Afghanistan is taking steps to improve its routine immunization coverage, after a drop in coverage led to a sharp increase in measles outbreaks last year, killing more than 300 children.
Since the start of the last Afghan winter, in November 2011, 9,000 measles cases were reported across almost every province in the country, as compared to 3,000 cases over the same period the year before. Aid workers described the increase as an emergency situation that should serve as a “ringing alarm bell”.
It was the culmination of several years of decreasing vaccination coverage due to rising insecurity, decreased access, difficult terrain and harsh winters that cut off thousands of villages. Last year’s severe drought also contributed.
Routine immunization is supposed to cover measles, polio, Hepatitis B, Haemophilus influenza type B, diphtheria, pertussis, tetanus and tuberculosis.
“The main issue is access,” said Maria Luisa Galer, the coordinator of the international aid community’s health cluster in Afghanistan. “We probably have to revise and adapt the strategy to this context,” she told IRIN.
In its 2011-2015 plan for the National Immunization Programme, the Ministry of Public Health writes: “Considering the current constraints and challenges in Afghanistan, reaching 95 percent [measles vaccine] coverage nationally and at least 80 percent in each district through routine immunization services is not easily achievable.”
According to the UN Office for Coordination of Humanitarian Affairs, the number of suspended or non-functional health facilities in Afghanistan increased by 40 percent between 2011 and 2012, reaching 540.
The Basic Package of Health Services (BPHS), the government programme responsible for healthcare delivery at the primary level, does not cover the whole country. “On paper it covers 80 percent, but practically it is close to 60 percent,” said Islam Saeed, director of the government’s Disease Early Warning System (DEWS). The rest is left to humanitarian NGOs and the private sector, but they, too, face challenges.
“Day by day, the [security] situation becomes worse and our access to the people for providing health services becomes more limited,” said Sayed Zubair Sadat, responsible for the Afghan Red Crescent Society’s 45 health clinics nationwide. “We had problems conducting the [Expanded Programme on Immunization] in the border areas and conflict provinces,” he told IRIN.
“Not covered by anyone”
Experts say nearly 30 percent of the population has no or very poor access to primary health care, including immunization, and the percentage is estimated to be as high as 70 percent in areas of conflict in the south. In some communities, the closest health facility is 70km away. Last year, there were some districts where the government was not present at all.
“We have lots of big areas… that are not covered by anyone - no health facilities, no private sector, no NGOs in the whole area,” Saeed told IRIN.
Where vaccinations do take place, quality can also be an issue, and government officials readily admit the lack of capacity of their staff to properly manage cold chains, for example.
“There has been a decline not only in the coverage, but also in the quality of routine immunization,” said Elena Vuolo, external relations officer with the World Health Organizations (WHO) in Afghanistan. BPHS, which is responsible for immunizations, “is overburdened with several activities they have to carry out with limited resources, and difficult access,” she told IRIN.
In the National Priority Programmes, which outline government priorities until 2015, the government admits many vaccinators lack initial training, and that budget shortages in past years prevented supervisory and monitoring visits by provincial level management teams. It found this to be “a major cause” in decreasing immunization coverage.
Quality of vaccinations
The last national measles vaccination campaign was in 2009, but according to Shakoor Waciqi, who used to manage the government’s immunization programme in the 1990s but now works with WHO, the target age group was limited and “the quality of the campaign was sub-optimal”.
Given the number of outbreaks last year, health workers say the immunization clearly did not reach 90 percent of children in every district - the minimum required to prevent outbreaks. According to DEWS, there have been 285 disease outbreaks, including 179 measles outbreaks, in 2012 so far. (An outbreak is defined as more than five cases within a defined geographical area within the incubation period of the disease).
“In some areas, the coverage is less than 20 percent. In some areas, it is zero percent,” Saeed, of DEWS, said.
Another problem is the lack of a baseline to accurately gauge how many children to target. Afghanistan has not conducted a census since the 1970s. Aid workers worry that the figures used to create targets are outdated, and thus many children are missing in the national statistics.
Preventing a repeat
As a new winter approaches, WHO is trying to prevent a repeat of last year.
In July, it began an emergency nationwide measles vaccination campaign, vaccinating more than six million children between nine months and 10 years old in 16 provinces. It is planning to continue with the remaining 18 provinces in November.
While measles cases are still appearing, the numbers have decreased sharply after the first phase of the measles campaign, WHO says. In November, the government and WHO will be training immunization officials in advance of the second phase of the measles vaccination campaign.
Health officials are also taking other steps to improve immunization.
This year, WHO, the UN Children’s Fund (UNICEF) and the Ministry of Public Health combined the measles and polio vaccination campaigns, Vuolo said, suggesting the “piggy-back” model could make better use of resources in the future.
As part of a winter contingency plan, health workers also started pre-positioning medicines in areas that will be cut off during the winter; and establishing temporary sub-health centres to serve villagers in remote areas through the winter.
Mobile health teams
The government is increasingly recognizing the important role of mobile health teams, in some cases airlifting teams by helicopter into remote areas. This is part of an approach to tailor immunization strategies to the specific context of an area, instead of applying “one blanket method for every province”, Galer said. The government is also planning to use more female vaccinators to increase access to women; and to improve the reporting forms to improve monitoring.
A new task force is aimed at coordinating activities linked to the surveillance of and response to diseases, bringing together people from different government departments as well as WHO, Saeed and Waciqi said.
There are also initiatives aimed at integrating the various disease surveillance systems into one mechanism and consolidating all health information under one department responsible for analysis.
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