information on health status, nutritional status and population and Household Questionnaire which gives information about the households’ demographic and economic characteristics. (Kumar, A; Mohanty S.K,2011). The recent Ministry of Health and Family Welfare and UNICEF published the recent CES, which was carried during November 2009 to January 2010, representing the most current available national data. The survey analysed the children from 12-23 months infants from rural and urban areas and the methodology was quite same as NFHS surveys.(National Fact Sheet, CES, 2009).
In NFHS-1 Survey the number of children that were fully vaccinated were 35.4% and 30% received any vaccination. NFHS-2 Survey reported 42% of fully vaccinated children and 14.4% of children with no vaccination. NFHS-3 reported full vaccination of 43.5% of children and 5.1% infants without any vaccination. This data shows that even though the vaccination coverage didn’t show much of the improvement in full vaccination of children, but many children were still partially immunized. Data from the recent vaccination coverage by the UNICEF 2009-2010 survey shows a dramatic progress with the complete vaccination rate of 61%. (Mathew, J.L, 2012).
Immunization rates are calculated with the help of immunization cards and with the help of mother’s report. Two immunization indicators are used. This is the basic method of measuring the immunization coverage using surveys in highly populated areas. ( Boerma and Bicego 1994; Langsten and Hill 1998). A child is considered to be fully immunized if he/she has received single dose of BCG, three doses of DPT and OPV each and one dose of measles when survey is conducted. A child is considered to be non-immunized if he hasn’t received all of these doses during the survey. (Kumar, A; Mohanty S.K,2011).
Immunization is a preventive health care practice, independent of need and free of service dominated by the public sector in India. The information about different policies which have worked or failed is given by the differential achievements of the states, rural/urban areas and the different socio-economic groups. The differentials in immunization coverage were largely by economic and social status of households in the year 2005-06. (Kumar, A; Mohanty S.K , 2011). Much of the Immunization in developing world covers the richest sections of the society. “According to the recent analysis children in the poorest 20% of households are at most 60% as likely to be fully immunized as are children from the wealthiest 20%”. (Gwatkin, Rutstein, Johnson, Pande,& Wagstaff,2000 ). Evidence of gender differential in immunization shows that boys show a higher rate of vaccination intake than girls in India and varies according to different states.(Pande,2000 ;Govindaswamy and Ramesh,1996;Kurz and Johnson-Welch,1997). “Studies in Rajasthan show that girls being less immunized also drop at a faster rate for the three dose vaccinations of DPT and Oral Polio Vaccine (OPV) (Gupta, Jain and Singh, 1978) and are immunized at a later stage than boys.”(Sharma and Sharma, 1991). A cross national analysis showed the gender inequality with immunization with high rate of mortality among the girl child as compared to boys. (Hill and Upchurch,1995).  In India, social inequities in immunization coverage based on caste, religion, wealth and gender are seen. (Gwatkin and Deveshwar-Bahl, 2000; Nichter, 1995; Pande and Yazbeck, 2002). Female and Muslim children are unlikely to be immunized than male and Hindu children, especially in North India. The difference in Immunization coverage is due to the caste system in India as well, basis of hierarchical organization of Hindu religion. Scheduled Castes (STs) and Schedule Tribes (STs), the castes identified by the Indian Government are considered the most backward socially and therefore children from these castes are less expected to be vaccinated. Other Backward Castes (OBCs), occupational castes identified by the Government of India are also socially backward, but children from these castes are more immunized than STs/SCs but unlikely to be immunized than the other forward castes.(Bonu, S; Rani, M.; Baker, T.D, 2003).  
The socio economic differentials in India and its states of full immunization vary according to parity, age of mother, place of residence, mother’s education, caste, exposure to mass media, antenatal care of mother and availability of health card. The data from year 2005-06 shows that immunization coverage was greater among lower-parity than higher-parity women that is 55% and 31% respectively. The coverage was greater in the young women and more educated mothers than the older ones and less educated mothers which was 44%, 74%, 29% and 30% respectively. People in urban areas showed a high coverage of 58% than the people living in rural areas showing lesser coverage of 39%. Similarly, data also shows that children who belonged to the forward caste had higher immunization coverage of 54% than the children belonging to backward caste (ST/SC) showing coverage of 37%. Greater vaccination rate is seen among infants whose mothers have taken 3 or more antenatal check-ups. Immunization is more among infants having health card (76%) than the infants not having health card (24%). (Kumar, A; Mohanty S.K , 2011).
