The Tamil Nadu government announced last week that all students of private and public schools would have to receive vaccinations under the national immunisation programme, irrespective of their personal and cultural beliefs. The decision follows the refusal earlier this year of some parents to allow their children participate in immunisation drives.

When the Union government launched an immunisation drive with a new measles-rubella vaccine earlier this year, rumours circulated through the WhatsApp messaging service warning parents that they would put their children’s health at risk. This resulted in poor turnouts at the health camps in schools.

By making the vaccinations compulsory, the Tamil Nadu government is “trying to tell the world that our vaccination campaign is equipped with legal backing also”, said Director of Public Health Dr K Kolandaisamy. “We want to reinforce that message. The few people who want to create rumours will keep quiet. We are not only relying on making it mandatory, but also on educating people and providing quality service. But in the case of a defiant person, we will enforce the law.”

The government has also asked schools to compulsorily submit annual vaccination records of students to the directorate of public health, reported the Times of India. It has achieved this by invoking the Madras Public Health Act 1939.

This need for the Tamil Nadu government to make vaccinations mandatory is striking, considering that about five years ago, the state had the highest vaccination coverage in India. Tamil Nadu’s public health system was considered to be a role model for other states, and vaccines were accepted, even demanded, by residents right from the village level, said Dr Rakhal Gaitonde, a public health expert and activist. Any new vaccine was first administered in Tamil Nadu and was usually well-received.

So what has happened in the last few years to make the government to take such a step?

Erosion of trust

According to Kolandaisamy, the immunisation drive was conducted in February amidst a spate of rumours about unsafe vaccinations introduced by the government. “We knew that people would not take this seriously, and they didn’t,” he said. “But then after some very cruel, morphed images of children suffering after vaccination were circulated through WhatsApp, the turnout declined.”

Public health activists said that these rumours gained wide creedance because trust in Tamil Nadu’s public health system had been eroded over time.

In his research paper “Public Trust in vaccination: an analytical framework”, Vijayaprasad Gopichandran noted an incident six years ago that caused the distrust to snowball.

“The overriding factors determining trust in vaccination are those of efficacy and safety. Vaccines carry with them reputations that are based on reports of successful prevention of diseases and Adverse Effects Following Immunisations or AEFIs. AEFIs lead to the erosion of trust in the specific vaccine. Given that no vaccine is completely free of adverse events, the vaccination policy should feature a sound surveillance system to detect AEFIs, and make provision for timely intervention and mitigation of the consequences. Following the introduction of the pentavalent vaccine in Tamil Nadu and Kerala in 2011, several vaccinated children were reported to have died. After 14 deaths were reported, investigations into the AEFIs were carried out. It was found that six deaths were due to co-morbid conditions, none of which was a substantial reason to attribute the deaths to the pentavalent vaccine. A detailed analysis of the deaths also revealed that a diagnosis of sudden infant death syndrome (SIDS) was highly unlikely. The callous attitude towards investigation, reporting, response and compensation for children who had suffered fatal AEFIs led to gross erosion of trust.”

— Indian Journal of Medical Ethics

Gaitonde said that following the deaths of children due to immunisation, the Tamil Nadu government immediately stopped all vaccinations at village level. It announced that vaccines would be administered only in institutions, in the presence of doctors.

“It was a unilateral decision, there was no discussion with the public,” said Gaitonde.

Soon, the vaccination coverage decreased in the state as marginalised communities such as daily wage labourers, single mothers, or those whose husbands had migrated for work, stopped attending health camps.

Four years down the line, after noticing that the coverage was dropping, the government tried to go back to administering vaccines at village levels. “But there was no official statement about why those deaths took place or what steps have been taken to prevent further such incidents,” said Gaitonde. “With no proper communication, how will people trust the public health system?”

Measle-Rubella vaccine campaign in February 2017. (Photo: Lions Clubs International via Facebook)

A necessary move?

Dr Subbiah Elango, former director of public health in Chennai, had led a survey by the Indian Public Health Association to gauge awareness about the measles-rubella vaccination drive, during the government’s February campaign in five districts across Tamil Nadu. Of the 1,050 people interviewed, the doctors found that 79% did not want the measles-rubella vaccine to be given to their child. When asked why, 55% responded saying that they were doubtful about the efficacy of the vaccine. Around 22% said that they were worried about adverse effects following immunisation and 21% said they had no confidence in the practitioners.

But Elango was of the opinion that making vaccinations mandatory was a good initiative of the government. “For a healthy nation, the children should all primary vaccinations in time,” he said. “The child should not get infection or be infectious to others.”

Prince Gajendra Babu, the general secretary of State Platform for Common Schools and president of Tamil Nadu Health Development Association, also felt that the move only generates awareness, and would help counter superstitious beliefs around diseases such as measles.

No longer will religious and personal beliefs be a reason to be exempted from vaccinations, said Kolandaisamy. “India is signatory to United Nation’s Child Rights declaration,” he said. “Under the right to survive, parents have no right to deny the service. Because of the parents’ ignorance, the child cannot be subject to being exposed to diseases. There is no question of consent. The moment the child is sent to school, the parents give an implied consent to the school for health, education and everything else.”

Little autonomy

But some public health experts see the move as a regressive step by the government.

According to Gaitonde, the moment vaccines are made mandatory, the public will become more suspicious about the vaccine drive. “I am not a part of the anti-vaccine lobby, but this move by the government may prove to be entirely counter-productive because of the lack of faith of the people in the public health system,” he said.

Additionally, underground markets for fake immunisation certificates could also thrive. Also, obfuscation of data by government employees could be a fall out. “Data could be cooked up just to show a 100% vaccination result,” he said.