ABSTRACT An Undergraduate Research Project entitled Accomplishment and Factors Affecting the Compliance to Immunization Program in Tacloban City

(2003-2012) submitted and prepared by ************************. This is an analytical study regarding the accomplishment of the immunization program in Tacloban City for the past ten years (2003-2012) and also the factors that affects the compliance to such. The objectives of the study includes: 1) find out the rate of compliance to EPI in the said locale for the past ten years, 2) identify the reasons affecting the compliance to the Expanded Program on Immunization and the current intervention scheme employed to comply it, 3) determine if the seven immunizable diseases are still present as the leading causes of morbidity and mortality. The data used in this research was gathered from the City Health Office of Tacloban City which provided the information regarding the compliance to immunization program and also the causes of morbidity and mortality. The researchers conducted a survey on ten health centers in the locale regarding the factors that affects the compliance to the said program. The findings of the study were; 1) that there is a high level of accomplishment to the immunization program in the locale for the past ten years, 2) however a declining trend in regard to the compliance had been seen as the years pass, 3) also a decline in compliance with the third stage of DPT, OPV, and HEPA had been recorded, 4) tuberculosis was the only disease in relation with the EPI was seen among the top ten leading causes of morbidity and mortality, 4) lack of knowledge and wrong perception regarding the immunization program resulted as factors that mostly affect the noncompliance. From the following result, it is recommended a stricter implementation of the immunization program to achieve a much higher accomplishment regarding the program.

Researchers: Lledo, Quennie Logrosa, April Rose Lorenzo, Emily Lozada, Jasmine Madera, Jamaika Marapao, Gabriel Louis Mercado, Ann Nicolac Mondonedo, Joanna Montezon,Valerie Hearty Muralla, Princess Ann Mendiola, Francis Vio Navilla, Liza Marie Mr. Agripino Limpiado Date: Adviser:

ACKNOWLEDGEMENT

ii

At the outset, the researchers express their heartfelt gratitude to our all mighty God. With a fervent prayer we offer every part of this masterpiece to Him. For sharing with us the knowledge and wisdom, and sound health needed for the compliance of this research. For providing the necessary materials and opportunities that will all contribute to Glorify His name. With profound gratitude we also acknowledge the persons who in every way contributed to the fulfillment of this research. To Mr. ***********, our adviser, who with all sincere concern and immeasurable patience provided guidance and support in this pursuit. To ************, the City Health Officer, who gave us the data and information needed in regard with the study. To *************, who guided us in the gathering of records and shared to us her experiences and knowledge regarding this field. To the respondents, who gave us their time in answering the questions provided and sharing thoughts about the research. To our dear families who showered us with unwavering support though thick and thin despite arguments and difficulties who nothing but encouraged us to go on above all uncertainties, thank you. To our Teachers, Mentors, Friends, Batchmates, Classmates, and Groupmates who unselfishly and selflessly offered themselves and shared their resources, all these will not be forgotten.

And lastly, whether mentioned, unmentioned and who with their anonymity we respect, a sincere gratitude we offer, for sharing their lives and provided support to our destined success.

The Researchers

TABLE OF CONTENTS Page TITLE PAGE . ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . i ii iii iv vii viii x

ACKNOWLEDGMENT TABLE OF CONTENTS LIST OF TABLES .

LIST OF FIGURES . LIST OF APPENDICES CHAPTER I

INTRODUCTION

. . .

. . . . . . . .

. . . . . . . .

. . . . . . . .

. . . . . . . . .

. . . . . . . . . . . . .

1 5 5 6 7 7 8 10 12 20 20 21 22

General Objectives Specific Objectives

Significance of the Study Scope and Delimitations Theoretical Framework Conceptual Framework Definition of Terms II III .

REVIEW OF THE RELATED LITERATURE METHODOLOGY . . . . . . . . . . . . . . . . .

. . . .

Data Gathering . Research Locale Instrumentation

Statistical Analysis IV V

. .

. .

. .

. .

. . . . .

24 25 50

RESULTS AND DISCUSSIONS

SUMMARY, CONCLUSIONS, AND RECOMMENDATIONS . . . . . . . . . . . . . .

BIBLIOGRAPHY APPENDICES .

LIST OF TABLES

Table 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 Records of Livebirths and Fully Immunized Child . Compliance with the BCG Immunization Compliance to the Measles Immunization Compliance to the DPT Immunization Accomplishment in OPV Immunization Accomplishment in HEPA Immunization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Page 26 27 28 30 31 33 35 37 38 39 40 42 43 44 45 46 48

Top Ten Leading Causes of Mortality of Year 2003 and 2004 Top Ten Leading Causes of Mortality of Year 2005 and 2006 Top Ten Leading Causes of Mortality of Year 2007 and 2008 Top Ten Leading Causes of Mortality of Year 2009 and 2010 Top Ten Leading Causes of Mortality of Year 2011 and 2012 Top Ten Leading Causes of Morbidity of Year 2003 and 2004 Top Ten Leading Causes of Morbidity of Year 2005 and 2006 Top Ten Leading Causes of Morbidity of Year 2007 and 2008 Top Ten Leading Causes of Morbidity of Year 2009 and 2010 Top Ten Leading Causes of Morbidity of Year 2011 and 2012

Factors Affecting Compliance of Mothers to Child Immunization . Problems Encountered by Health Centers to the Compliance of Child Immunization . . . . . . . .

49

LIST OF FIGURES

Figure 1 Schematic Diagram of the conceptual framework in determining the accomplishment and compliance of the immunization program in Tacloban City . . . . . . . . Map of Tacloban City . . . . . . .

Page

. .

9 22

Chapter I INTRODUCTION

Immunization has been one of the most significant and cost-effective publichealth interventions to decrease childhood morbidity and mortality. It prevents

debilitating illness and disability, and saves millions of lives every year. It is one of the reasons and key to reduce poverty, and improve human development. The contribution of immunization is especially critical to achieving the goal to reduce deaths among children under five years old. In preventive medicine, it is the process of rendering people immune to an infectious organism by inoculating them with a form of organism that does not cause severe disease but does provoke formation of antibodies. Immunization is done through various techniques, most commonly vaccination. Vaccines against microorganisms that cause diseases can prepare the body's immune system, thus helping to fight or prevent an infection. (wikipedia.org/immunization) Vaccines are the most effective protection against most diseases caused by viruses and related organisms because few antibiotics work against them. Vaccines have the power not only to save, but also to transform, lives giving children a chance to grow up healthy, go to school, and improve their life prospects (unicef.org). When vaccines are combined with other health interventions such as vitamin A supplementation, provision of deworming medicine and bed nets to prevent malaria immunization becomes a major force for child survival

(www.ncbi.nlm.nih.gov). According to the 2008 data from United Nations Children Fund (UNICEF), global effort to immunize children with vaccines against life-

threatening disease set a record high, reaching (106 million) and averting more than 2.1 million deaths along with countless episodes of illness and disability annually. However despite significant gains in recent years, some 23.5 million children (almost 20% of the children born each year) are not immunized, exposing them disabilities or premature death (unicef.org). Approximately three million children die each year of vaccinepreventable diseases. Recent estimates suggest that approximately 34 million children are not completely immunized, with almost 98% of them residing in developing countries (unicef.org). The eradication of small pox by vaccination is one of the greatest achievements of World Health Organization (WHO). Recognizing the serious problem of infectious childhood disease, and the benefits of immunization, WHO set up the Expanded Program on Immunization (EPI) with the goal of making immunization services available to all the world's children by 1990. It all supports program evaluation and field testing of improved equipment and methods. More children than ever before are being reached with

immunization: over 100 million children a year in 20052007. And the benefits of immunization are increasingly being extended to adolescents and adults providing protection against life-threatening diseases such as influenza, meningitis, and cancers that occur in adulthood. In developing countries, more vaccines are available and more lives are being saved. For the first time in documented history the number of children dying every year has fallen below 10 million the result of improved access to clean water and sanitation, increased immunization coverage, and the integrated delivery of essential health interventions. In the Philippines, which is one of the developing countries, a key method

