# Vaccination Coverage and Associated Factors among Children Aged 12–23 Months in Debre Markos Town, Amhara Regional State, Ethiopia

Authors: Tenaw Gualu; Abebe Dilie
Journal: Advances in Public Health
 (2017)

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## Abstract

Introduction. Vaccination is the administration of a vaccine or a biological substance intended to stimulate a recipient’s immune system to produce antibodies or undergo other changes that provide future protection against specific infectious diseases.Objective. To determine vaccination coverage and associated factors among children aged 12–23 months in Debre Markos town 2016.Methods. Community-based cross-sectional study was employed among 288 mothers/caretakers to child (12–23 months) pair. Study populations were selected using systematic random sampling technique. Structured interviewer administered questionnaires were used to collect data. Variables with P value of less than 0.05 in multivariate analysis were considered as statistically significant at 95% CI.Result. About 264 (91.7%) of children were completely vaccinated. Male birth 3.24 (1.16–9.04), wanted pregnancy 2.89 (1.17–7.17), having at least two ANC follow-ups 4.04 (1.35–12.06), and short distance from vaccination site 3.38 (1.29–8.86) were found positively associated with complete immunization.Conclusion and Recommendation. There was relatively high immunization coverage in the study. Child’s sex, ANC follow-up, type of pregnancy, and distance from health institution were factors associated with complete vaccination. Preventing unwanted pregnancy and promoting ANC and postnatal follow-up should be strengthened. Vaccination sites should also be further expanded.


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## Body

## 1. Introduction

Vaccination is the administration of a vaccine, that is, a biological substance intended to stimulate a recipient’s immune system to produce antibodies or undergo other changes that provide future protection against specific infectious diseases. Immunization is the stimulation of changes in the immune system through which that protection occurs [1].The Expanded Program on Immunization (EPI) was established by the World Health Organization in 1974 to control vaccine preventable diseases. In Ethiopian, EPI program was launched in 1980 [2]. It was launched with the aim of reducing mortality and morbidity of children and mothers from vaccine preventable diseases. The target group when the program started were children under two years of age until it changed to under one year in 1986 to be in line with the global immunization target [3].In a study conducted in Ethiopia, it was found that 73.2% of the children were fully immunized, 20.3% were partially immunized, and 6.5% received no vaccine [4]. In another study conducted, 76% of the children were fully immunized. Dropout rate was 6.5% for BCG to measles, 2.7% for Penta 1 to Penta 3, and 4.5% for Pneumonia 1 to Pneumonia 3 [5].Vaccination is a highly effective method of preventing certain infectious diseases. Routine immunization programs protect most of the world’s children from a number of infectious diseases that previously claimed millions of lives each year [6].In Ethiopia, vaccine preventable diseases contribute substantially to under-five mortality as well as morbidity. Diarrhea (18%), pneumonia (18%), measles (1%), and meningitis are the leading causes of child mortality in the country [3].Ten currently available EPI vaccines in Ethiopia include (BCG, measles, DPT-HepB-Hib or pentavalent, rotavirus, pneumococcus vaccine (PCV), and OPV. Moreover, it is directed in the implementation guideline to introduce Inactivated Polio Virus (IPV), measles-rubella, meningitis, and yellow fever vaccines for less than one-year-old children [2].However, many factors are linked to un/undervaccinated children. In Ethiopia, living in rural area and distance to health clinic, mothers with limited education, and socioeconomic capital are linked to low vaccine uptake and placing children at risk for vaccine preventable diseases [7]. Mother education, mothers’ perception to accessibility of vaccines, mothers’ knowledge to vaccine schedule of their site, place of delivery, and living altitude were independent predictors of children immunization status [4].As a result of the ten vaccines introduced, complementary with other interventions, many deaths due to vaccine preventable disease are being averted than ever before [3]. However, still related system-wide barriers are linked to incomplete vaccination or unvaccination of children.As a result, childhood immunization and associated factors should be targeted through educational research. This study was conducted to identify the current gaps and supplement the past studies. Thus, this study can be used as a reference for health care providers, health care educators, policy makers, and future researchers in this and/or related fields.


## 2. Objectives

The main objective is to determine vaccination coverage and associated factors among children aged 12–23 months in Debre Markos town, Amhara Regional State, Ethiopia, 2016.


