Achievement and maintenance of high vaccination coverage for vaccine-preventable diseases is an important part of programs to achieve control, elimination, or eradication of these diseases. Vaccination cards are considered a quality measure in vaccination services and are extremely important to obtain information about vaccination history. Of the children that participated in this study, 83.2% (56.0%) had a vaccination card. Registration increased after the family medicine system was implemented. Because family physicians are being audited (investigated, checked out) via computer and because they take performance fees for their services, records might have become better. However, registration is still a problem in Gaziantep although it is an urban region. It is possible that mothers lost their child’s vaccination cards. According to the countrywide Turkish Demographic and Health Survey, 2008 (TDHS 2008), 75.8% of 12–23 month old children had a vaccination card [14]. In a study performed by LQ technique in Ankara (the capital of Turkey), only 57.5% of parents/caregivers could present the card when asked in the interviews [13]. In another study from rural Kenya, vaccination cards were available for 86% of children [15]. Health workers’ attention about records, and familial concern about vaccination and keeping vaccination cards should be increased by health education.
Tuberculosis is a re-emerging problem around the world. Neonatal BCG vaccine is safe and effective, with an overall protective value of 75% [16]. Worldwide, different coverage rates have been obtained for this vaccine. BCG vaccine coverage was 98.5% (98.9%) in our study. In a study we conducted in the South-East Anatolia region (SEAP) of Turkey ten years ago (it was carried out between 2001 and 2002 and Gaziantep is a city in SEAP), BCG vaccine coverage was 76.7% in children aged 12–23 months [17]. In the last ten years, good progress has been achieved for BCG vaccine coverage. The small decrease revealed by the second study may be temporary, and due to the transition period. In the TDH 2008 survey, BCG coverage was 95.9% for the entire country [14]. In a study performed by LQ technique in Ankara in 2006, coverage for BCG vaccine was 99.4% [13]. In Nepal, BCG coverage was 96.7% [18]. In Dinghai, China, the timely BCG coverage rate was 22.26% [19]. In the UK, of 5308 infants born in 2003, 514 (9.6%) were at risk for TB; 423 (82.2%) of these infants were referred postnatal for BCG vaccination, and 391 received it [16]. Coverage of BCG was 89.3% in a rural South African population [20].
Of the children in this study, 99.1% (98.9%) received their first dose of Pentac-Hib vaccine. The coverage was 95.6% (97.6%) for the third vaccine dose. In the SEAP, coverage was 62.0% for the third dose of the Diphtheria, Tetanus, Pertussis (DPT) vaccine [17]. Coverage results from our two studies indicate that good progress for coverage of the third dose has been achieved in the past ten years. In a study performed by LQ technique in Ankara coverage for three doses of DPT was 98.5% in 2006 [13]. The TDH 2008 survey indicated that, in children 12–23 months of age, coverage for DPT 1 was 96.6%; for DPT 3 coverage was 85.9% for the entire country [14]. In Dinghai, the timely coverage rate of DPT was 91.40% [19]. In Kenya, 95% of children received three doses of the DTP-HepB-Hib vaccine [15]. In Nepal, 90.0% coverage was achieved for DPTHb-3 [18].
In this study, 93.8% (97.8%) of children received the first dose of oral polio vaccine. The coverage was 63.0% (59.7%) for the second dose. In the SEAP ten years ago, 62.0% received the third dose of oral polio vaccine [17]. In the TDH 2008 survey, Polio1 coverage was 95.8%, Polio2 coverage was 92.3%, and Polio3 coverage was 86.3% in children 12–35 months of age [14]. Our data indicate that, compared with the TDH 2008 survey, coverage for Polio2 was lower in Gaziantep, before and after the transformation. Because children receive inactive Polio vaccine in Pentac-Hib vaccine before, this may lead to neglect of second oral polio vaccine. In Nepal, the coverage for Polio3 was 97.6% [18]. In Dinghai, the timely coverage rate of OPV was 90.82% [19].
In this study, coverage for the third dose of Hepatitis B vaccine was 95.4% (97.7%). In the SEAP ten years ago the coverage was 44% for the third dose of Hepatitis B vaccine [17]. Good progress has been achieved in ten years. In a study performed by LQ technique in Ankara coverage for three doses of hepatitis B was 97.3% in 2006 [13]. The coverage rate was 84.7% in the TDH 2008 survey for the third dose of Hepatitis B vaccine [14]. In Dinghai, the timely coverage rate of Hepatitis B was 95.02% [19]. A Hepatitis B seroepidemiology study of ten European countries revealed that the seroprevalance of antibodies was lower than the reported in three countries [21]. Higher vaccination coverage should be obtained to achieve targeted antibody seroprevalence levels.