10

of reducing morbidity and mortality is childhood immunization however in 2003, only 69% of Filipino children received all suggested vaccinations. Data from the 2003 Philippines Demographic Health Survey were used to identify risk factor for none and partial-immunization. Results of multinomial logistic regression analyses indicate that the mothers who have less education and who have not attended the minimally recommended four antenatal visits are less likely to have fully immunized children.(Bondy, 2009) The Expanded Program on Immunization (EPI) in the Philippines began in July 1979 and in 1986, made a response to the Universal Child Immunization goal. The four major strategies include: a) sustaining high routine Full Immunized Child (FIC) coverage of at least 90% in all provinces and cities, (b) sustaining the polio-free country for global certification, (c) eliminating measles by 2008, and (d) eliminating neonatal tetanus by 2008 (wikipedia.org/EPI). The country is still fighting in eliminating measles and neonatal tetanus though a large decline in measles cases has been recorded. Philippines is one of the countries included in 86% decline measles cases which is bringing closer to its elimination. (www.measlesrubellainitiative.org) The country was certified polio-free

since October 2000 through high OPV3 (Oral Polio Vaccine) immunization coverage and good surveillance for polio. The standard routine immunization schedule for infants in the Philippines is adopted to provide maximum immunity against seven vaccine preventable disease in the country before the child's first birthday. The fully immunized child must have completed BCG1(Bacillus Calmette-Gurin) , DPT1, DPT2, DPT3 (Diphtheria-Pertussis-Tetanus Vaccine), OPV1, OPV2, OPV3 (Oral Polio Vaccine), HB1, HB2, HB3 (Hepatitis B Vaccine), and measles vaccine before the child is 12 months of age.

11

Every Wednesday is designated as immunization day and is adopted in all parts of the country. Immunization is done monthly in barangay health stations, quarterly in remote areas of the country. Because measles kills, every infant needs to be vaccinated against measles at the age of 9 months or as soon as possible after 9 months as part of the routine infant vaccination schedule. It is safe to vaccinate a sick child who is suffering from a minor illness (cough, cold, diarrhea, fever or malnutrition) or who has already been vaccinated against measles (Measles: Catch up Campaign, 2007). If the vaccination schedule is interrupted, it is not necessary to restart. Instead, the schedule should be resumed using minimal intervals between doses to catch up as quickly as possible (Zimmerman, 2000). Vaccine combinations (few exceptions), antibiotics, low-dose steroids (less than 20 mg per day), minor infections with low fever (below 38.5 Celsius), diarrhea, malnutrition, kidney or liver disease, heart or lung disease, non-progressive encephalopathy, well controlled epilepsy or advanced age, are not contraindications to vaccination. Contrary to what the majority of doctors may think, vaccines against hepatitis B and tetanus can be applied in any period of the pregnancy (Management of the Traveler: Vaccination, 2007). There are very few true contraindication and precaution conditions. Only two of these conditions are generally considered to be permanent: severe (anaphylactic) allergic reaction to a vaccine component or following a prior dose of a vaccine, and encephalopathy not due to another identifiable cause occurring within 7 days of pertussis vaccination (Management of the Traveler: Vaccination, 2007). Only the diluents

supplied by the manufacturer should be used to reconstitute a freeze-dried vaccine. A sterile needle and sterile syringe must be used for each vial for adding the diluents to the

12

powder in a single vial or ampoule of freeze-dried vaccine (General Recommendations on Immunizations, 2007). The only way to be completely safe from exposure to bloodborne diseases from injections, particularly hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV) is to use one sterile needle, one sterile syringe for each child (Hoekstra, 2006). Despite of the efforts of the Department of Health with the help of UNICEF and WHO, several factors affect the way EPI is implemented on the country which is sometimes external. Some children does not undergo to the standard process of immunization and for that reason the community must be aware of the factors that affect the compliance of the said program.

General Objectives This particular study aims to determine the accomplishment and the factors affecting the compliance to immunization program in Tacloban City for the past ten years (2003-2012).

Specific Objectives Specifically, it seeks to; 1. Find out the rate of compliance to EPI in the said locale for the past ten years (2003-2012) 2. Identify the reasons affecting the compliance to the Expanded Program on Immunization and the current intervention scheme employed to comply it.

13

3. Determine if the seven immunizable diseases are still present as the leading causes of morbidity and mortality among children.

Significance of the Study This study tends to benefit the students, professors, medical practitioners, health providers/ administrators, future researchers. Students. The knowledge as to their field of specialization through the determination of strengths, limitations, and their capabilities in understanding critical concepts. Professors .The result of this study could provide awareness on the importance of the adhering to WHO standards by encouraging the students to cognizance of the adverse effect if there is no compliance to regulation set by policy-making bodies. Medical practitioners. This study may add insight to motivate them to strictly adhere to regulations coming from the government as immunization programs are concerned. Administrators. The findings of the study may bring into focus the importance of adhering to the regulations coming from the government regarding immunization compliance to EPI and how it should be implemented properly in Tacloban City. Future Researchers. The findings of the study will serve as springboard for other researchers who may wish to conduct investigations on related fields of concept.

14

Scope and Limitation of the Study This study limits itself to the City of Tacloban, Leyte. It only concerns with the status of immunization compliance to Expanded Program in Immunization for the past ten years (2003-2012) in the said locale. It is to be conducted in selected Barangay Health Centers in Tacloban City during the third quarter of 2012. A quantitative method is to be used in analyzing and interpreting the data.

Theoretical Framework The theoretical framework of this study is based in the noble idea of collectively promoting public health through state-funded programs. Public health includes four major areas: a.) promotion of positive health and vitality; b.) prevention of infectious and non-infectious diseases as well as injury; c.) organization and provision of services for diagnosis and treatment of illness; and d.) rehabilitation of the sick and differently able people to their highest possible level of function. In the Philippines, it refers to various health projects of the Department of Health (DOH) such as free immunization to those who may be prone to illnesses. The EPI could be most equitable of health programs, yet as shown in this study, reaching the most vulnerable children remains difficult and is expensive so that an intervention system must be formulated towards full compliance by means of new underutilized vaccine as well as proper education to he recipient on the disadvantages of participating in this program.

15

Conceptual Framework As human beings we are subjected to different types of illnesses once exposed to an etiologic agent and if circumstances would allow. Due to this fact, vaccines were developed to serve as protection and prevention against diseases such tuberculosis, measles, tetanus, pertusis, and Hepatitis B. However, even with the efforts of health organizations and the government in order to promote strict compliance regarding immunization, there is still certain part of the population who are unable to follow it. Here are some of the variables and basis for non-compliance as well the reason for its compliance to immunization: 1) Interest, 2) Economic Status, 3) Knowledge, 4) Accessibility, 5) Lifestyle, 6) Location, 7) Past Experience, 8) Culture, and 9) Behavior. Interest plays a role in a sense that subjects would have enough will to comply with these vaccinations. Economic status could influence the decision of the subjects to comply. Lack of resources would most likely result to poor compliance to this program. Knowledge is the key for the subjects compliance for the idea regarding its pros and cons are the basis to formulate a smart decision. Accessibility determines the ability of the subject to avail the said matter. If there is a lack of stimuli regarding variables, it would lead to poor compliance of mothers to secure for their childrens privileges; hereby making them more susceptible to illness, making them prone to diseases. But if adequate weight is pressed on these variables the likelihood of diseases prevention and health promotion are well preserved along favorable circumstances. In this study, the researchers believe that the factors mentioned above, which are the basis for compliance and non-compliance, has something to do with the level of

16

accomplishment and compliance of the immunization program. The independent variables are the factors affecting the compliance and non-compliance and the dependent variable is the result of the accomplishment and level of compliance to the immunization program in the said locale.

FACTORS AFFECTING COMPLIANCE AND NONCOMPLIANCE Interest, Economic Status, Knowledge Accessibility Lifestyle Location Past Experience Culture Behavior Others LEVEL OF ACCOMPLISHMENT AND COMPLIANCE OF THE IMMUNIZATION PROGRAM

Independent Variable

Dependent Variable

Figure 1. Schematic Diagram of the conceptual framework in determining the accomplishment and compliance of the immunization program in ` Tacloban City.

17

Definition of Terms Department of Health. It is a government agency in the Philippines which focuses on providing remedies to illnesses and other general health problems of the citizenry, performing such functions as vaccination programs, free tests of diseases and other form of medical assistance. Expanded Program on Immunization. It refers to the routine immunization program for infants to provide maximum immunity against the seven preventable diseases in the country before the childs first birthday. The EPI is a World Health Organization agenda with the goal to make vaccines available to all children through the world. The EPI began in the Philippines last 1986 in response to the Universal Child Immunization Goal. Fully Immunized Child. It means that a child has received one dose of BCG at birth or anytime before reaching 12 months. Three doses of DPT and OPV, with at least four weeks interval for each dose. The first dose given at six weeks after birth or thereafter, as long as the third dose is given before the child reaches 12 months. One dose of measles vaccine at the age of nine months or before 12 months. And three doses of HPV vaccine with at least four weeks interval. Immunization Compliance. Refers to the level of compliance as mandated by health agencies with regards to the full implementation of the governments immunization program among the population. It also denotes as the manner of fulfilling by health providers and other concerned agencies in implementing the EPI according to the standards and guidelines set by the WHO.

