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Original article

Prevalence and associated factors of partially/non-immunization of under-five in Goma city, Democratic Republic of Congo: a community-based cross-sectional survey

Prevalence and associated factors of partially/non-immunization of under-five in Goma city, Democratic Republic of Congo: a community-based cross-sectional survey


André Mwanishayi Kabudi1, Prosper Mukobelwa Lutala2,&, Junior Mulaja Kazadi1, Inis Jane Bardella3


1Docs Learning Centre, Département de Médecine de Famille Université de Goma ,Quartier Keshyero Goma,Congo, 2Department of Family Medicine ,School of Public Health & Family Medicine, College of Medicine, University of Malawi, 3Faculty Development and Global Health Initiatives, Department of Family and Preventive Medicine, Chicago Medical School Rosalind Franklin University of Medicine and Science North Chicago, IL USA



&Corresponding author
Prosper Mukobelwa Lutala, Department of Family Medicine, School of Public Health & Family Medicine, College of Medicine, University of Malawi Private Bag: 360 Chichiri Blantyre 3 Malawi




Introduction: at the East part of DRC, anecdotal reports are advancing several causes of unsuccessful campaign of vaccination by the time going: rumors about use of vaccines for killing purpose, injection of vaccine to decrease the reproductive potential in coming generations, use of vaccines by some rebellions and neighboring countries to kill children indirectly, ineffectiveness of vaccines currently on market. While those rumors seem to be less reliable, potential beneficiaries are taking them seriously and justifying a reluctance to bring their children or siblings for immunization. Against this above background, our community Primary Health Care team indicates that still, in Goma city in general and even in the referral hospital catchment area, there are children who have never been vaccinated. Objective was to determine the prevalence and determinants of non-immunization of under-five children in Goma City. The study design was cross-sectional community- based survey.


Methods: a sample size of 384 children aged under-five years from the target population was used for the study. The ratio of under-five years of age Goma city to the total population of Goma city for the year 2012 was considered as the study population frame.


Results: the prevalence of under-five non-immunized children was 25.7%. There was an association between immunization status of children and their gender, school characteristics, age, sibling, the level of literacy, the marital status of their parents and the age of their mothers.


Conclusion: for improving the quality of under-five children immunization, the medical authorities must consider these different determinants.




One of the most important medical development in the twentieth century has been the control of once common childhood infectious diseases by the administration of highly effective vaccines [1]. Immunization saves more than 3 million lives worldwide each year, and it saves millions more from suffering illness and lifelong disability. Before the introduction of routine childhood vaccination, infectious diseases were the leading cause of child death globally. Every year, 10.6 million children die before the age of five years; 1.4 million of these are due to diseases that could have been prevented by vaccines. Taking into account both children and adults, vaccine-preventable diseases kill 3 million people around the world every year [2]. Globally, each year 130 million children are born, 91 million of which are in the developing countries. However, around 10 million children under the age of five years die every year and over 27 million infants in the world do not get full routine immunization. The estimate for global child deaths under five years was 10.8 million in 2000. About 41% of these were in Sub-Saharan Africa and 34% in South Asia. Immunization being one of the most cost-effective public health interventions which is directly or indirectly responsible to prevent the bulk of mortalities in under-fives [3], it is wise to look at its uptake carefully, to draw lessons and address them accordingly. Immunization saves lives of under-five children globally and more in developing countries. The ultimate outcomes after immunization can either be death or survival for children receiving it. However, even those who survive, serious complications and even death can occur thereafter. During the Millennium Development Goals meeting in 1990, the signatories agreed to curbe the mortality rates of underfive due to preventable diseases by two-thirds by scaling up the immunization coverage in less industrialized countries. The past 2 decades have seen a radical detection of cases due to a global compaign against some children-preventable diseases name llydiphtheria, measles, pertussis and polio [1]. Recently,WHO have reported a drastic reduction of deaths due to measles and its trends towards elimination. Even in Sub-Saharan some countries such as Rwanda, Malawi, Seychelles among others, mortality have been reduced drastically their under-five unlike in others where mortality figures have shown a pic in new cases in recent years. In 2010 Congo was at the top with 72 029 reported deaths due to measles [4]. locally in Goma, in spite these immunization campaigns conducted concurrently with the Routine Immunization since close to a decade and aiming to catch up the few non-immunised children and therefore increase progressively the overall coverage of immunization, outcomes' data from routine immunization campaign in Goma are still alarming. Considering only measles as an indicator of the remaining antigens , in North-Kivu Province statistics showed that measles is still a public health problem. In 2012 for exampler, 489 cases of measles have been reported with 7 deaths (1.4 percent) ; while in 2013 the province reported 819 cases with 1 (0.1 percent) death [5]. If we can consider the low access to care in some villages and cities infected by different armed groups, the difficult to keep the cold chain for vaccines and malnutrition, overcrowding in displaced population's camps, under reporting coming from all those problems ,poor response of the health system to respond to potential outbreaks, ; some can easily understand the importance of scaling-up immunization coverage and ensure close monitoring of immunization program


