by Pradeep Nair
Schools are the most appropriate place to deliver new vaccines to children and adolescents who may not receive them in a conventional healthcare set-up. However, engaging schools in vaccination programmes is not so easy, as the schools have their own administrative and resource limitations. The schools further have day-to-day academic operations and follow an academic calendar where it is very difficult to accommodate a healthcare intervention in between the academic sessions. Partnership and collaborations are required in a vaccination programme to involve and engage the school management, principals, teaching and adminis-trative staffs, student bodies, parents and community organisations. This commentary explores the possibilities of linking MR (Measles and Rubella) vaccination programmes to the goals, programmes and policies of public schools and the way it is implemented in India.
An Overview of MR Vaccination Programme in India
Measles is a contagious disease and spreads through coughing and sneezing of an infected person. It makes children vulnerable to life- threatening complications such as pneumonia, diarrhoea and brain infection. But this doesn't mean that it may not affect adults. Multiple outbreaks of the disease have been reported among adults in heterogeneous settings—urban areas, work places, disaster sites, during travel etc. The disease is generally transmitted by airborne route, and a number of deaths have been reported because of disease-associated complications.
Estimates of measles-related deaths have been considered a crucial indicator to evaluate the progress of any nation towards measles elimination (Sudfeld and Halsey, 2009). The global estimates for the year 2015 suggest that measles killed an estimated 134.2 thousand children mostly less than five years. In India, it killed an estimated 49.2 thousand children which is 36.66 per cent of the global measles-associated deaths. (WHO Measles Fact Sheet, 2015) Some of the studies conducted by scholars in India from 2010 to 2013 on the status of measles over four decades revealed that the median case fatality ratio was 1.63 per cent and the higher case fatality ratio was reported among under-five year children and children from the backward classes. (Simons et al., 2012; Morris et al., 2013; Murhekar et al, 2014) In comparison to measles, Rubella is a contagious but generally a mild infection. But it may develop hearing impairments, eye and heart defects and other lifelong disabilities in children if not detected/reported at the initial stage.
The first targeted campaign to prevent measles was introduced in India in 1985 under the Universal Immunisation Programme (UIP). Until 2008, India was the only nation among the 193 member-nations of the World Health Organisation (WHO) to make provision only for a single dose of measles in their national immunisation schedule, whereas all other nations opted for two doses of measles vaccine. (John and Verghese, 2011) A number of studies conducted on measles surveillance in India observed that a single dose of measles vaccine was insufficient to protect the general population and in 40 per cent cases, the patient acquired the disease despite being immunised with one dose of measles vaccine. (Bose et al, 2014) On the basis of these studies and the studies conducted by the Indian National Technical Advisory Group on Immunisation, the Government of India decided to launch a second dose of measles in late 2010 for all children between 16 to 24 months of age with the purpose to provide additional immunity to measles to children under age five and to improve the mortality indicators in children. (Verma et al., 2011)
In continuation, in February 2017, the Government of India has launched a nation-wide single vaccine programme for dual protection against measles and rubella as a part of the global initiative to fight these childhood diseases and to reduce the morbidity and mortality burden in developing countries. The single-shot Measles-Rubella (MR) vaccine nation-wide drive targets around 410 million children across the country and is considered as the largest immunisation campaign ever launched by the Indian Government. The campaign was initially launched in five Indian States and Union Territories with a target to cover 36 million children and is in nationwide expansion. Under the campaign, all children aged between nine months and less than 15 years were given a single shot of MR vaccination irrespective of their previous measles/rubella vaccination status or measles/rubella disease status. The vaccine is provided free of cost at school and outreach session sites under the Universal Immunisation Programme (UIP) and is expected to have a substantial effect on global measles mortality and rubella control as India accounted for 37 per cent global measles deaths in 2016 (WHO Measles Fact Sheet, 2016). With this nation-wide campaign, India may accomplish the goal of measles elimination by the year 2020 along with other member states of the South-East Asia Region of the WHO.
The Implementation Plan
In the pre-planning phase of the vaccination programme, the school representatives were made aware about the purpose of the vaccination programme and discussions were held to work out the efforts and co-ordination required in implementing the programme. Initiatives were taken to chart out the workforce and linkages required to implement the programme across the selected States. While partnering with the schools, the health officials visited the schools to work out the resources and strategy to implement the programme. Publicity literature, carrying the instructions related to the vaccines and other important information, were given to the schools to distribute among the students and staff and also in the neighbouring commu-nities to publicise the programme. The schools' managements were asked to properly inform the parents about the vaccination programme through diary notes, SMS and other social media activities. Circulars and posters about the vaccination programme were posted in the class-rooms, corridors, and at the display boards of the schools to inform the students and the school staff in advance. Consent forms were sent to the parents to get their consent for the vaccination of their wards. The parents, who had not given their consent regarding the vaccination of their wards within due time, were invited for a dialogue with the school authorities to convince them about the safety concerns of the vaccines. Vaccinations were done through the State Health Departments in the respective States in public schools by deploying special health teams comprising trained doctors, nurses and para-medical staff. The whole process on the day of vaccination was monitored by the Chief Medical Officers of the respective districts, Senior Medical Officers of concerned health facilitators, and by other senior health officials. Post-vaccination reviews were conducted to assess the impact of the vaccination programme and also to explore the future possibilities of collaboration.