18

Morbidity. It is the incidence of ill health resulting from lack or absence of proper immunization. It could mean also as the relative frequency of occurrence of a particular disease in a certain diseases in a certain area. Mortality. It is an incidence of death in a particular population. Specifically, it is the number of deaths that occur at a given time, in a given group from a given cause. United Nations Childrens Fund. Nations Programme headquartered United Nations Children's Fund is a United York City, that provides long-

in New

term humanitarian and developmental assistance to children and mothers in developing countries. It is one of the members of the United Nations Development Group and its Executive Committee. World Health Organization. The trusted authority in directing and coordinating health issues within the United Nations' structure.

19

Chapter II REVIEW OF RELATED LITERATURE

History of Immunization and Vaccination To most people, gasping breath and typical sounds of cough; the iron lungs and braces designed for children paralyzed by polio; and other devastating effects caused by incurable diseases, these infectious scourges simultaneously arouse fear and represent obscure difficulties in the past years. Infectious diseases such as measles, diphtheria, smallpox, and pertussis topped the list of childhood killers. Fortunately, many of these devastating diseases have been contained, especially in industrialized nations, because of the development and widespread distribution of safe, effective, and affordable vaccines.(Meckel, 2004) The history of vaccines and immunization started with the story of Edward Jenner, a country doctor living in Berkeley, England, who in 1796 performed the worlds first vaccination (Baxby, 2001). Taking secretion from a cowpox lesion on a milkmaids hand, Jenner vaccinated an eight-year-old boy, James Phipps. Six weeks later Jenner gave a shot to on two sites of Phippss arm with smallpox, yet the boy was unaffected by this as well as subsequent exposures (Barquet, et. al., 1997). Based on twelve experiments and sixteen additional case histories he had collected since the 1770s, Jenner published at his own expenses a volume that quickly became a classic book in the history of medicine. It was entitled "Inquiry into the Causes and Effects of the Variolae Vaccine." His affirmation that the cow-pox protects the human constitution from the infection of smallpox laid the foundation for modern vaccinology (Jenner, 1798).

20

Although Jenners milkmaid experiments may now seem like pretty fables, they provided the scientific basis for vaccinology. This is all the more remarkable especially that our current conceptions of vaccine development and therapy are now much more encompassing and firmly rooted in the science of immunology. Until the bright French chemist Louis Pasteur developed what he called a rabies vaccine in 1885, vaccines referred only to cowpox injection for treatment of smallpox. Although what Pasteur actually produced was a rabies antitoxin that functioned as a post-infection antidote only because of the long incubation period of the rabies germ, he expanded the term beyond its Latin association with cows and cowpox to include all inoculating agents.(Hansen, 1998) Thus, Pasteur should largely be thanked for this era's definition of vaccine as a suspension of live or inactivated

microorganisms, like bacteria or viruses, or fractions thereof administered to induce immunity and prevent infectious disease or its sequelae( Advisory Committee on Immunization Practices and the American Academy of Family Physicians). Jenners initial experiments were done in a pregerm theory era that lacked modern methods of quality control and sterilization. Thus, the possibility of contamination constantly came out over the development of smallpox vaccine, and many people were wary of catching another dreadful disease from injection. With a method that often involved extracting lymph from pustules on the arms of those recently vaccinated, it was not uncommon for existing microorganisms to accompany the vaccine from arm to arm, spreading diseases such as erysipelas, syphilis, and scrofula (Baxby, 2001). Vaccines are biologic agents and can be interrupted during development. This makes it different from most drugs which are basically chemical agents. Whether killedvirus, whole-cell, bacterial, or live-attenuated, vaccines can be interrupted at different points down the trip from the laboratory to the vial. Sure enough, quality control,
21

sterilization, and monitoring have become consistent for vaccine production. Even with firm standards, however, the likelihood of contamination persists, although it is extremely less probable today than several decades ago. In addition, vaccine creation must be closely managed to guarantee that vaccines bring immunity and do not produce serious infection. For example, the hopefulness regarding the polio vaccine in spring 1955 was momentarily restrained following 200 children catching the disease from a vaccine that had live polio virus that was produced by Cutter Laboratories in California (Smith, 1991, Baker, 2000, and Johnston, 2004).

Immunization and Vaccination Understanding immunization requires the knowledge of our own body's immune system. The human body has two types of immune system, the specific immune system (also known as adaptive immune system or acquired immunes system) and the nonspecific immune system or the innate immune system. The nonspecific immune system and is the primary defense of the body. It includes the cells and means to protect the host from viruses, bacteria, and other foreign organisms in a non-specific manner. That is, the cells of the innate system distinguish and react to pathogens in a basic and standard manner, but unlike the adaptive immune system, it does not grant a long-term immunity to the host. Nonspecific defense by itself may not entirely clear an infection, and in some cases parasites can avoid nonspecific defense (Frank, 2002). The specific immune system is composed of highly specialized, systemic cells and processes that eliminate or prevent pathogen growth. It protects us against specific

22

non-self organisms and substances. It is an induced response, that is, it must be taught which things to attack. More technically, pathogen-specific receptors of acquired immunity are acquired through a somatic expression process during the lifetime of the organism (Frank, 2002). Although vaccination and immunization are frequently switched terms, especially in the nonmedical language, the latter is a more general term because it implies that the application or injection of an immunologic agent essentially ends in the development of sufficient immunity (Stern, et. al., 2005). Immunisation is the process of defending people against dangerous infections before they make contact with them. It does this by means of the bodys own natural defence system, the immune response. When you are immunised you are given a vaccine, usually as an injection, which contains a small dose of either a live but weakened form of a virus, or killed/inactivated virus or bacteria or parts of these organisms, or a toxin produced by an infectious organism. Vaccination just means having the injection. When you are vaccinated, your body produces an immune response, just as you would if you were exposed to the infection, but without having the symptoms, and this builds up your resistance to that infection. If you come into contact with that infection in the future, your immune system will respond fast enough to prevent you from developing the disease. Immunization is the means of providing specific protection against most common and damaging pathogens. The means of immunity depends on the site of the pathogen and also the mechanism of its pathogenesis. Thus, if the mechanism of pathogenesis involves exotoxins, the only immune mechanism effective against it would be neutralizing antibodies that would prevent its binding to the appropriate receptor and

23

promoting its clearance and degradation by phagocytes. Alternatively, if the pathogen produces disease by other means, the antibody will have to react with the organism and eliminate by complement-mediated lyses or phagocytosis and intracellular killing. However, if the organism is localized intracellularly, it will not be accessible to antibodies while it remains inside and the cell harboring it will have to be destroyed and, only then antibody can have any effect. Most viral infections and intracellular bacteria and protozoa are examples of such pathogens. In this case, the harboring cells can be destroyed by elements of cell mediated immunity or, if they cause the infected cell to express unique antigens recognizable by antibody, antibody-dependent and complement mediated killing can expose the organism to elements of humoral immunity. Alternatively, cells harboring intracellular pathogen themselves can be activated to kill the organism. Such is the case with pathogens that have the capability of surviving within phagocytic cells (Male, et. al, 2006). There are two types of immunization, active and passive immunization. Passive immunity may be acquired naturally or artificially. Naturally acquired passive immunity, occurs when immunity is transferred from mother to fetus. Artificially acquired passive immunity is immunity which is often artificially transferred by injection with gammaglobulins from other individuals or gamma-globulin from an immune animal. Passive transfer of immunity with immune globulins or gamma-globulins is used in numerous acute situations of infection (diphtheria, tetanus, measles, rabies, etc.), poisoning (insects, reptiles, botulism), and as a prophylactic measure (hypogammaglobulinemia). In these situations, gamma-globulins of human origin are preferable, although specific antibodies raised in other species are effective and used in some cases (poisoning, diphtheria,

24

tetanus, gas gangrene, botulism). While this form of immunization has the advantage of providing immediate protection, heterologous gamma-globulins are effective for only a short duration and often result in pathological complications (serum sickness) and anaphylaxis. Homologous immunoglobulins also carry the risk of transmitting hepatitis and HIV (Male, et. al., 2006). Active immunization refers refers to immunity produced by the body following exposure to antigens. Vaccination is an active form of immunization. There are also two types of active immunization, naturally acquired active immunity and artificially acquired active immunity. Naturally acquired active immunity is exposure to various pathogens which leads to sub-clinical or clinical infections then resulting in a protective immune response against these pathogens (Male, et. al., 2006). Artificially acquired active immunity, on the other hand, is immunization by administering live or dead pathogens or their components. Vaccines used for active immunization consist of live (attenuated) organisms, killed whole organisms, microbial components or secreted toxins (which have been detoxified) (Male, et. al., 2006).

