Rajiv Gandhi University of Health Sciences, Karnataka, Bangalore

“A STUDY ON ADULT IMMUNIZATION:PERCEPTIONS AND PRACTICES AMONG MEDICAL PRACTITIONERS REGISTERED IN SELECTED MEDICAL ASSOCIATIONS IN BANGALORE”

SYNOPSIS OF DISSERTATION SUBMITTED TO RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, BANGALORE

In partial fulfillment of the regulations for the award of M.D. Degree in Community Medicine

Submitted By DR. JAMEEL FATEMA, MBBS POST GRADUATE STUDENT IN COMMUNITY MEDICINE (M.D.)

Under the guidance of DR. SHASHIKALA MANJUNATHA, MBBS., MD.,D.I.H., PROFESSOR AND HEAD, DEPARTMENT OF COMMUNITY MEDICINE RRMC&H, KAMBIPURA, BANGALORE

DEPARTMENT OF COMMUNITY MEDICINE RAJARAJESWARI MEDICAL COLLEGE AND HOSPITAL, KAMBIPURA,BANGALORE-560074 2013

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA, BANGALORE. ANNEXURE - II

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

DR. JAMEEL FATEMA NAME OF THE CANDIDATE AND 1. ADDRESS (in block letters) #3,PG QUARTERS, RAJARAJESWARI MEDICAL COLLEGE,

KAMBIPURA,MYSORE ROAD,

BANGALORE-570074

NAME OF THE INSTITUTION RAJARAJESWARI MEDICAL COLLEGE 2. AND HOSPITAL,

KAMBIPURA, MYSORE ROAD,

BANGALORE-560074

COURSE OF STUDY AND 3. SUBJECT M.D. IN COMMUNITY MEDICINE

4. DATE OF ADMISSION TO 29-05-2013 COURSE

5. TITLE OF THE TOPIC

“A STUDY ON ADULT IMMUNIZATION:PERCEPTIONS AND PRACTICES AMONG MEDICAL PRACTITIONERS REGISTERED IN SELECTED MEDICAL ASSOCIATIONS IN BANGALORE”

6. BRIEF RESUME OF THE INTENDED WORK 6.1 INTRODUCTION:

“When meditating over a disease, I never think of finding a remedy for it, but, instead, a means of preventing it”. Louis Pasteur (1822-1895).

“The impact of vaccination on the health of the world’s people is difficult to exaggerate. No other modality, except sanitation and safe water, has had such a major effect on mortality reduction and population growth”,(Plotkin and Plotkin 1988).

Vaccines are among the greatest achievements of biomedical science and public health, stimulating protective immune responses against acute and chronic infectious diseases, as well as some infectious diseases that result in cancer. Globally, vaccination programs have made a major contribution to the elimination of many vaccine-preventable diseases and significantly reduced the incidence of others.

Vaccine preventable diseases cause unnecessary morbidity and mortality among adults1, while inadequate immunization results in unnecessary societal and economic costs, including missed time from school and work, physician office visits,hospitalizations. treatment, and loss of income. Keeping in view the statistical data1 of suffering costs related to the non-utilization of immunization in adults, the need of hour has come to emphasize its importance.

Infant/Childhood immunization is one of the top public health success stories of the 20th century. Childhood vaccination coverage is high for the EPI diseases and has resulted in decreased incidence2 of diphtheria,tetanus,pertussis,measles,mumps,rubella,child and adolescent tuberculosis,while polio is on the verge of eradication.

Adult immunization is a neglected and underpublicised issue in India.Non and underutilization of vaccines in the adult population is the rule.WHO and CDC 3 publish annually updated guidelines and recommendations for vaccination of adults 19 years and older, and most of developed and industrialized countries have well implemented4 it as a national policy5,India does not have a national programme for adult immunization.India has population of 1.2 million,and 60% are above 19 years age..

The rationale for adult immunization lies in the fact that unvaccinated, undervaccinated, immunocompromised and aging adults with waning immunity,with increasing antibiotic resistance,all remain at risk from infection,mobidity and mortality from the identified vaccine preventable diseases and hence may benefit from preventive vaccination. Also herd immunity provided by mass vaccination will protect community as a whole,specially the children contacts.

Maintenance of immunity against "childhood infectious diseases" preventable with vaccinations is a new challenge; measles, rubella and pertussis occur now quite often in adults: the risk of complications is higher in these ages (measles), or expose to specific risk (rubella in pregnant women); adults may even become the source of the contamination of younger people (many infants affected with whooping cough have contracted the disease from their own parents).

