As poor countries around the world struggle to beat back the coronavirus, they are unintentionally contributing to fresh explosions of illness and death from other diseases – ones that are readily prevented by vaccines.
This spring, after the World Health Organization warned that the pandemic could spread swiftly when children gathered for shots, many countries suspended their inoculation programs. Even in countries that tried to keep them going, cargo flights with vaccine supplies were halted by the pandemic and health workers diverted to fight it.
Now, diphtheria is appearing in Pakistan, Bangladesh and Nepal.
Cholera is in South Sudan, Cameroon, Mozambique, Yemen and Bangladesh.
A mutated strain of poliovirus has been reported in more than 30 countries.
And measles is flaring around the globe, including in Bangladesh, Brazil, Cambodia, Central African Republic, Iraq, Kazakhstan, Nepal, Nigeria and Uzbekistan.
Of 29 countries that have suspended measles campaigns because of the pandemic, 18 are reporting outbreaks. An additional 13 countries are considering postponement. According to the Measles and Rubella Initiative, 178 million people are at risk of missing measles shots in 2020.
The risk now is “an epidemic in a few months’ time that will kill more children than COVID,” said Chibuzo Okonta, president of Médecins sans frontières (Doctors Without Borders) in West and Central Africa.
As the pandemic lingers, the WHO and other international public-health groups are now urging countries to carefully resume vaccination while contending with the coronavirus.
At stake is the future of a hard-fought, 20-year collaboration that has prevented 35 million deaths in 98 countries from vaccine-preventable diseases, and reduced mortality from them in children by 44 per cent, according to a 2019 study by the Vaccine Impact Modeling Consortium, a group of public-health scholars.
“Immunization is one of the most powerful and fundamental disease prevention tools in the history of public health,” Tedros Adhanom Ghebreyesus, director-general of the WHO, said in a statement. “Disruption to immunization programs from the COVID-19 pandemic threatens to unwind decades of progress against vaccine-preventable diseases like measles.”
But the obstacles to restarting are considerable. Vaccine supplies are hard to come by. Health care workers are increasingly working full-time on COVID-19, the infection caused by the coronavirus. And a new wave of vaccine hesitancy is keeping parents from clinics.
Many countries have yet to be hit with the full force of the pandemic itself, which will further weaken their capabilities to handle outbreaks of other diseases.
“We will have countries trying to recover from COVID and then facing measles. It would stretch their health systems further and have serious economic and humanitarian consequences,” said Robin Nandy, chief of immunization for Unicef, which supplies vaccines to 100 countries, reaching 45 per cent of children under the age of five.
The breakdown of vaccine delivery also has stark implications for protecting against the coronavirus itself.
At a global summit earlier this month, Gavi, the Vaccine Alliance, a health partnership founded by the Bill and Melinda Gates Foundation, announced it had received pledges of US$8.8-billion for basic vaccines to children in poor and middle-income countries, and was beginning a drive to deliver COVID-19 vaccines, once they are available.
But as services collapse under the pandemic, “they are the same ones that will be needed to send out a COVID vaccine,” warned Katherine O’Brien, the WHO’s director of immunization, vaccines and biologicals, during a recent webinar on immunization challenges.
Battling measles in Congo
Three health care workers with coolers full of vaccines and a support team of town criers and note-takers recently stepped into a motorized wooden canoe to set off down the wide Tshopo River in the Democratic Republic of the Congo.
Although measles was breaking out in all of the country’s 26 provinces, the pandemic had shut down many inoculation programs weeks earlier.
The crew in the canoe needed to strike a balance between preventing the transmission of a new virus that is starting to hit Africa hard, and stopping an old, known killer. But when the long, narrow canoe pulled in at riverside communities, the crew’s biggest challenge turned out not to be the mechanics of vaccinating children while observing the pandemic’s new safety strictures. Instead, the crew found themselves working hard just to persuade villagers to allow their children to be immunized at all.
Many parents were convinced that the team was lying about the vaccine – that it was not for measles but, secretly, an experimental coronavirus vaccine, for which they would be unwitting guinea pigs.
In April, French-speaking Africa had been outraged by a French television interview in which two researchers said coronavirus vaccines should be tested in Africa – a remark that reignited memories of a long history of such abuses. And in Congo, the virologist in charge of the coronavirus response said that the country had indeed agreed to take part in clinical vaccine trials this summer. Later, he clarified that any vaccine would not be tested in Congo until it had been tested elsewhere. But pernicious rumours had already spread.
The team cajoled parents as best they could. Although vaccinators throughout Tshopo ultimately immunized 16,000 children, another 2,000 eluded them.
This had been the year that Congo, the second-largest country in Africa, was to launch a national immunization program. The urgency could not have been greater. The measles epidemic in the country, which started in 2018, has run on and on: Since January, there have been more than 60,000 cases and 800 deaths. Now, Ebola has again flared, in addition to tuberculosis and cholera, which regularly strike the country.