State of the Worlds Vaccines and Immunization Since the Millennium Summit in 2000, one of the dynamic forces behind attempts to reach the Millennium Development Goals (MDGs) is immunization, particularly, the goal to reduce deaths among children under five years old. In addition, increasing number children are being immunized: over 100 million children a year in 20052007. And the gains of immunization are gradually being expanded to adolescents and adults. This

25

provides protection against life-threatening diseases such as influenza, meningitis, and cancers that occur in adulthood (WHO, UNICEF, and The World Bank, 2009). In developing countries, more vaccines are accessible and more lives are being saved. For the record in known history, the number of children dying every year has fallen below 10 million. This is due to the improved access to clean water and sanitation, increased immunization coverage, and the integrated delivery of essential health interventions (WHO, UNICEF, and The World Bank, 2009). Creation and improvement of vaccines are being done while some are by now in the late stages of clinical testing, making this decade the most productive in the history of vaccine development. More money is available for immunization through innovative financing mechanisms. And more creative energy, knowledge, and technical know-how are being put to use through the development of public-private partnerships which were forged to help advance the immunization-related global goals.(WHO, UNICEF, and The World Bank, 2009) Yet despite extraordinary progress in immunizing more children over the past decade, in 2007, 24 million children almost 20% of the children born each year did not get the complete routine immunizations scheduled for their first year of life. Reaching these vulnerable children typically in poorly-served remote rural areas, deprived urban settings, fragile states, and strife-torn regions is essential if the MDGs are to be equitably met (WHO, UNICEF, and The World Bank, 2009).

26

Immunization in the Philippines The Philippines through the Department of Health has implemented the Expanded Program on Immunization (EPI) which was established in 1976 to ensure that infants/children and mothers have access to routinely recommended infant/childhood vaccines. Six vaccine-preventable diseases were initially included in the EPI: tuberculosis, poliomyelitis, diphtheria, tetanus, pertussis and measles. In 1986, 21.3% fully immunized children less than fourteen months of age based on the EPI Comprehensive Program review (DOH, www.doh.gov.ph). Immunization rates in the Philippines have steadily been rising from 1990 until 1999. When the government changed its strategy of procuring vaccines in 2000, the coverage plummeted because the supplies were not delivered on time and inevitably resulted in stock shortage. In 2003, the government approved a new set of policies on the Expanded Program of Immunization (EPI) that included the procurement of vaccines through UNICEF. Complete immunization coverage for children below 2 years old reached almost 70 percent in 2003 (UNICEF, www.unicef.org). The value for Immunization, DPT (% of children ages 12-23 months) in Philippines was 87.00 as of 2010. Over the past 30 years this indicator reached a maximum value of 91.00 in 2008 and a minimum value of 47.00 in 1980 (WHO, www.who.int).

27

Chapter III METHODOLOGY

In this part of the paper will be on the discussion about the research design, locale of the study, instrumentation, data gathering procedure, and method of data interpretation employed in this study.

Research Design Analytic type of research was utilized in this study. The researchers focus on the accomplishment of the immunization program in the city with the data given by the health offices and with the information gathered from health centers in the city. The concepts of the research is to include the initial use of empirical generalizations and formal theory, which contains the factor affecting the program, to create questions and direction during the data collection process as well as the use of such academic viewpoints during the data analysis phase. The research also determines the extent of relationship between the given variables, on how the independent variables affect the success of the immunization program. The data that will be gathered will be analyzed and be correlated on the top ten leading causes of mortality and mortality.

Data Gathering There are two sets of data that will be gathered. The first one will come from the annual reports from the Tacloban City Health Office which contains the files and

28

documents regarding the Expanded Program on Immunization. The Health Offices in every town or city is required to keep record and information about the immunization program as part of the Department of Healths plan, together with WHO and UNICEF, to monitor the status of EPI in the different parts in the world including our country. The facts and figures that will be gathered in this office will be analyzed, be subject to comparative analysis, and be presented in the later parts of the paper. The second data is a small scale surveys on the ten existing health centers in Tacloban City which will answer a self-administered survey question regarding the factors that affect non-compliance to the immunization program. The data that will be gathered here are important to point out what affects the immunization program to its full accomplishment. This data will be correlated with the information gathered in the City Health Office regarding EPI.

Research Locale The locale of the study is the City of Tacloban, Leyte which is the capital of the province. The total population according to the 2010 census is 221,174 inhabitants. Number of Families counts at 47,014 with an Average Household Size of 5.1. Majority of the people in the are speaks Waray-Waray. Tacloban is culturally and linguistically diverse. Todays population consists of a mix of Spanish and Chinese mestizos, foreign expatriates and native Leyteos. The average recorded births every year in the past ten years is 5,936 according to the gathered in the City Health Office. The EPI had been followed by city since its implementation and had been rumored that it has high accomplishment regarding the
29

completion of the program. The health centers in which the data from the survey will be gathered are also present in the locale. In the next page is the map of the City of Tacloban.

Figure 2. Map of Tacloban City

Instrumentation The survey questionnaire used was a self-administered one which is to be answered by the respondents present in the health offices. It is composed of the Factors or Reasons Affecting the Non-compliance to the Immunization Program in which the researchers
30

asked to mark the factors or reasons that affect the non-compliance to the immunization program. This ranges from Interest, Economic Status, Knowledge, Accessibility, Lifestyle, Location, Past Experience, Culture, to Behavior. If the respondents answer is not included in the choices then he is given the option to specify it.

Statistical Analysis Statistical tools were used in this research in order to achieved and interpret the data gathered from different sources. In determining the overall accomplishment of the immunization program in the locale, the formula in finding the mean was used. Where:

= total sum of al data values n = number of data items in sample

Another significant method used in the research was determining the mortality and morbidity rate to know the top ten leading causes of mortality and morbidity in the locale. Rate was determined through the following formula:

Where: N (for mortality) = number of deaths from the specified cause (for morbidity) = number of people with illness from specified cause n = total population

31

32

CHAPTER IV RESULTS AND DISCUSSIONS

This part of the paper will interpret and discuss the results gathered by the researchers regarding the level of accomplishment to immunization program in Tacloban City. In this chapter also the data regarding the level of accomplishment would be correlated with the ten leading causes of mortality and morbidity. Consequently, the factors affecting the compliance and non-compliance to the immunization program will be illustrated.

Accomplishment of the Immunization Program in Tacloban City The accomplishment to the program will be analyze through the data and records obtained by the researchers in the City Health Office. Table 1 shows the total live births in Tacloban City for the past ten years which has an average of 5885. With this number an average of 5027 or 85 percent was fully immunized children. This only illustrates that in the past ten years there was a high level of compliance to the immunization program in Tacloban City. Only 15 percent of the live births or eligible population in the past ten years had been recorded to have not complied with the said program. However a trend was seen regarding the observance of fully immunizing once child as years pass by. The data recorded in the table shows that as years goes by the compliance to immunization is declining. As it can be observed, from year 2003 to 2005, a very high percentage of 96.00 percent was documented which only show that strict

33

implementation the EPI program was being made. On the other hand, in 2009 the percentage dropped to 60 percent, from the high percentage in 2003 it went down with almost 30 percent which can be a clear implication that the implementation of the program had been low. Recently the compliance had been able to rise up in the scales since in 2012 it had been 86.00 percent.

