Figures collected from various official sources and surveys provide evidence of the current outbreak of measles in different parts of Pakistan. More importantly, they indicate that this outbreak has resulted from insufficient rates of routine immunisation coverage, as the World Health Organization (WHO) confirmed here on Wednesday…

Unfortunately, as per the survey of Pakistan Social and Living Standards Measurement (2010–2011), Pakistan’s routine immunisation coverage does not meet the optimal routine immunisation rate of more than 80 per cent. “Pakistan’s routine immunisation coverage is close to 65pc with only some important cities of Punjab recording a better performance,” Dr Sabatinelli stated. He said that the huge difference of routine immunization coverage between provinces, districts and cities was at the root of the current measles outbreaks.

WHO press release: “Suboptimal routine

immunisation coverage causing measles

outbreaks”

Issued: January 2, 2013

The situation is dire: another measles epidemic threatens to grip Pakistan as it did last year and the year before that. A massive nationwide measles immunisation campaign, aimed at reaching 64 million children, has already kicked off in Khyber Pakhtunkhwa. But the question really is: are we systemically prepared to take on the epidemic of measles, or is the current drive merely another band-aid?

“When your emphasis is on ad-hoc campaigns, you tend to overlook the base – in this case, the foundation is routine immunisation,” argues Dr Mubina Agboatwala, head of the paediatrics department at Karachi’s Government Hospital Liaquatabad.

Pakistan is still among the countries struggling to curb measles. From 2009, the second dose of measles vaccine was introduced in the routine immunisation schedule – to be initially administered at 15 months.

Due to the deteriorating routine immunisation coverage regime across Pakistan, however, numerous measles outbreaks with thousands of cases have occurred since 2012. Thousands of children have suffered from measles across the country and hundreds have died. Most cases were those of children aged below 10 years, with about two-third reported to be unvaccinated.

“Measles reduces a child’s ability to fight other diseases, resulting in frequent illnesses,” explains renowned paediatrician Prof Dr D.S. Akram. “Measles deplete the body of Vitamin A, and any child who has contracted measles can develop problems such as diarrhoea, pneumonia and even blindness due to Vitamin A depletion, as well as encephalitis (inflammation of the brain) which can result in brain damage and/ or hearing loss and even death,” she says.

“No specific treatment against measles is available, since it is a viral infection. Therefore, vaccination is the only way to prevent the infection and related complications,” asserts Dr Akram, adding that serious side effects of the measles vaccine are very rare.

Although this year’s drive to immunise children against measles has seen an enormous effort and several months of careful planning by the Expanded Programme on Immunisation (EPI) going into it, it isn’t the most sustainable way forward. In fact, the current round of vaccinations are being carried out as “Supplementary Immunisation Activities” – this is a joint effort by the Pakistan government, the Global Alliance for Vaccines and Immunisation (GAVI Alliance), WHO, United Nations Children’s Fund (Unicef), and other development partners.

Dr Quamrul Hasan of the WHO however, claims that he has yet to see a “meaningful effort” from the EPI to exploit such opportunities. “I’m not making a generalised accusation; the degree of interest in the management of the programme varies among provinces,” argues Hasan. He is still concerned about “no significant social mobilisation activities” at the grass root level.

In fact, Pakistan’s EPI began in 1978 and is now supported by the WHO and the Unicef. The programme allows children to be immunised against diseases that put their lives at risk; initial vaccinations included childhood tuberculosis, poliomyelitis, diphtheria, pertussis (whooping cough), tetanus, and measles. Pregnant women too were vaccinated against tetanus toxoid to protect the newborn from neonatal tetanus. The EPI has since added Hepatitis B, Haemophilus influenzae type B and Pneumococcus (a germ that causes many cases of pneumonia and meningitis in children) vaccination in its childhood immunisation schedule.

Ever since the 18th amendment to the Constitution, however, health is no longer a federal subject and all powers and duties are now devolved to the provinces. As such, the responsibility for routine immunisations falls on provincial governments – a task not all provinces have been able to discharge efficiently till now.

