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Research Article
Factors Associated Participation in a School Based Typhoid Vaccination Campaign in Nepal
Imran Khan M1*, Deepak Bajracharya2,3, Alfred Pach 3rd1, Shyam Raj Upreti4, Sushant Sahastrabuddhe1, Thomas Wierzba1, Leon Ochiai R1 and VIVA Pilot Introduction Group-Nepal5
1International Vaccine Institute, Seoul, Republic of Korea
2MITRA Samaj Pani Pokhari, Kathmandu, Nepal
3Group for Technical Assistance, Sanepa, Nepal
4Department of Health Services, Child Health Division, Ministry of Health and Population, Kathmandu, Nepal
5VIVA Pilot Introduction Group

ABSTRACT
Objective
The study aimed to determine the factors associated with parents’ decision of their child participation in a school-based typhoid vaccination program in Lalitpur District, Nepal.

Methods
Following a typhoid vaccination campaign in 2012, a household cross-sectional survey, following a two stage stratified, cluster-sampling strategy. The strata were based on type of school (public/private) and geographic location (urban/rural). Data were collected through a structured questionnaire ensuring standard quality practices. Logistic regression analysis was used to assess the effect of socio-economic and behavioral characteristics with participation in the school-based vaccination campaign. The study was approved by Institutional Review Board of International Vaccine Institute and Nepal Health Research Council.

Results
A total of 1,248 interviews were conducted with parents of children from 42 schools with a response rate of 85 percent. The participation in the vaccination campaign was statistically significantly associated with confidence on the organization conducting the vaccination campaign (OR=0.2; 95% CI: 0.1 - 0.7) knowledge of typhoid vaccine preventing the disease (OR=9; 95% CI: 4.2 - 19.7), concern of vaccine related adverse events following vaccination (OR=0.3; 95% CI: 0.2 - 0.6), information on typhoid vaccination campaign (OR=3; 95% CI: 1.9 - 5.0), and receipt of a permission slip for the child to receive the vaccine from school (OR=2; 95% CI: 1.3 - 3.2).

Discussion
Our results suggest that participation in a school-based vaccination program is associated with knowledge of disease specific vaccine on safety and effectiveness, if the parent was reached effectively by the vaccination teams through information material, and if the population have confidence in the organization that is conducting the vaccination campaign. Our results are consistent with the findings from vaccination programs on typhoid and other vaccines, globally and in Asia on a perceived risk of the disease, knowledge and confidence over vaccines and a set of communication channels by which parents are informed about the vaccine benefits to the target population.
KEYWORDS
Bacterial infections; Nepal; Salmonella; Typhoid fever; Typhoid vaccines; Vaccination participation

Introduction
Salmonella entericserovars are associated with three distinct clinical syndromes: a) enteric fever results from infection by the typhoidal Salmonellas (Salmonella Typhi and Salmonella Paratyphi A, B, and C; b) non-typhoidal Salmonella gastroenteritis; and c) non-typhoidal Salmonella bacteremia (invasive disease caused by non-typhoidal Salmonellae) [1]. Enteric Fever (EF) is an acute systemic infection, representing two similar clinical illnesses, typhoid and paratyphoid fever, caused by different serotypes of the bacteria Salmonella enterica, serotypes Typhi (S. Typhi) and Paratyphi (S. Paratyphi A, B, and C), respectively. Combined morbidity and mortality caused by infections of Salmonella entericserovars is considerable since this group of bacterial pathogens are responsible for a global toll of approximately one million deaths annually, making them as one of the leading causes of mortality worldwide [2].

