Perspectives and Evidence Regarding Measles in Ugandan Children
Measles is a deadly disease for Ugandan children. Despite Uganda having vaccinated 80% of their children between 2009 and 2019 with one dose of the measles vaccine (MCV1),1 it is not enough to achieve herd immunity which is gained when 95% of the population are vaccinated.
It was the 2016-2018 measles outbreak that saw a 300% increase in measles cases that brought measles back to the top of the Ugandan government’s agenda.2 However, today there are still over 14 million Ugandan children under 5 years who live in highly endemic areas called “cold spots”, and over 12 million children who still need their MCV1.3
Measles is an infectious disease, with an attack rate of over 90% in at-risk persons.4 It is spread through the air and can infect a person’s respiratory tract up to two hours after an infected person was last in the room.5,6 Ugandan children are considered greatly at risk of contracting measles if they are unvaccinated, malnourished, have poor immune systems or living conditions, or any other factor that may compromise general health.
The symptoms most often associated with measles include a red, spotty rash over the entire body, a high fever, a cough and runny nose, and conjunctivitis.2,6 In children, it is often the complications that arise from measles that cause death. These complications can include pneumonia, severe diarrhea, ear-infections, and encephalitis which can cause lifelong brain damage and/or blindness.2,7
Among Ugandan children, measles is ranked fourth among the highest causes of mortality.8 Whilst the impact of death is indescribable, the economic costs and impacts on living standards can be measured. On average, Ugandan caregivers spend 30% of their monthly household income on treating measles during an outbreak.10 However, if a measles victim needed inpatient care, that alone would cost 33% of an individual’s monthly wage.10,11 This would greatly inhibit the economic ability to provide basic nutrition and education to the affected and/or remaining children. Further, if one victim of measles suffered life-long complications, the family would need to provide ongoing medical support and will have one less individual with wage-earning potential. These economic constraints further increase the vulnerability of the urban and rural poor,12 and constrict a child’s ability to succeed in the future.
Drivers within the context
There are a few key features of the Ugandan context that are of note in this piece.
Geographically, Lake Victoria is Africa’s largest lake and is a major source of fishing and water for the country.13 However, the water borne parasite Schistosoma mansoni commonly affects Ugandan communities that live along Lake Victoria’s shores (5). Infection with Schistosoma mansoni changes the body’s immune response and lowers the antibodies against measles, compromising MCV1 effectiveness.14
Additional geographic context relates to the infrastructure available in Uganda.9 Poor road conditions prove challenging for vaccine movement and logistics, and unstable electricity and housing may inhibit the effectiveness of cold chain.
Socioeconomic features factor in the Human Capital Index, where a Ugandan child is up to 3 times less productive than a child with a complete education and full health.15 Additionally, undernutrition rates are high in Uganda and stunting affects more than 29% of Ugandan children.15 More than 5% of children will not survive to their fifth birthday.15 Without intervention, these rates will worsen with time as already thin resources are stretched further. Uganda has a population growth rate of more than 3%, and their population is expected to grow from 42 million to 100 million by 2050.15
From a political perspective, MCV1 is subsidised by the Ugandan government and is included in the routine immunisation program for children as part of the Expanded Program on Immunisation (EPI).10 MCV1 coverage for Ugandan children had reached 86% in 2018.10 Additional supplemental immunisation activities (SIA) were conducted to increase vaccination coverage and interrupt measles transmission in 2003, 2006, and 2015.10 Although historically the government of Uganda has underestimated the number of vaccines required, resulting in many districts failing to secure MCV1 for their communities.9 The Ugandan government is also focussed on promoting universal health coverage; however, greater attention is needed on protecting citizens from covering the costs of care.10
Within this context, one of the primary drivers of Ugandan children’s susceptibility to measles concerns the timeliness of MCV1, the effectiveness of MCV1, and the timeliness of SIA. The recommended age for receiving MCV1 is 9 months, however studies have shown that more than 50% of Ugandan children receive MCV1 between the ages of 9 to 58 months.10 It is reported that delaying the MCV1 beyond 12 months of age is a risk factor for future measles outbreaks.16 WHO also reported that a significant proportion of Ugandan children who received MCV1 have still contracted measles,10 indicating that one dose of the vaccine is not effective. Additionally, the Ugandan government have not added MCV2, the second dose, to the EPI.17 Regarding the timeliness of SIA, the last SIA was conducted in 2015, and another SIA was planned for 2018 but is delayed.1 This delay could be partly responsible for the continuation of the 2018 measles outbreak.