Adult immunizations are administered in primary series like previously immunized, booster doses and periodic doses. Agents include Toxoids (Diphtheria and Tetanus), Live Virus Vaccines (Measles, Mumps and Rubella), and inactivated virus vaccines (Influenza), Inactive viral particles (Hepatitis B), inactivated bacterial polysaccharide vaccine (Pneumococcal) and Conjugate / Polysaccharide vaccine (Meningococcal).

Catch-up immunization is advisable for adults seronegative for hepatitis B virus, while immunization against the hepatitis A and varicella viruses may benefit those who remain susceptible5. Among older adults, immunization against influenza and pneumococcal infections is likely to be beneficial in reducing morbidity and mortality. Certain vaccinations are also recommended for specific groups, such as rubella for women of child-bearing age, typhoid for those travelling to high endemicity areas, and several vaccines for high-risk occupational groups such as health care workers.

New vaccines targeted at cancer prevention,like human papilloma virus vaccine,hepatitis B vaccine, have emerged.specific vaccines for diabetic patients,dialysis patients are recommended. The Centers for Disease Control and Prevention’s (CDC , Atlanta) recommendations3,4 clearly identify people who are at risk for these diseases and who should be immunized to prevent these diseases and their complications.

However in the Indian scenario,API-Association of physicians of India,recommends the following vaccines for adults 19 years and older6. Cholera, Diptheria-Tetanus-Pertussis, HepatitisA, HepatitisB, Herpes Zoster, HPV, Influenza, Japanese Encephalitis, MMR, Meningococcal Meningitis, Pneumococcal pneumonia, Rabies, Typhoid, Varicella.

Adults are more susceptible to morbidity and deaths,even though the incidence may be low, due to the vaccine preventable diseases as compared to children.Yet the adult immunization rates are far lower than childhood immunization rates.This “vaccine gap” needs to be addressed as a health care priority.A mass adult immunization programme,based on the success of childhood immunization programme,needs to be taken up as a national health policy7.

NEED FOR THE STUDY:

In India, a developing country with very depressing figures8 of patient awareness rates, iniatiatives and contributions from health care provider services have a greater role in implementing adult immunization practices,rather than expecting from patient population. Medical practitioners form the corner stone of a successful Adult Immunization Programme as they simultaneously operate as source of Awareness,Recommendation and Implementation of adult vaccination7,9.

Family physicians and General physicians are specialists in preventive care and can be leaders in vaccinating adult patients against vaccine preventable diseases. Physicians recommendations to their patients to receive the vaccinations for which they are indicated is strongly related to a patient's receipt of these immunizations10.

Equally significant are the Obstetrician-Gynecologists , who are the primary, and sometimes only, contact with the healthcare system for many adult women and hence are uniquely positioned to provide vaccination services to the country's female population. obstetric and gynecologic practitioners can integrate immunization services into reproductive health care , an opportunity to offer vaccination to many women who otherwise might miss these recommended vaccines11.

Considerably enough literature is available from developed countries on adult immunization practices in medical practitioners, the awareness-recommendation levels and the barriers encountered in vaccinating patient population12,13,14,15,while in India very minimal studies have been done16.

Hence the present study is planned to assess the perceptions* and practices of adult immunization in medical practitioners-Family physicians, General physicians, Obstetricians and Gynaecologists,based in Bangalore.

*Perception-a way of regarding, understanding, becoming aware of or interpreting something; a mental impression: intuitive understanding and insight .(oxford dictionary).

6.2 RESEARCH QUESTION:

What are the perceptions and practices of Adult Immunization among Medical Practitioners registered with selected Medical Practitioners’ Associations in Bangalore?

6.3 REVIEW OF LITERATURE

The initiative for Adult Immunization was started by WHO, first published in 1990,and global initiatives taken since then have been successful in establishing national immunization programmes in many developed countries:USA4,7,Canada,Australia and many more.USA is conducting national adult immunization summit from past three years5.

CDC,Atlanta,publishes yearly update of recommended vaccines for all adults, and also specific age groups, specific health groups and specific settings-travellers and health care workers3.

API-Evidence based clinical practice guidelines on Adult Immunization in India6 ,have been a major breakthrough in this regard, recommended by “Expert Group Meeting for evolving Consensus Recommendations on Adult Immunization in India” jointly organized by the Association of Physicians of India and the Department of Medicine, All India Institute of Medical Sciences (AIIMS), New Delhi, at the AIIMS on December 6-7, 2008. The committee proposed that Recommended Consensus Guidelines should be reviewed every 3 years to incorporate modifications of any emerging research from our country.Expert Group also recommended that health care professionals should involve in operational research,overcoming the resource constrained settings in India,so that more indigenous evidence-based interventions can be generated for the benefit of population.