The World Health Organization (WHO) recommends targeted typhoid fever vaccination in typhoid endemic regions through school-based and high-risk vaccination campaigns [3]. Typhoid polysaccharide vaccines are licensed for use in children older than 2 years, limiting their use in routine immunization programs such as Expanded Program on Immunization (EPI) in typhoid endemic countries. School-based programs are considered an effective strategy to attain high vaccination coverage rates. The key issue in the feasibility and value of conducting a school-based typhoid vaccination program is the additional logistical support required to reach all eligible children. Parental refusal to accept their child’s participation in a program affects vaccination coverage and in turn increases the cost per vaccine dose [4]. The influential reasons for parental acceptance and refusal in vaccination programs vary by region and country: from perceived vaccine efficacy, to perceived need for a vaccine, to perceived adverse events associated with vaccines and their cost. Socio-demographic factors also affect vaccination participation (e.g., a lack of risk perception for contracting the disease among the population with a high Socioeconomic Status (SES)) [5-8]. However, all of such concerns can be addressed through provision of adequate information on the disease, the vaccination program, and the organization leading the effort [9].

Typhoid fever is very common in Nepal, and has had repeated outbreaks in the past. Multi-drug resistance Salmonella typhi and paratyphi are the most common infectious organism isolated from the blood stream of children [10]. Drinking water in Kathmandu valley is highly contaminated with Salmonella Typhi and Paratyphi [11]. Approximately 9000 cases of S. Typhi were isolated between 1993 and 2003 from only one hospital, highlighting the magnitude and burden of enteric infection in the valley. Currently there are two vaccine licensed for marketing globally. The injectable, single dose Vi polysaccharide vaccine, and live attenuated oral Ty21a vaccine that has a four dose schedule. Both vaccines are licensed for two years and older population. The duration of protection for injectable vaccine is three to seven years, whereas the oral vaccine is five to seven years [12]. The Vi-based Vaccines for Asia Initiative (ViVA) of the International Vaccine Institute (IVI) aimed to provide evidence for the feasibility and effectiveness of school-based typhoid vaccination to reduce the burden of typhoid fever in school-aged children (5-15 years). Children in this age group have high rates of typhoid fever. In addition, resistance to commonly used antibiotics continues to increase in south Asia and in Nepal [13]. The Vi vaccine pilot introduction project was developed with support from the IVI and implemented by the District Public Health Office of Lalitpur District, Kathmandu Valley, Nepal with a help of a non-governmental organization, MITRA Samaj between 2010 and 2013. A single dose of injectable typhoid polysaccharide vaccine was given through a mass vaccination campaign to the children attending the schools of Lalitpur District, Nepal. Coverage records showed that nearly 35% of eligible students did not receive the vaccine through the school-based program. Initial reasons for parental refusal during social mobilization campaign and vaccination monitoring indicated that there was a fear of the vaccination due to rumors and prior experiences with other prevention/treatment campaigns. Along with skepticism towards the general safety of the vaccine, prior information on experiences with the vaccine added to the concerns of the parents [14].

We collected information following the vaccination campaign in order to understand the reasons that either engaged or hindered parents’ participation in typhoid vaccination campaign. Specifically, the study aimed to identify factors that influenced parents’ decision to allow their child/children participation in the school-based mass vaccination.
Methodology
We conducted a household survey of the parents of children attending schools in the Lalitpur District, Nepal. Lalitpur district is the largest district in Nepal and has comparatively better access to health care. The content of the survey was based on the theory of the Health Belief Model, which involves assessing perceptions of the severity and risk for typhoid fever, and value of a vaccine to prevent the disease [15]. The survey was further based on former socio-behavioral evaluations and the literature on vaccine acceptance [16,17]. Issues that arose during the conduct of the social mobilization and the vaccination campaign were also considered in developing and modifying survey topics and response categories (e.g., reasons for not participating).

The Lalitpur District is divided into Lalitpur Sub-Metropolitan City (LSMC) District (comprised of urban and semi-urban populations) and rural Village Development Committees (VDCs). The District has a total of 109,051 students in 498 schools. These students were the target group for receiving the vaccine in the typhoid vaccination program. The study involved a cross-sectional design to assess demographic, social mobilization, communication, and vaccine acceptance factors related to participation in the vaccination campaign.
Sample size and sampling strategy
A stratified two-stage cluster sampling strategy was adopted to enroll respondents in the survey. The sampling element for the survey was a parent (mother/father) or a caretaker (e.g., grandparent) whose child was enrolled in a school in the Lalitpur District. A total 42 schools were randomly selected from the list of schools collected as part of the project. The schools were stratified by rural/urban setting, public vs private and vaccination coverage. Vaccination coverage was categorized into low (<50%), medium (50% - 65%) and high (>65%). The survey sampling design ensured representation of the target population to understand issues related to variation in participation and experience in the vaccination program. Assuming a probability that a non-participant is exposed to Salmonella Typhi at 0.73, detecting odds ratio of 2.0 for an association of participating in the vaccination campaign to exposure to typhoid fever, with a power of 90%, type I error at 1%, and design effect of 1.2, one class per school from 42 schools were enrolled.