The second main driver concerns the settings where measles is most likely to be transmitted. In Uganda, women and children often move together to collect water and socialise.18 Many studies have shown that congregation at water-collection points is a major facilitator in the spread of measles.19 Drought also has the potential to increase the number of families who collect water from the same locations as other water sources dry up.
Thirdly, the infrastructure in Uganda has further challenged cold chain logistics and contributed to the number of children who missed the MCV1.20 The delay of the SIA will have also impacted the opportunity to investigate unreported cases of measles.21 This is a risk factor for the Ugandan government to under-order measles vaccinations again in the future.
There are also several features within the context that contribute to Ugandan children’s susceptibility to measles. The main risk factor that contributes to vulnerability surrounds the access to, and costs of, care. Studies have noted that out-patient waiting rooms are grossly overcrowded and there are severe understaffing problems among healthcare workers.5 Assuming Ugandan families can afford the costs of care, there is no guarantee that health consultations will be timely, and waiting rooms put families at greater risk of contracting measles. These factors are compounded by unreliable vaccine supplies.1
The other main risk factor that contributes to vulnerability relates to the distrust some Ugandans have for vaccines. A Ugandan spokesperson was quoted saying that reports of families preventing children from vaccination against measles “have been quickly dealt with”.1 Such actions do not result in an increase of trust for the government and can spread further distrust and misinformation.
Gaps in evidence
This report has focussed on evidence provided by researchers, government authorities, and media outlets. However, this does not indicate that a complete story has been told. Many studies mentioned that medical records used as references were out of date or had significant discrepancies,10 and others reported that mothers had misplaced immunisation cards and had to rely on memory to recall vaccination status of children.2,5 Additionally, it is stipulated that the societal costs of measles in Uganda is underestimated as the social costs associated with deaths were not recorded.9 Lastly, many studies stated that their patients were from a small geographical range close to the study site,2 suggesting that more rural communities have not been reached and are likely under-represented in figures.
Based on the above, it appears that mainly urban Ugandan communities’ experiences have contributed to the media’s representation of the impact of measles on children in Uganda. Whilst general trends such as congregating at water-collection points are noted, the research behind how rural families access medical centres, what supplies medical centres have, how medical information is dispersed, how climate change will impact this, and the economic impacts of measles on the rural poor were limited.
Additionally, whilst the Ugandan governments stance on vaccination is clear, there is very limited official documentation of the effort to address distrust and misinformation within communities. The Ministry of Health has ‘persuaded’ and ‘dealt with’ communities who are hesitant to vaccinate their children, but details are lacking. It is assumed this is due to political optics, however distrust and misinformation will still spread among rural families without proper intervention.
This report assumes that the gaps in evidence exist in part due to the difficult nature of reaching and engaging with remote communities. The EPI and SIA aim to reach 95% of Ugandan children to achieve herd immunity, however these efforts will be impeded without also addressing issues in infrastructure and in reducing the costs of care. On the other hand, it is speculated that evidence regarding vaccine resistance and government efforts to address this are limited because it is not productive for this information to be public from a government campaign perspective.
Implications for existing and future efforts
It is critical to address the gaps in evidence and perspectives for numerous reasons. Without proper documentation of the struggles of accessing care for the rural poor, it is difficult to identify what issues to address to create a horizontal health program to increase vaccine effectiveness rather than a vertical one solely for measles. Without an adequately staffed medical workforce in terms of personnel and supplies, prevention and treatment rates for measles in Ugandan children will decline and the country will not achieve herd immunity. Without addressing the distrust and misinformation, government efforts risk falling on deaf ears, communities could become more apprehensive, and the opportunity to educate communities on the importance of early treatment and quarantining will be lost.
Fundamentally, an incomplete picture of the context and its factors will never address the crux of an issue. In the case of measles affecting Ugandan children, the risk that an incomplete picture poses is a potentially ineffective measles campaign and the chance of more deaths associated from measles.
References
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