The outbreak of measles in Sindh, which has killed 210 children (more than half in the last three months of 2012), have prompted calls from health experts to look into the inefficient state vaccination machinery.
Calling it an epidemic, with very few under five getting measles shots, paediatrician Dr D.S. Akram, who works extensively in Sindh’s interior through HELP, a non-governmental organisation, said the deaths due to measles was a reflection of the gross “mismanagement” that exists in the government-run routine immunisation for children.
“Pakistan’s routine immunisation coverage is close to 65 per cent with only some important cities of Punjab recording a better performance,” said the World Health Orgnaistaion’s representative in Pakistan, Dr Guido Sabatinelli. According to the global health agency, the huge difference in routine immunisation coverage between the provinces, districts and cities was at the root of the current measles outbreak.
A contagious respiratory infection, caused by a virus, measles can cause lifelong disabilities and include brain damage and blindness. A small number of unvaccinated children can pose a danger to thousands of children.
It was a leading killer of children globally accounting for over 40 per cent of the 4.1 million annual deaths in 2002. But as a result of major national immunisation drives, worldwide measles deaths fell from 871,000 in 1999 to an estimated 454,000 in 2004, a dramatic plunge of 48 per cent.
However, in developing countries, it still remains a major killer, though it doesn’t have to be. To ward off the disease all it takes is two doses of an inexpensive, safe and available measles vaccine available since 1960.
Akram blamed the low coverage of routine immunisation in northern Sindh for the outbreak and warned that the disease was spreading in the urban metropolis of Karachi as well where routine immunisation coverage was reportedly as low as 55 per cent. In Sindh’s interior it stands at a dismal 22 to 25 per cent.
Officially the figure for Sindh is stated to be over 80 per cent, which Dr Zulfiqar Ahmed Bhutta, founding chair of women and child health at the Aga Khan University, Karachi, says is nothing but humbug. “If the coverage had been this high, so many deaths due to measles would not have occurred,” he pointed out.
GAVI Alliance has been assisting Pakistan since 2001 in increasing access to and strengthening the routine immunisation system.
Bhutta said the government figures were inaccurate as surveys led by several investigators from AKU in Karachi and nationally had given a “completely different picture”, which is now being acknowledged by all concerned.
“A national immunisation coverage survey conducted in 2011 and which included not just verbal reports and documentation of immunisation cards but also blood testing (for tetanus and measles) showed that only 50 to 55 per cent of infants were protected using antibodies,” said Bhutta. He warned the dismal vaccination coverage foretells that “an evolving disaster is waiting to happen”.
According to Bhutta, a member of the independent expert review group for maternal and child health for the United Nations Secretary-General, countries in South Asia like Bangladesh, Nepal and India have largely eradicated measles. “Even Afghanistan has not seen any major measles outbreaks recently. Are we now to be placed at par with the worst sub-Saharan African countries, as many countries in Africa have dramatically reduced measles mortality?” he wondered aloud.
The same was corroborated by Qadir Baksh Abbasi, the focal person for measles in the Expanded Programme on Immunisation.
“It is the responsibility of the provinces after the devolution. However, as a parent body, the centre provided the vaccine and all logistical support to Sindh back in 2010 -2011, but the province never bothered to inoculate the children. Did anyone ask where did all the vaccine go? So much money was spent, all to naught!” he said adding: “We can only request them to get their act together by showing them figures and facts; we cannot dictate them or take them to task!”
Abbasi, who has been with the EPI for over 25 years is also alarmed by the re-emergence of diphtheria in Khyber Pakhtunkhwa, which should come as a warning for government health practitioners. “That diphtheria had almost been eliminated and its re-surfacing does not portend well” he said with concern.
To stop the outbreak, the EPI has already began a measles campaign in eight districts of Sindh including Jacobabad, Kahmore, Shikarpur, Kambhar, Larkana, Khairpur, Gothki and Sukkur where children between the ages of nine months to 10 years will be vaccinated. According to World Health Organisation spokesperson, Maryam Younas, a total of 1,300,000 vaccine doses have been sent to the target population of 2,911,081. In addition, Vitamin A will be provided to all vulnerable children during the vaccination campaign.
The outbreak in Sindh, according to Akram can also be attributed to the increased malnourishment that has been observed in children who are more susceptible to measles and the resulting complications like pneumonia and diarrhoea.
A survey conducted by the Sindh government in 2010 with support from United Nations Children’s Fund (UNICEF) revealed a grave nutritional crisis among children.
With an estimated 90,000 under-five children malnourished, the survey report published in January 2011 showed a global acute malnutrition (GAM) rate of 23.1 per cent in children aged six months to five years old in northern Sindh and 21.2 per cent in southern Sindh.
The National Nutrition Survey 2011 carried next confirmed the Sindh government’s survey. The national rate of stunting was found to be 43 per cent with Sindh standing at 70 per cent. Wasting in Sindh was found at 19.4 per cent against the overall national rate of 16.8 per cent.
In addition, things are not looking good for newborns, many of whom have not been immunised for BCG “due to ineffective outreach activities” said Akram.
Questioning the entire vaccine machinery under the EPI, Akram said: “Either the BCG vaccine is not available, or the field workers were not doing their job.” She also questioned the maintenance of cold chain and the political recruitment of health workers in some instances.
Further, there are reports that vaccinators are facing resistance with parents are refusing to get their children vaccinated for measles.
“This couldn’t be farthest from the truth,” said Bhutta. “We have undertaken qualitative studies on vaccinations in general all over Pakistan and nowhere have we encountered substantive refusals for injectable vaccines.” He said adding that in most instances people complain of unavailability of vaccines or vaccinators not coming to vaccinate children regularly.
However, Akram said the resistance can easily be tackled through training lady health workers to vaccinate and to counsel and educate parents about the side effects. “If there are refusals to vaccinations it is because parents feel the child develops fever; by forewarning parents and giving a Calpol to bring the fever down is all that is needed for the smooth running of routine immunisation,” she said.
Many experts have, over the years, said routine immunisation coverage has suffered due to the attention given to one disease – polio. “There should be a balance,” pointed out Abbasi, adding: “There are other debilitating childhood diseases that need equal attention.”
Bhutta also agreed with the mismatch between the resources available for the polio programme and routine immunisations. “There is a lot of talk of eradicating polio, but never of strengthening routine immunisation; why can’t the two be given the same importance?” he failed to understand. What is worse, he said, those at the helm of affairs at the finance ministry and the federal planning commission had washed their hands off social sector development issues completely.
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