The 189 signatory nations of Millennium Development Goals (MDG) have committed to reduce mortality rates among children under five by two thirds between 1990 and 2015.1 Out of eight interrelated goals, MDG-4 regarding child mortality covers collective efforts of nations and technical agencies along with civil society organizations to scale up immunization coverage in less industrialized countries. There are numerous factors and barriers that hinder timely and effective immunization programs and adversely affect immunization coverage. These factors and barriers to immunization (Table 1) can be mainly grouped in three levels viz. (i) Individual & family level, (ii) Society level and (iii) Immunization program level. If many African countries have reached high immunization coverage, the situation is still bad in East of Congo with rates going as low as 40% due to conflicts and their aftermaths. Further armed conflicts and resurgence of diseases, which were already declared eliminated, are 2 factors which are playing a role in funding recent immunization campaigns in the Democratic Republic of Congo (D.R.C) and some central-African countries [6]. A systematic education effort addressing misconception is needed. Physician, nurses and other providers of primary care have a unique opportunity to educate parents because parents see them as the most important source of information about immunization [7]. However, there is a need to tailor the message to local realities to expect good response in turn. So far, few studies have addressed this gap. Before doing this systematic educational effort, we decided to assess the status of non-immunization of children among under-fives with the specific objectives to determine the prevalence of non-immunization in under-five children in the study area and secondly to determine the determinants of the non-immunization in those children




Study design: this was a Cross-sectional community-based survey conducted among household in Goma health zone in which there was under-five children.


Study setting: the study was conduct in Goma city at North Kivu, Democratic Republic of Congo and all under-five children were involved. Routine immunization is organized in each health center one day per week by nurses who were in charge of immunization. The session of immunization begun by health talk on a subject by a nurse. Mothers are divided in different groups according to the age of their children determining for most, the type of vaccine they will receive. Vaccine is provided by the government at an affordable cost. Mother or guardians have to pay 900 Congolese Francs (equivalent to one American dollar) to get an immunization card of their children during the first visit. At subsequent visits they paid only the firth of the first amount (200 Francs) to receive the scheduled vaccine.


Population study: the study population was all under-five children living in Goma city. They were estimated at 127,516. Goma city had two municipalities: Karisimbi with 7 quartiers and Goma with 6 quartiers. The ratio of the total number of rural quartiers to the total quartier of Goma city was 7/13= 0.538 and the ratio of the total number of urban quartiers to the total quartier of Goma city was 6/13= 0.461 Applying the above ratios within each municipality (due to the heterogeneous nature of the population of Goma city), a total of 7 quartiers was selected, 4 of which are rural and 3 are urban. Within each municipality, rural and urban quartiers were selected randomly. First, we have randomly selected the quartier (the lowest administrative unit) from each commune, reflecting the urban/rural spread in each health zone, and with the number selected according to the population in each commune. The official list of communes provided by the Mayor's office was the sampling frame for the selection of quartiers. From each commune we have randomly selected two quartier (village) in which 4 streets were further selected randomly. In each selected street, the sample included a group of 80 spreading out from a random starting point. They were no sampling within the site; all the eligible contiguous households up to 100 were included [8].


