LAHORE, May 23: All four provincial governments have come up with similar views on the 2012 measles outbreak, as they say “devolution of EPI functions to provinces, especially procurement of vaccines” is one of the key factors responsible for low coverage, which resulted in death of 413 children last year.
The provinces were unanimous that only the federal government should procure vaccine to avoid such outbreaks in future. “Vaccines must be procured by the federal government through the Unicef Supply/Procurement Division to ensure standardisation and timely availability,” suggests the Sindh government.
The Punjab government says “the procurement of vaccines and logistics is more feasible at the federal level”.
The provincial governments presented their reports to the prime minister through a committee, which was formed by the federal ombudsman to look into the measles outbreak of 2012 and death of 413 children from the disease. The report was submitted to Prime Minister’s Secretariat in the last week of April.
Global health bodies and donor agencies also submitted their reports to the committee on the same issue.
Punjab govt’s point of view
Punjab government’s representative reported that their requirement, 90 per cent of immunisation coverage, was 8,772,348 doses. Against this requirement, they received 8,017,300 doses from the Federal EPI Cell in 2012. Hence, no shortage of measles vaccine was reported in Punjab in 2012.
Reasons for recent increased number of measles cases in Punjab:
(i) EPI coverage in many districts was not satisfactory. The evaluated EPI coverage in Punjab was 57.5 per cent, as done by the Institute of Public Health (IPH), Lahore in October, 2012.(ii) The efficacy of measles vaccine was around 85 per cent.
(iii) In spite of coverage above 80 per cent in some areas, 35 per cent of children who do not develop sero-conversion (immunity) remain susceptible and will create a pool of susceptible equal to a birth cohort. Hence there is need for a mass measles campaign every 3-4 years as per the recommended global strategy. (iv) At least 2,180 suspected measles cases were reported in districts of Punjab from December 2012 to January 2013.
About improvement in the system of vaccine procurement and vaccination, the Punjab government said EPI vaccines had been procured by the Federal EPI Cell, Islamabad for the last about 25 years. These vaccines were provided to the provinces every month on the basis of population. Later, all functions of EPI like procurement were devolved to the provinces.
Punjab initiated the process of procurement of vaccines and syringes at the start of financial year in July 2012. As the procurement at large scale was being done for the first time in Punjab, many difficulties were faced, mainly due to capacity issues and unavailability of expertise and logistics like cold rooms to store vaccines in bulk.
Later, as per decision of the federal government, PC-1 of the Federal EPI was extended for one year i.e. up till June 2013 and procurements were shifted again to the Federal EPI Cell for the ongoing financial year.
The procurement of vaccine and logistics is more feasible at the federal level because of (i) economy of scale in procuring bulk quantities for the entire country, (ii) expertise available at the Federal EPI Cell, as they have been doing it for the last about 25 years, (iii) logistics like 18 cold rooms are installed at the Federal EPI Cell, which can handle bulk quantities of vaccine and injection equipment.
Improving vaccination
As pointed out earlier, immunisation coverage in Punjab as evaluated by IPH, Lahore was 57.5 per cent, the Federal EPI Cell, Islamabad planned to conduct Third Party Evaluation (TPE) of immunisation coverage with the support of GAVI and other partners in March/April 2013.
“Improving routine EPI coverage at district and UC level to more than 85 per cent is required to stop transmission of vaccine preventable diseases,” the Punjab government said. In Punjab, it has been decided that improving routine EPI coverage up to 85 per cent is the only solution.
If the Federal PC-1 was not extended beyond 2013, procurement of vaccines and logistics will be the functions of provinces/areas.
To cope with the situation, following steps need consideration:
i) The PC-1 (to be funded by the federal government) for Strengthening of Expanded Programme on Immunisation in Punjab from July 2013 to June 2015 that was submitted to the Planning Commission, Islamabad in October 2012 may be approved without a delay so that procurement process for 2013-14 can be started immediately.
ii) The capacity of the province may be developed through support of development partners to handle procurement functions efficiently.
iii) Ten out of 18 cold rooms in the Federal EPI Cell, Islamabad may be handed over to Punjab for storage of bulk quantities of procured vaccines and syringes.Sindh government’s point of view
Total target children for two doses of measles vaccine at the age of nine months and 15 months were 2.74 million and measles vaccine requirement for Sindh for the year 2012 was 3.570 million doses to cater to routine measles immunisation.
The Federal EPI Cell provided 5.504 million doses of measles vaccine including some vaccine for measles campaign against the annual requirement of Sindh.