Table 1. Records of Livebirths and Fully Immunized Child Eligible Population Year (Livebirths) 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 Total Average 5469 5668 5748 5829 6169 5864 5765 5874 6426 6041 58853 5885 Fully Immunized Children (9-11 months) 5270 5438 5541 5183 5627 5127 3515 4519 4875 5175 50270 5027 96.00 96.00 96.39 89.00 91.00 87.00 60.97 79.00 76.00 86.00 857.36 85.73

Percentage

34

Table 2 illustrates that there is a high compliance regarding the immunization with BCG. The average percentage shown is over hundred percent. The reason for this is the fact that once a newborn is delivered, BCG is assured. Since this is routinely given for every newborn child deliveries in hospitals plus the out-patient department. The only discrepancy that can be seen is the low percentage on the year 2012 which was only 78%. Very low compared with the other years (almost always one hundred percent).

Table 2. Compliance with the BCG Immunization Eligible Population Year (Live Births) 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 Total Average 5469 5668 5748 5829 6169 5864 5765 5874 6426 6041 58853 58853 BCG (Bacillus CalmetteGurin) 6012 6193 6243 6654 7013 6382 5415 6500 6426 4996 61834 6183 Percentage

109.92 109.00 109.00 114.00 114.00 109.00 92.48 111.00 97.00 78.00 1043.4 104.34

35

Table 3 shows a high level of compliance with the measles vaccine. Data shows that it has been consistent with its implementation. The only low point was when in 2009 when it hits a low 70 percent. But overall the compliance regarding measles vaccine has been high and well.

Table 3. Compliance to the Measles Immunization Eligible Population Year (Live Births) 2003 2004 2005 2006 2007 2008 2009 2010 2011 Total Average 5469 5668 5748 5829 6169 5864 5765 5874 6426 58853 5885 5469 4919 5767 5451 6045 5583 4064 4652 5096 52221 5222 100.00 86.78 100.00 93.51 98.00 95.00 70.44 79.00 79.00 887.73 88.73 MEASLES Percentage

36

Table 4 demonstrates compliance to the DPT immunization in the past ten years. Since there are three processes for the vaccination for DPT the level of compliance will be discussed separately and be compared. On the first, DPT-1, a high percentage was recorded. An average of 97.15 percent was recorded. As shown in the table, mostly the percent for accomplishment in 2003 to 2011 is over ninety. Only last year when hits low, 76 percent. Overall, there was a high compliance to the DPT immunization. DPT-2 has a 90.26 percent; many of the children from the first process came back for the second. Only seven percent did not have the second DPT, overall it was a high level of compliance for the second part in comparison with the first. A 92.27 percent have been analyzed in comparison with the percentage that came back for the second stage (5307/5722) which can be seen as high relative to DPT-1. The record regarding DPT-3 shows a declining rate in compliance. In 2008 the City Health Office recorded an amazing 98 percent of children who took DPT-3, however after a year it turned down to 77.06 percent only. Viable reasons for this are. The development was also show in the following years which also recorded below 80 percentages. 12 percent in overall were the children recorded who have not been fully immunized wit DPT. Reasons for these decrease will be analyze when the researchers interprets the data regarding the factors that affect non-compliance to the program.

37

Table 4. Compliance to the DPT Immunization Eligible Population (Live Births) 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 Total Average 5469 5668 5748 5829 6169 5864 5765 5874 6426 6041 58853 5885 5147 5470 6231 6005 6351 6266 5245 5781 6114 4610 57220 5722 94.11 96.5 108 103 103 107 90.98 98 95 76 971.59 97.15 5149 5713 5541 5653 5678 5758 4655 5120 5347 4464 53078 5307 94.13 100 96.39 97 92 98 80.74 87 83 74 902.26 90.26 5011 5328 5966 5683 5838 5765 4443 5874 4659 4592 53159 5315 91.62 94 104 97.49 95 98 77.06 79 73 76 8851.17 88.51

Year

DPT 1

Percentage

DPT 2

Percentage

DPT 3

Percentage

38

Table 5 indicates that a high compliance in the OPV immunization was observed since then. It can be inferred by the high percentages that were recorded. There are bottom lows like in year 2011 that from 83 percent of OPV-1, it suddenly hit to 69 percent in the 3rd stage. However only in that year where a large discrepancy was seen, the other years showed stability in the implementation for immunizing the eligible population. A 12 percent was recorded for not being fully-immunized with OPV.

Table 5. Accomplishment in OPV Immunization Eligible Population (Live Births) 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 Total Average 5469 5668 5748 5829 6169 5864 5765 5874 6426 6041 58853 5995 5332 5341 6188 6020 6366 6506 5205 4683 5329 5511 56481 5648 97.49 95.81 98.00 103.00 103.00 97.15 90.28 97.00 83.00 91.00 955.73 95.57 5311 4814 5634 5645 5766 5804 4719 5196 4798 5204 52891 5289 96.63 84.93 98.00 97.00 93.00 86.71 81.85 88.00 75.00 86.00 887.12 88.71 5458 5402 5850 5612 5861 5794 4495 4699 4465 4986 52622 5262 99.79 95.30 102.00 96.27 95.00 86.59 77.97 80.00 69.00 83.00 884.92 88.49

Year

OPV-1

Percentage

OPV-2

Percentage

OPV-3

Percentage

39

Table 6 illustrates the findings regarding the accomplishment of HEPA immunization. Of all the immunization trends, HEPA was the one which took a different route. It has the lowest of overall accomplishments and actually started with low percentages unlike the past four vaccines which have high compliance in year 2003 to 2005. Only 75.99 percent was recorded in 2003 which dropped down to 67.98 percent on the third stage. Same movement was observed in the following years up to 2005. Strong compliance was then documented starting 2006 to 2011. From stage 1 to 3 a good turn-in can be seen. Stage one recorded 106 percent at most in these years. Awareness of the disease HEPA might be the reason for this. In these years, was the breakthrough in which news about the disease spreading prompt the people to have its vaccines. The City Health Office took the chance and campaigned for the strong implementation of the immunization program. The most remarkable point in the data was in 2012 where it had been able to record a low compliance in all stages. Starting from 71.01 percent, then 54.00, and ending with 50.00 percent. The lowest percentage recorded so far in ten years. Almost a 30 percent turn-out was recorded from stage-one to three. Hepatitis is one of the most difficult infections if not prevented. The very high turn-out recorded in 2012 must be addressed and give attention to be able to know its cause.

40

Table 6. Accomplishment in HEPA Immunization Eligible Population (Live Births) 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 Total Average 5469 5668 5748 5829 6169 5864 5765 5874 6426 6041 58853 5885 4156 4434 4175 5534 6556 6261 5682 5932 6762 4290 53782 5378 75.99 78.22 73.00 95.00 106.00 96.00 98.56 100.68 105.23 71.01 899.69 89.96 3829 4037 3630 5078 5481 5737 4790 5209 5560 3242 46593 4659 70.00 71.22 63.19 87.11 89.00 88.00 83.08 89.00 87.00 54.00 781.6 78.16 3718 4105 3581 5070 5688 5635 4511 4962 5122 3022 45414 4541 67.98 72.42 62.29 87.00 92.00 86.47 78.24 84.00 80.00 50.0o 760.4 76.04 HEPAB1 HEPAB2 HEPAB3

Year

Percentage

Percentage

Percentage

41

Relationship Between the Accomplishment of the Immunization Program and Top Ten Causes of Mortality and Morbidity in Tacloban City This part of on the chapter will discuss the relationship between the mortality and morbidity rate to the accomplishment of the immunization program. The data above will be compared with the result gathered regarding mortality and morbidity. The researchers will look for a connection between the two variables. First the observations made in the results regarding the table. For the past ten years CP arrest had been the top leading cause of mortality in Tacloban City. Only in the last three years was CP Arrest reduced and did no appear in the table. Also frequent diseases that occur in the table are pneumonia, acute MI, diabetes, hypertension, and tuberculosis. With the result below following the tables that were analyzed, the only disease which can be correlated is tuberculosis which appears as one of the leading causes of deaths in Tacloban City. It is alarming to know that eventhough with the high compliance recorded regarding immunization with BCG which is over a hundred percent (See Table 2), it is still one of the leading causes of deaths in the locale. It maintains a spot at number five or six at most. This is the one that taints the immunization program. It must be discuss and put to notice on health officials so that reasons causing these result will be look upon to. On a lighter note, although Hepatitis B and neonatal Tetanus was recorded they were ranked low enough not to make in the top ten. This result would show that the implementation of the EPI program is successful and have good results for it prevented diseases like heap, polio, measles, and Diphtheria to spread. As shown in the table, the

42

seven-preventable diseases are not present in the leading causes of mortality except for tuberculosis. This only means a high accomplishment to the compliance of immunization program in Tacloban City in the specified years.

