The majority of children immunised under the government’s universal immunisation programme don’t get their vaccinations on time. New research shows that two-thirds of children under the age of five had either not been vaccinated at all, or received their vaccine shots much later than prescribed.

More than 1.5 million children die, and more than a million are disabled every year in India, due to vaccine-preventable diseases. India’s high mortality rate among children under the age of five is 48 deaths for every 1,000 live births. It has missed its Millennium Development Goal of bringing under-five mortality down to 42 per 1,000 live births. The government’s Universal Immunisation Programme has helped reduce this mortality figure from 125 in 1990 by focusing on immunisation coverage, that is, by increasing the number of children getting vaccinated. But a missing link seems to be in ensuring that the vaccination is administered on time.

Researchers from the University of Michigan analysed countrywide data from the third District Level Household Survey conducted in 2007 and 2008 and found that only a third among more than 2.7 lakh children got the measles vaccine and the Bacillus Calmette-Guérin, or BCG, vaccine used against tuberculosis, at the appropriate age. Similarly, fewer than 20% got the DPT vaccine against diphtheria, pertussis and tetanus on time.

“To stop the transmission of diseases from one kid to another, the vaccine has to produce herd immunity,” said Nijika Shrivastwa, epidemiologist at the University of Michigan, and author of the study. "For that herd immunity, the vaccine coverage has to reach a certain level, for instance, 95% for measles."

By herd immunity, Shrivastwa refers to the basis on which mass immunisation works, which is that if enough people in a community are vaccinated it is much harder for the disease to pass between people who haven’t been vaccinated.

Shrivastwa explained that the measles vaccine is given to a child at the age of nine months because that is when they become susceptible to the disease. Up to nine months, children have maternal antibodies that linger after childbirth and are supplemented through breastfeeding. But as the maternal antibodies subside, a child’s risk of infection increases. The longer it takes to administer the vaccine, the larger the window during which a child might fall sick and also transmit the disease to other non-vaccinated children.

No records

One reason why immunisations are delayed for children in India is the lack of immunisation records. “Many families don’t keep immunisation records for children and the parents don’t know to ask for the vaccination,” said Shrivastwa who had to rely on a statistical analysis based on mothers recalling when they got their children vaccinated.

Other local studies have shown findings similar to those in Shrivastwa’s analysis. Scientists from Dibrugarh in Assam, who looked into age-appropriate immunisation in two districts, found that although immunisation coverage rates were satisfactory, the timeliness of vaccination was poor. Factors that contributed to delays included poor education of the mother and low socio-economic status.

Getting infants and children in India immunised is a no mean task. The Universal Immunisation Programme reaches 27 million infants and 30 million pregnant women every year free of cost, according to the National Health Mission website.

And yet, only 60% of children who reach the age of two are fully vaccinated on time, said Ranjan Kumar Pejaver, professor of neonatology at the Kempegowda Institute of Medical Sciences in Bengaluru. "Just take the BCG vaccine, which is given few days after delivery while the patient is in hospital itself. The uptake is 85%," said Pejaver. "But by the time the MMR [measles, mumps, and rubella vaccine] comes, the uptake goes down to about 65%." Pejavar observes that early vaccinations, which fall in the period a new mother is still on maternity leave, or when women go to their maternal homes, are given in a more timely manner.

Vaccination reminders

Pejaver is one of the founders of Immunize India, an SMS alert system run by the Indian Academy of Paediatrics, which reminds new parents about vaccination schedules for their children. The reminder service, which you need to register for, has 1.3 million registrations as of now from urban centres as well as from smaller towns.

Meanwhile, the government also introduced new vaccines like the pentavalent vaccine to prevent five diseases – diphtheria, pertussis, tetanus, Hepatitis B and a certain strain of pneumonia. It has also launched the rotavirus vaccine against diarrhoea.

“The rotavirus vaccine is completely dependent on timing,” said Shrivastwa. "If it is not given on time it will not work. Imagine all the money that we will spend to giving the new vaccine and then it doesn’t work.”

Tracking immunisation

The University of Michigan team observes that although the Indian government has put significant effort into improving infant and childhood vaccination, the magnitude of the problem in India surpasses other similar economies. For instance, the health department has a software called Mother and Child Tracking System that health officers use to track when vaccines need to be administered to each patient. A group of paediatricians also launched a vaccination reminder SMS service in March 2014 to increase immunisation compliance.

Shrivastwa is waiting to analyse data from the latest District Level Household Survey conducted in 2012 and 2013 to see if these measures have worked. “It is very possible that the trends might have become better because in the last couple of years the Indian government has focused on improving immunisation services,” said Shrivastwa. “But unless you analyse the data you can’t say for sure.”