An article in the January 2022 collection of BMC Public Health explores the value added by doing vaccinations in school sites. Other research has shown that school-based programs have a broader reach, better coverage, help to familiari8ze young people with health care services and can be linked directly with classroom instruction as well as individual education and school activities. This article explores the feasibility of school-base vaccinations in a small pilot study. "Vaccination rates for measles, mumps, and rubella (MMR) and diphtheria, tetanus, pertussis, and polio (Tdap-IPV) are not optimal among German adolescents. Education in combination with easy access to vaccination may be a promising approach to improve vaccination rates. The present paper describes a pilot study of a planned cluster randomized controlled trial (cRCT) in which we aim to improve MMR and Tdap-IPV vaccination rates together with knowledge and self-efficacy in a school setting." The findings of the pilot study indicated good feasibility. Of the total sample, 437 students (50.9%) brought their vaccination cards to school, 68 students received Tdap-IPV vaccinations, and 11 received MMR vaccinations. Out of six knowledge questions, on average, the students had more correct answers before and after the class and positive changes to self-efficacy .

ISHN Comment: Further comparative research on the impacts of school-based vaccinations during and after the Covid pandemic are urgently needed.

Read more in the article.    

The Covid pandemic has underlined the need to a public or societal concern for the health of others. Many in the USA, like other countries, consider health to be a personal responsibility, de-emphasizing the other side of the equation, whereby public authorities are able to provide supports in times of need, especially during health crises like Covid. An article in Issue #1, 2022 of Preventive Medicine documents the fragile state and erosion of public support for social safety nets during the pandemic, even as a new President assumed power.  "We surveyed a nationally representative cohort of 1222 U.S. adults in April 2020 and November 2020 to evaluate changes in public opinion about 11 social safety net policies and the role of government over the course of the pandemic. ....The share of respondents believing in a strong role of government also declined from 33% in April to 26% in November 2020".

ISHN Comment: One of the poorly understood goals of an effective health & life skills education program is to promote a concern for the health of others. In the US, that specific goal has been part of the National Standards for Health Education for many years. Yet, progress towards that goal is rarely reported.  There are other societal underpinnings to health education that could be used in a comparison study. For example, in Africa, one could examine the impact of the "ubuntu" concept (which emphasizes the connection between individuals and the village. Or an indigenous perspective, one that views health as a set of relationships with the land and with our ancestors could be considered. Eastern world views, such as that which has emerged in Bhutan, which measures "happiness" in relation to economic and social progress should al;so be on the list.  This discussion should be a part of any review of the failure of health education in many jurisdictions to have an impact on the fundamental values which should guide our responses to health and other crises.

Go to the Preventive Medicine Journal article.

The Lancet has published a report on a large cross-sectional survey of school health monitoring in 17 provinces in China. The study used data from 2428 schools from 17 provinces in China in 2018. Data were collected using a questionnaire administered by the Ministry of Education through its monitoring system, and included infectious diseases (e.g., reporting system for student infectious diseases), non-communicable diseases (e.g., regular student health examinations), and school physical environments (e.g., monitoring of classroom light, microclimate and drinking water). "Findings: Overall, the coverage rate of full school health monitoring systems was 16·6%. The coverage rates of school health monitoring systems for infectious diseases, non-communicable diseases, and school physical environments were 71·2%, 68·5%, and 24·9%, respectively. Coverage was higher in schools from urban rather than rural areas, in schools from areas with greater wealth, and in senior secondary schools rather than junior secondary and primary schools. Overall, the coverage of school health services monitoring was higher in urban areas, in wealthier areas, and in senior secondary schools."

The monitoring of infectious diseases is likely higher than most other countries. "The proportion of schools with all infectious disease monitoring systems was 71·2%. Overall, infectious disease monitoring systems were established in more than 90·0% of schools. The exception was in the use of student enrolment inoculation cards, which were adopted by only 76·4% of schools. The use of enrolment inoculation cards requiring an inspection system varied by school type, being highest in primary schools (96·4%), followed by junior secondary schools (47·3%) and senior secondary schools (25·6%)." Further "Since the SARS outbreak in 2003, the Chinese government has invested heavily in infectious disease control and prevention, with demonstrated improvements in disease surveillance.
This may explain why we found few differences in the coverage of infectious disease prevention and monitoring systems between urban and rural locations, regional SES groups, and primary and secondary schools, which is consistent with the widespread implementation of school-based monitoring systems around infectious diseases. Among the components of infectious disease monitoring in schools, the one exception to high coverage was around a system to review student enrolment inoculation cards (a certificate inspection system) which was evident in only 76·4% of schools, well lower than for other components." .