Mother’s education is considered to be one of the most important factors for monitoring the differentials of child’s health. It leads to better social, cultural and human capital which helps in increasing the rate of immunization in children. There are various benefits which explain the importance of mother’s education which play a role in giving care to their children. First, educated mothers have a good knowledge and are know about benefits of health care known as human capital advantage. Second, with studies women develop more contacts with people who have a wide knowledge of benefits of care and have an access to health care services which is categorised as the social capital advantage. Third, with education women develop skills which are valued and give them a higher status which helps in building self-confidence and thus links with medical providers; which is identified as cultural capital route. Lastly, with education women become more active in household and society which makes them more focussed to seek better care for their child. Literacy helps them to access other sources of heath information such as mass media. (LeVine, LeVine and Schnell, 2001). A mother who has inadequate knowledge of the doses and timing of the vaccines will have less understanding of completing her child’s immunization schedule. (Jamil, Bhuiya, Streatfield and Chakrabarty, 1999). Having different networks with people helping in getting care, for example association with religious or caste organization hinder mother’s to seek immunization for children due to orthodox norms and beliefs. On the other hand knowing about advantages of immunization and going to the local immunization campaigns is increased in association with development organizations which might help in encouraging modern thoughts. (Vikram, K; Vanneman,R; Desai, S,2012).
Mother’s Antenatal care (ANC) is also one of the important policy variable. ANC motivates women for child immunization through motivational messages. ( Munshi and Lee, 2000). A study of women visiting maternity hospitals in Lucknow, Uttar Pradesh show a strong relation between family planning acceptance and provision of immunization.(Roy, Mishra and Sharma, 1988).  
“Through public health delivery systems and mass campaigns, major institutions such as the government (e.g. the Health Ministry) or the mass media (radio, television, and newspaper) endeavour to mobilize various social actors towards recognizing the efficacy of immunizations.”(Perez-Cuevas et al., 1999). The basic logic behind this is an increase in demand will lead to more supply leading to more immunization among children. (Das and Dasgupta, 2000). To make this effort successful people should actively demand rather than passively accepting the message. (Nichter,1995; Bonu, Rani & Baker, 2003).  
Some of the trends were seen in NFHS-3 survey like individual vaccines showed higher coverage than the full vaccination coverage showing that the as the infants grew older decline in the vaccination coverage was seen. This is due to the significant decrease in the following dose of DPT/OPV and between the 3rd dose of DPT/OPV and measles vaccine. Another interesting observation was seen in the difference of DPT and OPV coverage even though they were administered at the same age.
Chapter 3: Regional Variations of Immunization Coverage
UNICEF survey in 2009-10 showed that 16 out of 29 states had higher immunization coverage rate with average of 61% nationally. Union territories together showed immunization coverage of 71.3%. The states which had more than 80% of complete vaccination coverage were Goa with 87.9%, Sikkim with 85.3%, Punjab with 83.6% and Kerala with 81.5%. The countries which had less vaccination coverage were Arunachal Pradesh with 24.8% and Nagaland with 27.8%. All other states in India had vaccination coverage of more than 40%. The states which had a poor performance in the previous year’s showed an improvement rate in vaccination coverage like Bihar with 49%, Madhya Pradesh with 42.9%, Rajasthan 53.8% and Uttar Pradesh (U.P) with 40.9%. (UNICEF, Coverage Evaluation Survey). But comparing the state profile of the country, worst immunization coverage tend to be in the Northern and Eastern part of India like Bihar, U.P. Nagaland and Arunachal Pradesh being the worst performers. None of the states in South were poor performers and most of them performed above average particularly Kerala, Tamil Nadu, Maharashtra and Karnataka, had a higher full immunization status among the children aged 12-23 years. Some northern states like Punjab, Himachal Pradesh and Haryana were good performers and have a very small number of non-immunized children show full immunization more than 60%. (National Fact Sheet UNICEF, 2009). States like Bihar, Madhya Pradesh, Rajasthan and U.P (BIMARU) showing a good coverage from previous years have highest population base which may be a factor responsible for immunization coverage as compared to other states. ( Sahu, D et al, 2009).
NFHS in the year 1992-93 showed that northern states have more immunization inequalities than the southern states in India. (Pande, R.P; Yazbeck, A.S,2003).
