Malnutrition and infectious disease morbidity among children missed by the childhood immunization program in Indonesia.

Although it has been thought that child immunization programs may miss the children who are in greatest need, there are little published quantitative data to support this idea. We sought to characterize malnutrition and morbidity among children who are missed by the childhood immunization program in Indonesia. Vaccination and morbidity histories, anthropometry, and other data were collected for 286,500 children, aged 12-59 months, in rural Indonesia. Seventy-three point nine percent of children received complete immunizations (3 doses of diphtheria-pertussis-tetanus, 3 doses of oral poliovirus, and measles), 16.8% had partial coverage (1-6 of 7 vaccine doses), and 9.3% received no vaccines. Of children with complete, partial, and no immunization coverage, respectively, the prevalence of severe underweight (weight-for-age Z score < -3) was 5.4, 9.9, and 12.6%, severe stunting (height-for-age Z score < -3) was 10.2, 16.2, and 21.5%, and current diarrhea was 3.8, 7.3, and 8.6% (all p < 0.0001), respectively. In families where the child had complete, partial, and no immunizations, the history of infant mortality was 6.4, 11.4, and 16.5%, and under-five child mortality was 7.3, 13.4, and 19.2% (both p < 0.0001). Expanded programmatic coverage is needed to reach children who are missed by childhood immunizations in rural Indonesia, as missed children are at higher risk of morbidity and mortality.

Malnutrition and morbidity are higher in children who are missed by periodic vitamin A capsule distribution for child survival in rural Indonesia.

Universal periodic high-dose vitamin A capsule distribution is a cost-effective intervention to increase child survival in developing countries. It is unclear whether children who are missed by the program are at higher risk for malnutrition and infectious disease morbidity. Based on data from the Nutritional Surveillance System, we compared nutritional status and other health indicators of children aged 12-59 mo in rural Indonesia who did and did not receive a vitamin A capsule within the last 6 mo. A total of 241,087 of 335,034 children (72.0%) received a vitamin A capsule between 1999 and 2003. In children who did and did not receive a vitamin A capsule, respectively, the proportion with weight-for-age, height-for-age, and weight-for-height Z scores <-2 were 37.0 vs. 42.5%, 39.2 vs. 45.6%, and 6.9 vs. 7.4% (P < 0.0001). Similarly, the proportion with anemia, diarrhea during the last wk, current diarrhea, and current fever was 49.2 vs. 54.8%, 6.7 vs. 8.4%, 4.4 vs. 6.0%, and 1.4 vs. 1.7% (P < 0.0001). Children who did not receive vitamin A were also less likely to have received childhood immunizations and belonged to families with higher infant and under-5-y child mortality than children who receive vitamin A. Although a lack of access to other public health interventions and demographic factors may also contribute to the rate of malnutrition in children missed by the vitamin A capsule program, it is likely that increased coverage of vitamin A supplementation would help to maximize the benefits for child survival.