Adequacy of well-baby clinic visits and immunizations at Al Khobar Primary Health Care Centers, 1415-1419 H

The Preventive Health Program for children under 5 years of age in Saudi Arabia includes a series of well-baby clinic visits and immunizations. Vaccines have to be given on schedule to maximize protection. A retrospective cohort study of immunization and well-baby clinic visits for children born in 1415 H was conducted at primary health care centers in Al Khobar city to assess the adequacy of well-baby clinic visits and immunizations.

The first objective of this study was to determine the proportions of children who were up to date (UTD), and those who were age-appropriately immunized (AAI) with the recommended vaccines, and to estimate the frequency of visits to well-baby clinics and the activities done in these visits, such as recording of weight, height. and head circumference, growth chart plotting and examination of child by a physician. Up to date (UTD) children were defined as having received all vaccinations by the particular age being evaluated. Age-appropriately immunized (AAI) children were defined as having received all scheduled vaccinations no later than 30 days of the recommended age.

Immunization registries, medical records, and well-baby clinic registries were reviewed for the period from 1415 H through 1419 H. A random sample proportionate to the number of children in each primary health care center was selected. giving a total of 116 children who had completed their fifth birthday; sixty (48.3 %) were male, eighty-eight (75.9 %) were Saudi and 28 (24.1 %) were non-Saudi.

The proportions of UTD and AM children were found to decrease with age. By the first birthday, 69.8% of children were found to have completed the primary immunization series, while only 19% were AAI. By the end of the second birthday, 58.6% of children had completed the primary immunization series and the first booster doses of DPT & OPV, while only 10.3% were AAI. By the end of the fifth birthday, 30% of children had completed the primary immunization series and both the first and the second booster doses of DPT & OPV, while only 7.8% were AM.

The UTD and AM were higher for any individual vaccine than for all vaccines together at 12 months of age, except for MMR (UTD). At 12 months, UTD children ranged from 100% for the BCG vaccine, to 3.4% for the MMR vaccine. The corresponding figure for AM children ranged from 97% for BCG to 33.6% for hepatitis B. At 24 months, UTD children ranged from 100% for BCG to 59.5% for DPT & OPV. The corresponding figure for AM ranged from 97% for BCG to 15.5% for DPT & OPV. At 60 months, UTD children ranged from 100% for BCG to 31.9% for DPT & OPV. The corresponding figure for AM ranged from 97% for BCG to 9.5% for DPT & OPV.

With regards to recommended well-baby clinic visits, 90.4% of visits in the first year of life were completed, 61% in the second year of life, and only 28% in the fifth year of life. Well-baby medical care was found to decrease substantially over time with increasing age: being highest in the first year and lowest in the fourth year of life. All utilization levels were lower than expected at any given age.

This study demonstrated a wide gap between the proportion of children who were UTD on vaccination at a particular age and the proportion who were AM with these vaccines. Furthermore, it showed that the utilization level of well-baby clinics is much lower than recommended except in the first year of life.

Children under 5 years of age represent 20% of the Saudi population(I). The Preventive Health Program for children under 5 years of age was adopted by the Ministry of Health (MOH) in Saudi Arabia and implemented at primary health care level since 1404 H (I). The Expanded Program of Immunization began in 1979, becoming an essential element of primary health care in 1984 [2,3].

No study in Saudi Arabia has estimated the percentage of age-appropriately immunized (AAI) children and the adequacy of well-child clinic visits. The Immunization coverage survey conducted in eight regions of Saudi Arabia in 1990 reported that 84.8% of children had completed their immunization schedule by the end of their first year of life and 91.9% by the end of their second year. Overall, vaccination coverage was 97.5 %, 94.3 %, and 86.0 % for BCG, DPI & polio, and measles respectively[3]. Al Mazrou et al reported that the percentage of fully vaccinated children in the eastern province was 91.5 %. The coverage for BCG was 99.7 %. Hepatitis B vaccination coverage was 96.5% for the first dose, 94.9% for the second and 92,9% for the third dose. DPI & OPV coverage was 96.4%, 95.7% and 94.7% for the first, second and third (51.7 %) of them were female and 56 doses respectively. The coverage for Measles and MMR was 92.8% and 94.7%, respectively[4]. A retrospective cohort study evaluating the number and activities of well-baby clinic visits at Al-Qurayat district in 1419 H for children born in 1413 H, reported that 98% of children had completed the primary immunization series by their first birthday and 91% had had regular follow up visits in the first year of life. Follow-up visits subsequently declined in the following years.[5]

This study reports a low proportion of children receiving all the immunization series. The highest figure was for children who had received the primary immunization series (1 dose of BCG, 3 doses of DPT, 3 doses of polio, 3 doses of hepatitis B, 1 dose of measles, and 1 dose of MMR), followed by those receiving the primary immunization series and the first booster dose of DPT & OPV. The lowest figure was the proportion of children who had received the primary immunization series in addition to the recommended 2 booster doses of DPI & OPV. The fall in vaccination coverage when booster doses are added may be attributed to the length of the time between completion of the primary immunization series (at 1 year), and the recommended administration time of the first (18 months) and second (4-6 years) booster doses of DPI & OPV. During this time, major changes may have occurred, such as change of residential area, travel during the recommended immunization time, or the child may have received the vaccine in other non-MOH health sectors.

The proportion of children who were up to date in this study was lower than expected from previous national surveys(3'4). Although the proportion of age-appropriately immunized children was not reported in previous national studies, the low levels of AAI and UTD in this study is consistent with findings of other international studies (6' 7).

Preventive medical care was found to decrease substantially with increasing age and was not adequate beyond the first year of life. The mild improvement in the number of well-child clinic visits in the fifth year may be attributed to the recommended fifth dose of DPT & OPV between 4-6 years, as prerequisite to school admission.

The immunization schedule has to be strictly followed to maximize protection from vaccines and particular attention has to be paid to children after they complete their first birthday.