LAHORE, May 20: The frequent epidemics of measles were the outcome of the terribly low coverage of vaccine among children in the country which has ultimately led to a ‘national failure’.
It was a unanimous finding of global health agencies, donors, local institutions and experts in the backdrop of 413 deaths of children occurred due to measles from January 2012 to January 2013.
The World Health Organization, Unicef, USAID, Agha Khan University, National Institute of Health, Pakistan Medical Research Council (PMRC) and the Ministry of Inter-Provincial Coordination (IPC)/Federal EPI Cell, were the key partners and stakeholders which came up, for the first time, with the comprehensive analysis on the countrywide failure of the immunization system.
Global agencies and donors have shifted the responsibility to federal and provincial authorities by dispelling an impression that Pakistan has been facing stock-out situation of vaccine.
Statements of these stakeholders were submitted to the Prime Minister Secretariat in the last week of April in a report on ‘measles outbreak’ prepared and finalized by a committee constituted by acting Federal Ombudsman Salman Farooqi. A copy of the report is also available with Dawn.
USAID’s point of view on failure of the immunization system:
It said Pakistan’s EPI systems appear to be in a free fall of disrepair and cannot be strengthened without high-level political commitment and technical leadership at both federal and provincial levels.
The immediate epidemic and long-term collapse of EPI systems demand both short and long-term financing and commitment to accountability.
Critical immediate and short-term measures are:
(i) All vaccine procurements must be run through Unicef for the immediate future.
(ii) Federal and provincial levels must clarify and develop consensus on responsibilities under devolution, including procurement, planning, cold chain maintenance, resource mobilization, adequate operations funding at the district level, agreement on the installation of supply chain systems, monitoring and reporting at sub-district and district levels. Rapid regional assessments of the current situation should also be carried out.
(iii) Provincial governments must provide adequate resources to ensure cold chain integrity in the face of constant electricity loadshedding. Backup electricity systems (generators with petrol, and/or solar panels in high risk districts should be provided).
(iv) The indicators definition of the fully vaccinated child must be revised and properly reported. Districts are currently reporting a once-vaccinated child as fully covered when the new protocol recommends second dose of anti-measles vaccine at 15 months of age.
(v) Moreover, information for the EPI is generated at three levels, namely: (a) “Disease Early Warning System (DEWS), (b) District Health Information System and (c) EPI Cell.”
There is an urgent need that mechanisms and systems for the use of information should be revitalized to ensure that information generated at various levels is used to manage and analyze disease outbreaks and programme response.
The Unicef has furnished the following information on current measles outbreak in Pakistan, particularly with reference to Sindh province.
(i) Because Sindh province implemented measles Supplementary Immunization Activities (SIAs) between October 2010 and March 2011 and reported 118 per cent coverage, it was not allocated any measles vaccines for 2012-13 and the current outbreak of measles is suggestive of poor quality of the measles SIAs as well as routine EPI coverage.
(ii) The Unicef proposes that a technical forum comprising EPI stakeholders, including Unicef, WHO, federal EPI and provincial EPI, should be established and made fully operational to jointly discuss the situation and response at regular intervals in order to challenge measles crisis.
Most of the affected children died due to post measles complications such as pneumonia, post measles encephalitis and diarrhea.
Primary reasons identified by the WHO for the measles outbreak and such large number of resultant deaths are: (i) Low rate of routine vaccination in the field. (ii) Poor health services management. (iii) Untrained staff at health facilities and in the field. (iv) Inability and incapacity of health personnel in hospitals and in field to treat post-measles complications such as pneumonia, post-measles encephalitis and diarrhoea.
NIH point of view
Routine measles vaccination for children, combined with mass immunization campaigns is recommended in countries with high measles cases and death rates.
Suspected cases are reported to the WHO-supported Disease Early Warning System (DEWS) being implemented in all provinces of Pakistan.
This system recorded a total of 17,338 suspected cases during the period from January 1, 2012 to January 19, 2013 with 413 deaths and a Case Fatality Rate of 2.38 per cent.
Most of the affected children died due to post-measles complications such as pneumonia, post-measles encephalitis and diarrhoea.
Though Sindh appears to be worst-affected, cases and deaths have been reported from all provinces and areas indicating it as a generalized issue.
The NIH had already alerted all stakeholders, including provincial and district health authorities, for measles preparedness through Seasonal Awareness and Alert Letters (SAAL).
The current measles episode highlights the critical inability of the healthcare delivery system in following terms: i) Failure to find and vaccinate vulnerable populations, ii) Inability of the EPI monitoring and surveillance system to identity, investigate and respond to the issues related to the measles outbreaks from district to district