The teams then visited the schools and randomly selected one class from the total number of classes in the school. An information slip was sent from the school through the teacher to schedule the interview time and date with the parents at their respective homes. During the visit, the survey teams collected information on the demography of respondents, their use of health care; their knowledge and perceptions of the symptoms of typhoid fever, their perceived risk of the disease, its severity, prevention and treatment, and the most useful sources and communication channels of information and social mobilization for the vaccination. It also collected information on reasons why parents did or did not allow their child to participate in the vaccination.

Data was collected through a structured questionnaire by trained field staff. Study teams extensively reviewed the questionnaire. Field staff received classroom training on the purposes and issues of the study, and data collection principles and procedures. There was a careful terminological and conceptual review of the items of the questionnaire, mock interviews and pilot testing of ten percent of total sample size. Revisions in the questionnaire were made where needed to ensure its intelligibility and conceptual accuracy. On a regular basis completed questionnaires were reviewed in the field, a detailed tracking list was maintained every day and daily debriefing was conducted to ensure the quality of the collected data.
Data Analysis
The data analysis involved descriptive statistics for sample demographics using Stata version 9.0. Pearson’s chi square test was performed for categorical variables, along with t-tests and ANOVA for continuous variables to test statistically significant difference between groups. Based on the results from the descriptive analyses, adjusted analyses were performed to determine factors affecting vaccination participation using logistic regression analysis.