## 3. Methods

### 3.1. Study Area

The study was conducted in Debre Markos town. Debre Markos is found in East Gojjam Zone of Amhara Regional State of Ethiopia.


### 3.2. Study Period

The study was conducted from August to September, 2016.


### 3.3. Study Design

Community-based cross-sectional study design was used.


### 3.4. Source Population

The source population was all mothers/caretakers to children aged 12–23 months pair in Debre Markos town.


### 3.5. Study Population

The study population included all mothers/caretakers to children aged 12–23 months pair in Debre Markos town who fulfill the inclusion criteria.


### 3.6. Inclusion Criteria

The inclusion criteria were all mothers/caretakers to children aged 12–23 months pair who are permanent residents (for at least six months) in Debre Markos town.


### 3.7. Exclusion Criteria

(i)
Mothers/caretakers with missed immunization card
(ii)
Mentally/critically ill mothers/caretakers
(iii)
Not volunteering to participate/being unable to give required information


### 3.8. Sample Size

The sample size was determined by using single proportion formula, by using prevalence of complete immunization coverage in children as 22.9% from previous study conducted in Ethiopia [8], 95% CI, and 10% nonresponse rate. Hence, the sample size calculated was 298.


### 3.9. Sampling Procedure

There were seven kebeles in the town. All the seven kebeles were included in the study. At each kebele, households are selected by using systematic random sampling. The sample in each kebele is allocated proportional to the number of households. When two or more eligible mothers/caretakers to child pair were found, only one was included by lottery method.


### 3.10. Instrument and Personnel

Structured interviewer administered questionnaire was used to collect the data. It was adapted from previous researches done on similar title [4, 7, 9]. The questionnaire was first prepared in English and translated to Amharic and back to English to maintain the consistency of the content of the instrument. Seven nursing students participated as data collectors.


### 3.11. Data Quality Control

Orientation and training were given to data collectors regarding purpose of study and ethical issues. Pretest was done on 5% of the actual study subjects out of the study area. After pretest, vague terms and questions were discarded. The result of pretest is not included in the study result.


### 3.12. Data Processing and Analysis

The data was cleaned, coded, and entered in EpiData version 3.1 and transferred to SPSS version 20.0 for analysis. Descriptive and inferential statistics were used to present the data. Descriptive statistics like frequency and percentage were used to summarize the sociodemographic characteristics of the study participants. Variables showed statistical significant in bivariate analysis, that is,P value < 0.05, and were entered in the final model of multivariate analysis. And P value of less than 0.05 in multivariate analysis was considered as statistically significant at 95% CI.


### 3.13. Operational Definitions

Complete Vaccination. A child who received ten basic vaccines (one dose of BCG, three doses each of the DPT-HepB-Hib (pentavalent), three doses of polio vaccines, three doses of PCV, two doses of Rota vaccine, and one dose of measles vaccine before first birth date) is considered to be completely vaccinated.Incomplete Vaccination. A child who received some of the vaccines and/or not the full dose of the ten vaccines before first birth date is considered to have received incomplete vaccination.


### 3.14. Ethical Considerations

Ethical clearance was obtained from research and publication committee of Debre Markos University, College of Health Sciences. The purpose and importance of the study was explained to mothers and caregivers. And informed written consent was obtained from the mothers/caregivers of the children. Privacy and confidentiality was maintained throughout the study.


## 3.1. Study Area

The study was conducted in Debre Markos town. Debre Markos is found in East Gojjam Zone of Amhara Regional State of Ethiopia.


## 3.2. Study Period

The study was conducted from August to September, 2016.


## 3.3. Study Design

Community-based cross-sectional study design was used.


## 3.4. Source Population

The source population was all mothers/caretakers to children aged 12–23 months pair in Debre Markos town.


## 3.5. Study Population

The study population included all mothers/caretakers to children aged 12–23 months pair in Debre Markos town who fulfill the inclusion criteria.


## 3.6. Inclusion Criteria

The inclusion criteria were all mothers/caretakers to children aged 12–23 months pair who are permanent residents (for at least six months) in Debre Markos town.


## 3.7. Exclusion Criteria

(i)
Mothers/caretakers with missed immunization card
(ii)
Mentally/critically ill mothers/caretakers
(iii)
Not volunteering to participate/being unable to give required information


## 3.8. Sample Size

The sample size was determined by using single proportion formula, by using prevalence of complete immunization coverage in children as 22.9% from previous study conducted in Ethiopia [8], 95% CI, and 10% nonresponse rate. Hence, the sample size calculated was 298.