Sampling size: a sample size of 384 children aged under-five years from the target population was used for the study. The ratio of under-five years of age Goma city to the total population of Goma city for the year 2012 was considered as the study population frame.Bennett´s formula was used to calculate this sample size. = 384.16 =384 -Z is the z score which is standard= 1.96 -p is the expected prevalence of the group population (50% or 0.5) -q= 1-p which is 0.5 -d is the marginal error (degree of precision) which is 0.05 or 5% -def. is stand for design effect which is 1 among the 384 children, 57 who had their immunization schedule pending were excluded.

collection: the data were collected by questionnaire in which there were questions in relation with household characteristics and community profile. The researcher explained and administered questionnaires to mothers, once the consent was obtained. The immunization card was required to collect supplementary data and cross-check others information.

Data analysis: the data were analyzed using SPSS (version 17.0) software to determine Pearson Chi -Square and likelihood ratio of categorical variables. The probability was set at 0.05 and any value was calculated to determine statistical significance of association. P- Valuewas used to determine whether differences statistically significant




Socio demographic data of participants

In Table 1 Number Males children is higher than females in our samples (59.6 versus 40.4 for females), most of them aged more than 12 months (95.4%), born after 2-3 years after their siblings, living within a radius of 2 kilometers from the health facilities, half of the parents of children are earning 0-100USD per month and only 4% can reach 1,000USD per month (while 3% are unable to give what they can get per month).

Socio-demographic data of parents

Most parents are between 23 to 26 years old, Christians (91.1%), of either tertiary education level for fathers (43.2% ) or secondary education level for mothers ( 43.4%), married (89.5%), unemployed ( 57%) for mothers or working in informal sector for fathers ( 41.9%) (Table 2).

Immunization status

The prevalence of under-five non-immunized children was 25.7% and by antigen in Table 3. All non-immunized did not receive measles and yellow fever vaccines. However, for the remaining antigens, only 5.6 % of participants who didn't receive others immunizations such as BCG, Polio, and DTC+Hib+PCV 13. Negligence of parents was the main cause of incomplete immunization. Among the children who were incompletely immunized, 69.0% were males against 31.0% of females.

Determinants of full immunization

In this Table 4 there was a significant association between immunization status and gender (Pearson Chi-Square= 4.162; p< 0.05).The table shows that among the children, who are completely immunized, 22.6% was in preschool classes and 77.4% was not at school. There was a very high association between school characteristics and immunized status (Pearson Chi-Square= 15.545; p< 0.01). Among children who were completely immunized, 98.4% were between one to five years. There was a very high association between immunization status and age of children (likelihood ratio was 22.061; p< 0.01), increasing of literacy level of their mother (Pearson Chi-Square= 34.517; p<0.01) their father (Pearson Chi-Square= 28.391; p< 0.01), marital status (married) of parents (Likelihood ratio: 0.039; p< 0.05); and age ranges of mother (likelihood ratio= 28.432; p< 0.01). The chance to be completely immunized decreased for the last born with the increasing of child number in the household. The location sibling and the immunization status was strongly associated (likelihood ratio was 28.157; p<0.01).

Child location in the siblings on immunization

In Table 5 Shows somehow mixed trends between immunization status and the order of siblings in the family. However, complete immunization is high for those born first, second and third of the families in respective 33.7, 24.7, and 17.3% des cas. When reaching the rank 4, 5, and 6; the proportions of incomplete immunization are high in respectively 9.5, 14.3 and 11.9% of cases. From rank 10 onward there is a slight high proportion of non-immunized children.




Aim and objectives of the study:this study was conducted in Goma in the DRC to determine the prevalence and determinants of non-immunization (partially/total) among under five in Goma. The main results of the study were as follow: The prevalence of non-immunization among those children is 25.7% (Table 3). Following factors in Table 4 were found having an association with incomplete immunization: female sex, low age of child, low educational level of parents, divorce marital status and the age of the mothers. Male children have a high probability to be incompletely immunized. We found a significant association between immunization status and sex (Pearson Chi-Square= 4.162; p< 0.05).Children's gender is significantly positively associated with full vaccination [9]. This affirmation corroborates our results which can be justified by the high number of male among the incomplete immunized children. A big part of children (188) 77.4% are completely immunized before going to school. But, we observe after all only 22.6% who are completely immunized at preschool (see Table 4). We found a strong association between immunization status and school characteristics. This situation can be explained by the fact that they are only 17.7% of children at preschool classes and the achievement of immunization schedule is done when the children are too young for going to preschool classes. For our study and the Khartoum study [8], age of children is a determinant of immunization. In our study, the children who have 9 months or more, have chance to be completely immunized. That can be explained by the fact that, our immunization schedule plan for the complete immunization at nine months. After this age, children can be immunized when there is vaccination campaign which is generally organized against poliomyelitis or measles.