The research was approved by the Institutional Review Board (IRB) of the International Vaccine Institute, the Nepal Health Research Council and the Ministry of Health and Population of the Government of Nepal.
Results
Coverage and demographic results
A total of 1,248 interviews were conducted with parents of children from 42 schools. 965 interviewees (77%) were enrolled from the Lalitpur Sub-Metropolitan City and 283 (23%) from the Village Development Committees. Based on the vaccination coverage, 117 (9%) from low, 895 (71%) from medium and 236 (19%) from high coverage schools were enrolled (Table 1). A majority of the respondents (parents) had some form of formal education (85%). There was no statistical difference on average household members, monthly household income and household expenditure between the household where a child was vaccinated compared to where the child was not vaccinated (Table 2).
Disease and campaign related factors to participation
A parent was 2.3 times more likely to vaccinate their child if he/she thought that typhoid fever was a very serious disease compared to those who thought it was not a serious disease; 40% more likely to receive vaccine if they considered that cost of treatment would have an effect on their household budget compare to those who did not think typhoid disease would have an effect on their household budget; and 8 times more likely if they had the knowledge that typhoid can be prevented with a vaccine. For parents who thought that all household members should be vaccinated, their child was 4.4 times more likely to have received the vaccine (Table 3).
Sources of campaign information, consent and communication
If the parents had information about the vaccination campaign (OR=3.39; 95% CI: 2.5 - 4.6), and the information was conveyed by the child (OR=2.43; 95% CI: 1.86 - 3.17), teacher and/or a letter was sent by the school as a request for consent/permission to participate (OR=1.82; 95% CI: 1.41 - 2.36), their child was more likely to participate in the vaccination campaign (Table 4). Though concerns on adverse events related to vaccine were a significant factor in receiving the vaccine. However, if the parent discussed concerns with her/his respective health care provider and or the teacher at the school, she/he was seven times more likely to have her/his child receive the vaccine (OR=6.76; 95% CI: 1.61 - 28.35) (Table 4). In spite of finding the language technical, respondents who signed the consent/permission form were more likely to vaccinate their child (OR=4.51; 95% CI: 2.2 - 9.2) (Table 5). Among the sources of information that were used to inform the community about the vaccination campaign, if the parent had received the brochure from the school (OR=2.82; 95% CI: 2.12 - 3.75), had seen the banner outside school (OR=2.72; 95% CI: 1.79 - 4.13), and had heard public service messages (OR=1.7; 95% CI: 1.16 - 2.49), he/she was more likely to have his/her child vaccinated. Those parents whose children received the vaccine had a better recall of information material compared to those who did not vaccinate their children (Table 5).
School-based vaccination and participation in the vaccination
The parents who were encouraged to vaccinate their child by the school were more likely to vaccinate their child compared to those where the school did not encourage the vaccination (OR=3.2; 95% CI: 2.4 - 4.4) (Table 6). The parents who agreed to a school vaccination program (OR=3.5; 95% CI: 2.3 - 5.3), and wanted to be present at the time of vaccination (OR=1.6; 95% CI: 1.2 - 2.2) were more likely to vaccinate their child. Nevertheless, there was disagreement with the idea that schools may not be capable of handling an emergency in case a child experienced an adverse event following vaccination. Parents were more likely to trust the organization (district public health office) that conducted the campaign compared to those who did not vaccinate their child (Table 6).
Key factors independently associated with participation in the typhoid vaccination
The adjusted analysis across the multiple influential variables showed that the parents who had information on the vaccination campaign (OR=3.0; 95% CI: 1.9 - 5.0), considered that typhoid can be prevented by a vaccine (OR=9.0; 95% CI: 4.2 - 19.7), and had received a consent/permission letter from the school (OR=2.0; 95% CI: 1.3 - 3.2), were more likely to have their child vaccinated in the school based vaccination program in district Lalitpur Nepal. In addition, those that were concerned about adverse events following immunization (OR=0.3; 95% CI: 0.2 - 0.6) and did not have confidence in the organization conducting vaccination program (OR=0.2; 95% CI: 0.1 - 0.7) were less likely to vaccinate their child (Table 7).
Discussion
Our results provide important insights into factors associated with participation in a school-based, typhoid vaccination program in the Lalitpur. We also assessed how social mobilization and the dissemination of communication material and activities affected participation. We explored the importance of vaccination campaign logistics, such as the consenting process as affecting participation in the vaccination program with a vaccine that is not given in routine immunization program in Nepal. Our results suggest that participation in a vaccination program is built over a long duration through parental education about the benefits of vaccines, the reputation of the organization in their handling previous community or school-based programs, and regular and proper communication with the parents. Our results are consistent with the findings globally and in Asia on a perceived risk of the disease, knowledge and confidence over the vaccines, and a communication channel by which parents are informed about the vaccine benefits to the children and the population in general [18-20].

The routine immunization coverage for Nepal is one of the highest in the in South Asia (coverage rate of 90% for Diphtheria, Tetanus and Polio (DTP3)) . The DTP3 coverage has improved from 72% in 2001 to 90% in 2012. However, the vaccination campaign for typhoid in an urban and semi-urban setting could only achieve 71%. School vaccination coverage is usually higher than vaccination at health posts due to access to a group of children, especially in areas where school enrolment is high, such as Nepal . The comparatively lower vaccination participation in our study highlights the importance of parental confidence, knowledge and communication of the vaccination administration group with the target population. The results of adjusted analyses indicate that there were three important areas that determined the participation: individual knowledge of disease and vaccine safety, information and communication, including prior information on the campaign, and communication by the school administration staff with the parents through permission slips, and prior experience with the vaccination administration authorities. Although vaccine demonstration projects do focus on social mobilization and communication as was in this project, a sustained effort over time as opposed to a short term strategy will have more beneficial effects. We did not find a statistically significant effect in usage of any particular social mobilization and communication material on the vaccination participation. The permission slip/consent form had a statistical significant effect on vaccination participation; however, we are unable to differentiate the effect of permission slip/consent form from the effect of a message from school. This could possibly have been due to the regular communication between the parents and the school and not just because of the letter as a mode of communication. We adjusted our final model for the income group, but we did not find a statistically significant association of parental socio-demographic factors with vaccination participation.

