Nepal offers textbook lesson on vaccinations
Where is it more likely that kids will get recommended vaccines — Nepal or Texas? The answer might surprise you.
In 2001, I worked in Nepal as part of the U.S. Centers for Disease Control and Prevention’s (CDC) Stop Transmission of Polio (STOP) program, a global public health program made up of volunteers trained to improve polio surveillance and help plan, implement and evaluate vaccination campaigns. My Nepali partner and I traveled throughout the western region of Nepal to assist in implementing the World Health Organization’s eradication strategies in some of the most remote regions on the planet. Simple techniques, such as national immunization days and effective surveillance, have been used worldwide since the launch of the global polio eradication efforts in 1988. Everyone in Nepal got their polio vaccination.
The Texas Medical Center with 21 renowned hospitals, 14 support organizations, 10 academic institutions, eight academic and research institutions, seven nursing programs, three public health organizations, three medical schools, two pharmacy schools, and a dental school, is the largest medical center on the planet. Interestingly, the enormous complex sits smack in the middle of one of the largest, most diverse school systems in the country, the Houston Independent School District. With more than 215,000 students attending schools spread out over 301 square miles, it is the seventhlargest school system in the nation and the largest in Texas. The HISD population is diverse: 25 percent African-American, 62 percent Hispanic, 8 percent white and nearly 4 percent Asian. More than 75 percent of students are classified as economically disadvantaged.
However, even with the TMC in the district’s midst, the health-care infrastructure for vaccination delivery within HISD is limited. Of 283 schools, there are only 10 on-site health clinics and two mobile vans. The capacity for vaccination delivery within the Houston Health Department, meanwhile, varies depending on need. During emergencies or influenza pandemics, nurses, pharmacists and private partners are rapidly mobilized. Under normal operations, however, the Health Department has limited capacity to conduct on-site, school-located vaccine clinics.
Nepal does better than Texas. In 2014, 92 percent of Nepali children had reached local surveillance targets for pertussis vaccination (three doses of DTaP) versus 81.5 percent (four doses of DTaP) in Texas. As per the CDC’s 2015 National Immunization Survey, Texas is currently ranked 48th for immunization uptake for children age 19-35 months
Tracking the vaccination status of children within this expansive community is challenging. Currently, HISD reports vaccination status to the Department State Health Services for only three grades: prekindergarten, kindergarten and seventh grade. Although vaccinations for most HISD children reported to the state agency are “up to date,” as per school requirements for Texas, many children (6,349, or 3.1 percent) are “delinquent,” meaning the child has not received at least one dose of each specified age-appropriate vaccine by October, 90 days into the school year. HISD reports, for example, that 11 percent (1,604) of prekindergarten students had not received their first dose of measles vaccine; 4.4 percent (762) of kindergarteners and 4.2 percent (573) of seventh-grade students had not received two doses of measles vaccine. Such rates of nonvaccination suggest thresholds for maintaining the so-called “herd” immunity are being crossed.
For parents, understanding school vaccine requirements and keeping accurate track of the vaccinations can be challenging, even with the summer break to catch up.
For schools, maintaining high attendance rates conflicts with national school mandates requiring children to be kept out of school if unvaccinated. For our vaccine providers, reaching children means reaching parents, a challenge in any diverse community. For legislators, repeated attempts since 2007 to change our vaccine registry (“ImmTrac”) back to its original “Opt Out” format, where children are included unless parents sign to opt out, have failed due to privacy concerns. Texas is one of only four states with such a system.
Similar to the Nepalese polio eradication program, enhancing vaccination surveillance within a community of 200,000 children will take partnerships, commitment, awareness and funding. It will require the glistening Texas Medical Center to get out in the community, to listen to single, working parents, to visit schools without health clinics, to work alongside busy school nurses, and to understand administrative, economic and psychological hurdles.
Texas is not Nepal. When it comes to coordinating vaccination programs, it should try harder to be.