Weeks of missed immunisations could drive new outbreaks of preventable diseases like measles, according to doctors in Pakistan, who warn another health emergency is looming even as the country battles the coronavirus pandemic.
Routine immunisations have been at a standstill since late March, when the government imposed coronavirus lockdown measures that shuttered schools and public transport. Overwhelmed with COVID-19 patients, many public and private hospitals also closed the out-patient departments where newborns and mothers would normally receive immunisations.
Already, there are early signs of an uptick in vaccine-preventable diseases, doctors say.
“The government has diverted all its resources and staff to tackle the coronavirus,” said Dr. Afzal Khan Khattak, a paediatrician and provincial president for the Pakistan Paediatric Association in northwest Khyber Pakhtunkhwa Province, which has a large refugee population and poor health access. “We are already receiving increasing cases of measles.”
Public transport shutdowns have also made it difficult to reach facilities that are open, including government-run immunisation clinics known as EPI centres. Fear of contracting the coronavirus also continues to keep many parents away, though the World Health Organisation says older people generally have the highest risk.
“There is a perception among parents that children are more vulnerable to the virus,” said Dr. Anjum Qadeer, the coordinator for immunisation in Chakwal district in eastern Punjab, a province that has recorded more than a third of the country’s total cases.
To reduce the risk of inadvertently spreading the coronavirus, the WHO and global vaccine advocates have recommended that countries postpone mass vaccination campaigns, such as door-to-door polio programmes, in areas with no active outbreaks.
“The government has diverted all its resources and staff to tackle the coronavirus.”
But they also urged routine immunisation programmes in fixed clinics and hospitals to continue. In Pakistan and many parts of South Asia, however, these routine immunisations have been “severely disrupted”, according to UNICEF.
Global health advocates have warned that more than 117 million children worldwide may miss out on measles vaccines alone as campaigns and routine immunisations get suspended. The risks are magnified in countries with already low immunisation rates. Pakistan’s routine immunisation coverage stood at 66 percent in 2018, according to a government health survey published last year – far short of the 95 percent target health experts say is needed to prevent outbreaks.
A new study by Johns Hopkins University researchers, published in The Lancet on 13 May, projects that between 42,000 and 192,000 more children worldwide could die each month due to COVID-19’s indirect impacts on health and food access – with more than one in 20 of these additional deaths related to vaccine-preventable diseases. The data projects Pakistan could face the third-highest total of additional child deaths of 118 countries measured, behind India and Nigeria.
National health authorities say more out-patient departments and immunisation clinics have started re-opening as of 9 May, when Pakistan began to ease some of its lockdown measures. The coordinator of Pakistan’s Expanded Programme on Immunisation (EPI), Dr. Rana Muhammad Safdar, said missed vaccinations are driven by parental fears and closed public transport.
“There is no issue of service delivery from the government end,” he said.
But several doctors told The New Humanitarian that many hospital out-patient departments, or OPDs, are still closed.
“We have received no order of the government that OPDs should be opened,” said Dr. Muhammad Zubair, the medical officer at Sir Ganga Ram Hospital, one of the biggest public sector hospitals in Lahore, Punjab’s capital.
Parents fear hospital outbreak risks
Pakistan faces a two-pronged problem in scaling up routine immunisation coverage: keeping hospitals and clinics open and accessible, and convincing parents to use them in the middle of a pandemic.
“We have to increase both demand and supply to ensure maximum coverage,” said Dr. D S Akram, a Karachi-based paediatrician and founder of the Health Education and Literacy Programme, or HELP, a non-governmental organisation working on maternal and child health.
But rising hospital worker infections – there were more than 900 coronavirus cases among Pakistani health workers as of 12 May, according to government data – have pushed some major hospitals to scale back services or close, and driven parental fears.
On 5 May, for example, the government sealed a maternal hospital and the operating room at a children’s hospital at the Pakistan Institute of Medical Sciences – Islamabad’s biggest medical university – after 15 staffers contracted the coronavirus. A separate hospital in Peshawar also closed its gynaecology unit.
“I can’t risk visiting the public sector hospital for vaccinating my child, when hundreds of doctors and health workers themselves have contracted the virus,” said Madiha Naz, a 27-year-old mother in Islamabad whose newborn child missed his scheduled vaccinations.
She said a private hospital in an upscale area of the Pakistani capital had suspended vaccinations and closed its out-patient department to discourage large crowds. Now, she plans to buy the needed vaccines herself and find a health worker to administer them.
“I can’t risk visiting the public sector hospital for vaccinating my child, when hundreds of doctors and health workers themselves have contracted the virus.”
“My child is at risk of contracting preventable diseases,” she said. “I don’t know if the coronavirus, or missing vaccinations, is more dangerous to my kid.”
It’s unclear how many children have missed immunisations since Pakistan’s coronavirus outbreak began. The EPI programme targets 7.9 million children this year, as well as the same number of pregnant women. It offers free essential vaccinations covering 10 diseases, including tuberculosis, polio, diarrhoea, pneumonia, whooping cough, tetanus, hepatitis-B, meningitis, diphtheria, and measles.
Safdar, the programme’s coordinator, said it was “difficult to ascertain” exact figures.
But Akram of HELP said between 12,000 and 15,000 children are born every day in Pakistan according to government statistics, suggesting that the number of newborns potentially missing their first immunisations for tuberculosis and polio could stretch into the hundreds of thousands.
Older children requiring vaccinations for measles, tetanus, and other diseases will have also gone without, she warned, adding that more measles cases are already being reported in Karachi’s hospitals. Pakistan, one of only three countries where polio is still endemic, has recorded 47 wild poliovirus cases this year as of mid-May – more than double the number recorded at the same point last year. The country has suspended its nationwide, door-to-door polio vaccination campaign until at least the end of May.
“All these things indicate the threat that cases of vaccine-preventable diseases among children is likely to increase,” Akram said.
How to restart immunisations
Though re-openings of hospital out-patient departments and the government EPI centres vary across the country, health workers say they’re trying to jumpstart vaccinations as soon as possible.
“Our vaccination services were affected by the closure of the OPDs of large hospitals but now we are trying to resume our services at all EPI centres,” said Qadeer, the immunisation coordinator in Punjab’s Chakwal district, adding that many families are still not coming due to fear of the coronavirus and mobility issues.
Khattak, the paediatrician in Khyber Pakhtunkhwa, said the government could improve the situation by easing fears among parents – marking off separate spaces for immunisations in public hospitals, for example.
Dr. Asher Pervaiz, a programme officer on immunisation with the Pakistan Red Crescent Society, said the organisation’s regular 15-day vaccination programmes at EPI centres have been on hold since the start of the outbreak in March. But Red Cross vaccinators are now doing shorter, seven-day programmes, including targeting villages in two districts of southwestern Balochistan, which has seen years of instability and is one of the country’s poorest provinces.
Akram said she hoped normal immunisation schedules could get back on track within a month. But even then it could still take two months or longer for routine immunisations to catch up with the number of children who have already missed vaccinations, she said.