Vaccination is considered to be the most cost-effective public health tool in preventing infectious diseases responsible for child mortality in developed and developing countries.
Immunisation programmes have led to global eradication of smallpox, elimination of measles and poliomyelitis from certain regions of the world, and substantial reductions in morbidity and mortality attributed to diphtheria, tetanus, pertussis, pneumonia and infectious diarrhoea.
Such successes have resulted due to the use of safe and effective vaccines against these diseases, in addition to the control of important risk factors. However, the challenge of achieving continued high coverage rates for routine vaccines in developing countries persists. It is estimated that 1.4 million child deaths occur each year due to vaccine-preventable diseases in developing countries.
Pakistan has a high incidence of typhoid fever, a systematic illness caused by the bacteria Salmonella typhi. Ninety-seven percent of culture-proven typhoid cases were identified in children 2-12 years of age. However, currently available typhoid vaccines are recommended only for children older than 2 years, and hence, typhoid vaccination cannot be incorporated into the routine Expanded Programme on Immunisation (EPI).
A targeted immunisation programme in urban areas that uses schools as a platform may be a cost-effective strategy considering that typhoid incidence is high in Pakistan’s urban settings, immunisation coverage is sustained with previous experience in measles catch-up campaigns and polio vaccination campaigns at school settings, and that school enrolment rate is higher in urban settings compared to rural settings.
Gulshan-e-Iqbal and Jamshed towns were selected to pilot the initial typhoid vaccination campaign. The purpose of inclusion of all institutions in the targeted townships was to identify and obtain a comprehensive list of educational establishments where children aged 5-15 years were enrolled.
In 39 days, with a total of 24 data collection personnel and three field supervisors, we were able to collect data from 1,096 schools in two towns of Karachi. Fifty-eight (5 percent) schools refused to provide data to our field teams. The reasons for refusal were absence of an authorised person to provide data at the time of the visit, uncertainty by school administration about the vaccine type and need for its use at the school level, and previous unsatisfactory experience with vaccination or health-related activity. In total, 304,836 students were enrolled in public, private, and religious schools in Gulshan-e-Iqbal and Jamshed towns. Twenty-five percent (276) of all schools had an enrolment of fewer than 100 students, whereas 3 percent (36) had an enrolment of over or equal to 1,000 children.
One-quarter of public schools, 41 percent of private schools, and 23 percent of madrassas previously participated in a vaccination campaign that used the school as a venue. The majority (275/1,090) of these school-based campaigns were for polio vaccination, which was carried out under Pakistan’s polio eradication programme. Ninety-five schools provided vaccines that were not included in the government immunisation programmes (EPI, polio eradication programme, and measles second chance programme). These vaccines were typhoid (provided in five schools), varicella (three schools), and hepatitis B (89 schools). Many of these vaccines were sold at a price, especially in the private schools.
Vaccine price was frequently cited (59 percent respondents) as first choice as a barrier to vaccination of children by parents in schools in Gulshan-e-Iqbal Town. In Jamshed Town, the proportion was even higher (71 percent). Among other factors that were considered to be important barriers to a school-based vaccination campaign in the two towns were vaccine side effects (24 percent in both towns), and lack of awareness about the vaccine (34 percent in Gulshan-e-Iqbal Town and 38 percent in Jamshed Town). Almost one-third of the respondents did not select a third choice when considering factors that may promote vaccine uptake, but among those who did respond, risk of disease, vaccine side effects, and lack of awareness about the vaccine were considered to be the most important factors that could affect the vaccination campaign.
The respondents were then asked in a similar fashion to comment on factors that might increase student participation in the immunisation programme. In Gulshan-e-Iqbal Town, permission from parents was the first choice among 67 percent respondents, followed by distribution of vaccine-related information materials (47 percent) and involvement of teachers (28 percent). In Jamshed Town, the school administration staff considered distribution of vaccine-related information materials as an important factor (74 percent), followed by involvement of the city government (55 percent), and involvement of teachers (32 percent).
Majority of the schools were willing to participate in a school-based vaccination campaign, but were unsure of the response from parents. Though there are indications from other endemic areas and countries that people are willing to pay for typhoid vaccine, schools with past experience of charging a fee for vaccines did not believe a school-based vaccination campaign was very promising. To address concerns of parents and school administration, it is, therefore, worthwhile to focus on increasing awareness in the population about the disease, its consequences, and importance of a vaccine. A well-designed social mobilisation campaign targeting decision-makers would also help increase acceptance of vaccines in schools.
There are several limitations in this school census. First of all, there were refusals from 58 schools, which may have biased data as they represent 5 percent of all schools surveyed. Secondly, the school census could not obtain some important information. There were no records or information from schools regarding vaccination coverage for vaccination campaigns carried out at the schools. The procurement system for vaccines with a user fee was also not elucidated during the interviews. Provided that there is a user fee, vaccines may be priced at private market cost or may have little subsidy. As vaccine cost is a burden to many parents, provision of vaccines at subsidised price through schools will increase coverage. Third, as we interviewed the school administrators regarding the parents’ willingness to participate, information may not truly reflect parents’ points of view. Further, our respondents for interview varied from owner of the school to a teacher in-charge. Therefore, the responses may have varied by the characteristics of the respondents and their individual association with the establishment. Lastly, this census was conducted to identify the baseline for the pilot school-based typhoid vaccination programme and there were no pre-determined scientific consideration for analysis.
Despite the recent interests in additional platforms for vaccine introduction as stipulated in the Global Immunisation Vision and Strategy, challenges remain in implementing vaccination outside the regular immunisation programmes. The school census in Karachi addressed key information which may be similarly applicable to other countries. We found that health education or providing health facilities to students in the two townships is not part of the curriculum. In a country like Pakistan, where vaccination coverage is low, schools can be used to augment immunisation services for children in addition to other health activities such as nutrition. Schools can also be used for catch-up vaccination initiatives such as measles or polio. However, to accomplish this, government’s departments of education and health have to collaborate and a joint approach is needed to overcome the problem of low immunisation coverage. To do that, understanding of school infrastructure becomes important. Schools can be used as important platform for health-related initiatives such as legislation of presenting immunisation cards at the time of school admission, and thereby, influence parents’ approaches to vaccination. This could also improve retention of immunisation cards and can influence vaccination coverage as dropouts are high even for those children who do come in contact with immunisation centres.
The findings from this census have significant implications for developing countries where vaccination coverage is low. Schools could be used as a venue for vaccination programmes as has been done in other countries provided that appropriate information is disseminated to parents through a well-designed social mobilisation campaign, the government include school administration in planning such activities, vaccine safety concerns are addressed through a proper adverse events monitoring platform, and a multi-sectorial approach is adopted by the health department among other major stakeholders such as private healthcare providers, religious and community leaders, private school associations, and school administrators.
Extracted from the research paper titled ‘Schools as potential vaccination venue for vaccines outside regular EPI schedule: results from a school census in Pakistan’ authored by Sajid Bashir Soofi, Inamul Haq, M Imran Khan, Muhammad Bilal Siddiqui, Mushtaq Mirani, Rehman Tahir, Imtiaz Hussain, Mahesh K Puri, Zamir Hussain Suhag, Asif R Khwaja, Abdul Razzaq Lasi, John D Clemens, Michael Favorov, R Leon Ochiai and Zulfiqar A Bhutta.
