Indian Journal of Medical Sciences Medknow Publications on behalf of Indian Journal of Medical Sciences Trust ISSN: 0019-5359 EISSN: 1998-3654 Vol. 59, Num. 1, 2005, pp. 3-8

Indian Journal of Medical Sciences, Vol. 59, No. 1, January, 2005, pp. 3-8

Original Article

Knowledge about tetanus immunization among doctors in Delhi

Kumar Rajesh, Taneja DK, Dabas P, Ingle GK, Saha R

Department of Community Medicine, Maulana Azad Medical College, New Delhi - 110 002
Correspondence Address:Department of Community Medicine, Maulana Azad Medical College, New Delhi - 110 002, prtickle@rediffmail.com

Code Number: ms05001

ABSTRACT

KEY WORDS: Tetanus, toxoid, immunization, schedules, knowledge, doctors

INTRODUCTION

Tetanus toxoid is one of the most commonly administered vaccines. In spite of clear-cut guidelines regarding tetanus immunization we have observed that tetanus toxoid injection is often given after injury, without taking into consideration previous immunization status. Although one of the reasons for this could be that records are usually not available and the history is not reliable. But this may not be the sole reason for this practice. The other reason could be that doctors and health care providers themselves are not aware of the correct immunization schedules in different groups or they simply don′t realize importance of the previous immunization status. In a study from Karachi, Pakistan, among general practitioners, it was observed that doctors had poor knowledge of tetanus immunization.[1] If health care providers have the correct knowledge then they will pass on the correct message to the community also. With this backdrop this study was planned with the following objectives 1. To assess the knowledge about tetanus immunization in relation to injuries among doctors in Delhi and 2. To assess their knowledge about tetanus immunization schedules in children, pregnant women and adults.

MATERIALS AND METHODS

It was a cross-sectional study conducted among all the government allopathic hospitals, dispensaries and all general private practitioners in Delhi.

In Delhi a number of agencies are providing health care services. Some of them are available to the general population but some are catering to a specific group of population only e.g. Railways, Central Government Health Services and Employees State Insurance etc. For the present study, only those agencies, which were providing services to general population viz., Directorate of Health Services, Municipal Corporation of Delhi, New Delhi Municipal Committee and Delhi Government Health Services were included.

For the purpose of sampling Delhi was divided into five zones viz., East, West, North, South and Central zone. Out of total 40 government allopathic hospitals for general population, 2 hospitals, from each zone were selected in such a way that each agency was represented in proportion to number of hospitals it had.[2] Out of total 227 government allopathic dispensaries for general population, five dispensaries from each zone were selected in proportion to the number of dispensaries in these agencies.[2] The dispensaries were selected randomly after stratifying them zone-wise and agency-wise. Two qualified (MBBS) general practitioners were selected in nearby area of each selected dispensary.

All the doctors regularly posted for casualty duty at the time of visit (this excludes doctors from different specialists on emergency duty viz., Surgeons and Anesthetists etc.), all doctors posted in the selected dispensaries and all selected private practitioners were included in the study. Verbal consent was taken from the participants. Out of the total 135 doctors included in the study 7 private practitioners and 8 government doctors refused to participate in the study.

A structured performa for self-administration was made in English, and was pre-tested in 20 doctors. All the selected doctors were contacted personally and performae were administered and collected then and there only. The data was analyzed using a computer, chi-square test/Z test and ′ Fisher′s Exact" test was applied wherever applicable. The knowledge was compared to the standards as given below and categorized as correct and incorrect accordingly. [Figure]

RESULTS

A total of 120 doctors were included in the study, out of which 43 were private practitioners, 41 were working in dispensary and 36 were working in hospitals, 70 were males and 50 were females.

As much as 38.3% doctors were in favor of giving TT immunization after every injury [Table - 1]. Significantly more private practitioners (51.2%) than dispensary doctors indicated need for TT immunization after every injury (P=0.02,df =1,CI 7.1-46.9). Also significantly higher number of male doctors (50%) recommended TT immunization after injury compared to only 22% female doctors (P=0.003,df=1,CI 11.6-44.6). Of those doctors who opposed giving TT after every injury, only 59.4% of them could state the correct reason that TT is not required if a person is already immune. The Knowledge regarding post-injury management was even poorer as only one-fifth of doctors knew it correctly when to give anti-tetanus-serum (ATS) along with TT.

Majority of doctors favored giving TT after burns [Table - 1], the response being significantly higher among dispensary doctors (97.6%) as compared to private practitioners (P=0.03,df=1,CI 1.9- 25.9) and hospital doctors (P=0.02,df=1,CI 3.2-30.7). A higher number of male doctors (91.4%) recommended TT immunization after burns compared to 82% female doctors but the difference was not significant.