Group of international researchers analysed the factors to determine the childhood immunization between two diverse states of India, Maharashtra and Bihar. The states were chosen because they had identical population that is around 90-95 million but showed a completely opposite spectrum in the development. Maharashtra is one of the wealthier states in India. Mumbai, its capital city is also considered as the economic capital of India. Bihar has very less per capita income in the country. Life expectancy is higher in Maharashtra by 6 years and infant mortality is less by 50% and it is a known to be a well-administered state unlike Bihar which is known for its corruption and crime. Using state level data from NFHS-2, state specific community, household and individual characteristics were recognized that help to identify the receipts of immunizations and policies to increase the coverage of immunization coverage in these states. The data was analysed in children aged 1-3 years and number of children to be used for analysis were 1979 and 1188 in Bihar and Maharashtra respectively in the datasets. The results showed that two-third of children in Maharashtra were fully vaccinated with only 10% vaccination in Bihar. The major differences in coverage reported were higher education level of parents in Maharashtra, more exposure to mass media, greater use of prenatal services by mothers and higher standard of living by the people of Maharashtra. More interestingly, the study shows that there was complete vaccination in the rural areas of Maharashtra than urban areas which resulted in better health care services in rural areas. The discrimination against girl child is seen in many states of India and nevertheless it is in Bihar too, being a poorer state of the country. (Gatchell, M ;Thind,A; Hagigi, F,2008).
A comparison between two states of India, U.P in north and Karnataka in south is done to analyse difference in the immunization coverage. According to UNICEF data, full immunization in U.P shows coverage of 42% and Karnataka shows 78% of the coverage. U.P is one of the states which had least immunization coverage on the contrary Karnataka was one of the state ranked highest on the list amongst children aged 12-23 years.(Karnataka and U.P Fact Sheet, CES, 2009).U.P, with 199.6 million people in India is the most populous state which accounts for 16.5% of the population in country which could be one of the reasons for less immunization. Conversely, population in Southern states like Tamil Nadu, Kerala, Karnataka and Arunachal Pradesh has decreased its proportion from 22.5% in 1991 to 20.8% in 2011 of living population. The census, 2011 showed the literacy rate to be 69.7% in U.P of which 79.2% males and 59.3% females were literate which is low as compared to other southern states like Karnataka, the other major reason for difference in immunization between two states. (Rath S.P; Das, B; Mishra, S.K, 2011).If females especially mothers are literate they have adequate knowledge of benefits of immunization and they are concerned about the immunization schedule to be followed. According to NFHS-3 survey of U.P, one quarter households are in urban areas and three-quarters are in rural areas and most of the population comprises of Hindus heads (82%) or Muslims heads (17%). Higher proportions of household are headed by Muslim in U.P than in India as a whole (13%). In Karnataka, two-fifths of households are in urban areas and three-fifths are in rural areas. The majority household heads in Karnataka are Hindus (85%), then Muslims (10%) and Christians (3%). As per the report, major part of U.P comprises of rural areas and 17% of Muslims which is more when compared to Karnataka are also the socio-economic differentials of immunization coverage in these states. The reasons for no immunization in U.P were that people being unaware of the vaccines and did not know about the advantages of vaccination because of the illiteracy. (U.P Fact sheet CES, 2009). On the other hand in Karnataka literacy rate is high as compared to U.P and people knew about vaccination but no immunization was due to less feel of any need for it. (Karnataka Fact sheet CES, 2009).
A study was conducted among children 12-23 months for rapid assessment of immunization coverage in one of the Union Territories in India, Chandigarh. According to NFHS-2 survey, immunization coverage reported as fully immunized was 72.23% in Chandigarh with the range of 11% in Bihar to 89% in Tamil Nadu. Though Chandigarh is one of the most literate cities of India with excellent health infrastructure, vaccination coverage tended to be lower because of migration of population from states of Bihar and U.P and development of slums having one third of total population. Lack of monitoring, poor health infrastructure in slums, lack of information, education and communication activities further led to poor immunization in Chandigarh. ( Bhatia, V.et al, 2004).
A study sample data of 1279 children aged 12-35 months in West Bengal were examined from District Level Household Survey under Reproductive and Child Health Project (2002-04). 54% of children were fully immunized even though there was a wide difference in vaccination rates across 18 districts of the state. The immunization coverage of the state is slightly above national average having satisfactory uniformity in district level immunization with only few exceptions. West Bengal is multi-ethnic and is home to geographically diverse people and has very diverse economic groups. Lesser coverage were due to inadequate access to health services, less participation of people belonging to minority groups, poor households and people living in rural and remote areas. First reason for non immunization seen in the state was lack of awareness about the immunization and other reasons were due to socio-cultural phenomenon in some of the districts which are concentrated of minority groups, poverty and low literacy. Two districts of North Dinajpur and Murshidabad showed the least coverage as compared to other districts because of high level of Muslim community and natural conditions like flooding and erosion which lead to family displacement. The rural-urban difference in the state also had a significant effect on the immunization coverage. ( Som,S; Pal, M;Chakrabarty,S and Bharati,P, 2010).