Table 7 to 11. Top Ten Leading Causes of Mortality in Tacloban City for the Each Past Ten Years Table 7. Top Ten Leading Causes of Mortality of Year 2003 and 2004 2003 Rank Causes/ Diseases CP Arrest Acute Respiratory Failure Cardiogenic Shock Central Brain Hernation Hypolemic Shock Pneumonia Deaths Rate 2004 Rank Causes/ Diseases Deaths Rate

1 2

818 51

456.58 28.37

1 2

CP Arrest Acute Respiratory Failure Pneumonia

579 178

322.10 99.02

18

10.01

84

46.73

15

8.34

Acute MI

83

46.17

12

6.67

Central Brain Hern. Multiple Organ Failure

52

28.92

Acute Hemorrhage Septis Shock Sepsis

11

6.11

Vehicular Accident Uremia

49

27.25

5.00

46

25.59

Multi Organ Failure

3.89

Diabetis Mellitas

36

20.02

43

Hepatic Ensephalopathy 9 Metabolic Enseplotitis Drowning 10 Asphyxia 5 2.78 10 Acute Renal Failure 27 15.02 6 3.33 9 Hypertensive, Severe 28 15.57

44

Table 8. Top Ten Leading Causes of Mortality of Year 2005 and 2006 2005 Rank Causes/ Diseases CP Arrest Multi Organ Failure Pneumonia Accidents Deaths Rate 2006 Rank Causes/ Diseases Deaths Rate

1 2

369 147

205.27 81.77

1 2

CP Arrest Pneumonia

1001 127

504.45 64.00

3 4

116 98

64.53 54.51

3 4

Hypertension Vehicular Accidents Diabetes Millitus PTB

101 78

50.90 39.30

5 6

Tubercolosis Acute Renal Failure Diabetes Mellitus Cerebro Vascular Diseases Viral Hepatitis

78 77

43.39 42.83

5 6

57 53

28.72 26.70

68

37.82

Stab/ Gunshot Wound Heart Diseases Kidney Diseases

53

26.71

49

27.25

46

23.18

39

21.69

Multi Organ Failure Uver Cirrhosis

41

20.66

10

Hypertension

38

21.13

10

Cancer

28

14.11

45

Table 9. Top Ten Leading Causes of Mortality of Year 2007 and 2008 2007 Rank Causes/ Diseases CP Arrest Pneumonia Neonatal deaths Cerebro Vascular Diseases Acute MI Deaths Rate 2008 Rank Causes/ Diseases Deaths Rate

1 2 3 4

798 54 34 26

402.15 27.21 17,13 13.10

1 2 3 4

CP Arrest Neonatal Deaths Pneumonia Acute MI

853 55 47 22

429.87 27.72 23.68 11.08

23

11.59

Heart Diseases Hypertension Pulmonary TB

18

9.07

6 7

Pulmonary TB Fetal Death in Uterus Stab Wounds Liver Cirrhosis Vehicular Accidents

21 19

10.58 9.57

6 7

Kidney Diseases Cerebro Vascular Diseases Stab Wounds Septicemia

15 14

7.56 7.06

8 9

10 9

5.03 4.53

8 9

11 9

5.54 4.53

10

CA stage IV Meningitis

4.03

10

CA Stage IV

3.53

46

Table 10. Top Ten Leading Causes of Mortality of Year 2009 and 2010 2009 Rank Causes/ Diseases CP Arrest Hypertension Pneumonia Acute MI Vehicular Accident Diabetes Septecemia Pulmonary TB Kidney Diseases Liver Cirrhosis Deaths Rate 2010 Rank Causes/ Diseases Deaths Rate

1 2 3 4 5

385 223 212 140 123

194.02 112.38 106.84 70.55 61.98

1 2 3 4 5

Pneumonia Acute MI Trauma Diabetes Hypertension

357 211 167 142 140

178.45 105.47 83.48 70.98 69.98

6 7 8 9

120 95 89 69

60.47 47.87 44.85 34.77

6 7 8 9

Pulmonary TB CHF Asthma CP Arrest

92 57 46 44

45.99 28.49 22.99 22.00

10

58

29.22

10

Dengue

36

18.00

47

Table 11. Top Ten Leading Causes of Mortality of Year 2011 and 2012 2011 Rank Causes/ Diseases Acute MI Pneumonia Hypertension Trauma Pulmonary TB Diabetes CHF G.I. Bleeding Kidney Disease Renal Failure 10 Liver Cirrhosis 45 20.34 10 Anemia 36 16.08 Deaths Rate 2012 Rank Causes/ Diseases Deaths Rate

1 2 3 4 5 6 7 8 9

473 267 123 96 93 85 64 63 55

213.85 120.71 55.61 43.40 42.04 188.00 28.93 28.48 24.87

1 2 3 4 5 6 7 8 9

Acute MI Diarrhea Trauma Hypertension Septecemia Kidney Diseases CHF G.I. Liver Cirrhosis

556 318 176 117 124 107 78 68 67

248.50 142.00 79.60 52.20 55.40 47.80 34.80 30.30 29.90

48

The tables below show the top ten leading causes of morbidity in Tacloban City for the past ten years. As observed from the table URTI is the leading cause of morbidity in past earlier six years. It was then replaced by ARI in the last four. Reasons for the disappearance of URTI in the rankings may be for the strict prevention program and availability of the cure. Frequent diseases that are on the list of top ten are pneumonia, TB, dengue fever, diarrhea, animal bites, soft skin infections, and wounds. Pneumonia and diarrhea are also recorded as top ten leading causes of mortality. In correlation to the compliance to the seven-preventable diseases, only tuberculosis appears in the top ten leading causes of morbidity. The result is similar with mortality in which tuberculosis also appeared as one of its leading causes and consistently appear each year. This is only a clear indication that even with the high successful rate of compliance to BCG, many still dies with this disease. It can be seen as one of the leading diseases in the city that causes deaths to many. Cases of Hepatitis B and tetanus was also seen in the table but very far to be recognize as top leading causes of morbidity. The result regarding tuberculosis only shows that EPI must still be pursued intensively.

49

Tables 12 to 16. Top Ten Leading Causes of Morbidity in Tacloban City for the Past Ten Years Table 12. Top Ten Leading Causes of Morbidity of Year 2003 and 2004 2003 Rank Causes/ Diseases URT I Pneumonia UTI Diarrhea Animal Bites Whooping Cough Dengue Fever Wounds Deaths Rate Rank Causes/ Diseases URT I Pneumonia TB Dengue Fever Diarrhea Animal Bites 2004 Deaths Rate

1 2 3 4 5 6

4140 1915 1846 1034 606 510

2303.12 1065.33 1026.95 575.22 337.12 283.72

1 2 3 4 5 6

4514 2952 1130 738 732 660

2511.18 1642.23 628.63 410.56 407.22 367.16

7 8

501 445

278.71 247.56

7 8

Skin Trauma Soft Skin Infection Musculoskeletal Pain Bronchial Asthma

500 456

278.15 253.68

TB

421

234.21

422

234.76

10

Bronchitis

411

228.64

10

374

208.06

50

Table 13. Top Ten Leading Causes of Morbidity of Year 2005 and 2006 2005 Rank Causes/ Diseases URT I Musculoskeletal disorder Diarrhea TB Deaths Rate Rank Causes/ Diseases URT I ARI 2006 Deaths Rate

1 2

12370 2133

6881.55 1186.61

1 2

17833 3014

9920.67 1676.72

3 4

1232 784

685.37 436.15

3 4

Pneumonia Soft Tissue Infection PTB Wound

1791 1064

996.35 591.91

5 6

ARI Bronchial Asthma Soft Tissues Infections Acute Tonsilitis Hypertensive Disorder Animal Bites

719 564

399.99 313.76

5 6

803 648

446.72 360.49

499

277.60

Bronchial Asthma Diarrhea Bronchitis

571

317.65

8 9

496 475

275.93 264.25

8 9

539 536

299.85 298.18

10

474

263.69

10

Animal Bites

527

293.18

51

Table 14. Top Ten Leading Causes of Morbidity of Year 2007 and 2008 2007 Ran k 1 Causes/ Diseases Death s 13203 Rate Ran k 1 Causes/ Diseases URT I 2008 Death s 4809 Rate

