Knowledge and practices of childhood immunization

among primary health care providers in Riyadh City:

Part I: Handling and administration of vaccines
Author(s): Ibrahim H Al-Ayed

Vol. 9, No. 1 (2005-10 - 2005-12)

Curr Pediatr Res 2005; 9 (1 & 2): 15-21

Ibrahim H Al-Ayed

Department of Pediatrics, College of Medicine & King Khalid University Hospital, King Saud University, Kingdom of
Saudi Arabia.

Key words: childhood immunization, knowledge & practices, primary health care providers.

Accepted June 14 2005

Abstract
The knowledge and practice of physicians and nurses with regard to immunization has been assessed. A self-
administered questionnaire with 50 statements related to knowledge and practice of vaccination was distributed
among workers in 50 MOH PHCs in Riyadh city.

506 questionnaires were returned, 479 were analysed. A response rate of almost 70%. For most of the statements
cited a correct response of knowledge & practice was obtained from more than 80% of the sample. However for few
others, correct response has dropped to 40% or less. Experience in dealing with vaccination, and a formal training in
vaccination were not significantly associated with the responses of both physicians and nurses.

Inspite of the limitations of this study it could be fairly concluded that the overall knowledge and practices of childhood
immunizations among the primary care providers surveyed was good. Significant gaps still exist. This highlights the
need for continuous training and supervision of health care providers dealing with children immunization.

Introduction
Vaccination has proved to be one of the most cost-effective part of health promotion [1]. The WHO estimates that
current immunization programs save more than 3.2 million lives each year and full utilization of existing vaccines
could save an additional 1.7 million lives per year [2]. The WHO through its expanded program on immunization (EPI)
launched in 1974 and “Health for All” by the year 2000 programme has significantly contributed towards increasing
levels of immunization coverage in many parts of the world [3]. However despite these impressive advances, still
some three million children die each year from vaccine preventable diseases and another three million are
permanently disabled [3,4].

Saudi Arabia is one of the developing countries that accelerated its immunization programme to reach full coverage
by 1990. Since 1984 the EPI has been implemented as an essential and integral element of primary health care [5].
Over the last twenty years reports from the Kingdom have correlated the marked decline in the incidence of vaccine
preventable diseases with high rates of immunization coverage among infants and preschool children in most parts of
the kingdom. At the present time more than 90% of school age children are completely immunized and the incidence
rates of vaccine preventable diseases had decreased by more than 90% [2]. Other factors like improvements in the
socioeconomic status of the population and increase in education levels have certainly played an important role for
this decline.
In addition to tight legislations and public health education which help to maintain high rate of immunization coverage
one has to make sure of a high level of knowledge and appropriate standard of immunization practices among health
care providers to achieve high level of seroconversion [1,5,6,7,8].

This is the first report of a study to assess how much those who administer vaccines in the primary health care
centres of the Ministry of Health in Riyadh are aware of the proper handling, administering of vaccines in addition to
side effects, complications and contraindications of vaccines, to determine to what extent these practices and
knowledge of primary health care providers meets the standard practices of immunization and whether the duration of
experience or attendance of a training course on vaccinations has any significant effect on the knowledge and
practices of immunization. This first report is concerned with the handling and administration of vaccines. The second
report will be devoted for knowledge of contraindication to vaccinations.

Methods
A selfadministered questionnaire in Arabic and English of almost 50 items encompassing knowledge and practices of
storage and handling, administration, scheduling, doses, routes, contraindications, side effects and complications of
the nine vaccines included in the Kingdom Vaccination Schedule (MMR, DPT, BCG, OPV, & HBV) was distributed
among 50 out of 59 Ministry of Health (MOH) Primary Health Care Centres in Riyadh City, personally by the
investigator.

The study was conducted just before addition of Haemophilus Influenzae vaccine to the National Vaccination
Schedule. The questionnaire was piloted on a sample of twenty nurses and physicians dealing with vaccination
before final approval. The study was explained in detail to the most senior worker(s) available in each center at the
time of distribution and queries were answered.