## 3.9. Sampling Procedure

There were seven kebeles in the town. All the seven kebeles were included in the study. At each kebele, households are selected by using systematic random sampling. The sample in each kebele is allocated proportional to the number of households. When two or more eligible mothers/caretakers to child pair were found, only one was included by lottery method.


## 3.10. Instrument and Personnel

Structured interviewer administered questionnaire was used to collect the data. It was adapted from previous researches done on similar title [4, 7, 9]. The questionnaire was first prepared in English and translated to Amharic and back to English to maintain the consistency of the content of the instrument. Seven nursing students participated as data collectors.


## 3.11. Data Quality Control

Orientation and training were given to data collectors regarding purpose of study and ethical issues. Pretest was done on 5% of the actual study subjects out of the study area. After pretest, vague terms and questions were discarded. The result of pretest is not included in the study result.


## 3.12. Data Processing and Analysis

The data was cleaned, coded, and entered in EpiData version 3.1 and transferred to SPSS version 20.0 for analysis. Descriptive and inferential statistics were used to present the data. Descriptive statistics like frequency and percentage were used to summarize the sociodemographic characteristics of the study participants. Variables showed statistical significant in bivariate analysis, that is,P value < 0.05, and were entered in the final model of multivariate analysis. And P value of less than 0.05 in multivariate analysis was considered as statistically significant at 95% CI.


## 3.13. Operational Definitions

Complete Vaccination. A child who received ten basic vaccines (one dose of BCG, three doses each of the DPT-HepB-Hib (pentavalent), three doses of polio vaccines, three doses of PCV, two doses of Rota vaccine, and one dose of measles vaccine before first birth date) is considered to be completely vaccinated.Incomplete Vaccination. A child who received some of the vaccines and/or not the full dose of the ten vaccines before first birth date is considered to have received incomplete vaccination.


## 3.14. Ethical Considerations

Ethical clearance was obtained from research and publication committee of Debre Markos University, College of Health Sciences. The purpose and importance of the study was explained to mothers and caregivers. And informed written consent was obtained from the mothers/caregivers of the children. Privacy and confidentiality was maintained throughout the study.


## 4. Result

### 4.1. Sociodemographic Characteristics of Parents

The study included a total of 298 eligible participants. Among this, 288 of participants voluntarily agreed to participate in this study. This made the response rate of the study to be 96.6%.Majority of the participants, 193 (67%), were in age groups between 26 and 35. The mean age of the participants was 30.01. And about 279 (96.9%) of the participants were Orthodox Christian followers (Table1).Table 1
Sociodemographic characteristics of parents in Debre Markos town, Amhara Regional State, North West Ethiopia, September 2016. (N=288).
Variables
Frequency (N)
Percentage (%)
Relation of the respondent to the child
Biological parent
269
93.4
Nonbiological parent
19
6.6
Age
15–25
61
21.2
26–35
193
67
36–45
34
11.8
Religious affiliation
Orthodox Christian
279
96.9
Muslim
5
1.7
Protestant
4
1.4
Marital status
Not married
17
5.9
Married
254
88.2
Divorced
11
3.8
Widowed
6
2.1
Ethnicity
Amhara
285
99
Oromo
1
0.3
Tigre
2
0.7
Educational status
Not educated
25
8.7
Primary education
36
12.5
High school
164
56.9
College/university
63
21.9
Occupational status
Employed
245
85.1
Non employed
43
14.9
Family size
≤3
68
23.6
>3
220
76.4
Household monthly income in Ethiopian Birr
<1000
18
6.3
1000–25000
42
14.6
>2500
228
79.1
Living condition
Both parents are alive
257
89.2
Mother only
12
4.2
Both parents are not alive
19
6.6


### 4.2. Characteristics of the Child

About 158 (54.9%) of the children were females and majority were first in birth order (Table2).Table 2
Characteristics of children aged 12–23 months in Debre Markos town, Amhara Regional State, North West Ethiopia, September 2016. (N=288).
Variables
Frequency (N)
Percentage (%)
Sex of the child
Male
130
45.1
Female
158
54.9
Average birth weight in grams
<1500
22
7.6
1500–2500
36
12.5
≥2500–4000
230
79.9
Birth order
First
131
45.5
Second
79
27.4
Third
64
22.2
Fourth
14
4.9


