Is Pakistan losing the battle against measles?

Pakistan has seen a growing number of measles cases in recent years, with more than 25,000 reported last year, including 321 deaths.

“It is vital we bring the situation under control to save the lives of children and offer people better health care,” said Anita Zaidi, professor of paediatrics at the Aga Khan University Hospital in Karachi.

In 2012 there were nearly 15,000 cases, and in 2011 4,380 cases. The steady rise comes despite a government measles vaccination programme that has been running for more than 35 years.

Although confirmed deaths so far this year stand at only 13 from 1,329 reported cases, health officials are still concerned not enough is being done to deal with the repeated outbreaks of measles.

“There have been at least nine deaths from measles this year in the province [Balochistan],” Ishaq Panezai, provincial deputy coordinator of the Expanded Programme on Immunisation (EPI), told IRIN. The latest six deaths came in Kalat District, where four children died in late April, and in Pishin District where two others died around the same time. There have also been deaths in the Zhob District and the provincial capital Quetta.

“There should be a vaccination drive [in Kalat], but local authorities tell us it is too hazardous to visit,” said Panezai.

EPI started work in 1978, initially covering six diseases, but it has since grown to cover nine (poliomyelitis, tetanus, measles, diphtheria, pertussis, hepatitis-B, pneumonia, meningitis and tuberculosis).

Impediments to vaccination

Insecurity is certainly one factor that has limited some of the EPI’s vaccination campaigns; others blame disruption caused by heavy monsoon flooding in recent years. Yet others blame a decentralization of health services to the provincial level.

In a study published earlier this year, researchers from the Quaid-e-Azam University in Islamabad said corruption was the principal cause of the high number of measles infections, notably in Sindh and Punjab provinces, something that was leading to “ineffective healthcare system, shortage of vaccinators and low immunization coverage.”

A 2010 report by Transparency International Pakistan found 48 percent of patients surveyed faced corruption after admission to hospital. The two most common complaints were: Having to pay money under the table to get a bed (26 percent), and being asked to pay extra money to get allocated medicine (18 percent).

“Mismanagement and corruption go together, and these affect every sector including health,” Sikander Lodhi, a Lahore-based economic analyst, told IRIN.

Health officials in public hospitals say vaccines, given for free, are often stolen.

“Funds, medicines, vaccines provided free of cost by the government are pilfered by people working here and sold to the private clinics or shops,” said an employee at the health department in Quetta, who asked not to be named. “The lack of proper supervision allows this to happen, and also creates an environment of indifference, where no one is really interested in providing health cover to people, except as a kind of mechanical duty.”

The UK-based medical journal, The Lancet, voiced similar concerns saying the “poor quality and ailing” vaccination programmes, ridden with corruption, were a factor in the surge of measles cases.

Measles in Pakistan
	DEATHS	CONFIRMED CASES	REPORTED CASES
2011	64	2,533	4,380
2012	310	2,676	14,687
2013	321	5,969	25,401
2014*	13	92	1,329
*January-May Source: Pakistan Ministry of Health

The key impact of corruption, in the case of measles, is a reduced vaccination rate.

“The low national EPI coverage [across all EPI vaccine programmes] of 54 percent of children, according to the Pakistan Demographic Health Survey for 2012-13, with declining coverage trends over time in Sindh and Balochistan, coupled with increasing number of polio cases in the low transmission season, are the major challenges for Pakistan,” Saadia Farrukh, an immunization specialist at the UN Children’s Fund (UNICEF) Pakistan, told IRIN.

Most patients recover from measles without treatment, but complications can develop, particularly where victims are malnourished. Almost 40 percent of children in Pakistan are underweight, according to the UN Food and Agriculture Organization.

Government efforts

At a federal level, some steps are now being taken to strengthen routine immunization, with a “Vaccine Management Assessment” under way across the country.

Supplementary Immunization Activities, postponed due to the unavailability of funds, are also now due to be launched after the release of funds by the federal government, EPI National Manager Ejaz Khan told the media in March. But he said the number of measles cases reported this year was “worrisome” and indicated an epidemic was possible.

Despite official promises, health experts remain concerned. At a media briefing in Karachi at the end of April, the Pakistan Paediatric Association (PPA) said 53 percent of children in the country were not vaccinated against any disease. PPA attributed this to misconceptions about vaccines, including those linked to fertility, or the belief that because vaccines caused fever at times, they were “not good” for children’s health.

“Actually the government is more focused on donor-driven polio campaigns, due to which, other diseases remain ignored,” said Hasan Orooj, director of health services at the Capital Development Authority (CDA).

Some families complain of a lack of information. “I took my six-month-old infant for his shots at a government hospital. He was given three or four jabs, but the doctor refused to answer my questions about what they were for. He developed high fever that night, so we will not be taking him again,” Rafiq Ahmed told IRIN.

Experts agree there are major flaws in the system, leading to deaths that could have been prevented. “We need a holistic plan for vaccination cover. The focus on polio alone has not helped. The EPI programme needs to be treated as a whole, and all vaccination given importance,” said paediatrics professor Zaidi.

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