Measles outbreaks expose SA’s growing childhood vaccination crisis

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JEREMY MAGGS: South Africa is being warned that decades of progress against preventable childhood diseases could be slipping away. This is worrying. The proportion of infants under one receiving no vaccinations has tripled from around 12%, as I understand it, in 2017, to more than 36% in the first four months of this year.

While measles, rubella and other diseases are already emerging, that has been well documented. It does raise an important question: why are parents turning away from vaccines that are free and proven to save lives?

Someone who is front and centre in this debate is Professor Shabir Madhi, who is dean of the Faculty of Health Sciences and professor of vaccinology at Wits University here in Johannesburg. Professor, welcome back to the programme.

How does a country with free childhood vaccines then end up with more than a third of infants receiving none at all? What’s happening here?

SHABIR MADHI: Jeremy, the data that’s been released by the National Department of Health certainly is of concern, but I think, firstly, the thing we need to do is take a step back and actually interrogate the data for its veracity.

It’s extremely unlikely that things could have gone so [far] south so rapidly in South Africa.

Now, when the National Department of Health released this data, it’s based on an understanding of the number of children who are born over the past year and the number of doses of vaccine that might have been deployed to facilities, and that’s the way they calculate it.

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So it’s based on an administrative calculation, rather than actually doing a survey to determine what percentage of children are vaccinated.

South Africa does have a problem in terms of children being undervaccinated, but it’s extremely unlikely, in my mind, that it’s one third of the children who are suddenly not receiving at least one dose of vaccine in South Africa.

JEREMY MAGGS: Professor, I fully understand that the data has to be verified, but would you suggest, based perhaps more on your anecdotal understanding of the situation, that there is a degree or an increasing degree of vaccine hesitancy? Perhaps, possibly as well, the health system itself is not doing enough to reach children.

SHABIR MADHI: There definitely is an issue around vaccine confidence. I think there are a number of factors that are contributing to it.

So the canary in the mine, when it comes to vaccine coverage, is really measles because it’s highly infectious. If you don’t have at least 95% of the population receiving two doses of measles vaccine, that’s when you get these outbreaks.

Currently, I think we’ve had over 3 500 cases just this year in South Africa. So it certainly tells us that our vaccine coverage is not what it should be, and that’s the starting point.

What are the reasons for a lack of vaccine trust? There are obviously issues around healthcare facilities itself.

Parents tend to lose confidence in terms of the immunisation programme, when you take children to clinics and the clinics are either closed because they might have closed at 12:00pm. Alternatively, clinics might not have vaccines available and then parents are expected to visit again on another day.

Obviously, that creates problems.

So we do need to look at the architecture of our primary healthcare to ensure that it’s accessible to parents at the convenience of parents, and not necessarily just between 8:00am and 12:00pm, as an example, for immunisation clinics.

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There are other issues around misinformation and disinformation that obviously are also entering into the public discourse. Certainly, that creates some issues in terms around vaccine confidence.

So I think it’s multi layered, but there are certainly issues in terms of the healthcare facilities itself, which is a big contributor, in my mind, in terms of the reasons why there are not an adequate number of children who are being vaccinated in South Africa.

JEREMY MAGGS: Professor Madhi, unless that architecture is improved, it is going to be very difficult, surely, to restore confidence. I’m wondering how difficult that’s going to be, and whether perhaps we’ve reached some tipping point where it’s going to be an almost impossible hurdle to overcome.

SHABIR MADHI: I don’t think it’s an impossible hurdle to overcome. It requires a political will, and it requires a commitment on the part of healthcare workers. It also requires much more on the part of government in terms of advocating as to why vaccines are important.

To some extent, I think parents might also have become complacent because of the successes that vaccines have had.

So it’s uncommon nowadays to know of another child who died of measles, something which was very common in the early 1990s, as an example.

So vaccines have been highly impactful and consequently, there might also be an element of complacency setting in.

So that’s all the more reason why government needs to become much more active in terms of getting communities to understand what the role of vaccines has been in reducing childhood deaths in South Africa, as well as in terms of relieving pressures on our healthcare facilities by preventing children from being hospitalised for these vaccine-preventable diseases.

JEREMY MAGGS: Professor, as far as measles are concerned, as you’ve referenced, we’ve already recorded thousands of cases this year. Are we at a point now where we are beyond warning about outbreaks and are actually living through one?

SHABIR MADHI: Oh, absolutely. In South Africa, we’ve had this ongoing circulation of measles resulting in these epidemics that we’re experiencing currently as well as last year.

So we’re certainly living through year-on-year epidemics, almost. That tells us that our vaccine programme is certainly nowhere close to what it should be.

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Like I mentioned, for us to be able to control the circulation of measles, all children should receive at least two doses of vaccine before they turn two years of age. Currently, we’re probably sitting at not more than two thirds of children receiving two doses of measles vaccine, which is highly, highly problematic.

And again, that really is the canary in the mine in that when you have these measles outbreaks, it tells us that there’s something seriously wrong with our immunisation programme.

JEREMY MAGGS: Professor, when officials say that we are losing our herd immunity, what does that mean in practical terms for children not only who are vaccinated but those who are unvaccinated?

SHABIR MADHI: When we refer to herd immunity, what we’re really referring to is even if there’s a new case of measles, as an example, that’s imported into the country, it won’t spread because there’s an adequate percentage of the population that have developed immunity against it.

So there’s an interruption of the circulation of the virus in the case of measles. What we’re facing now with the circulation of wild-type measles, it tells us we are nowhere close to herd immunity.

Like I said, it’s not a new problem, it’s been ongoing for the past decade, if not more, because of our [ineffective] measles vaccine coverage.

But the bigger concern, like you mentioned, is not just for those who are unvaccinated because they have a really heightened susceptibility of being infected, but it’s also a problem for people who are immunocompromised, who even if vaccinated, the vaccine might not protect them adequately, or they might not be able to get vaccinated because they’re immunocompromised and they can’t get some vaccines, especially a vaccine such as measles.

So it also poses a risk to individuals who are immunocompromised, both adults as well as children who are unable to be vaccinated by virtue of their medical condition, who then become victims to others not having been vaccinated and allowing for a virus such as measles to circulate.

JEREMY MAGGS: Professor Shabir Madhi, thank you very much indeed. Dean of the Faculty of Health Sciences and professor of vaccinology at Wits University. Professor, thank you so much.

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