### 4.3. Obstetrics History

While about 260 (90.3%) of the mothers had ANC follow-up, 254 (88.2%) gave birth at health care institutions (Table3).Table 3
Obstetrics history of the mothers in Debre Markos town, Amhara Regional State, North West Ethiopia, September 2016. (N=288).
Variables
Frequency (N)
Percentage (%)
Gestational age in weeks
<32
1
0.3
32–36
16
5.6
37–42
262
91
≥42
9
3.1
ANC follow-up (at least two)
Yes
260
90.3
No
28
9.7
TT vaccination (at least two)
Yes
250
86.8
No
38
13.2
Place of delivery
Health institution
254
88.2
Home
34
11.8
Type of pregnancy
Wanted
227
78.8
Unwanted
61
21.2


### 4.4. Level of Vaccination

Among 288 children, 264 (91.7%) were completely vaccinated, 19 (6.6%) were partially vaccinated, and 5 (1.7%) were not vaccinated at all. The overall dropout rate was 5% (Table4).Table 4
Type of vaccines received by children aged 12–23 months in Debre Markos town, Amhara Regional State, North West Ethiopia, September 2016. (N=288).
Variables
Frequency (N)
Percentage (%)
BCG
Yes
278
96.5
No
10
3.5
Polio O
Yes
273
94.8
No
15
5.2
Polio 1
Yes
279
96.9
No
9
3.1
Polio 2
Yes
269
93.4
No
19
6.6
Polio 3
Yes
266
92.4
No
22
7.6
Penta 1
Yes
279
96.9
No
9
3.1
Penta 2
Yes
267
92.7
No
21
7.3
Penta 3
Yes
265
92
No
23
8
PCV 1
Yes
277
96.2
No
11
3.8
PCV 2
Yes
267
92.7
No
21
7.3
PCV 3
Yes
265
92
No
23
8
Rota 1
Yes
278
96.5
No
10
3.5
Rota 2
Yes
269
93.4
No
19
6.6
Measles
Yes
264
91.7
No
24
8.3About 274 (95.1%) of the mothers/caretakers perceived vaccination as important. The main reasons that respondents vaccinated their children were protection, immunity, and good health, prevention of infections, advice from professionals, and being compulsory, 272 (96.1%), 247 (87.3%), 17 (6%), and 2 (0.7%), respectively.


### 4.5. Factors Associated with Complete Immunization

Relation to the child, occupational status, child’s sex, type of pregnancy, place of delivery, ANC follow-up, knowledge of time of vaccination schedule, and distance from vaccination site were found to be significant on bivariate analysis. And child’s sex, type of pregnancy, ANC follow-up and distance from vaccination site were found to be associated with complete vaccination on multivariate analysis (Table5).Table 5
Factors associated with complete immunization of children aged 12–23 months in Debre Markos town, Amhara Regional State, North West Ethiopia, September 2016. (N=288).
Variables
Complete immunization
P value
Yes
No
COR (95% CI)
AOR (95% CI)
Relation to the child
Biological parent
249
20
3.32 (1.00–1.95)
Nonbiological parent
15
4
1
Occupational status
Employed
229
16
3.27 (1.30–8.21)
Unemployed
35
8
1
Child’s sex
Male
124
6
2.66 (1.02–6.91)
3.24
(1.16–
9.04)
∗
0.025
Female
140
18
1
1
Type of pregnancy
Wanted
213
14
2.98 (1.25–7.10)
2.89
(1.17–7.17)
∗
0.022
Unwanted
51
10
1
1
Place of delivery
Health institution
236
18
2.81 (1.03–7.66)
Home
28
6
1
ANC (at least 2 follow-ups)
Yes
242
18
3.67 (1.32–10.19)
4.04
(1.35–
12.06)
∗
0.012
No
22
6
1
1
Vaccination schedule
I know
228
16
3.17 (1.26–7.94)
I do not know
36
8
1
Distance from vaccination site
≤20 minutes
231
16
3.5 (1.39–8.82)
3.38
(1.29–
8.86)
∗
0.013
>20 minutes
33
8
1
1
1 = reference;P∗ value < 0.05 (significant).