Vaccines exist for all these diseases, although they are not always available. In late 2018, the country began an immunization initiative in nine provinces. It was a feat of co-ordination and initiative, and in 2019, the first full year, the percentage of fully immunized children jumped from 42 per cent to 62 per cent in Kinshasa, the capital.
This spring, as the program was being readied for its nationwide rollout, the coronavirus struck. Mass vaccination campaigns, which often mean summoning hundreds of children to sit close together in schoolyards and markets, seemed guaranteed to spread coronavirus. Even routine immunization, which typically occurs in clinics, became untenable in many areas.
The country’s health authorities decided to allow vaccinations to continue in areas with measles but no coronavirus cases. But the pandemic froze international flights that would bring medical supplies, and several provinces began running out of vaccines for polio, measles and tuberculosis.
When immunization supplies finally arrived in Kinshasa, they could not be moved around the country. Domestic flights had been suspended. Ground transport was not viable because of shoddy roads. Eventually, a UN peacekeeping mission ferried supplies on its planes.
Still, health workers, who had no masks, gloves or sanitizing gel, worried about getting infected; many stopped working. Others were diverted to be trained for COVID.
The cumulative impact has been particularly dire for polio eradication – around 85,000 Congolese children have not received that vaccine.
But the disease that public-health officials are most concerned about erupting is measles.
More contagious than COVID
Measles virus spreads easily by aerosol – tiny particles or droplets suspended in the air – and is far more contagious than the coronavirus, according to experts at the U.S. Centers for Disease Control and Prevention.
“If people walk into a room where a person with measles had been two hours ago and no one has been immunized, 100 per cent of those people will get infected,” said Yvonne Maldonado, a pediatric infectious disease expert at Stanford University.
In poorer countries, the measles mortality rate for children under the age of five ranges between 3 per cent and 6 per cent; conditions such as malnutrition or an overcrowded refugee camp can increase the fatality rate. Children may succumb to complications such as pneumonia, encephalitis and severe diarrhea.
In 2018, the most recent year for which data worldwide has been compiled, there were nearly 10 million estimated cases of measles and 142,300 related deaths. And global immunization programs were more robust then.
Before the coronavirus pandemic in Ethiopia, 91 per cent of children in the capital of Addis Ababa received their first measles vaccination during routine visits, while 29 per cent in rural regions got them. (To prevent an outbreak of a highly infectious disease such as measles, the optimum coverage is 95 per cent or higher, with two doses of vaccine.) When the pandemic struck, the country suspended its April measles campaign. But the government continues to report many new cases.
“Outbreak pathogens don’t recognize borders,” said Dr. O’Brien of the WHO. “Especially measles: Measles anywhere is measles everywhere.”
Wealthier countries’ immunization rates have also been plunging during the pandemic. Some American states report drops as steep as 70 per cent below the same period a year earlier, for measles and other diseases.
Once people start travelling again, the risk of infection will surge. “It keeps me up at night,” said Stephen Cochi, a senior adviser at the global immunization division at the CDC. “These vaccine-preventable diseases are just one plane ride away.”
After the WHO and its vaccine partners released the results of a survey last month showing that 80 million babies under a year old were at risk of missing routine immunizations, some countries, including Ethiopia, Central African Republic and Nepal, began trying to restart their programs.
Uganda is now supplying health workers with motorbikes. In Brazil, some pharmacies are offering drive-by immunization services. In the Indian state of Bihar, a 50-year-old health care worker learned to ride a bicycle in three days so she could bring vaccines to far-flung families. Unicef chartered a flight to deliver vaccines to seven African countries.
Cochi of the CDC, which provides technical and program support to more than 40 countries, said that whether such campaigns can be conducted during the pandemic is an open question. “It will be fraught with limitations. We’re talking low-income countries where social distancing is not a reality, not possible,” he said, citing Brazilian favelas and migrant caravans.
He hopes that polio campaigns will resume swiftly, fearing that the pandemic could set back a global, decades-long effort to eradicate the disease.
Dr. Cochi is particularly worried about Pakistan and Afghanistan, where 61 cases of wild poliovirus Type 1 have been reported this year, and about Chad, Ghana, Ethiopia and Pakistan, where cases of Type 2 poliovirus, mutated from the oral vaccine, have appeared.
Thabani Maphosa, a managing director at Gavi, which partners with 73 countries to purchase vaccines, said that at least a half dozen of those countries say they cannot afford their usual share of vaccine costs because of the economic toll of the pandemic.
If the pandemic cleared within three months, Mr. Maphosa said, he believes the international community could catch up with immunizations over the next 1½ years.
“But our scenarios are not telling us that will happen,” he added.
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