Information communication and social mobilization plays an important role in all public health programs especially in vaccine programs. New vaccine introduction in a country is a critical step and should involved bringing in major stakeholders, and the community. The recent examples of such efforts are introduction of strep. Pneumococcal Vaccine, Rotavirus Vaccine, and Human Papilloma Virus Vaccine. These vaccine introduction initiatives have from the very beginning have focused on population information need and the channels that will affect decision making in vaccine update. The global polio eradication campaigns in India proved that community engagement plays an important achieving vaccination targets.

The study has limitations that are mentioned here that limits are analysis of these variables with the outcome. 1) Parents’ educational background, financial backgrounds, and cultural backgrounds can have huge impacts on this study. Comprehensive background information on respondents was not collected; 2) more than two thirds of our sample is from the metropolitan area.
Conclusion
Vaccination campaigns with vaccines that are being newly-introduced in a country’s immunization program often focus on short term strategies for information communication and social mobilization. The factors that determine compliance with a new intervention need a long-standing channel of communication between the organizing group and the target population. This may not be possible with projects such as ours; however, the results need careful interpretation if participation in intervention studies is found to be lower compared to routine programs. Additionally, prior experience and knowledge of disease and the intervention play a major role for wider coverage of preventive programs in the desired population, such as vaccines.
Acknowledgement
The authors wish to thank Pradhan YV, Sue Kyoung Jo, staff at Child Health Division, the District Public Health office, Lalitpur Sub-Municipal City and the community in the district for their support. This study was conducted through a grant (Vi Vaccines for Asia Initiative) from the Bill & Melinda Gates Foundation. The International Vaccine Institute receives core funding support from the Governments of Korea and Sweden. We are especially thankful to Dr. Raul Gomez for the editorial review of the manuscript.

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Tables
Vaccination Coverage Number of participants Total
Low Medium High
Area n % n % n % n %
LSMC 71 7.36 741 76.79 153 15.85 965 77.3
VDC 46 16.25 154 54.42 83 29.33 283 22.7
Total 117 9.38 895 71.71 236 18.91 1248  
Table 1: Distribution of the study sample by area and vaccination coverage in the typhoid vaccination campaign in Lalitpur, Nepal.
LSMC=Lalitpur Sub-Metropolitan City
VDC=Village Development Committee