Approaching Parents and the Community
School diaries and SMS messages were most commonly used as the method of communication to approach the parents about the vaccination programmes. In the urban centres, parents were approached through whatsapp groups and through school-specific applications. The pre-programme coverage of the MR vaccination programme was given in local newspapers and it was further publicised on the websites and social media.
In a school-based vaccination programme, informing the parents about the vaccination programme is easy as the schools already have a regular communication system to stay in contact with the parents regarding the academic programmes and day-to-day school activities. But reaching to the community is a challenging task. (Limper, 2014) Specially designed information kits about the vaccination programme were distributed to inform and make the community people aware about the programme. To reach out the opinion leaders, the rapport and networking of the school staff with the community was used as an outreach strategy.
At the adolescent stage, students prefer to take their own vaccination decision and the parents just sign the consent form. That is why massive sensitisation programmes were conducted to inform and make the young people aware about vaccination so that they can multiply this information in their respective families and communities.
The Workforce and Linkages
Vaccination is a large scale programme and requires a lot of resources and administrative efforts at the level of all the stakeholders involved in the programme. When a vaccination programme is reported to the school at a very short notice, asking them to provide delivery support, it becomes very difficult for the schools to accommodate the programme in-between their academic sessions. (Cooper, Ward and Skinner, 2011) Further the schools find it really difficult to prioritise the resourcing needs to implement the programme. Informing, engaging and involving the school staff in the vaccination programme is also a challenge, as the teaching staff in most public schools are already over-burdened in managing the day-to-day academic affairs. The teachers, besides taking their classes, are required to update the attendance on a day-to-day basis, to prepare the SMS messages regarding the subject home assignments, clicking the photographs of the lecture delivered on the display board and uploading it on the school applications, checking the class works and doing other routine academic duties. So, when the school management asks them to facilitate a vaccination programme, they mostly take it as a burden rather than as an initiative to be engaged in. Incentives or some other benefits shall motivate the teacher to take up the programme with some commitment, but currently no such provision is available.
Hence, only an innovative approach to engage the teaching and adminis-trative staff of a school in a vaccination programme will work. A voluntary school-based vaccination programme becomes successful only when the cost, access and implementation of a vaccination pro-gramme is planned in advance. Further, schools are not made for the delivery of healthcare services. Their primary objective is to impart education. So, partnering with schools for a vaccination programme needs a clear under-standing of the means and methods of prioritising the schools' activities. The decisions related to engagement are mostly taken at the school management level, so proper channel approach is required to partnership with the schools. The linkages and workforce to implement the programme along with resources, funding, time and staff deployment must be charted out. Some kind of incentive to offer the school in exchange for its cooperation and assistance should be plamed. If a vaccination programme is not planned well in advance in accordance with the academic calendar of the school, it will affect the academic mandate of the school and then become a forced burden on the school.
Conclusion
To engage public schools in vaccination programmes one needs to frame communication with the school leaders in tune with the policies, goals and programmes of the school. During a vaccination programme, a lot of information is to be documented and verified. The million dollar question is: who in the school is going to manage and update this data? Further identifying and contacting each child's vaccination need requires to be shared among the school staff engaged in the vaccination programme, the healthcare providers and vaccination/immunisation registers. So, initiating school-based vaccination programmes requires an understanding of the role of public schools in strengthening the delivery of vaccination programmes. It can be developed by reviewing the current scope of the school health resources and the experience gained during the implementation of the first round of MR vaccination programmes in India.
This experience-based learning will also help the implementation agencies to explore the potential barriers to vaccination activities in schools. There is no doubt that through a school- based vaccination programme, diverse student population and communities can be covered at the most approachable manner. Here, the only requirement is to develop policies to encourage collaborations and partnership among health departments, intervention agencies and schools for future vaccination efforts.
References
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Pradeep Nair, Ph.D, is an Associate Professor and Dean, School of Journalism, Mass Communication and New Media, Central University of Himachal Pradesh, Dharamshala. His research interests include Media and Civic Engagement, Health Governance and Political Communication. He can be contacted by e-mail at: nairdevcom[at]yahoo.co.in