A study on knowledge about Tetanus Immunization among Doctors in Dehli,India,2005,by R.Kumar , concludes that 38.3% doctors favoured tetanus immunization,while the knowledge of immunization in children,pregnant women and adults was 75.5%, 90.8%,35.8% respectively.Knowledge on booster immunization was even poorer17.

A Cross-Sectional Study on the Knowledge of Hepatitis B Infection among Dental Professionals by Sowmya Kasetty Madhya Pradesh, India,2013,reveals that 58.21% dental professionals were ignorant about the investigation procedures & diagnosis of hepatitis. While 82.15%, 95.36%, 58.22% and 93. 93% had good knowledge about hepatitis infection and its transmission, vaccine, attitude towards HBV patients and post exposure prophylaxis respectively. However, the status of awareness among dental practitioners, postgraduate students and interns was found to be insignificant (p >0.05)18.

In a study on H1N1 vaciination profile of health care workers and medical students by Pandey 19conducted in Pune,India,it was observed that 58.5% doctors were immunized against influenza,while the awareness status was about 39.2%19.

A study on Attitudes and practices of obstetrician-gynecologists regarding influenza vaccination in pregnancy by Kissin DM , reported that majority of ob-gyns reported routinely offering both seasonal and 2009 H1N1 influenza vaccination to their pregnant patients (77.6% and 85.6%, respectively) during the 2009-2010 season; 21.1% and 13.3% referred patients to other specialists.Seasonal and 2009 H1N1 influenza vaccination during the first trimester was not recommended by 10.6% and 9.6% of ob-gyns, respectively11.

Influenza immunization rates, knowledge, attitudes and practices of health care workers in Iran by Zahra Khazaeipour reveals that most health care workers (80.6%) had received an influenza vaccination for the season,, and 65.4% intended to receive vaccination in the coming year. The knowledge score for the 35 items ranged from 0 to 34 (mean 17.37). Mean knowledge scores differed between educational levels13.

Family physicians beliefs and attitudes regarding adult pneumococcal and influenza immunization in Lebanon by Maya H Romani, reveals that accurate knowledge of influenza and pneumococcal vaccination guidelines was 58.1% and 53.5%, respectively. Thirty-eight physicians (88.4%) believe that influenza and pneumococcal vaccines are important, while 36 (83.7%) recommend influenza vaccine and 33 (76.7%) pneumococcal vaccine. Barriers for recommending vaccines were reported by 14 participants (32.5%)14. A study on Knowledge, Attitudes and Practices of General Practitioners in Karachi District Central about Tetanus Immunization in Adults,by S.I.Hamed ,observes that only 25% general practitioners had adequate knowledge about pre-exposure and13% both pre- and post-exposure tetanus immunization. All were ready to participate in any program to update their knowledge. Ninety seven percent were practicing only post-exposure immunization. Only 13% GPs advised their patients to complete three doses of TT after initial contact15.

6.4 AIM/OBJECTIVE OF THE STUDY:

1.To asses the Perceptions regarding Immunization of Adults -19 years and older, among Medical Practitioners of Selected Medical Practitioners’ Associations in Bangalore.

2.To assesss the Practices of Adult Immunisation among the Medical Practitioners of Selected Medical Practitioners’Association in Bangalore.

7. MATERIALS & METHODS:

7.1 SOURCE OF DATA: Selected group of Medical practitioners of Bangalore, relevant to the study, which include, 1.Family physicians registered with FPA:Family Physicians Association,Bangalore. 2.General physicians registered as members with API:Association of Physicians of India,Karnataka Chapter. 3.Obstetricians and Gynaecologists registered as members with BSOG:Bangalore Society of Obstetricians and Gynaecologists.

Inclusion Criteria: -Allopathic Medical Practitioners, -Residing and in Bangalore -Practising as Family Physicians, General Physician, Obstetricians and Gynaecologist -Registered with Respective Associations.

Exclusion Criteria: -Medical Practitioners from specialities other than those mentioned above. -Doctors who do not consent to participate in the study. 7.2 ESTIMATION OF THE SAMPLE SIZE:

Sample size:

The total population under study sums up to 1400, which includes 400 Family physicians,

400 General physicians and 600 Obstetricians and Gynaecologists, registered with the respective Associations,and Residing in Bangalore.