Variable Received vaccine Did not receive vaccine Odd Ratio 95% CI for Odds Ratio
  Yes (893) No (356)    
  N % n %    
School attendance
No 136 15.3 52 14.7 REF  
Yes 755 84.7 302 85.3 1.1 0.76 - 1.59
Education Level
Primary 94 12.5 25 8.2 REF  
Lower Secondary 72 9.5 22 7.2 0.92 0.48 - 1.78
Secondary 158 21.0 64 21.1 0.69 0.4 - 1.19
Higher Secondary 166 22.0 74 24.3 0.6 0.34 - 1.05
Bachelor 185 24.5 87 28.6 0.56 0.32 - 0.98
Masters 79 10.5 32 10.5 0.61 0.32 - 1.17
Household member (Mean/SD) 5   4.75   1.06 0.99 - 1.13
Monthly Household Income (Mean/SD) 25308 30135 1 1
Monthly Household Expenditure     1.4 0.69 - 2.82
Table 2: Distribution and association of respondents’ socio-demographic factors with participation in the typhoid vaccination campaign in Kathmandu, Nepal.
Variable Received vaccine Did not receive vaccine Odd Ratio 95% CI for Odds Ratio
  Yes (893) No (356)    
How serious of a disease is typhoid fever?
Not serious 121 13.7 72 20.6 REF  
Serious 644 73.0 249 71.1 1.45 1.04 - 2.02
Very serious 117 13.3 29 8.3 2.31 1.39 - 3.83
Bearing the cost            
No 183 21.7 96 29.5 REF  
Yes 660 78.3 229 70.5 1.4 1.04 - 1.89
Do you think typhoid can be prevented by a vaccine?
No 12 1.5 26 7.4 REF  
Yes 809 98.5 223 63.9 7.8 3.84 - 15.81
Do you think all members from your family should be vaccinated for typhoid?
No 41 5.0 57 19.5 REF  
Yes 779 95.0 236 80.5 4.4 2.86 - 6.78
Table 3: Distribution and independent association of typhoid fever knowledge with participation in the typhoid vaccination campaign in Kathmandu, Nepal.
Variable Received vaccine Did not receive vaccine Odd Ratio 95% CI for Odds Ratio
  Yes (893) No (356)    
Typhoid vaccination campaign knowledge 
No 114 12.8 115 32.4 REF  
Yes 779 87.2 240 67.6 3.39 2.5 - 4.58
Typhoid Knowledge source - Child 
No 208 23.3 150 42.1 REF  
Yes 685 76.7 206 57.9 2.43 1.86 - 3.17
Typhoid Knowledge source - Letter from school 
No 456 51.1 234 65.7 REF  
Yes 437 48.9 122 34.3 1.82 1.41 - 2.36
Typhoid Knowledge source - Teacher 
No 815 91.3 344 96.6 REF  
Yes 78 8.7 12 3.4 2.48 1.32 - 4.65
Children could not receive vaccine (Mean/SD) 0.2   1.33   0.1 0.08 - 0.13
Concern of vaccine adverse effect 
No 771 89.2 207 71.6 REF  
Yes 93 10.8 82 28.4 0.3 0.21-0.42
Discussed AE concern with health care provider 
No 857 96.0 354 99.4 REF  
Yes 36 4.0 2 0.6 6.76 1.61-28.35
Discussed AE concern with teacher 
No 862 96.5 352 98.9 REF  
Yes 31 3.5 4 1.1 2.96 1.03-8.52
Table 4: Distribution and independent association of campaign knowledge with participation in the typhoid vaccination campaign in Kathmandu, Nepal.
Variable Received vaccine Did not receive vaccine Odds Ratio 95% CI for Odds Ratio
  Yes (893) No (356)    
Did you receive any information about the typhoid vaccination program from the school? 
No 79 9.3 80 27.8 REF  
Yes 775 90.7 208 72.2 3.98 2.8 - 5.68
What information did you receive? Vaccinate your children 
No 468 52.4 262 73.6 REF  
Yes 425 47.6 94 26.4 2.46 1.87 - 3.23
Did you get a permission letter from school that was asking your permission for vaccinate your child?
No 120 14.4 68 25.0 REF  
Yes 716 85.6 204 75.0 1.93 1.37 - 2.71
Did you have any reservations in signing the form requesting your permission for vaccinating? 
No 579 83.5 146 76.0 REF  
Yes 114 16.5 46 24.0 0.61 0.41 - 0.91
Did you/other responsible person sign the form? 
No 17 2.4 17 8.4 REF  
Yes 702 97.6 186 91.6 4.51 2.2 - 9.25
Did you think the information in the permission form was too technical?
No 438 74.2 126 85.7 REF  
Yes 152 25.8 21 14.3 2.28 1.36-3.82
We distributed a brochure that was given to the child to bring it to you. Did you receive it? 
No 364 44.7 206 68.7 REF  
Yes 451 55.3 94 31.3 2.82 2.12-3.75
Did you think the brochure had enough information required making a decision of vaccinating your child?