The points of honest, sincere response to the questionnaire was stressed to all health care providers hoping to get an
overall response reflecting the actual knowledge and practice of the responders. More than 70% of the target
population responded to the questionnaire.

The data has been entered in MS Excel and analyzed using the SPSS Pc+ statistical software. The descriptive
statistics (proportions) was calculated for the positive responses of all outcome variables. Further, all the responses
(correct/ incorrect) of physicians and nurses were used to observe the association with their expereinces in dealing
with vaccination (<5 years / > 5 years) and formal training on vaccination (yes / no). Chi-square test was used to
observe the statistical association between two categorical variables. A p-value of <0.05 was considered as
statistically significant.

Results
Among 479 respondents 189 (39.4%) were physicians, 290 (60.5%) were nurses (including midwives). Of the
physicians 51% were males and 49% were females. Only 8.3% of them were Saudis. Of the nurses 66.2% were
Saudi nationals. 72.9% of physicians and 39.2% of nurses indicated that they were working in the field of vaccination
for more than 3 years. 46.8% of physicians and 77.7% of nurses indicated that they attended at least one training
course on vaccine practices during their work in the Kingdom.

Table I indicates the knowledge of vaccine handling among respondents. It is evident that the right response was
indicated by more than 80% of the candidates to all but one of the items.

Table II shows the response of candidates when asked few questions about handling of vaccines which reflects their
actual practice.

Again it is evident that more than 90% of the respondents comply with the standard practice of vaccine handling.

Table III depicts knowledge of vaccine administration among respondents. Again more than 80% seems to have the
right knowledge.

Table IV represents the report of the care providers when asked about their practice or knowledge of response nine
miscellaneous items during vaccination. For 2 of the 9 items only 40% or less indicated a complying with the standard
practice. When asked whether mothers should not breastfeed their children for 20 minutes after OPV administration,
surprisingly 66.6% of the respondents agreed to this incorrect statement. Likewise 68.1% agreed to the false
statement that vaccination of preterm babies hould be delayed to compensate for prematurity. No statistically
significant association was found between the responses of both physicians and nurses, with their experience in
dealing with vaccination and having a formal training on vaccination.

Table I: Knowledge of Vaccine Handling

Correct Responses
Correct Physicians % Nurses‫ ٭‬% &
Statement
Answer & (No.) Total = (No.) Total =
189 290
Vaccines should be stored in the
90%
refrigerator at a temperature between False 90% (160/177)
(233/258)
10-12°C.
No harm if vials of dried MMR vaccine 48%
True 38.8% (68/175)
are stored in the freezer. (120/257)
Diluent for dried vaccines should not 92.6% 85%
True
be frozen. (162/175) (230/270)
MMR vaccine should be discarded 88%
True 89% (152/171)
after 8 hours of reconstitution. (235/268)
Opened vaccine vials could be stored
97%
in the refrigerator for next day’s False 98% (180/183)
(267/276)
session.
DPT, DT, Tetanus and Hepatitis B
86.5%
vaccine vials should not be in direct True 86% (144/168)
(230/266)
contact with ice.
BCG and measles vaccines should 95.6%
True 99% (178/180)
not be exposed to direct sunlight. (261/273)
Vaccines vials should be taken out
from the refrigerator only at the arrival 86.6%
True 88% (159/181)
of the first child for that immunization (239/276)
session.

‫ ٭‬Includes midwives and paramedics

Table II: Practice of Vaccine Handling

Correct Correct Responses

Statement
Practice Physicians % Nurses‫ ٭‬%
 & (No.) & (No.)
Total = 189 Total = 290
I keep food, drinks and medicines 97%
No 98% (181/184)
in the vaccine refrigerator. (265/273)
I keep vaccines in the door shelf of 94%
No 98% (161/169)
the refrigerator. (255/270)
I check for signs of vaccine
99%
damage (change of color, Yes 97% (172/177)
(263/265)
precipitate, etc.)
I check the expiry date of vaccines 100%
Yes 98% (181/184)
before opening them. (281/281)

‫٭‬Includes midwives and paramedics.