The sibling is associated with immunization status of children. Our study shows that the chance of children for being completely immunized increase with the increasing of their mother age and tend to decline when mother have more than 34 years olds (Table 2). After receiving DTC+Hib+PCV 13 and VPO3 at 14 weeks, mothers will stay at home since the child will have six months for receiving vitamin A and nine for having the last vaccine according to our immunization schedule. So, this long time at home could be the center of mother forgetting for completing the immunization. Also, a big part of mothers are housewife with low level of literacy, and more they have children, more the birth interval is short and they will have a lot of small children to tend. This situation could also explain the difficulty to control correctly the situation of all children. In our study, children chances to be completely immunized increase with the level of literacy of the father and/or the mother. More the literacy level of mother and /or father is high, more children have chance to be completely immunized. It corroborates the Khartoum study done by Ibnouf AH and al [8] which showed that Khartoum children increased their chance to be completely immunized if their mother had a high level of literacy. A case study done at Tanzania showed also the same [10]. Others studies conducted in Sub Sahara Africa by Kawakatsu [4], Omutanyi [11], Kamau [12] in Kenya, Chalres S Wiysonge [13] and Lucius Darby Donsa in Malawi Showed also similar results. This situation could be explained by the fact that the one who have high level of literacy is able to understand easily the benefits of immunization. He can also plane the appointment according to the immunization schedule and understand for example that the fever which can occur after a vaccination is a reaction which cannot destroy the child immunity and it treatable. In our study (Table 5), children who are living with their both parents have more chance to be immunized than who have their parents divorced, separated or are living only with their mother. This situation can be justified by the high number of children who are coming from married couples. Even if the likelihood ratio shows the relationship between immunization status of children and marital status of their parents. The weak number of parents who are divorced, separated or single compare to the married make us prudent to have a strong conclusion. Our study shows a significant relationship between age of mother and immunization status. More mothers have an advanced age, more their children have chance to be completely immunized (Table 2). This result corroborates the studies done in Kenya by Kawakatsu [4] and Omutanyi [11]. The advanced age is associated with maturity. The maturity of mother could explain their awareness about immunization. We observed in our study a tendency of having less children completely immunized after 34 years olds. That could be explained by the small number of mother in this age interval.


This study must be understood in light of several weaknesses. As strength, this study has focused on a topic which is an epicenter of health authorities locally and internationally. Congo is on top of countries in WHO-African region where cases of measles are still being reported. As of 2010, for example while a drop of cases has been found globally, (from 562, 000 in 2000 to 122,000 in 2012) DRC reported alone 72,029 cases alone. Also, measles is one of the markers of the infant's mortality which can give an idea on the decline and achievement of millennium development goals we are now in 2015. Unfortunately, immunization one of the pillars in fighting children mortality remains very porous with weaknesses in the whole health system. The main weakness of the study is its inability to catch- up some groups of children, like those born at home and not declared at a health facility. The quality of vaccines used for immunization was not assessed by our questionnaire; further, the risk of recall bias for some information of children whose mothers didn't bring with them the immunization cards and who were obliged to give information was high.




The present study indicates that the prevalence of non-immunized under-five children in Goma is 25.7%. The determinants of under-five non-immunization in children are gender, parent's school characteristics, age of children, child location in the sibling, marital states of parents, and the ages of the mother.



Competing interests

The authors declare that they have no competing interests.



Authors’ contributions

KMA: substantial contributions to the conception and design of the study, acquisition of data, and analysis and interpretation of data and drafting the first manuscript; PML: assisting in study design, critically drafting and revising the article for important intellectual contents, JMK: assisted in data collection and analysis; and IBJ: director of the MMed thesis from which the manuscript derived and gave input for this manuscript; all authors read and gave consent to the submitted form at different stages.




We are very grateful to all parents who accepted to participate in this this study as well as to nurses in charge of health




Table 1: socio-demographic data of children

Table 2: sociodemographic data Parents

Table 3: immunization status

Table 4: determinants of Full immunization

Table 5: child location in the siblings




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