## 4.1. Sociodemographic Characteristics of Parents

The study included a total of 298 eligible participants. Among this, 288 of participants voluntarily agreed to participate in this study. This made the response rate of the study to be 96.6%.Majority of the participants, 193 (67%), were in age groups between 26 and 35. The mean age of the participants was 30.01. And about 279 (96.9%) of the participants were Orthodox Christian followers (Table1).Table 1
Sociodemographic characteristics of parents in Debre Markos town, Amhara Regional State, North West Ethiopia, September 2016. (N=288).
Variables
Frequency (N)
Percentage (%)
Relation of the respondent to the child
Biological parent
269
93.4
Nonbiological parent
19
6.6
Age
15–25
61
21.2
26–35
193
67
36–45
34
11.8
Religious affiliation
Orthodox Christian
279
96.9
Muslim
5
1.7
Protestant
4
1.4
Marital status
Not married
17
5.9
Married
254
88.2
Divorced
11
3.8
Widowed
6
2.1
Ethnicity
Amhara
285
99
Oromo
1
0.3
Tigre
2
0.7
Educational status
Not educated
25
8.7
Primary education
36
12.5
High school
164
56.9
College/university
63
21.9
Occupational status
Employed
245
85.1
Non employed
43
14.9
Family size
≤3
68
23.6
>3
220
76.4
Household monthly income in Ethiopian Birr
<1000
18
6.3
1000–25000
42
14.6
>2500
228
79.1
Living condition
Both parents are alive
257
89.2
Mother only
12
4.2
Both parents are not alive
19
6.6


## 4.2. Characteristics of the Child

About 158 (54.9%) of the children were females and majority were first in birth order (Table2).Table 2
Characteristics of children aged 12–23 months in Debre Markos town, Amhara Regional State, North West Ethiopia, September 2016. (N=288).
Variables
Frequency (N)
Percentage (%)
Sex of the child
Male
130
45.1
Female
158
54.9
Average birth weight in grams
<1500
22
7.6
1500–2500
36
12.5
≥2500–4000
230
79.9
Birth order
First
131
45.5
Second
79
27.4
Third
64
22.2
Fourth
14
4.9


## 4.3. Obstetrics History

While about 260 (90.3%) of the mothers had ANC follow-up, 254 (88.2%) gave birth at health care institutions (Table3).Table 3
Obstetrics history of the mothers in Debre Markos town, Amhara Regional State, North West Ethiopia, September 2016. (N=288).
Variables
Frequency (N)
Percentage (%)
Gestational age in weeks
<32
1
0.3
32–36
16
5.6
37–42
262
91
≥42
9
3.1
ANC follow-up (at least two)
Yes
260
90.3
No
28
9.7
TT vaccination (at least two)
Yes
250
86.8
No
38
13.2
Place of delivery
Health institution
254
88.2
Home
34
11.8
Type of pregnancy
Wanted
227
78.8
Unwanted
61
21.2


## 4.4. Level of Vaccination

Among 288 children, 264 (91.7%) were completely vaccinated, 19 (6.6%) were partially vaccinated, and 5 (1.7%) were not vaccinated at all. The overall dropout rate was 5% (Table4).Table 4
Type of vaccines received by children aged 12–23 months in Debre Markos town, Amhara Regional State, North West Ethiopia, September 2016. (N=288).
Variables
Frequency (N)
Percentage (%)
BCG
Yes
278
96.5
No
10
3.5
Polio O
Yes
273
94.8
No
15
5.2
Polio 1
Yes
279
96.9
No
9
3.1
Polio 2
Yes
269
93.4
No
19
6.6
Polio 3
Yes
266
92.4
No
22
7.6
Penta 1
Yes
279
96.9
No
9
3.1
Penta 2
Yes
267
92.7
No
21
7.3
Penta 3
Yes
265
92
No
23
8
PCV 1
Yes
277
96.2
No
11
3.8
PCV 2
Yes
267
92.7
No
21
7.3
PCV 3
Yes
265
92
No
23
8
Rota 1
Yes
278
96.5
No
10
3.5
Rota 2
Yes
269
93.4
No
19
6.6
Measles
Yes
264
91.7
No
24
8.3About 274 (95.1%) of the mothers/caretakers perceived vaccination as important. The main reasons that respondents vaccinated their children were protection, immunity, and good health, prevention of infections, advice from professionals, and being compulsory, 272 (96.1%), 247 (87.3%), 17 (6%), and 2 (0.7%), respectively.