Table III: Knowledge of Vaccine Administration

Correct Responses
Correct Physicians % Nurses* %
Statement
Answer & (No.) Total & (No.)
= 189 Total = 290
According to the local national
immunization schedule the first dose 83%
False 95% (173/182)
of DPT should be given at 3 months of (232/278)
age.
MMR, DTP and OPV can be safely 87%
True 78% (136/175)
given simultaneously to the same child. (227/262)
Children who suffered inconsolable
crying for more than 3 hours after 95%
False 94% (134/143)
previous full DTP dose should be given (230/243)
half of the usualDTP dose.
If a child misses the 2nd dose
of DTP and OPV for more than 2 93%
False 85% (146/171)
months, vaccination schedule should be (248/267)
restarted again from 1st dose.
Preterm babies should receive half the 91%
False 98% (164/168)
dose of vaccine given to term babies. (232/256)
According to the national immunization
94%
schedule the MMRvaccine is given at True 99% (181/183)
(257/273)
12month of age.
BCG must be given intradermally in the 96%
True 97% (172/178)
upper third of the left arm. (266/276)
Five drops of OPV are given to children 91%
False 94% (169/179)
whose weight is above 20 kg. (247/272)
Injectable vaccines should be given
94.5%
preferably in the anterolateral aspect of True 94% (170/180)
(260/275)
the thigh or in the deltoid muscle.
Separate injection sites should be used
96%
to administer more than one injectable True 98% (180/184)
(265/275)
vaccine at the same time.

‫٭‬Includes midwives and paramedics

Table IV: Miscellaneous Immunization Practices

Correct Responses
Correct
Statement Practice / Physicians % Nurses‫ ٭‬% &
Answer & (No.) Total = (No.) Total =
189 290
I read the package insert
99%
(manufacturer’s instructions) before Yes 98% (142/145)
(208/209)
giving any vaccine.
I advise parents to give regular
92%
antipyretics e.g. Adol Yes 79% (66/83)
(206/223)
afterDTP vaccine.
I ask children to wait for 15-20
81%
minutes in the centre after Yes 92% (107/116)
(146/180)
vaccination
I record the date, name of the
patient, type of vaccine for every 97.5%
Yes 97% (181/186)
child in the immunization record (277/284)
book of the centre.
I record the Batch no. of the
91%
vaccine used in the immunization Yes 90% (139/155)
(220/241)
record book of the centre.
I check immunization record of
95%
every preschooler who attends the Yes 96% (148/154)
(234/246)
centre.
I call dropout children for Yes 97% (150/155) 99.6%
completion of missed vaccination. (258/259)
Mothers should not breastfeed their
children for 20 minutes after
False 40% (69/182) 30% (81/267)
administration of oral poliovirus
vaccine.
Vaccination of preterm baby should
be delayed to compensate for their False 40% (67/172) 31% (81/262)
prematurity.

‫ ٭‬Includes midwifes and paramedics

Discussion
Majority of respondents (66%) supported the false statement that mothers should not breast-feed their children for 20
minutes after oral poliovirus vaccine (OPV). This advice is strongly rejected by scientific evidence of enhancement of
immunity to vaccines in breast-fed babies [9]. The justification for such advise by some health workers is to avoid loss
of vaccine absorption if the child vomits during or immediately after vaccination, moreover, crying may induce
vomiting, if the child had an injectable vaccine given simultaneously with the OPV. Breast-feeding does not interfere
with successful immunization with OPV. Although high concentrations of antipoliovirus antibody in milk of some
mothers theoretically could interfere with the immunogenicity of OPV, no such association has been demonstrated.
Infants should be immunized according to the recommended schedule regardless of the infant’s mode of feeding [10].

Similarly, respondents (68.1%) indicated that vaccination of premature babies should be delayed to compensate for
their prematurity. This is not in accordance with the recommendation that the appropriate age for initiating most
immunizations in the prematurely born infant is the usual recommended chronologic age. Vaccine doses should not
be reduced for preterm infants [10].