ISHN Comments: This Chinese example of SH monitoring is likely among the best in the world and underlines the need to better surveillance policies and practices. The relative "problems" with tracking student vaccination rates would be likely be seen as a success in most other countries. The discussion of monitoring and reporting (See the ISHN and FRESH Partner (pp 38-39) summaries on Monitoring, Reporting, Evaluating & Improving) should be linked directly to improvement planning and policy-making. Countries could learn more from each other on implementing better MREI practices which have been underlined  by the recent Covid pandemic.

Read the Lancet article here

(An item from the ISHN Member information service)   A register-based study of 90,000 girls and their parents in Norway was used to examine the demographic, socioeconomic and behavioural correlates of HPV vaccination of preadolescent girls in a publicly funded, school-based vaccination programme. "Data for all Norwegian girls born 1997–1999, eligible for routine school-based HPV vaccination in 2009–2011 (n = 90,842), and their registered mother and father, were merged from national registries. Correlates of girl vaccination status were analysed by unadjusted and multivariable logistic regression. In total, 78.2% of the girls received the first dose of the HPV vaccine, 74.6% received three doses, and 94.8% received the MMR vaccine. Correlates associated with initiation of HPV vaccination included parental age, income and education, maternal occupational status and cervical screening attendance, and girl receipt of the MMR vaccine. Rates of completion of HPV vaccination among initiators were high, and disparities in completion were negligible. " The authors conclude that "Routine school-based vaccination generally provides equitable delivery, yet some disparities exist. Information campaigns designed to reach the sub-groups with relatively low vaccine uptake could reduce disparities." The Norwegian vaccination programme is administered by the municipality health services, who are obliged by law to provide the included vaccines to all children. HPV vaccination was included in the programme in 2009. The vaccine is usually given by the school nurse during school hours. Among other vaccines, the childhood immunisation programme also offers vaccination against MMR (measles, mumps and rubella combined) in the sixth grade. Vaccination is optional, and the vaccine and their parents/guardians have to consent to vaccination. Written consent is not required, but is encouraged for vaccination of school children." Read More>>

(An item from the ISHN Member information service)  "The weekly epidemiological record of the World Health Organisation 15th May 20151 states that ‘the cases of Middle East Respiratory Syndrome (MERS) recently exported to other countries have not resulted in sustained onward transmission to persons in close contact with these cases on aircraft or in the respective countries outside the Middle East.’ This situation has changed rapidly and remarkably. Five days after the publication of this report, the first case of a MERS-coronavirus (MERS-CoV) infection in Seoul, South Korea was reported...". This first sentence in an article in the July 2015 Issue of International Journal of Infectious Diseases got our attention. It is noteworthy that South Korea closed 2700 schools quickly during the outbreak. In discussions with Toronto public health and school officials after the SARS outbreak, we learned that closure of schools was difficult due to poor communications and unclear definitions of decision-making roles. The authors of the MERS article conclude that " Moving forward, it is critical that global efforts are focussed urgently on the basic science and on clinical and public health research so that the exact mode of transmission to and between humans, and new drugs and other therapeutic interventions and vaccines can be developed6, 7. Two coronaviruses, SARS-CoV and now MERS-CoV, which cause severe respiratory disease with high mortality rates emerged within the past two decades10, reinforcing the need for clinically efficacious antivirals targeting coronaviruses. Lessons learnt from the recent Ebola Virus Disease could also be applied to MERS11. Whilst MERS does not yet constitute an International Public Health Emergency the Korean outbreak is an extraordinary event." Read more>>

