Measles in Balochistan

Dr Aryana Kaker (MPH student)

Measles is a highly contagious viral disease that remains an important
cause of death among young children globally despite the availability of a
safe and effective vaccine. The most common complications of measles
are pneumonia and diarrhea with dehydration requiring hospitalization.
Malnourished children experience more complications and have longer
hospital stay. Mortality is significantly associated with infancy,
unvaccinated status and encephalitis. The Millennium Development
Goal-4 aims to reduce the under 5 mortality rate by two-thirds between
1990 and 2015 and routine measles vaccination coverage is a key
indicator of monitoring progress. All 194 WHO Member States have
committed to reduce measles deaths by 95% by 2015 and accordingly in
2011, about 84% children had received one dose of measles vaccine by
their first birthday. In 1980, before wider vaccination, measles caused
about 2.6 million deaths globally which have been reduced to 158,000
deaths in 2011 because of the improved vaccination coverage. Yet, this
exponential decrease is not reflected in South Asia or sub- Saharan Africa
that still account for 89 percent of the worlds measles deaths as of 2012
statistics. Measles vaccine is given in most countries/areas at 9-12 months
of age, usually in the form of monovalent measles vaccine. The 2-dose

policy is implemented in 12 countries. In 8 countries, the second dose is

given as measles-mumps-rubella (MMR) vaccine, and in 3 countries as
monovalent measles vaccine. The age for the second dose varies. In 10
countries, it is given at 12-15 months of age, and in the Libyan Arab
Jamahiriya at 18 months of age. 95% of measles deaths occur in lowincome countries with weak health infrastructures. More than 60% of the
estimated 21.5 million children who were not vaccinated against measles
at 9 months of age last year came from 6 countries: India (6.4 million),
Nigeria (2.7 million), Pakistan (1.7 million), Ethiopia (1.1 million),
Indonesia (0.7 million) and Democratic Republic of Congo (0.7 million).
The World Health Organization regions of Africa and Southeast Asia had
70% of incident cases and 84% of measles-related deaths; 11 countries
alone (Afghanistan, Burkina Faso, Democratic Republic of the Congo,
Ethiopia, India, Indonesia, Niger, Nigeria, Pakistan, Somalia, Uganda)
account for 66% of deaths. The World Health Organization warned that
progress towards the elimination of measles has stalled. The number of
deaths from measles increased from an estimated 122,000 in 2012 to
145,700 in 2013.
Pakistan has one of the highest burdens of measles and measles-related
deaths in the world. The number of measles cases in Pakistan has
surprisingly increased even though immunization campaigns have been
rolled out for any years. In 2011, the total number of reported cases was

around 4,500, out of which almost 2,500 were confirmed. In 2012 the
figure of suspected cases tripled to 12,354, out of which 2,975 were
confirmed. In 2013, the number of suspected cases rose exponentially to
33,314 cases out of which 8,616 were tested positive. From 2012 to 2013,
600 children died of measles in the country, according to studies
conducted by civil society organizations and independent health
consultants. As of 2012-2013, under the EPI around 74.3% children were
vaccinated in urban areas and 55.6% in the rural. Furthermore, ICT had
the highest prevalence (85.2%) of measles immunization followed by
Punjab (70%), Khyber Pakhtunkhwa (57.8%), Gilgit-Baltistan (51%),
Sindh (44.6%) and lastly Balcohsitan (37.3%). Being highly infectious,
effective prevention and control of Measles outbreaks requires
vaccination coverage of at least 80%. In accordance with the targets set in
the EPI PC-I, vaccination coverage of 80% was required to be achieved
in all districts of Pakistan. But the poorest families continue to have the
poorest service. In Pakistan, large numbers of children do not access
vaccination against measles despite the national government's effort to
achieve universal coverage. Despite significant

efforts by the

Government and partners, Pakistan's immunization indicators have not

met the expected benchmarks. Barriers to achieving immunization goals
are related to limited access to immunization services, lack of parent
awareness and weak management. There are striking inequities in

immunization coverage between different parts of the country. Barriers to

universal immunization coverage include programmatic dysfunction at
lower tiers of the program, socioeconomic inequities in access to services,
low population demand, poor security, and social resistance to vaccines
among population sub-groups. Recent conflicts and large-scale natural
disasters have severely stressed the already constrained resources of the
national EPI. Immunization programs remain low priority for provincial
and many district governments in the country. The recent decision to
devolve the national health ministry to the provinces has had immediate
adverse consequences.
Severe measles is more likely to occur among undernourished young
children, especially those with insufficient vitamin A intake or whose
immune systems other diseases have weakened. In endemic countries,
Measles attains epidemic proportions every 2nd or 3rd year and its
outbreaks can be particularly deadly in countries experiencing natural
disaster or conflict. In case of measles vaccine, it is universally
recognized that 15% of vaccinated children after first dose do not develop
required level of immunity for various reasons that could be genetic
weaknesses of immunity system and levels of malnutrition etc. prevailing
in a given society.
According to the Pakistan Demographic Health Survey 2012-13, only 16
per cent of children are immunized against nine diseases in Balochistan.