Comparative data from the Pakistan Demographic and Household Survey, 2012-2013 shows that only 53.8pc of all children in Pakistan are fully immunised. In terms of provinces, while the nationwide immunisation coverage has not gone down over the years, it has decreased considerably in Sindh in the recent past; only 29pc of children are fully immunised in the province today. In Khyber Pakhtunkhwa, this figure stands at 56pc.

“The EPI is busy with micro-planning, and does not pay attention to, or monitor, routine immunisation,” says Dr Agboatwala. “They are also faced with limited resources at their disposal. They have introduced more diseases to the routine regimen but that is not enough; motivation and resources are the main things.”

The reasons for the situation that Pakistan finds itself in are manifold, and not only restricted to the government but also extend to the public. “Unfortunately, parents in Pakistan still do not view immunisation as a right of their children,” notes Saira Tarar, Minister of State for National Health Services, Regulations and Coordination. “This results in poor utilisation of immunisation services made available by the government. We therefore continue to observe outbreaks of measles, pneumonia, and polio in different parts of the country.”

Besides a general lack of awareness about what diseases a child should be immunised against, door-to-door polio vaccination campaigns are being conducted frequently. Doctors believe such campaigns sometimes make people both wary and weary.

“While there is some adverse impact of focused campaigns on routine immunisations, it is probably not as much as it is made out to be. The increased focus on polio and measles should be used and channelled to increase the routine immunisation as well. A win-win situation can be made” argues Dr Asad Ali, assistant professor of paediatrics at the Aga Khan University, Karachi.

Then there are issues such as poor accountability, management, and shortage of human resources; health practitioners contend that there are not enough vaccinators or vaccination centres to cater to the need of the people. When people lack awareness they will not take the trouble to go long distances to get their children immunised. “Perhaps it is too much of the same thing for them,” says Dr Agboatwala.

Despite the systemic challenges, officials remain hopeful of the promise this time’s drive offers – in part because they remain confident that some systemic challenges have been addressed.

“We want parents to know that the measles vaccine given during this campaign is considered as an extra dose, and will not be marked on the immunisation card,” says Dr Unaiza Hadi, deputy director at Federal EPI, Islamabad. “All children aged six months to less than 10 years will be vaccinated regardless of previous vaccination status and illness,” she adds.

In order to eliminate measles, it is important to immunise “high-risk” and under-served populations, often missed by routine vaccination. “It is vital to know who the un-reached are, where they are, and why they are under-served; with this information, managers can be helped to develop effective strategies to reach this segment of the population,” says Dr Hadi.

During the current vaccination drive, children will be vaccinated at EPI fixed centres such as public and private health facilities. Special arrangements have been made to vaccinate school going children, in their respective schools and madressahs. There will also be outreach vaccination teams going to communities to administer measles vaccines.

When your emphasis is on ad-hoc campaigns, you tend to overlook the base — in this case, the foundation is

routine immunisation

Mobile vaccination teams have also been constituted. Their primary job is to cover children likely to be missed: street children, school or madressah absentees, highly-mobile nomadic children, those living in slums, working children in industries, shops, hotels, markets, bus stops, farms and in households. Children in prisons, orphanages, hospitals (accompanied with their parents) will also be vaccinated, says Dr Dure Naz Jamal of the Sindh EPI, adding that plans are afoot to vaccinate high-risk children in urban areas who may not attend school or go to community vaccination sites.

On the plus side, Dr Hasan, feels that political interest for the ongoing measles supplementary immunisation activities is greater than any other such event in the past. Public awareness about measles and its danger is also very high due to recent massive outbreaks. “We are targeting 64 million children and at least 95pc coverage is required in every district to gain the full benefit of this expensive campaign,” he says.

Once the dust settles and this year’s outbreak is (hopefully) controlled, it might be time to revisit systemic shortcomings again. “The supply side challenges include the policy environment, programme management, material and the quality of services,” says Dr Hasan. “The demand side challenges in public include access to services, lack of knowledge, competing priorities and the socio-cultural milieu.”

The reasons for Pakistan’s failure to eradicate polio are well known, but why have we failed to control repeated outbreaks of measles?

Dr Agboatwala reiterates his belief in routine immunisation: “In order to achieve our targets, management and policy needs to be changed. More time and resources need to be spent on routine immunisation.”

Published in Dawn, Sunday Magazine, May 25th, 2014