(From the ISHN Member information service)  An article in December 2014 Issue of BMC Public Health examined the potential impact of several non-pharmaceutical strategies for responding to influenza outbreaks. These included school closures, work place closures, travel restrictions, voluntary and obligatory quarantines and more. The most effective non-pharma response to such outbreaks was closing any school quickly when infections reached a certain level. The authors conclude that "Our methodology was able to design effective NPI strategies, which were able to contain outbreaks by reducing infection attack rates (IAR) to below 10% in low and medium virus transmissibility scenarios with 33% and 50% IAR, respectively. The level of reduction in the high transmissibility scenario (with 65% IAR) was also significant. As noted in the published literature, we also found school closure to be the single most effective intervention among all NPIs". Read more>>  

 (From the ISHN Member information service)  An article in Issue #49, 2014 of Vaccines reports on a WHO led study on the growing trend among parents around the world. "Vaccine hesitancy refers to delay in acceptance or refusal of vaccines despite the availability of vaccination services. Different factors influence vaccine hesitancy and these are context-specific, varying across time and place and with different vaccines. Factors such as complacency, convenience and confidence are involved. Acceptance of vaccines may be decreasing and several explanations for this trend have been proposed." The WHO Strategic Advisory Group of Experts (SAGE) has developed an explanatory model that was tested and found useful in explaining the results of this interview-based study in Immunization Managers in several countries. "Even if there had been reports of vaccine hesitancy in their country, 11 of the 13 IMs considered that vaccine hesitancy was not common and that it did not have a significant impact on vaccine uptake in the routine immunization programmes. IMs from two countries indicated that mass immunization campaigns, rather than routine immunization programmes, were affected by vaccine hesitancy. Factors concerning convenience and ease of access were perceived to be important by nine of the IM's Convenience was a factor for sub-populations which did not use the health services provided and for hard-to-reach populations. However, two IMs stated that vaccine hesitancy was an important issue in their country." When IMs were asked about the percentage of non-vaccinated and under-vaccinated individuals in their country due to lack of confidence in vaccination, only six provided estimates ranging from less than 1% to 20%. Four IMs reported issues of complacency in their countries." Religious beliefs were often a causal factor in vaccine hesitancy (cited by nine IMs).Risk perceptions were identified by seven IMs as causal factors. This included concerns regarding vaccine safety, lack of perceived benefits of vaccination and lack of understanding of the burden of vaccine-preventable diseases. The new, basic understanding of vaccine hesitancy from this first study, which shows an apparent lack of urgency among Immunization Managers, runs counter to the many news stories of returning diseases such as measles in high income countries as well as renewed concerns about infectious diseases in low resource countries. Schools are a convenient site for vaccinations as well as a strong connection for educating parents. School policies about vaccination requirements are also key. More attention and action are warranted. Read more>>

 (From the ISHN Member information service)  An article in Issue #5, 2015 of Vaccine provides an update on the number of countries currently using schools to deliver vaccinations to their populations. The article covers only the delivery of the vaccines and does not discuss the other roles that schools can play in informing parents, educating students, and responding to outbreaks but it underlines the need for a global discussion of the school's role in immunization, development and in national policies/committees." Every year since 1998, UNICEF and WHO collect data through the “WHO-UNICEF Joint Reporting Form (JRF)”, which is completed by Ministries of Health in all Member States [5]. Since 2009, the data includes data on whether a school-based approach is used in a country, what vaccines are being given at what grade and to what age groups, the sex of the children targeted, as well as some additional questions. Countries are asked whether “routine immunization is given to school-aged children using the school as a venue” and should include only “doses that are given as part of the national immunization schedule”, i.e. excluding campaigns". "Of the 195 countries and territories that had been requested to complete the JRF report in 2013 (reporting 2012 data), 189 submitted a JRF form, of which 174 included information on whether a school-based approach was used in their country as of 2012. Of these, 95 answered positively, while 79 said no school-based approach was being used for immunization services". "64% of high income or higher middle income countries reported the existence of a school-based immunization program, against 28% of lower and lower middle income countries". "Most countries provided more than one antigen using a school-based approach, often using combination vaccines. Only 13 countries just gave one antigen, while at the other extreme 3 countries gave 10 different antigens." Read more>>

The report notes that "Vaccines and immunization have created a healthier world. Progress is being made towards polio eradication. Measles and neonatal tetanus deaths are on the decline and new vaccines are being
introduced into the national programmes of low -and middle-income countries with associated reductions in morbidity and mortality. Still, national governments, development partners and international agencies
must invest more to meet the Decade of Vaccines’ goals of disease eradication or elimination and to reduce mortality and morbidity from vaccine-preventable diseases. However, the report also notes that :

