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.

Unicef viewpoint

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.

WHO viewpoint

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

PMRC point of view

(A) Present Measles Outbreak: i) The PMRC said the present outbreak is due to the overall low coverage of EPI vaccination in Pakistan. Average coverage did not exceed 60 per cent for many years. The coverage data from WHO shows that urban areas are relatively better covered as compared to rural.

ii) Stock positions showed that none of the provinces had shortage of stocks. iii) Efficacy of the vaccine should not be doubted as no such event has been reported from any country. All neighboring countries have excellent coverage of EPI vaccines and have eradicated or controlled these diseases much earlier.

(B) It suggested that the future supply of EPI vaccines should be done through Unicef which has standard rate, supplies on time, supplies full quality and the quality is also guaranteed.

View Point of Ministry of IPC/Federal EPI Cell:

At the federal level, the federal EPI cell under the Ministry of IPC was primarily responsible for planning and implementation of the EPI Programme throughout Pakistan.

After devolution of the Ministry of Health in June 2011, the provinces/areas were supposed to procure vaccines on their own.

In February 2012, the Planning Commission decided in consultation with the provinces that actual procurement would be done by provinces themselves as federal entity of EPI had ceased to exist.

It was as late as mid October 2012 that provincial governments finally showed their inability to procure vaccines and EPI had to be resurrected in October 2012 (through extension of PC-1) to perform this vital function.

Tenders were floated four times for purchase of measles vaccine through open bidding as per PPRA rules but the same could not be materialized, therefore, total measles vaccine during the year 2012 was purchased through Unicef.

Ever since its inception in October 2012, the EPI did not receive any official request from provinces regarding non-availability of stocks nor indicating any impending shortages over and above what they had been receiving on quarterly basis against their routine demand.

It is pertinent here to mention that the federal EPI is essentially concerned with supply of vaccines for routine immunization in the country.

It is an established fact that same has been caused by the pathetically low routine immunization during this period, a fact independently corroborated by the World Bank.

Routine immunization against the disease involves important management decisions at the provincial, district and down to the union council level which leaves a lot to be desired.

In order to combat these gaps, hosts of SoPs were continually developed by the federal government for impressing upon the provinces to adopt the same to ensure effective routine immunization.

However, the actual coverage remains lower than 50 per cent apart from Punjab where it is around 60 per cent. Unanimous view of the technical experts has confirmed that routine immunization ought to be 95 per cent which could spell some hope for elimination of the measles disease from the country.

The EPI further took a stance that vaccine meant for 100 per cent coverage is supplied to provinces as per their demand but utilization reports from provinces/areas was not received in the federal EPI despite continued efforts.

“The above mentioned facts clearly show that recent deaths due to measles outbreak in some parts of the country were not due to shortage of measles vaccines; rather it has been a case of pathetic low routine coverage (less than 50 per cent), a failure of implementation at the district and union council levels”, the EPI claimed.

Findings

“In view of the evidence brought on record and duly discussed in this report, there is general consensus that the most important cause of the measles outbreak is the deterioration in, and failure of, routine EPI system in Pakistan”, the report says.Despite provision of adequate quantity of vaccine which largely met the demands placed by provincial authorities and calculated on the basis of 85 per cent coverage, the assessed coverage (WHO, Unicef, third party surveys) is only 60 per cent in Punjab and approximately 43 to 50 per cent in Sindh, KPK and Balochistan.

This means a colossal wastage of national resources without any accountability consequences. Nobody has been held responsible for this blatant disproportion between reported use of the vaccine and outcomes in terms of the assessed coverage.

There is unanimity on the point that the EPI coverage in Pakistan remains unacceptably low. As officers, whether belonging to health administration, district administration and officers of provincial governments are basically responsible for ensuring targeted coverage, all concerned need to be held accountable for this failure in performance.

A proper accountability system needs to be put in place nationally, in provinces and districts.

The evidence brought on record shows that the cold chain is also in a state of disrepair, which means that there is no surety about the quality and efficacy of the vaccine, even if it is procured in time.

Electricity breakdowns have played their part. There is insufficient investment going into EPI infrastructure at provincial levels. Most of the trained manpower has been diverted to polio campaigns which have caused neglect in tackling other diseases like measles.

There is no monitoring and evaluation system which can be described as reliable or effective. The surveillance system is extremely fragmentary and unreliable. It is unable to furnish signals, alarms or alerts in a systematic manner to health managers. This explains why the outbreak gets reported in the media first and is not captured by the system itself.

The views of WHO, Unicef and USAID have been separately brought on record. The opinions of professionals and specialists have also been elicited. All concur on one point that ‘unless the quality and efficacy of EPI system can be drastically improved and coverage of over 90 per cent achieved in all the provinces, there will be no let-up in outbreaks and epidemics not only of measles but also in other vaccine-preventable childhood diseases.