## 4.5. Factors Associated with Complete Immunization

Relation to the child, occupational status, child’s sex, type of pregnancy, place of delivery, ANC follow-up, knowledge of time of vaccination schedule, and distance from vaccination site were found to be significant on bivariate analysis. And child’s sex, type of pregnancy, ANC follow-up and distance from vaccination site were found to be associated with complete vaccination on multivariate analysis (Table5).Table 5
Factors associated with complete immunization of children aged 12–23 months in Debre Markos town, Amhara Regional State, North West Ethiopia, September 2016. (N=288).
Variables
Complete immunization
P value
Yes
No
COR (95% CI)
AOR (95% CI)
Relation to the child
Biological parent
249
20
3.32 (1.00–1.95)
Nonbiological parent
15
4
1
Occupational status
Employed
229
16
3.27 (1.30–8.21)
Unemployed
35
8
1
Child’s sex
Male
124
6
2.66 (1.02–6.91)
3.24
(1.16–
9.04)
∗
0.025
Female
140
18
1
1
Type of pregnancy
Wanted
213
14
2.98 (1.25–7.10)
2.89
(1.17–7.17)
∗
0.022
Unwanted
51
10
1
1
Place of delivery
Health institution
236
18
2.81 (1.03–7.66)
Home
28
6
1
ANC (at least 2 follow-ups)
Yes
242
18
3.67 (1.32–10.19)
4.04
(1.35–
12.06)
∗
0.012
No
22
6
1
1
Vaccination schedule
I know
228
16
3.17 (1.26–7.94)
I do not know
36
8
1
Distance from vaccination site
≤20 minutes
231
16
3.5 (1.39–8.82)
3.38
(1.29–
8.86)
∗
0.013
>20 minutes
33
8
1
1
1 = reference;P∗ value < 0.05 (significant).


## 5. Discussion

In this study, it was found that 91.7% of children were completely vaccinated, 6.6% were partially vaccinated, and 1.7% were not vaccinated at all and there is 5% overall dropout rate. The result showed increased vaccination coverage when compared to previous studies done in different areas [4, 7]. This may be due to increasing access of vaccination and community awareness from time to time.Adjusting for other factors, child’s sex was significantly associated with complete immunization. Males were three times more likely to be completely vaccinated 3.24 (1.16–9.04) when compared to females. The result is in line with previous study done in northern Ethiopia [5]. But in a study done in Iran, no correlation was detected between gender and immunization status [10]. The difference might from cultural differences between study populations.The type of pregnancy was another factor which predicts complete immunization. The odds of wanted pregnancy were two times more likely for complete immunization 2.89 (1.17–7.17) than unwanted pregnancy. The study is not congruent with previous study which showed no statistical association between immunization and wanted pregnancy [11].Another factor that affects complete immunization was ANC follow-up during pregnancy. Mothers who had at least two ANC follow-ups during pregnancy were four times more likely to vaccinate 4.04 (1.35–12.06) their children when compared to mothers who did not have ANC follow-up during pregnancy. This is in line with a study done previously in which there was inverse correlation between delayed vaccination and the number of periodical visits of health centers [12]. This might be because mothers during ANC visit would receive counseling and education about the importance of postnatal visits and activities.Distance of home from vaccination site was another predictive factor for children complete vaccination. Parents who are less than or equal to twenty minutes away from vaccination sites were three times more likely to vaccinate their children 3.38 (1.29–8.86) than parents who are more than twenty minutes away. But in a study done previously, no correlation was detected between vaccination delay time and distance from health centers [12].


## 6. Conclusion and Recommendation

There was relatively high immunization coverage in the study. About 91.7% were completely vaccinated, 6.6% were partially vaccinated, and 5 (1.7%) were not vaccinated at all and the overall dropout rate was 5%.Child’s sex, ANC follow-up during pregnancy, type of pregnancy. and distance from health institution were factors associated with complete vaccination of children.Preventing unwanted pregnancy through family planning and promoting ANC and postnatal follow-up should be strengthened.Vaccination sites should also be further expanded and accessible to the community. And health education should also be given largely to the community about the need to vaccinate all children.



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*Source: 5352847-2017-07-18.xml*