• As the world nears the final stages of the polio eradication effort, the challenges to achieve success have increased. It is imperative that all stakeholders now redouble their efforts to complete the job, as failure would represent a failure not only for the immunization community but for public health
• All countries are urged to establish national action plans to introduce at least one dose of inactivated poliovirus vaccine and switch from the use of trivalent oral polio vaccine to bivalent oral polio vaccine
• Measles and rubella/congenital rubella syndrome elimination, while long accomplished in the Region of the Americas, is a new challenge for other regions. Currently, in addition to the Region of the Americas, only the Western Pacific Region is on track for reaching the regional measles elimination target; the African, European and Eastern Mediterranean regions are not on track and the South - East Asia Region has only just established an elimination goal and target year..

Read more. 

(An item from the ISHN Member information service) Several articles in Issue #4, 2013 of the Journal of School Nursing provide insights into school-located immunization programs. The editorial notes that: " The development of immunizations is considered 1 of the 10 great accomplishments of public health in the first decade of the 21st century (Morbidity and Mortality Weekly, 2011). School nurses are inextricably associated with the substantial declines in vaccine-preventable diseases, and five of the original research articles in this issue provide evidence of the actual and potential school nursing contributions." The articles examine immunization programs in different contexts, including minority communities, private schools and other contexts. Another examines how five school districts in the USA strengthened their programs in diverse ways. Read more>>

(An item from the ISHN Member information service) An article in the April 2013 Issue of BMC Public Health explores the process, reception and reactions to school closings during an outbrerak of influenza or other diseases. School closings, if done quickly and effectively, may disrupt the disease transmission vectors in such outbreaks. The authors note that "Drawing on Thompson et al’s ethical framework for pandemic planning, we show that considerable variation existed between and within schools in their attention to ethical processes and values. In all schools, health officials and school leaders were strongly committed to providing high quality care for members of the school community. There was variation in the extent to which information was shared openly and transparently, the degree to which school community members considered themselves participants in decision-making, and the responsiveness of decision-makers to the changing situation. Reservations were expressed about the need for closures and quarantine and there was a lack of understanding of the rationale for the closures. In our study, trust was the foundation upon which effective responses to the school closure were built. Trust relations within the school were the basis on which different values and beliefs were used to develop and justify the practices and strategies in response to the pandemic. Read more>>

(An item from ISHN Member information service) An article in the February 2013 Issue of PLOS Neglected Tropical Diseases reviews the impact of school-based deworming programs and found that they can be effective in reducing the infection rates among those children. However, the authors caution that the overall impact of such school programs on the community may be lessened if the proportion of people in the community who are infected are adults rather than children. Really? Who would have thought that school programs do not reach adults? Really  Read more> 

(An item from ISHN Member information service) An article in Issue #4, 2012 of International Health provides a summary of the reasons why children afe not vaccinated. The authors prove this summary based on a review of the grey literature. "In collaboration with WHO, IMMUNIZATION-basics analyzed 126 documents from the global grey literature to identify reasons why eligible children had incomplete or no vaccinations.The main reasons for under-vaccination were related to immunization services and to parental knowledge and attitudes. The most frequently cited factors were: access to services, health staff attitudes and practices, reliability of services, false contraindications, parents’ practical knowledge of vaccination, fear of side effects, conflicting priorities and parental beliefs. Some family demographic characteristics were strong, but underlying, risk factors for under-vaccination. Studies must be well designed to capture a complete picture of the simultaneous causes of under-vaccination and to avoid biased results. Although the grey literature contains studies of varying quality, it includes many well-designed studies. Every immunization program should strive to provide quality services that are accessible, convenient, reliable, friendly, affordable and acceptable, and should solicit feedback from families and community leaders. Every program should monitor missed and under-vaccinated children and assess and address the causes. Although global reviews, such as this one, can play a useful role in identifying key questions for local study, local enquiry and follow-up remain essential. Read more. 