Most of the doctors (92.5%) advocated giving TT after animal bite [Table - 1]. There was no significant difference in the response workplace-wise or sex-wise.

When respondents were asked how many years after primary immunization; will a booster be indicated, in case of injury? Less than half of the doctors responded correctly. There were wide variations in the time-period recommended for booster, ranging from six month to ten years [Figure - 1]. [Table - 2] shows that more than three-fourth of doctors had correct knowledge of tetanus immunization schedule in children less than five years. Knowledge regarding this was highest (85.4%) among doctors working at dispensary, followed by private practitioners (74.4%) and hospital doctors (66.7%), but the difference was not significant. The knowledge was significantly better among female doctors (88%) compared to 67.1% among male doctors (P=0.02,df=1,CI 6.7-35.1).

TT immunization schedule in pregnant females was correctly known to 90.8% of doctors. Females had significantly better (98%) knowledge than males (P=0.02,df=1,CI 3.2-21.4). The knowledge did not differ much according to workplace. Correct knowledge of booster in pregnancy was observed in 78.3% of doctors, maximum being in doctors working at dispensary (82.9%). Again the knowledge was better in females (86%) compared to males (72.9%) but the difference was not significant.

The correct schedule of TT immunization in previously unimmunized adults was known to only one-third of doctors. The knowledge was significantly better in private practitioners as more than half of them knew the correct schedule compared to dispensary doctors (P=0.04,df=1,CI 1.5-42.3) and hospital doctors (P=0.02,df=1,CI 5.6-46.8). Here the knowledge was also significantly better among males (48.6%) compared to 18% in females (P=0.001, df=1,CI 14.8-46.4). The knowledge regarding when to give boosters after a complete primary immunization was very poor as less than one-tenth of the doctors knew it correctly. The knowledge did not vary much with workplace. Correct knowledge was slightly better among males (11.6%) compared to only 4% in females, but the difference was not significant.

DISCUSSION

The study has brought out major lacunae in the knowledge of doctors in Delhi. More than one-third of doctors were not aware of protective duration of immunity as 38.3% favored administration of TT after every injury. This coupled with poor knowledge about exact duration when to give TT booster in case of injury, is likely to result in unnecessary repeated immunization which may predispose to hyper-immunisation.[5] Although level of knowledge regarding TT immunization after burns and animal bites was good however a small lack of it among doctors is not acceptable.

Although National Immunization Schedule has been disseminated widely since the launch of "Expanded Programme of Immunization" in 1978, and it is expected that all the doctors know the correct immunization schedule, only three-fourth of doctors knew it correctly in relation to immunization against tetanus in children, 90.8% in pregnant women. Knowledge of TT booster in pregnancy was still poorer.

It was surprising to know that only one-third of doctors knew correctly the schedule for TT immunization in adults. The findings are similar to a study done in Karachi where only 25% of general practitioners had correct knowledge of pre-exposure TT immunization.[1] Even though the knowledge regarding post-exposure management of injury in an un-immunized person with TT and ATS was poor in the present study however it was much better compared to the study in Karachi wherein only 2% of general practitioners knew it correctly.[1] The knowledge of doctors in relation to their workplace and sex was on the expected lines. The poor knowledge regarding TT immunization in general population and patients as observed in various studies reflects the poor knowledge among doctors.[6],[7]

The present study has sound methodology as a pre-designed and pre-tested performa was used in this study. Sampling method ensured representation of doctors from all over Delhi, both, government as well as private. However, the findings represent knowledge among doctors (non specialist) serving general population of Delhi only. Its findings cannot be extrapolated to specialists or doctors from other agencies, serving specific sections of population like Railways or ESI etc. Further studies to elicit information on practices of different categories of doctors on the subject are recommended.

The findings of the study indicate need for inclusion of tetanus immunization in relation to injuries as a priority topic for Continuing Medical Education (CME) programs for doctors.

SUMMARY

The findings indicate need for reorientation of all doctors, at different workplaces, on tetanus immunization with emphasis on completion of immunization schedules rather than single injection after every injury. They should also know the various vaccines available for tetanus prevention and their use e.g. DPT/DT in children and TT in pregnant women, adolescents and adults. It should also be emphasized that all types of injuries, including burns and animal bites are potentially at risk of tetanus. Doctors also need to know the duration of protection by tetanus immunization and importance of assessing previous immunization status in order to avoid unnecessary repeated immunization. Through CME programs including discussion on findings of such studies as the present one, besides posters at the workplace can be used to educate the knowledge to doctors.

REFERENCES

Copyright 2005 - Indian Journal of Medical Sciences

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