URTI

6081.0 0 4062.2 9 765.48

2214.9 1 1453.1 2 280.03

ARI

8820

ARI

3155

Soft Tissue Infection Muscuskeletal Pain HPN/HCVD

1662

Soft Tissue Infection Pneumonia

608

1257

578.95

461

212.33

1041

479.46

HCVD Muscuskeleta l Pain

321

147.85

6 7 8

Loss of Appetite Pneumonia Headache

945 889 887

435.25 409.45 408.53

6 7 8

EENT TB Bronchial Asthma Loss of Appetite GIT

258 221 214

118.83 101.79 98.56

EENT

806

371.22

211

97.18

10

Ostee/Rheumatoi d Arthritis

693

319.18

10

193

88.89

52

Table 15. Top Ten Leading Causes of Morbidity of Year 2009 and 2010 2009 Rank Causes/ Diseases ARI Acute Bronchitis Chronic Bronchitis Rheumatic Arthritis HCVD Soft Tissue Skin Infection Pneumonia Bronchial Asthma Headache Deaths Rate 2010 Rank Causes/ Diseases Deaths Rate

1 2

2158 2155

975.70 974.35

1 2

ARI Chronic Bronchitis Acute Bronchitis

1935 1863

874.88 842.32

2016

911.50

759

343.17

1311

592.75

Soft Tissue Infections HCVD Pneumonia

1159

524.02

5 6

894 860

404.21 388.83

5 6

741 683

335.03 308.81

7 8

617 415

278.97 187.64

7 8

Rheumatic Art Systematic Viral Infections Headache Wound PTB

574 362

259.52 163.67

350

158.25

298

134.74

10

Loss of appetite

349

157.79

10

223

100.83

53

Table 16. Top Ten Leading Causes of Morbidity of Year 2011 and 2012 2011 Rank Causes/ Diseases ARI Deaths Rate Rank Causes/ Diseases Systematic Viral Infectiom ARI 2012 Deaths Rate

4260

1962.06

1193

549.47

Systematic Viral Infection Acute Bronchitis Soft Tissue Skin Infection HCVD AURI Pneumonia

1910

879.70

897

413.14

1595

734.62

Pneumonia

904

416.36

1300

598.75

Scabies

402

185.15

5 6 7

589 519 451

271.28 239.04 207.72

5 6 7

Essential HPN Wound Bronchial Asthma Impetigo

264 178 173

121.59 81.98 79.68

Bronchial Asthma Diarrhea PTB

371

170.87

150

69.09

9 10

269 250

123.90 115.14

9 10

Allergic Rhinitis PTB

117 109

53.89 50.20

54

Factors Affecting the Compliance to the Immunization Program In this part the researchers will discuss the different factors that affect the compliance to the immunization program. These are one of the reasons why there is still percentage left who does not comply with the necessary process in immunizing ones child. Ten health care centers where interviewed and surveyed in the research locale regarding the current study. Table 17 shows the most common grounds that affects compliance of mothers to her childs immunization. These are lack of knowledge, wrong perception, location of health center, unpleasant experience, economic expense, lack of trust to the healthcare provider, socio-economic differences, and some other reasons that the respondents have specified. Lack of knowledge and wrong perception regarding immunization are the factors which have the highest frequency. This only inform us that there are still mother who lack the necessary orientation regarding the importance of her childs immunization which may result to more drastic problems. The other one is the misconception of the mothers regarding immunization, this can be accounted also for the lack of orientation or beliefs of the mother that having their child undergoes these vaccinations would only threaten their offsprings health. Some mothers affected by our old culture does not rely on modern medicine and believe that this prevention is harmful to their children. These beliefs and wrong notions can be cured by proper orientation and advocacies on mothers regarding the seven-preventable diseases and the goodness immunization can bring. Other factors although have low frequencies but significant as well came from unpleasant experience, economic expense and socio-economic differences. These can also affect the compliance to immunization. Unpleasant experiences in complying are one
55

of the reasons why some mothers do not come back for the second or third stages which are important especially in DPT, OPV, and HEPA. Turn-outs which were recorded in the earlier tables can be effect of the following factors especially the last four. When unpleasant experience happens together with lack of trust to the healthcare provider then there is a high probability for the mother and child to return for the second process. Clients and patients should be treated well enough and be assured that everything is alright for them to trust and come back o fully immunize the child. Other reasons cited was busy, not-prioritized, they sees it as a burden, and laziness.

Table 17. Factors Affecting Compliance of Mothers to Child Immunization Factors Affecting Compliance of Mothers to Child Immunization lack of knowledge wrong perception / misconception of mothers regarding Immunization Location of the health center unpleasant experience economic expense lack of trust to the healthcare provider socio-economic differences Frequency 9 8 2 4 4 2 4

Table 18 indicates the problems encountered by health centers to the compliance of child immunization. The difficulties cited were lack of supply, absent health care provider, no permanent or fixed schedule, lack of support from the government, and infrastructural defect. The result of this survey and interview is very important because it does not only refers to us the health centers as a whole but also as an independent provider. This reflects also the situations in each health centers. The table shows that the most common problem health centers faces are the lack of supply in implementing the program. This is one of the greatest dilemma, many
56

programs have failed because of the lack of supply needed to sustain it. This problem has to be addressed more by the providers and especially the government who is supporting this. Saving young ones and health must be on the top of the list on the programs the government must have its attention to. Table 18. Problems Encountered by Health Centers to the Compliance of Child Immunization Problems Encountered by Health Centers to the Compliance of Child Frequency Immunization lack of supply 8 absent healthcare provider 3 no permanent schedule 3 lack of support from the government 2 infrastructural defect 0 CHAPTER V SUMMARY AND CONCLUSION

With the acquired data and the analysis done, we can now safely conclude the study. it has been found out that the total live births in Tacloban City for the past ten years has an average of 5885. With this number an average of 5027 or 85 percent was fully immunized children. This only illustrates that in the past ten years there was a high level of compliance to the immunization program in Tacloban City. Only 15 percent of the live births or eligible population in the past ten years had been recorded to have not complied with the said program. However a trend was seen regarding the observance of fully immunizing once child as years pass by. The data recorded in the table shows that as years goes by the compliance to immunization is declining. As it can be observed, from year 2003 to 2005, a very high percentage of 96.00 percent was documented which only show that strict implementation the EPI program was being made. On the other hand, in 2009 the
57

percentage dropped to 60 percent, from the high percentage in 2003 it went down with almost 30 percent which can be a clear implication that the implementation of the program had been low. Recently the compliance had been able to rise up in the scales since in 2012 it had been 86.00 percent. The study has found out that there is a high compliance regarding the immunization with BCG. The average percentage shown is over hundred percent. The reason for this is the fact that once a newborn is delivered, BCG is assured. Since this is routinely given for every newborn child deliveries in hospitals plus the out-patient department. The only discrepancy that can be seen is the low percentage on the year 2012 which was only 78%. Very low comparing with the other years which was almost always one hundred percent. The study has also found out that there is a high level of compliance with the measles vaccine. Data shows that it has been consistent with its implementation. The only low point was when in 2009 when it hits a low 70 percent. But overall the compliance regarding measles vaccine has been high and well. On the first, DPT-1, a high percentage was recorded. An average of 97.15 percent compliance was recorded. DPT-2 has a 90.26 percent; many of the children from the first process came back for the second. Only seven percent did not have the second DPT. A 92.27 percent have been analyzed in comparison with the percentage that came back for the second stage (5307/5722) which can be seen as high relative to DPT-1. The record regarding DPT-3 shows a declining rate in compliance. In 2008, the City Health Office recorded an amazing 98 percent of children who took DPT-3, however after a year it turned down to 77.06 percent only. Viable reasons for this are. The

iii

development was also show in the following years which also recorded below 80 percentages. 12 percent in overall were the children recorded who have not been fully immunized wit DPT. Reasons for these decrease will be analyze when the researchers interprets the data regarding the factors that affect non-compliance to the program. Regarding OPV immunization, it has been found out that there is a high compliance in the said immunization. There were bottom lows like in year 2011 that from 83 percent of OPV-1, it suddenly hit to 69 percent in the 3rd stage. However only in that year where a large discrepancy was seen, the other years showed stability in the implementation for immunizing the eligible population. A 12 percent was recorded for not being fully-immunized with OPV. Of all the immunization trends, HEPA was the one which took a different route. It has the lowest of overall accomplishments and actually started with low percentages unlike the past four vaccines which have high compliance in year 2003 to 2005. Only 75.99 percent was recorded in 2003 which dropped down to 67.98 percent on the third stage. Same movement was observed in the following years up to 2005. Strong compliance was then documented starting 2006 to 2011. Awareness of the disease HEPA might be the reason for this. In these years, was the breakthrough in which news about the disease spreading prompt the people to have its vaccines. The City Health Office took the chance and campaigned for the strong implementation of the immunization program. The most remarkable point in the data was in 2012 where it had been able to record a low compliance in all stages. For the past ten years CP arrest had been the top leading cause of mortality in Tacloban City. Only in the last three years was CP Arrest reduced. Tuberculosis was