Some of the factors responsible for the 2012 measles outbreak are:
i) Delayed receipt of measles vaccine, syringes, safety boxes and other logistics from the Federal EPI Cell.
ii) Case-based measles surveillance has been introduced in the country and blood samples of suspected cases were sent to the National Institute of Health for analysis.
iii) Inability of the Federal EPI Cell to develop an efficient system for disease surveillance in provinces.
iv) Had there been a proper system of surveillance, the Federal EPI Cell would have immediately swing into action and alerted public health officials of Sindh when the Measles Surveillance Laboratory set-up at the NIH started reporting confirmed measles cases on the basis of virology tests.
v) The Federal EPI Cell failed in developing a robust system of monitoring and evaluation to gauge coverage of routine immunisation in the country and give feedback to the provinces on the real data for action. In the absence of a regular data collection system and coverage evaluation survey on a yearly basis, it became difficult to maintain high coverage, which was essential to guard against outbreaks.
vi) Poor performance of the affected districts in providing immunisation services to people was also one of the main factors responsible for the 2012 measles outbreak.
Suggestions for improvement in the vaccine procurement system:
The federal government, as per a decision of the Council of Common Interests (CCI), is bound to provide financial assistance to provinces for immunisation services in the country till announcement of the next NFC Award.
The Sindh government said procurement of EPI vaccines and other logistics must be exempted from Public Procurement Rules 2004, as recommended by Public Procurement Regulatory Authority’s Board under Clause 21 of PPRA Ordinance 2002 in January 2012 to check inordinate delays in the procurement of vaccines and other EPI logistics.Recommendations:
In order to pre-empt recurrence of outbreaks, the following steps are suggested on behalf of the Sindh Government:
i) There are limited producers of WHO pre-qualified EPI vaccines in the world. All of them are not producing all antigens to cater to immunisation needs of the world. A couple of them are producing measles vaccine, half a dozen are producing OPV, two are manufacturing pentavalent vaccine, a couple of them are producing pneumococcal vaccine, three to four are preparing Tetanus Toxoid vaccine and three to four are producing BCG. Only three of the manufactures, Glaxo Smith Kline, Sanofi Pasteur and Novartis, have their sub-offices in Pakistan. Others have their agents based in Pakistan.
In most cases of procurement through public bidding over the last five years, there have been a few cases in which there was more than one bidder in the competition. Taking advantage of their monopoly and cartelisation and compulsions of the programme, local agents quote exorbitant prices, putting the EPI in a difficult situation.
It is, therefore, suggested that procurement of all EPI vaccines, immunisation devices and other logistics should be done through the Unicef Supply/Procurement Division, which supplies quality products at cheaper prices.
ii) Even after the current NFC Award, the provinces should pool their resources for centralised procurement through Unicef for smooth functioning of immunisation services all over the country.
iii) Case-based measles surveillance has been introduced in the country and blood samples of suspected cases are being sent to the NIH for analysis.
The Ministry of Inter-Provincial Coordination, in collaboration with the provincial EPI cells, should develop a strong surveillance system in the country to immediately come to knowof the outbreak in any part of the country and recommend corrective and remedial measures.
v) The ministry as an executing agency of immunisation programme must develop a robust monitoring and evaluation system to regularly gauge immunisation coverage in the provinces and districts.
As soon as the coverage goes down, it should raise alarm and bring the matter to the attention of the provincial and district governments to hold inefficient EPI workers accountable and take corrective measures.
Khyber Pakhtunkhwa’s point of view
The vaccine requirement of provinces for the entire year 2012 was 277,600 vials. The Federal EPI Cell provided them 202,462 vials ie.2,024,620 doses on a demand basis and no shortage of vaccine was noticed.
Reasons of current measles epidemic:
In KPK there was no major outbreak in 2012, sporadic suspected measles cases reported in all over the province were 5,967. However, post-18th Amendment situation at the provincial and federal level has a bearing on the EPI situation.
The KPK mentioned some factors behind the outbreak of the disease in the province, which primarily included poor socioeconomic conditions, congested population, influx of IDPs/security situation, influx from the FATA, earthquake and other disasters in the province, less focus on measles and more focus on polio and influx of Afghan refugees.
KPK’s suggestions for improvement in the vaccine procurement system:
i) Procurement of vaccine through Unicef.
ii) Effective vaccine management at district and provincial level.
iii) Demand creation for vaccine in the community
iv) Putting in place an accountability mechanism
v) Enhancing involvement of LHWs in routine EPI
vi) Proper training for EPI technicians
vii) Strengthening supervision and monitoring mechanism
Balochistan government’s point of view:
Routine measles vaccine demanded from the Federal EPI Cell for Balochistan in 2012 was 433,890 doses and it had received 420,280 doses. In addition, it received 2,600,000 doses to launch measles vaccine campaign in December 2012. So, there was no shortage of measles vaccine during 2012 in Balochistan.
Reasons for current measles outbreak:
i) Measles outbreaks in adjacent districts of Sindh.
ii) Low routine immunisation coverage.
iii) Low coverage of previous measles campaigns.
Blochistan government’s recommendations:
Provinces’ capacity should be improved for handling post-18th Amendment procurement of vaccines and other EPI items. At least three-month stocks of measles vaccines should be supplied for use in emergencies.