Chapter 4: Challenges and Reasons for not Immunizing Children
Immunization is a cost-effective and life-saving intervention which prevents needless suffering through sickness, disability and death. It benefits all mankind through improvements in health and life expectancy and also through its social and economic impact at the global, national and community level. In today’s increasingly interdependent world, acting together against vaccine-preventable diseases of public health importance and preparing for the possible emergence of diseases with pandemic potential will contribute significantly to improving global health and security.
The immense scientific achievement of vaccines and immunization, targeting children in all countries, represents one of the most successful and cost-effective public health interventions in history. Immunization services must be sustainable as more than 100 million children are born every year and need to be immunized. In an increasingly globalized world, the global community has a clear interest in the widespread use of current vaccines, as well as the rapid development of new vaccines against emerging diseases. The establishment of strong national immunization services in many countries over recent years has ensured that today over 70% of the world’s targeted population is reached with immunization. However global commitment to immunization has not been sustained in all countries. In 2003 an estimated 27 million infants and 40 million pregnant women worldwide remained in need of immunization. (Global Immunization Vision and Strategy, 2006-2015).
India has one of the lowest routine immunization (RI) rates in the world. Estimates from 2005-2006 Indian National Family Health Survey (NFHS-3) indicates that only 43.5% of children age 12-23 months were fully vaccinated (received BCG, measles, and 3 doses of DPT and polio vaccines), and 5% had received no vaccinations at all. Over 12.5 million children are under-immunized each year out of 24 million surviving infants and an under 5 year mortality rate of 74/1000, while national-level immunization rates are an important indicator of population protection, heterogeneity in sub-national and local immunization coverage often provides a critical mass of susceptible individuals that can result in outbreaks. For example, in UP and Bihar, only 23% and 32.8% of all children age 12-23 months, respectively were fully vaccinated. Heterogeneity of coverage rates is not the only problem faced by RI in India, the falsification of data and over-reporting of rates, are major concerns. The discrepancy in the number estimated is more evident in Uttar Pradesh, Bihar, Madhya Pradesh, Orissa and Rajasthan. Evidence also suggests that coverage levels are significantly higher in those areas with regular access to the services (63%) as compared to those communities where sessions are less frequent or irregular (33%).
The size and diversity of India, resource constraints and competing priorities makes it challenging to successfully implement RI program. A major challenge for immunization programs in India is the way to achieve better utilization of available vaccines. One of the major challenges is to achieve uniformly high coverage with available vaccines, particularly in the states having higher disease burden.
Following are the numerous reasons for poor immunization rates:
• Inadequate delivery of health services where there is shortage of supply, many vacant staff positions and lack of training. There is less supply of vaccines or staff doesn’t open new vial or some vaccines are systematically not used during some days of the week. Insufficient training results in poor treatment from the health workers and poor injection techniques causing pain or side effects.
• Improper and inadequate information on the specific locations and age recommendations for receiving immunizations. Many of the health workers do not inform mothers as to why and then they have to come for additional doses.
• Lack of accountability, inadequate supervision and monitoring, and no micro-planning at district level. Health workers should focus on community participation by whatever means to increase the coverage. They should involve district heads for assessing the coverage among the population.
• Weak surveillance for all vaccine preventable diseases (VPD) except polio. Immunization services may are also not adequately or readily available.
• Lack of inter sectoral coordination which eventually results in missed opportunities to improve immunization coverage and quality. Missed opportunities are because facilities fail to vaccinate children even if they have come on time when they should be vaccinated despite of having adequate health workers and staff.
• The varying date, place, and time of immunization sessions making it difficult for parents to access services. Sometimes women are positively inclined toward immunization if long travel and waiting time is not involved. If it requires major investment, costs become an obstacle for many mothers.
• Complacency, for reasons such as the belief that uncommon diseases are not important, or a mistaken belief that measles is common, therefore not a dangerous disease. Rural population know a great deal about measles and therefore beliefs surrounding the disease prevent the parents from bringing their children for treatment at an early stage. Many people believe that food should be withheld from the child when he is sick as it can exacerbate the condition. (WFPHA,1984).
• Lack of awareness that children need routine immunizations and the belief that vaccines are not effective or, that only the polio vaccine is necessary. It is more among the parents in rural areas because they are unaware of the need of the immunization.
• Parental time constraints and parental non-acceptance of