iv

found as one of the leading causes of deaths in Tacloban City. It is alarming to know that even though with the high compliance recorded regarding immunization with BCG which is over a hundred percent, it is still one of the leading causes of deaths in the locale.. It must be discussed and put to notice on health officials so that reasons causing these result will be look upon to. On a lighter note, although Hepatitis B and neonatal Tetanus was recorded they were ranked low enough not to make in the top ten. This result would show that the implementation of the EPI program is successful and have good results for it prevented diseases like heap, polio, measles, and Diphtheria to spread. This means that a high accomplishment to the compliance of immunization program in Tacloban City in the specified years. It has also been observed that URTI is the leading cause of morbidity in past six years. It was then replaced by ARI in the last four. Frequent diseases that are on the list of top ten are pneumonia, TB, dengue fever, diarrhea, animal bites, soft skin infections, and wounds. Pneumonia and diarrhea are also recorded as top ten leading causes of mortality. In correlation to the compliance to the seven-preventable diseases, only tuberculosis appears in the top ten leading causes of morbidity. The result is similar with mortality in which tuberculosis also appeared as one of its leading causes and consistently appears each year. This is only a clear indication that even with the high successful rate of compliance to BCG, many still die with this disease. The result regarding tuberculosis only shows that EPI must still be pursued intensively. The most common grounds that affects compliance of mothers to her childs immunization are lack of knowledge, wrong perception, location of health center,

unpleasant experience, economic expense, lack of trust to the healthcare provider, socioeconomic differences, and some other reasons that the respondents have specified. Lack of knowledge and wrong perception regarding immunization are the factors which have the highest frequency. This only inform us that there are still mother who lack the necessary orientation regarding the importance of her childs immunization which may result to more drastic problems. The other one is the misconception of the mothers regarding immunization, this can be accounted also for the lack of orientation or beliefs of the mother that having their child undergoes these vaccinations would only threaten their offsprings health. Some mothers affected by our old culture does not rely on modern medicine and believe that this prevention is harmful to their children. These beliefs and wrong notions can be cured by proper orientation and advocacies on mothers regarding the seven-preventable diseases and the goodness immunization can bring. Other factors although have low frequencies but significant as well came from unpleasant experience, economic expense and socio-economic differences. Unpleasant experiences in complying are one of the reasons why some mothers do not come back for the second or third stages which are important especially in DPT, OPV, and HEPA. When unpleasant experience happens together with lack of trust to the healthcare provider then there is a high probability for the mother and child to return for the second process. Clients and patients should be treated well enough and be assured that everything is alright for them to trust and come back o fully immunize the child. Other reasons cited was busy, not-prioritized, they sees it as a burden, and laziness. The study also found the problems encountered by health centers to the compliance of child immunization. The difficulties cited were lack of supply, absent

vi

health care provider, no permanent or fixed schedule, lack of support from the government, and infrastructural defect. The table shows that the most common problem health centers faces are the lack of supply in implementing the program. This is one of the greatest dilemma, many programs have failed because of the lack of supply needed to sustain it. This problem has to be addressed more by the providers and especially the government who is supporting this. Saving young ones and health must be on the top of the list on the programs the government must have its attention to.

vii

BIBLIOGRAPHY Books Stern A.M. and Markel H., (2005): The History Of Vaccines And Immunization: Familiar Patterns, New Challenges, Health Affairs, 24, no.3 611-621 doi: 10.1377/hlthaff.24.3.611 D. Baxby, "Jenners Smallpox Vaccine: The Riddle of Vaccinia Virus and Its Origin," (London: Heinemann Educational Books, 1981) D. Baxby, "Smallpox Vaccine, Ahead of Its Time," (Berkeley, U.K.: Jenner Museum, 2001) D. Baxby, "Vaccination: Jenners Legacy," (Berkeley, U.K.: Jenner Educational Trust, 1994) D. K. Male, Jonathan Brostoff, David B. Roth, and Ivan Roitt, "Immunology." 7th edition. UK: Elsevier 2006 J.S. Smith, "Patenting the Sun: Polio and the Salk Vaccine," (New York: Anchor Books, 1991) R.A. Meckel, Levels and Trends of Death and Disease in Childhood, 1620 to the Present, Children and Youth in Sickness and Health: A Handbook and Guide, Greenwood Press, 324. 2004 R.D. Johnston, Contemporary Anti-Vaccination Movements in Historical Perspective, in The Politics of Healing: Histories of Alternative Medicine in Twentieth-Century North America, ed. R.D. Johnston (New York: Routledge, 2004), 259286. Journal Articles "General Recommendations on Immunizations" (PDF). Epidemiology & Prevention of VaccinePreventable Diseases--The Pink Book 10th Edition. Centers for Disease Control and Prevention. 2007-02-14. Retrieved 2007-05-12. "Management of the Traveler: Vaccination". Travel Medicine. Portal de Sade Pblica. 1997. Retrieved 2007-05-12. "Measles (Catch Up Campaigns) - Toolkit for Volunteers". Health Initiative 2010. http://www.measlesrubellainitiative.org/portal/site/mi/menuitem.caedca62b84344 63c106 2b10133f78a0/?vgnextoid=dca7f4d85e0b9310VgnVCM10000089f0870aRCRD

viii

Advisory Committee on Immunization Practices and the American Academy of Family Physicians, General Recommendations on Immunization, Morbidity and Mortality Weekly Report 51, no. RR02 (2002): 34. African Red Cross & Red Crescent. Archived from the original on 2007-04-15. Retrieved 2007- 05-12. (11 page 4) B. Hansen, Americas First Medical Breakthrough: How Popular Excitement about a French Rabies Cure in 1885 Raised New Expectations for Medical Progress, American Historical Review 103, no. 2 (1998): 373418. Department of Health, Expanded Program on Immunization, DOH, Republic of the Philippines, accessed: Feb 25, 2013, http://www.doh.gov.ph/node/1067.html Department of Vaccines and Biologicals (2000-12). "WHO Recommendations for Diluents" (PDF). Vaccines and Biologicals Update (World Health Organization): pp. 3. Retrieved 2007-05-12. E. Jenner, "Inquiry into the Causes and Effects of the Variolae Vaccine," (London: Sampson Low, 1798), 45. Hoekstra, Edward. "Immunization: Injection Safety". UNICEF Expert Opinion (UNICEF). Retrieved 2007-05-12. J.P. Baker, Immunization and the American Way: Four Childhood Vaccines, American Journal of Public Health 90, no. 2 (2000): 199207 . Lymphoma Association (2011), Vaccinations and immunisation, Lymphoma Association retrieved:http://www.nhs.uk/ipgmedia/national/Lymphoma%20Association/Asset s/Vaccinationsandimmunisation(LA3Pages).pdf (02/16/2013) N. Barquet and P. Domingo, Smallpox: The Triumph over the Most Terrible of the Ministers of Death, Annals of Internal Medicine 127, no. 8, Part 1 (1997): 635642. S. A. Frank, "Immunology and Evolution of Infectious Disease," Princeton University Press 2002 UNICEF, Children's Rights, UNICEF, accessed: Feb 24 2013 http://www.unicef.org/philippines/childrensrights_8920.html#.US2HcDDYeM0 WHO, UNICEF, World Bank. State of the worlds vaccines and immunization, 3rd ed. Geneva, World Health Organization, 2009 retrieved: http://whqlibdoc.who.int/publications/2009/9789241563864_eng.pdf 02/20/2013 World Health Organization, Monitoring and Assessing Immunization Systems and Safety, WHO, accessed: Feb 24 2013, http://www.who.int/immunization_monitoring/routine/en/http://www.ncbi.nlm.ni h.gov/p mc/articles/PMC2980896/http://www.unicef.org/immunization/files/SOWVI_full _report english_LR1.pdf
ix

Zimmerman, Richard Kent (2000-01-01). "Practice Guidelines - The 2000 Harmonized Immunization Schedule". American Family Physician. Retrieved 2007-0512.[dead link]