A study by R.Kumar17 on Tetanus immunization practices among doctors in Dehli, shows that the awareness level is 38.3% in the medical practitioners, lowest among the reviewed studies. Based on this study, expecting the same prevalence, and using the formula n=4pq/L2 , with an allowable error (L) = 15% of p i.e., 15% of 38.3=5.745, n=4x38.3x61.7 (5.745)2 =286.3 Hence the sample size is estimated as 286, rounded off to 290.

Sampling method: Three Medical Practitioners Associations,relevant to the study,are chosen. 1: Family physicians in Family Physicians Association,Bangalore. 2: General Physicians in Association of Physicians of India-Karnataka Chapter. 3:Obstetrics and Gynaecologists in Bangalore Society of Obstetricians and Gynaecologists. Using Proportional Probability Sampling Technique, the proportional sample size in each strata will be 83 Family physicians,83 General physicians and 124 Obstetricians and Gynaecologists,who will be selected from the official list obtained from the Respective Associations,by simple random sampling,using random number table.

7.3 METHOD OF COLLECTION OF DATA : Study design: Cross sectional study Study period: One year. Study population: Selected Medical Practitioners’ Associations in Bangalore. Study Method: Data will be collected by pre-tested, semi-structured, self-administered questionnaire, after obtaining informed consent. The questionnaire deals with adult immunization practices with reference to the following 14 vaccines recommended by API: Associations of Physicians of India and adopted from guidelines of WHO: World Health Organisation, namely: Cholera, Diptheria-Tetanus-Pertussis, HepatitisA, HepatitisB, Herpes Zoster, HPV, Influenza, Japanese Encephalitis, MMR, Meningococcal Meningitis, Pneumococcal pneumonia, Rabies, Typhoid, Varicella.

PLAN FOR DATA ANALYSIS

The Data will be collected and entered in MS excel sheet and analyzed using SPSS version 20. Descriptive statistics will be used to present the data. Qualitaive variables will be presented as frequencies and percentages and quantitative variables will be presented as means and standard deviation.Suitable Statistical tests of significance will be employed as relevant.

7.3 DOES THE STUDY REQUIRE ANY INVESTIGATIONS OR INTERVENTION TO BE CONDUCTED ON OTHER HUMANS OR ANIMALS? IF SO, PLEASE DESCRIBE BRIEFLY. NO

7.4 HAS ETHICAL CLEARENCE BEEN OBTAINED FROM YOUR INSTITUITION IN CASE OF 7.3? YES

8. LIST OF REFERENCES: 1. WHO vaccine-preventable diseases: monitoring system. 2013 global summary. http://apps.who.int/immunization_monitoring/globalsummary/countries? countrycriteria[country][]=AUT. accessed on Oct 10th 2013.

2. WHO Estimates of disease burden and cost-effectiveness. http://www.who.int/immunization_monitoring/burden/estimates_burden/en/.acessed on Oct 10th 2013.

3. Centers for Disease Control and Prevention (2013). Recommended adult immunization schedule-2013. http://www.cdc.gov/vaccines/schedules/downloads/adult/adult-schedule-easy- read.pdf.acessed on Oct 10th 2013. 4. Gregory A Poland, Abigail M Shefer, Mary McCauley et.al. Standards for Adult Immunization Practice. Am J Prev Med 2003 Aug;25(2):144-50

5. A K Shen.The first national adult immunization summit 2012:Implementing change through action.Vaccine 2013;31:279-84.

6. S K Sharma,R K Singh,A K Agarwal et.al. API Guidelines “Executive Summary The Association of Physicians of India Evidence-Based Clinical Practice Guidelines on Adult Immunization” Expert Group of the Association of Physicians of India on Adult Immunization in India .JAPI 2009;57:345-56

7. Litjen Tan et.al. A pathway to leadership for adult immunization: recommendations of the National Vaccine Advisory Committee.Public Health Rep 2012; 127(1):1-42.

8. M C Steinhoff, K Thomas.The indiaclen invasive bacterial infection surveillance (ibis) study: The burden of vaccine preventable illness. http://www.inclentrust.org/uploadedbyfck/file/complete%20Project/30_The %20IndiaCLEN%20IBIS%20study(Monograph6).pdf ; accessed on 9th Oct 2013.

9. Nowalk MP, Zimmerman RK, Feghali J. Missed opportunities for adult immunization in diverse primary care office settings.Vaccine 2004;22:3457–3463

10. Raul Herzog, Jose Alvarez-Pasquin, Camino Diaz, Jose Luis Del Barrio, Jose Manuel Estrada, Angel Gil. Are healthcare workers’ intentions to vaccinate related to their knowledge, beliefs and attitudes? A systematic review; BMC Public Health 2013;13:154-58.