No 8 3.0 9 19.6 REF  
Yes 256 97.0 37 80.4 9.16 3.19-26.3
Able to recall any information from the brochure?
No 739 82.8 330 92.7 REF  
Yes 154 17.2 26 7.3 2.75 1.77-4.26
Able to recall: Typhoid is dangerous 
No 798 89.4 337 94.7 REF  
Yes 95 10.6 19 5.3 2.16 1.28-3.65
Saw the campaign banner outside the school?
No 685 76.8 306 90.3 REF  
Yes 190 21.3 29 8.6 2.72 1.79-4.13
Did not accompany the child 17 1.9 4 1.2 1.98 0.65-5.99
Saw the campaign poster in the school?
No 719 80.6 298 87.9 REF  
Yes 152 17.0 32 9.4 1.92  1.27-2.89
Did not accompany the child 21 2.4 9 2.7 1.05 0.47-2.33
Did you hear about typhoid on the radio during the vaccination program? 
No 737 82.5 315 89.2 REF  
Yes 156 17.5 38 10.8 1.7 1.16-2.49
Did you think the public service message on radio was informative? 
No 7 8.4 2 11.8 REF  
Yes 76 91.6 15 88.2 1.33 0.24-7.34
Table 5: Distribution and independent association of the consent process, project communication and social mobilization with participation in the typhoid vaccination campaign in Kathmandu, Nepal.
Variable Received vaccine Did not receive vaccine Odd Ratio 95% CI for Odds Ratio
Did your child’s school encourage you to vaccinate your child? 
No 218 27.2 123 53.9 REF  
Yes 584 72.8 105 46.1 3.24 2.38 - 4.41
Do you think the fact that this vaccination program was being conducted at the school influenced your decision of participation in the campaign?
No 268 32.7 174 69.3 REF  
Yes 552 67.3 77 30.7 4.83 3.54 - 6.58
Do you think the fact that this vaccine was given free influenced your decision of vaccinating/not vaccinating?
No 623 75.7 188 75.2 REF  
Yes 200 24.3 62 24.8 0.94 0.67 - 1.32
Do you think schools are an acceptable place for vaccinating children? 
No 49 5.6 55 17.6 REF  
Yes 825 94.4 258 82.4 3.49 2.3 - 5.28
Are you satisfied with the way the vaccination program was conducted? 
Not satisfied 7 0.8 27 17.6 REF  
Satisfied 739 88.7 125 81.7 23.17 9.85 - 54.5
Very Satisfied 87 10.4 1 0.7 319.5 37.6 - 2718.1
The vaccine should be given at a health clinic? 
Agree 346 39.4 148 44.2 REF  
Disagree 533 60.6 187 55.8 1.25 0.97 - 1.62
The child will miss a school day in case the vaccination 
Agree 530 60.2 223 66.6 REF  
Disagree 350 39.8 112 33.4 1.24 0.95 - 1.62
I want to be present while my child receives the vaccine 
Agree 656 74.6 282 81.7 REF  
Disagree 223 25.4 63 18.3 1.61 1.18 - 2.21
In case something happens to my child, school is not prepared to handle the situation 
Agree 175 31.1 51 18.3 REF  
Disagree 563 100.0 227 81.7 0.69 0.49 - 0.98
We are not sure of the competitiveness of the staff conducting the vaccination. 
Agree 251 31.3 101 34.8 REF  
Disagree 551 68.7 189 65.2 1.33 0.99 - 1.78
The organization conducting the vaccination campaign is important 
Agree 862 98.4 317 93.0 REF  
Disagree 14 1.6 24 7.0 0.22 0.11 - 0.44
Table 6: Distribution and independent association of factors related to the4 school- based vaccination affecting decision making o and participation in the typhoid vaccination campaign in Kathmandu, Nepal.
Household Income (UNIT)
< 17,000 1  
17,001 - 30,000 1.1 0.7 - 1.8
> 30,000 1.7 0.4 - 1.1
Can typhoid be prevented with a vaccine?
No 1  
Yes 9.1 4.2 - 19.7
Concern of Adverse Event    
No 1  
Yes 0.3 0.2 - 0.6
Information on Typhoid campaign
No 1  
Yes 3 1.9 - 5.0
Permission Slip
No 1  
Yes 2 1.3 - 3.2
Organizational Confidence
Agree 1  
Disagree 0.2 0.1 - 0.7
Table 7: Adjusted effect of factors affecting participation in the typhoid vaccination campaign in Kathmandu, Nepal.

Citation: Khan MI, Bajracharya D, Pach 3rd A, Upreti SR, Sahastrabuddhe S, et al. (2016) Factors Associated Participation in a School Based Typhoid Vaccination Campaign in Nepal. J Vaccines Res Vaccin 2: 004.
Copyright: © 2016 Khan MI, et al., This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.