There is a general impression among health professionals that the

reported Measles vaccination coverage under EPI does not match ground
facts. In one district in eastern Balochistan measles vaccine coverage was
only 1% on card verification and 4.7% on recall, 49.4% were found to be
unaware of vaccination services for EPI, 73.7% reported that the
vaccination teams were not reaching their households and 56.6% reported
that the health facility was too far away for them to visit it for
vaccination. There is general consensus that the most important cause of
the Measles outbreak is the deterioration in, and failure of, routine EPI
system in Balochistan. This failure is evident in the low immunization
coverage achieved to date. There is a wide discrepancy between reported
coverage and assessed coverage (WHO, UNICEF and Third Party
surveys). The evidence further shows that the Cold Chain is 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 are also responsible for the adverse situation. There is
insufficient investment going into EPI infrastructure at provincial level.
The surveillance system is extremely fragmented and unreliable. It is
unable to furnish signals, alarms or alerts in a systematic manner to the
health managers. This explains why the outbreak gets reported in the
media first and is not captured by the system itself. The responsibility for
this low coverage falls squarely on the provincial government who has

not taken up this issue with the priority it deserved. Here the cold-chain
is in disrepair. The supervisory system and training regime are deficient.
The monitoring is slip shad. The surveillance system is not functioning. .
Unless the quality and efficacy of EPI system can be drastically improved
and coverage of over 90% 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.
Balochistan is half of the country in terms of landmasses and majority of
the people do not have access to the basic health units. The health experts
say that immunization coverage of Balochistan is merely 16% and 227
union councils dont have a vaccinator. Similarly, there are 943
vaccinators and measles coverage is only 22.9% in whole province.
Measles vaccination in Balochistan province fell from official 70% in
2006 to official 54% in 2007. According to the WHO, Punjab has the
second highest number of measles outbreaks after Balochistan, where 33
outbreaks were reported in the first three weeks of 2013. Claiming 350
lives through the year 2013, measles became a headache for the health
agencies, authorities and common people. According to the report, 2,447
measles cases were reported during three weeks of January 2013, while
only 447 cases were reported in January 2012. In the first three weeks of
January, 1,211 measles cases were reported in Sindh, 290 in Khyber
Pakhtunkhwa and 483 in Balochistan. The highest number of measles

cases and deaths was reported in the Naseerabad district (220 cases and
20 deaths),followed by Jaffarabad (73 cases and five deaths), Killa
Saifullah (39 cases and four deaths) and Jhal Magsi (23 cases and one
death). The coverage data from WHO, shows that urban areas are
relatively better covered as compared to rural and east and north of
Balochistan has the lowest coverage. : Vaccination coverage varies from
district to district in Pakistan and between urban and rural areas in any
district. Common factors are associated with vaccination, but their
relative importance varies between locations. Four out of five districts
where measles outbreak occurred also belong to the same eastern part of
Balochistan next to Sindh.
The sudden appearance of the virus in different parts of the country both
rural and urban at the same time can be linked to more than one cause.
The notable being corruption in health system, poor health infrastructure,
destabilized routine immunization, shortage in number of vaccinators,
negligence among parents, and floods. In Balochistan, measles claimed
the lives of 22 children in the province and affected over 1,350 children
in 2014. Health Minister Rehmat Saleh Baloch said that corruption in the
anti-measles drive in the past had halted the vaccination campaign for
seven years in the province. About 500 children have died of measles in
different areas of the province during the last seven years, as an antimeasles drive could not be launched there during this period, Health

experts say the entire focus nationally is on the anti-polio drive while no
measure is being taken to prevent other diseases in Pakistan. Most of the
trained manpower is diverted to Polio Campaigns that has caused neglect
in tackling other diseases like Measles, and then there is no monitoring
and evaluation system that can be described as reliable or effective. At the
level, the bulk of trained manpower, financial resources, and
administrative energies are being taken up by Polio Eradication
Campaigns. The health officials have stated that lack of funding and
volatile security situation has hampered efforts to vaccinate children
against various measles among other diseases. Insecurity to the EPI
related staff faced in 2012 till now has seriously affected vaccine
administration in the years in Balochistan. In the aftermath of the recent
terrorists attacks on health workers, the challenges of routine
immunization have further been compounded. A list of terrorist
attacks/security incidents undertaken during the year 2012 till now on
health vaccinators in the province where almost a dozen health workers
died.
The only guarantee to avert future measles epidemics is by revamping the
Routine EPI system so as to make it efficient, reliable, evidence-based
and accountable. In concrete terms, it means a system that can provide
high quality and duly-tested vaccines in time to the service delivery
cadres; adequately trained staff; a system of monitoring and evaluation

involving WHO, UNICEF and Third Parties; proper system of

forecasting; a highly credible surveillance system that is not fragmented
as at present but integrated and coordinated and which is actually used by
health managers for recognizing alerts and emergencies and a Cold Chain
that can ensure both quality and efficacy of the vaccine.

Status of vaccine received in 2012

Routine

Measles

Vaccine 433890 doses.

demanded from the Federal EPI

during year 2012
Routine Measles Vaccine received 420280 doses.
from Federal EPI during year 2012
Campaign
Measles
vaccine 26,00,000 doses.
received from Federal EPI in
December 2012
The above-mentioned facts clearly show that the deaths due to measles
outbreak in some parts of the province were not due to shortage of
measles vaccines; rather it has been a case of pathetic low routine
coverage (less than 50%), a failure of implementation at the district and
union council level.