11. Kissin DM, Power ML, Kahn EB et.al. Attitudes and practices of obstetrician- gynecologists regarding influenza vaccination in pregnancy. Obstet Gynecol 2011 Nov;118(5):1074-80.

12. Carolyn B. Bridges et.al. Advisory Committee on Immunization Practices (ACIP) Recommended Immunization Schedule for Adults Aged 19 Years and Older — United States, 2013. http://www.cdc.gov/mmwr.acess:Oct 10th2013.

13. Khazaeipour Z,Neda R, Najmesad H.Influenza vaccine knowledge, attitude, practice J Infect Dev Ctries 2010; 4(10):636-644.

14. Romani M H ,Umayya M Musharrafieh, Najla A Lakkis and Ghassan N Hamadeh. Family physicians beliefs and attitudes regarding adult pneumococcal and influenza immunization in Lebanon,Family Practice.2011;28(6):632-637.

15. Ahmed SI, Baig L, Thaver IH, Siddiqui MI, Jafery SI, Javed A. Knowledge attitude and practices of general practitioners in Karachi District Central about tetanus immunization in adults. J Pak Med Assoc 2001; 51:367-9.

16. Isahak I, Adult immunization – a neglected issue in southeast asia , Southeast Asian J Trop Med Public Health 2000 Mar;31(1):173-84.

17. R Kumar,D K Taneja,P Dabas,G K Ingle,R Saha. Knowledge about tetanus immunization among doctors in delhi .Indian J Med Sci 2005 Jan;59(1):3-8.

18. Sowmya Kasetty, Anubhuti Mohania, Dhara Dwivedi, Manisha Tijare, Shreenivas Kallianpur and Sandeep Gupta. A Cross-Sectional Study on the Knowledge of Hepatitis B Infection among Dental Professionals.Journal of Virology & Microbiology 2013; Article ID 288280, DOI:10.5171/2013.288280

19. Pandey S, Kushwaha A S, Mahen A . HINI vaccination profile of health care workers and medical students;Indian J Med Res 2013 Feb:388-90.

9. SIGNATURE OF THE CANDIDATE

10. REMARKS OF THE GUIDE This study depicts Adult Immunization Practices among Medical Practitioners, specially Family Physicians, General Physicians, Obstetrics and Gynaecologists. This study also reflects on Observed practices and Expected Practices as recommended by WHO: World health organization and adopted in India by API: Association of Physicians of India.

11. NAME AND DESIGNATION (in block letters) 11.1 GUIDE DR. SHASHIKALA MANJUNATHA, MBBS., MD.,D.I.H., PROFESSOR AND HEAD, DEPARTMENT OF COMMUNITY MEDICINE RRMC&H, KAMBIPURA, BANGALORE-74.

11.2 SIGNATURE

11.3 CO-GUIDE (if any) …………… 11.4 SIGNATURE

11.5 HEAD OF THE DEPARTMENT DR. SHASHIKALA MANJUNATHA, MBBS., MD.,D.I.H., PROFESSOR AND HEAD, DEPARTMENT OF COMMUNITY MEDICINE RRMC&H, KAMBIPURA, BANGALORE-74.

11.6 SIGNATURE

12. 12.1 REMARKS OF THE CHAIRMAN AND PRINCIPAL 12.2 SIGNATURE

INFORMED CONSENT

I / we confirm that I / we have been explained and understood all the details (need, type, duration) about this study and I / we have had the opportunity to ask relevant questions related to the study. I / we understand that my participation in this study is voluntary and that I am free to withdraw anytime, without giving any reasons, without my medical care or legal rights being affected. I / we understand that all those working in this study have accesses to my medical records without my permission. I / we understand that my identity will not be revealed or published. I / we agree not to restrict the use of data or results that arise from this study for scientific purposes. After understanding all the details I / we, am/are willing to take part in this study and give my full consent for the same.

Name and Signature of the investigator signature of participant/witness

CERTIFICATE The dissertation topic “A STUDY ON ADULT IMMUNIZATION:PERCEPTIONS

AND PRACTICES AMONG MEDICAL PRACTITIONERS OF RANDOMLY

SELECTED MEDICAL PRACTIONERS’ ASSOCIATIONS IN BANGALORE” by

Dr.Jameel Fatema, Post-Graduate student in the Department of Community Medicine has been approved by the Institutional ethical committee RAJARAJESWARI MEDICAL COLLEGE,

BANGALORE.