Insufficient knowledge, inadequate training and less enthusiasm about immunizations by health professionals have a
heavy negative impact on the quality of immunization services for children. Health professionals’ perceptions of
immunization against vaccine-preventable diseases must inevitably be transmitted to parents, and parents can be
perplexed by the confusing and contradictory messages they may receive from health professionals [6]. Strong
professional commitment is the key to improved immunization uptake [1].

In the Kingdom two legislation’s have played a major role towards a higher rate of immunization in children. One is
the Royal Decree of 1979 which made basic immunization mandatory for obtaining the birth certificate at the end of
the first year of life. The other is that requiring parents to provide proof of completed immunization as a prerequisite
for school entry. Such legislation has been found to be effective in improving immunization coverage and reducing
the incidence of vaccinepreventable diseases in a number of countries [13]. However in the study by Al-Shammari et
al only 1.8% of parents interviewed said they immunized their children to obtain the birth certificate, a fact that led the
authors to conclude that birth certificate was only a minor motive for immunizing children [8]. It may be reasonable to
state that for some vaccination contribute more towards a higher level of vaccine coverage than other measures do.

Lapreiato, et al, in their “Assessment of Immunization compliance among children in the department of defense
health care system” found that immunization delay was primarily the result of failure to track patients and notify
parents of immunizations due [11]. It is encouraging to know from our study that more than 90% of the respondents
claimed that they always call vaccination dropouts.

The fact that there are gaps in the knowledge and practice among the health care providers in our study is not singled
out. Many studies addressing beliefs and practices of providers regarding vaccine administration have found them not
in compliance with current immunization recommendations [7]. England, et al, in their study of pediatric residents
beliefs and practices of immunization concluded that during residency many patients visits are underutilized for
vaccination purposes and that contra-indications are not always appropriately followed [7].
In their report of 1991 National Immunization Coverage Survey in the Kingdom, M.K. Farag, et al, had found that the
percentage of children partially immunized is considerably high (14%). This was partially due to failure of health
workers to pay attention to the time schedule of immunization. This emphasizes provision and maintenance of basic
and refreshing training programmes for both medical and paramedical personnel. In addition, much more attention
should be paid to the quality of immunization activities in the primary health care settings [12]. In our study almost
35% of respondents denied any previous training in immunization. This highlights the need for training of health care
providers dealing with children immunization a fact which has been pointed out by health care authorities worldwide
[1].

Potential limitations of our study include: 1) around 30% nonresponse rate and 2) self-report format. It is of course
impossible to know to what extent if any of the nonrespondents differ with regard to their knowledge, attitudes and
practices concerning childhood immunizations. In spite of the limitations of studies based on self-administered
questionnaires, it remains sometimes the only means of gathering objective information. Generalizations from our
study are obviously limited to the survey’s target population; primary care providers who see moderate to large
numbers of preschool children.

Conclusion
It is concluded from the study that the knowledge of the health care providers at the primary health care centres in
Riyadh City about immunization is good and their reported practice is mostly in compliance with the current
immunization recommendations. However, there are significant gaps in knowledge and noncompliance in some
practices. It may not be easy to extrapolate from this study how much this practice may have contributed to the
present level of immunization coverage. The training received by majority is apparently not adequate. This highlights
the need for more efficient training and continuous education of primary health care providers in the field of
immunization practices.

Acknowledgments

We are grateful to all colleagues in the Directorate of Health Affairs in Riyadh region and colleagues in the primary
health care centers surveyed, for their invaluable help in administrative faciliation and data collection. My special
thanks goes to Dr. Shafi Sheik for his help in the statistical analysis and reviewing the manuscript and to
Nayeemuddin M. Abdulqader and Loida Manalo for their secreterial assistance.

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Correspondence:
Dr. Ibrahim H. Al-Ayed
Department of Pediatrics (39)
College of Medicine & King Khalid University Hospital
King Saud University, PO Box 2925, Riyadh-11461
Kingdom of Saudi Arabia
Phone: +9661-467 9401, Fax: +9661- 467 9463
e-mail: ialayed(at )hotmail.com