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Doctors' knowledge of and attitudes toward NIDs for oral poliovirus vaccine in Riyadh, 1997

National Immunization Days (NIDs) are mass vaccination campaigns in which supplemental doses of oral poliovirus vaccine (OPV) are given to all children under 5 years of age, regardless of immunization status, two rounds of door-to-door OPV delivery, 4-6 weeks apart over a short time period as possible, during low poliovirus transmission season, to interrupt the circulation of wild polioviruses. Effective implementation of NIDs has led to the eradication of wild polioviruses in the Americas and progress toward its eradication from several countries of other regions [1]. NIDs, a critical strategy for global poliomyelitis eradication, has been implemented in Saudi Arabia, simultaneously with other Gulf states. [2]
The objectives of this study are to find out the level of awareness of doctors working in Riyadh city, Kingdom of Saudi Arabia (KSA), about the objective of conducting NIDs, and to find out their knowledge, attitudes and practices toward NIDs.
The doctors' community was divided into three strata according to their place of work: hospitals, primary health centers and private polyclinics. From each stratum a probability sample was selected. Using a self-administered questionnaire, 175 doctors working in 23 health facilities were interviewed. In analysis, doctors were further stratified according to their nationalities and specialization. Tests between two proportions were used to examine the difference between different groups of doctors as indicated, using a level of significance (a) of 0.05 for one-tailed test.
A total of 175 physicians participated in this survey: 35 (20% of sample size) pediatricians (Peds), 82 (47%) general practitioners (GPs), and 58 (33%) physicians of other specialties (OS). Forty-eight doctors (27.4 %) were working in hospitals, 38 (21.7%) in primary health care centers (PHCCs) and 89 (50.8%) in private polyclinics (PCs). Of all doctors interviewed, 149 (85%) were from Arab countries and 106 (61%) were males. About 51% of Peds, 27% of GPs and 36% of OS thought NIDs were for developing countries only. between 9% to 23% of Peds, 15%28% of GPs and 22%-29% of OS were unaware of the main objective of NIDs, considered NIDs a simple booster dose for an already vaccinated child, and would not advise vaccinated children to receive additional oral polio vaccine (OPV) doses during NIDs scheduled for 1997. Five percent of doctors did not vaccinate their children during the NIDs of 1996. Five doctors (3%) stated that eradication of wild poliovirus in KSA was impossible due to the dynamic and continuous flow of religious visitors and expatriate workers. Peds, GPs and OS thought breast-feeding (9%), current routine childhood immunization, having three doses of OPV in the first year of life, and/or protein-energy malnutrition (9%-11% of Peds, 15%-22% of GPs, 19%-26% of OS) were contraindications for OPV. Two Peds (6%) did not know that prompt reporting of cases of acute flaccid paralysis was required.
Reading MOH circulars was associated with awareness about NIDs (p<0.05, chi-square test). Non-Arab doctors read MOH circulars more regularly than Arab doctors, and 45% of doctors preferred reading circulars from MOH written in English. Doctors working in PHCCs and private polyclinics, regardless of their specialty, were more aware about and familiar with activities related to NIDs. Conversely, doctors working in governmental hospitals were less informed about NIDs. Table 1 summarizes some of most important findings of the survey.

Editorial note:

The results of this survey showed that there were some deficiencies in knowledge regarding NIDs among physicians working in Riyadh. Although all doctors knew that poliomyelitis is currently targeted for eradication, some doctors, including Peds, were largely misinformed or had misconceptions about NIDs that potentially could have reduced the impact of such nationwide community-based health intervention programs The response of doctors could be due to inability of some doctors to understand the ultimate objective of NIDs, which is to interrupt the circulation of wild polioviruses through systematic and extensive mass immunization campaigns with OPV.
Failure to differentiate between the objectives of routine OPV vaccination and NIDs could be due to inadequate communications between MOH and doctors. Doctors, especially pediatricians, need to be more involved in planning, executing and evaluating any community outreach programs that relate to a child's health. During national intervention programs, circulars released by MOH must be written in both Arabic and English to all doctors, regardless of their specialty or their affiliation.
  1. Birmingham ME, Aylward RB, Cochi SL, Hull HF. National immunization days: state of the art. J Infect Dis 1977; 175 (Supp 1):S183-8.
  2. National immunization campaign for the eradication of poliomyelitis, Saudi Ara­bia, Nov. and Dec. 1996. Saudi Epi­demiol Bull 1996;3:3:18.
Table 1: Physicians' attitude toward and knowledge of various aspects of NIDs for polio, Riyadh, 1997.
Doctors thought that:
Peds (N=35)
GPs (N=82)
OS (N=58)
No. (%)
No. (%)
No. (%)
NIDs are a global activity
15 (42.9)
51 (62.2)
30 (51 7)
The target year for global poliomyelitis eradication is 2000
74 (90.2)
NIDs in KSA targeted children < 5 years
34 (97.1)
80 (97.5)
56 (96.6)
NIDs for polio in KSA are expected to continue for a total of three years
21 (60.0)
55 (67.1)
23 (39.7)
NIDs are recommended regardless to current OPV coverage rate
29 (82.9)
68 (82.9)
44 (75.9)
OPV used during NIDs is safe
35 (100.0)
78 (95.1)
51 (87.9)
Mass vaccination in NIDs is by one dose of OPV
2 (5.7)
5 (6.1)
The main objective of NIDs was to:
Eradicate wild poliovirus
23 (65.7)
58 (70.7)
38 (65.5)
Increase community awareness
6 (7.3)
4 (6.9)
Eradication of poliomyelitis is everybody's responsibility
17 (48.6)
45 (54.9)
28 (48.3)
An outbreak of poliomyelitis could strike KSA
7 (20.0)
22 (26.8)
16 (27.6)
Poliomyelitis affects children <5 only
5 (14.3)
34 (41.5)
32 (55.2)
Contraindications for OPV (especially during NIDs) include:
Child <1 month old
14 (40.0)
21 (25.6)
22 (37.9)
4 (4:9)
15 (25.9)