Schools as potential vaccination venue for vaccines outside regular EPI schedule: results from a school census in Pakistan

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 [1]. Immunization programs 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 diarrhea [2]. 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 [3]. It is estimated that 1.4 million child deaths occur each year due to vaccine-preventable diseases in developing countries [4–6].

The Expanded Program on Immunization (EPI) was introduced in 1974 with the aim of reducing vaccine-preventable deaths in children in developing countries. The coverage rate for DTP3 under EPI increased to almost 75% by the 1990s globally and to 82% in 2009 [7, 8]. However, new vaccines that have become available are yet to be introduced in routine vaccination programs in developing countries where cost is a major factor in limiting the use of new vaccines. In addition, the existing health delivery system in developing countries may not be able to bear the load of storage and supply of new-generation vaccines [9]. In areas of high school enrolment, schools provide an opportunity for a catch-up vaccination for routine vaccines such as measles and routine vaccination for vaccines that cannot be administered under EPI such as typhoid. In most developed countries, immunization record is a requirement for school enrolment, and additionally, schools have been used as a platform for immunization for measles, Japanese Encephalitis, influenza, and HPV. Such a strategy for developing countries has been under discussion and several assessments have been made by the World Health Organization (WHO) [10]. Similarly, the Global Immunization Vision and Strategy (GIVS) outlines the need for expansion of "vaccination beyond the traditional target group of infants" [11]. Health education in school settings is increasing in the developing countries, but immunization programs at schools have been mostly limited to campaigns and not in routine [12]. Only few developing countries have implemented routine school immunization programs.

Pakistan has a high incidence of typhoid fever (> 100/100,000 population per year), a systematic illness caused by the bacteria Salmonella Typhi [13]. Ninety-seven percent of culture-proven typhoid cases were identified in children 2-12 years of age [14]. However, currently available typhoid vaccines are recommended only for children older than 2 years and hence, typhoid vaccination cannot be incorporated into the routine EPI program. A targeted immunization program 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, immunization 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 [5, 15].

The old-generation killed whole cell typhoid vaccines were used in schools in developing countries, including Pakistan, in the 1970s. However, due to high rates of adverse events, the vaccination program was discontinued. But the accumulation of recent evidence of the burden of typhoid from population-based studies and the availability of the Vi polysaccharide vaccine in Pakistan have resulted in growing interest from the public health sector for wider use of typhoid vaccines in children [14, 16, 17]. As part of the Vi-based Vaccines for Asia (VIVA) Initiative,^a which aims to accelerate the adoption of Vi polysaccharide vaccines into developing countries of Asia, a pilot school-based immunization program in Karachi, Pakistan was developed. In preparation for the program, we conducted a census of schools in the study setting to collect information on total enrolment, school location and willingness of school administration to participate in a school-based typhoid vaccination program, and to identify any factors that will increase their participation in such a program. We assessed to find out if there were any social and health service delivery determinants in increasing access to immunization services in Pakistan. In this paper, we present the findings from the school census and implications for a school-based vaccination program, particularly for typhoid fever, in Pakistan.

The average minimum school fee for schools charging a fee ranged from 615 to 821 rupees^b (7.60 to 10.18 USD) per month. Jamshed town had a lower median minimum school fee of 350 rupees (4.30 USD) per month. A welfare system to support the educational expenses of deserving students was available in 56% of public schools, 71% of private schools, and 66% of Madrasahs. Approximately 8% of public schools, 17% of private schools, and 14% of Madrasahs provided some form of health education (Table 1).

The school census activity in two towns of Karachi provided information on vaccine use and vaccine acceptance, in addition to characteristics (e.g., number of schools, fee structure, and student enrolment) of the schools. Our data from school census shows that there is wide variation in characteristics of the educational institutions of Karachi, Pakistan. Our results also show that majority of education services are provided by private sector. Health and education have recently been dominated by private sector in Pakistan [20, 21]. The reasons of such transition have been well documented for Pakistan and other developing countries that include quality of service, consumer satisfaction and access. In such a situation, private schools' significant role not only in education but also in health cannot be ignored. Immunization policies in Pakistan therefore should take into account schools' role and private schools in particular to meet global standards of immunization coverage.

Mapping of the schools identified that many schools are located in close proximity to each other on major streets in the study setting. The smaller schools are located in sections of houses of the school owner or administrator. This type of small school may present logistical issues at the time of the vaccination campaign regarding accessibility. The student size at private schools varies from as low as five students at a school to approximately 3,000 students. Such variety in school size also presents a challenge in terms of properly scheduling a vaccination campaign.

Regular health programs offered at the school level were not very common in this study setting. Increasing health awareness in students in schools may be limited due to limited existing resources at the schools. School-based vaccination campaigns may have to adopt strategies that are attractive and innovative in order to create the need and demand for vaccines in schools. This is in line with the global effort to integrate health activities at schools such as FRESH and WASH campaigns [22–24]. Furthermore, based on the census teams' interviews with school administration, participation rates were very low in immunization programs where the vaccine was offered at a price.

The majority of 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 [25–27], schools with past experience of charging a fee for vaccines did not believe a school-based vaccination campaign was very promising. In order 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 mobilization 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 the data as they represent 5% 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 subsidized 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' point of views. Further, our respondents for interview varied from owner of the school to a teacher incharge. Therefore the responses may have varied by the characteristics of the respondent and their individual association with the establishment. Lastly, this census was conducted to identify the baseline for the pilot school-based typhoid vaccination program and there were no pre-determined scientific consideration for analysis.

Despite the recent interests in additional platforms for vaccine introduction as stipulated in the WHO-UNICEF Global Immunization Vision and Strategy [28], challenges remain in implementing vaccination outside of the regular immunization programs. 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 [29], schools can be used to augment immunization 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, in order 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 immunization coverage. In order 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 immunization cards at the time of school admission and thereby influence parents' approaches to vaccination. This could also improve retention of immunization cards and can influence vaccination coverage as drop outs are high even for those children who do come in contact with immunization centers [30, 31].

The findings from this census have significant implications to developing countries where vaccination coverage is low. Schools could be used as a venue for vaccination programs as has been done in other countries provided that: a) appropriate information is disseminated to parents through a well-designed social mobilization campaign; b) the government include school administration in planning such activities; c) vaccine safety concerns are addressed through a proper adverse events monitoring platform; and d) a multi-sectorial approach is adopted by the Department of Health among the major stakeholders such as private health care providers, religious and community leaders, private school associations, and school administrators.

^a Vi-based Vaccines for Asia (VIVA) Initiative is a five-year program supported by the Bill & Melinda Gates Foundation and coordinated by the International Vaccine Institute (IVI). VIVA's goal is to reduce typhoid fever mortality and morbidity in infants and children in countries that are afflicted by typhoid through the accelerating adoption of existing typhoid vaccines (Vi polysaccharide vaccine), and by developing a new and affordable Vi conjugate vaccines. http://viva.ivi.int

^b 1USD = 80.69 PKR