Child health experts in Pakistan say that the country's measles outbreak could have been prevented if the government had heeded warnings about poor vaccine coverage. Haris Riaz reports.
Poor quality and ailing vaccination programmes, beleaguered with corruption, have been blamed for Pakistan's recent surge in measles.
The epidemic, which started in October, 2012, has claimed more than 200 lives and has resulted in a large number of hospital admissions. Compared with the 64 deaths in 2011, measles witnessed a staggering upsurge in 2012 with a record 306 fatalities, according to WHO. The number of measles cases has also increased from 4000 in 2011 to 14 000 in 2012.
Zulfiqar Bhutta, Founding Chair of the Division of Women and Child Health at Aga Khan University, Karachi, Pakistan, tells The Lancet that the community demand for childhood vaccines is not being fulfilled in most areas of the Sindh province, where most of the deaths (210 of 306 in 2012) have occurred. He insists that the poor coverage is due to the lack of human and vaccination resources “to those who need it the most”.
“We have also confused people over the years by delivering some vaccines such as polio door to door and insisting that parents take their young infants and children many a mile for other vaccines”, he adds.
“This was a tragedy in waiting. We have been predicting for a while now that without adequate cover with routine immunisations in many parts of Pakistan, notably in rural populations, there was bound to be a situation where you would have an outbreak like this.”
Bhutta suggests that the problem has been compounded by several factors including devolution of health care to provinces and transition of services such as the extended programmes of immunisation without adequate preparation.
He adds: “One contributing factor to excess mortality could be the massive rates of malnutrition, particularly in Sindh, which probably would lead to reduced immunity and adverse consequences of disease. The fact that the disease [measles] is completely preventable and has been prevented in countries including Afghanistan with a much more meagre health-care system, puts the blame squarely and solely on the failure of routine immunisation systems.”
Bhutta denounces the reports suggesting a link between floods and the measles epidemic. “The floods of 2010 and 2011 could have contributed to the outbreak, but the distribution of the disease belies that. These are much more mainstream regions which have just witnessed a massive failure of public health preventive programmes.”
Firdous Jahan, Head of the Family Medicine Department at Oman Medical College, Oman, who has previously worked at Aga Khan University, adds that the vaccination campaigns in Pakistan are fraught with corruption. “There is tremendous corruption at the highest level necessitating a transparent organisation responsible for audit of the funds and accountability of the involved personnel.” She thinks that WHO should consider diverting funds from the governmental agencies to “credible” agencies.
President of the Pakistan Paediatric Association, Iqbal Memon, recommends that the vaccination be done in a regional manner rather than countrywide immunisation on predesignated days. He emphasises the need for more vaccination centres, provision of vaccines to paediatric practitioners, and increased accessibility to the vaccination centres for the public.
Abdul Momin Kazi from the Department of Pediatrics and Child Health, Aga Khan University, says: “Health has never been a high priority for government. In addition to the poor health system, low health budget, lack of awareness, misconceptions regarding polio vaccine, and corruption are key hurdles. Social unrest due to the war on terror, mistrust due to a fake vaccination campaign, [and the] issues of refugees and conflict zones add to the complications.”
“The majority of measles cases we encountered were unaware of immunisation; those who were aware lacked access”, says Aisha Mehnaz, Head of Paediatrics at the Civil Hospital Karachi. She adds that with the exponential increase in the population, the allocation of funds to the health sector should also be amplified.
Ashfaq Mala from Konpal, a non-governmental organisation working against child abuse in Pakistan, blames government agencies for making false claims about coverage and estimates that the actual coverage is “much less than 70%”. He also expresses concerns about training of personnel and the ability of centres to maintain an appropriate cold chain.
Meanwhile, the government has tried to respond to the outbreak with a drive to immunise around 3 million children in high-risk zones during the first weeks of January.