As measles is a highly infectious disease, the UK recommendation is for at least 95% of children to receive a first vaccination with the MMR vaccine before age 2 years and a booster before age 5 years to achieve herd immunity and prevent outbreaks [22]. The coverage of the MMR vaccine was 92.0% (97.4%) in our study. In the SEAP ten years ago, coverage for the measles vaccine was 62.7% [17], which indicates that good progress is being made. Prevalence of having at least one dose of vaccination against measles was 93.9% in Ankara [13]. The TDH 2008 survey revealed that coverage was 85.8%, countrywide [14]. In Nepal, the coverage for measles was 78.1% [18]. In Dinghai, the timely coverage rate of the measles vaccine was 95.40% [19]. In a rural South African population, coverage of measles was 77.3% [20]. In a rural area in Kenya, 88% of children received the measles vaccine [15]. An elimination program in the WHO European Region aimed to achieve and maintain a coverage of 95% for two doses of MMR. Despite strong health care systems in European countries, in recent years this region has experienced an outbreak of measles. In fact, one of the largest outbreaks in the world occurred in Europe [23]. Similar outbreaks by an incidence of 1/100.000 (according to WHO criteria, a higher incidence of elimination) was occurred not only in France; but also in other European countries; Bulgaria, Ireland and Switzerland. Germany and Greece were also influenced by the outbreak [24]. In a study in India by LQ technique, coverage of measles vaccine was 97.7% [11]. In this globalized world, it is not enough to reach the coverage goals in one country or area; all countries should achieve them. Imported cases are an important problem that all countries should address.
In this study, the coverage of the first PCV dose was 98.6% (98.3%). The second, third, and booster doses were 97.0% (97.7%), 95.2% (97.0%), and 88.3% (92.6%), respectively. Because this vaccine was added to the schedule in recent years, there were no studies available for comparison.
The timeliness of children’s vaccination varies widely between and particularly within countries, and published yearly estimates of national coverage do not capture these variations. Delayed vaccination could have important implications for the effect of new and established vaccines on the burden of disease [25]. In our study, 84.0% of children were fully vaccinated after the transition to the family medicine system, which was significantly lower than before the transition (93.7%) (p < 0.005). When calculated as weighted to the population, full vaccination coverage increased to 85.64% (93.62%). In the SEAP ten years ago, only 30% of children had received all required vaccines [17], so major progress has been achieved in ten years. In the TDHS 2008 study, coverage was 74.9% for the entire country [14]. In Istanbul, Turkey, the completed vaccination rate was 84.5% [26]. The coverage of fully vaccinated children was 75.1% in Edirne and was 88.9% in Bolu by LQ technique studies performed in the second year of the transition. These cities in western Turkey began the transition to the family medicine system before Gaziantep City [27, 28]. In the EPI of Turkey, the main objectives are to achieve 95% coverage for each vaccine in the schedule, to maintain coverage throughout the country, and to achieve full immunization for 90% of children 12–23 months of age [6]. The coverage of fully vaccinated children is under the goal of EPI all in all provinces (Gaziantep, Bolu and Edirne Provinces). In another study by LQ technique in Ankara 91.3% of participants were fully vaccinated in 2006 [13]. In a study in İstanbul by the same method, 75.6% of the children aged 12–23 months were fully vaccinated in 2001 [9]. However, it should be kept in mind that studies had been conducted in different years and different threshold levels were used. In a LQ technique study, full vaccination of children in India was 84.09% [29]. In a study from rural Nigeria, a cluster survey study revealed that vaccination coverage against the seven childhood vaccine preventable diseases was 61.9% [30]. In a study in Nairobi, up-to-date coverage with all vaccinations at 12 months of age was 41.3% [31]. According to the results of 2009 national survey in Haiti, 40.4% of children had received the eight recommended vaccinations [32]. Worldwide, more progress is needed on achievement of full vaccination coverage.
The number of unacceptable lots increased from 5 lots to 21 lots after the transition to family medicine. This result indicates that >15% of children in these lots were not fully vaccinated. If we take the EPI criterion (>90%) as threshold [6], then fewer lots are meeting this goal. The specific lots that were classified as acceptable or unacceptable were different before and after the transition. Individual characteristics of the health care personnel working in an area may be as important for lot quality as the socioeconomic and cultural characteristics of the community. Because different health care personnel were working at the lots after the family medicine system was established. In addition, it is too early to say, type of health care system may affect this.
Information on coverage and reasons for non-vaccination is vital for the improvement of vaccination programs. The mothers mentioned the following reasons for non-vaccination of their children: “I don‘t know when I will take my child to be vaccinated” (11.8%); “family problems” (8.7%); “child was ill” (8.7%); and “rumors on vaccines ” (7.9%). These reasons are similar to the reasons recorded in other studies and seemed to be related with incorrect knowledge and educational status. The reasons reported for non-vaccination in a study in Ankara were “being unaware of a need for vaccination”, “not knowing that a subsequent dose is also needed”, “being away from home/area at the time for vaccination” and/or “familial reasons” [13]. In Nigeria, completeness of vaccination was significantly correlated with a mother’s knowledge about immunization [30]. In Haiti, reasons for under-vaccination included insufficient time to reach the vaccination location (24.8%), having a child who was ill (13.8%), and not knowing when, or forgetting, to have the child vaccinated (12.8%) [32]. One frequently reason found in all studies was “the child was ill”. It is important to educate parents about accurate reasons for non-vaccination. The use of mass media may help in such activities and qualitative researches on reasons for non-vaccination may be helpful to understand the problem in-depth.
More attention should be given to public education if high coverage levels are to be achieved and maintained. Health personnel should focus on vaccination during their health education activities; they should also encourage mothers not to lose vaccination cards. Efforts to improve the immunization program should include training for vaccination staff to encourage initiative, so that missed opportunities will be minimized.