(An item from ISHN Member information service) An article in the November 2012 Issue of PLOS Neglected Tropical Diseases suggests that school or community-based vaccinations to prevent Schistosomiasis (infections from snails) is more effective than the current WHO treatment guidelines. The researchers report that "Our study used available field data to calibrate advanced network models of village-level Schistosoma transmission to project outcomes of six different community- or school age-based programs, as compared to the impact of current 2006 W.H.O. recommended control strategies. We then scored the number of years each of 10 typical villages would remain below 10% infection prevalence (a practicable level associated with minimal prevalence of disease). All strategies that included four annual treatments effectively reduced community prevalence to less than 10%, while programs having yearly gaps (‘holidays’) failed to reach this objective in half of the communities. Effective post-program suppression of infection prevalence persisted in half of the 10 villages for 7–10 years, whereas in five high-risk villages, program effects on prevalence lasted zero to four years only. At typical levels of treatment adherence (60 to 70%), current WHO recommendations will likely not achieve effective suppression of Schistosoma prevalence unless implemented for longer than years.  Read More 

(An item from ISHN Member information service) Four articles in the October 2012 issue of the Journal of School Nursing examine the costs, coordination and coverage of school-based influenza vaccination programs. The cost of school vaccination programs was calculated by estimating the time spent by school nurses outside their normal clinic duties (22 out of 69 hours). and the calculation estimates such costs at $15.36 per dose. A second article calculated the per dose during the recent H1N1 campaign to be $13.51. The third article examined feasibility and acceptability and reported that "school personnel and the vaccinator viewed the school-located vaccinations as feasible and beneficial. However, the vaccinator identified difficulties with third-party billing as a potential threat to sustainability. The fourth article examined the coordination of school and state immunization records in Washington state. Read more. 

(An item taken from the daily/weekly/monthly ISHN Member information service) An article in Issue #4, 2012 of the Journal of School Nursing reports on the experiences of several stakeholders in using elementary schools as the place for influenza vaccinations. study examined the initiation and logistics, funding, perceived barriers and benefits, and disruption of school activities by school-located influenza vaccination (SLIV) programs conducted during the 2008–2009 influenza season. Seventy-two interviews using a structured protocol were conducted with 26 teachers, 16 school administrators, and 30 health care professionals from 34 schools in 8 school districts. Most respondents (96%) reported minimal school-day disruptions. The perception of most stakeholders is that SLIV programs can be relatively easy to initiate, minimally disruptive and can become more efficient with experience, especially with feedback from all stakeholders. Readers may also want to review the articles we collected as we monitored this issue during the H1N1 outbreak a year ago, where we cited studies showing that school-based vaccinations were also significantly more cost effective and efficient. Read more..

(An item taken from the daily/weekly/monthly ISHN Member information service)  Immunization is discussed in four articles in Issue #6, 2012 of Pediatrics. Two of those articles once again demonstrate how school-based immunization programs cost less and are more effective in reaching youth. (Similar studies have shown that school-based immunization is less costly and more effective in initial campaigns.) The first article reports that immunization recalls to 800 adolescents in four Denver clinics. Post the recall, the intervention group had significantly higher proportions of receipt of at least 1 targeted vaccine (47.1% vs 34.6%, P < .0001) and receipt of all targeted vaccines (36.2% vs 25.2%, P < .0001) compared with the control group. Three of the four clinics made a profit from the recall, one did not. (Average costs for administering vaccines are usually about $15 in a physicians office). The other study, also in Denver, recalled 529 teens from four school-based health centres. At the end of the demonstration study, 77% of girls had received ≥1 vaccine and 45% had received all needed adolescent vaccines. At the end of the RCT, 66% of recalled boys had received ≥1 vaccine and 59% had received all study vaccines, compared with 45% and 36%, respectively, of the control group (P < .001). The cost of conducting recall ranged from $1.12 to $6.87 per recalled child immunized via school-based clinics.  Read more... 

(Posted by ISHN) April is Vaccinations month around the world, so it is fitting that this blog post discusses the school's critical role in vaccinations. This posting has been prompted by a series of excellent articles in the February 2012 issues (#6-10) of the journal Vaccine. These articles examine the attitudes and concerns of parents, community norms, factors that affected the uptake of vaccinations during the recent H1N1 outbreak. The International School Health Network has been tracking this issue in its monitoring of over 200 research journals, over 100 news media outlets and over 75 social media sources. A quick summary of some of those articles, reports and reviews can be found here. Read more.