Vaccination: Nurses strike and the coming disease crisis

Nurses at Coast General Hospital protest outside the facility after they were threatened with dismissal letters by the Council of Governors on September 11, 2017. While politicians and technocrats have been haggling over budgets, promotions, salaries and their effects on government recurrent expenditure, few people have paused to think about what the current impasse is doing to the country’s children, who are not receiving scheduled vaccines.

Kenya is staring into a huge health crisis as hundreds of thousands of children are going without vaccination due to a prolonged nurses strike, now inching towards the fifth month.

Healthcare services in all public facilities countrywide have ground to a halt, and that means children are not getting vaccinated against some of the world’s most debilitating diseases, including polio, pneumonia, meningitis, measles, influenza, and hepatitis.

These diseases, long identified as among the biggest health threats in the region, could ravage the nation in the coming years if these hordes of vulnerable children are exposed to their vectors. For health experts, it is hard to fathom the gravity of the situation.

When we recently visited the Obama Ward at Jaramogi Oginga Odinga Teaching and Referral Hospital (JOOTRH) in Kisumu, there was neither the usual choir of wailing babies receiving vaccinations nor the pageantry of expectant mothers visiting for routine clinics.

Dr Juliana Otieno, the JOOTRH medical superintendent, says she is worried that a medical catastrophe is in the making.

“The threat of death by disease isn’t the only medical consequence of skipping vaccinations,” she says. “An unvaccinated child faces lifelong health difficulties.

The coming crisis is huge and we must prepare to address it. The cost of treating unvaccinated children will be very expensive for the government.”

She is looking at the silent, unreported consequence of the nursing strike. While politicians and technocrats have been haggling over budgets, promotions, salaries and their effects on government recurrent expenditure, few people have paused to think about what the current impasse is doing to the country’s children.

When a child misses a polio vaccine and there is an attack, for instance, the likelihood of that child going down with the virus is huge because the child is not covered. The World Health Organisation recommends an oral polio vaccine dose immediately a baby is born — called a zero dose — followed by a series of three primary doses and a minimum one inactivated dose.

Now that more women of child-bearing age and their children are going without immunisation, the disease profile in the country is likely to be affected, for the worse.

“Vaccines are the safest way to protect children and pregnant mothers from a long list of serious and potentially life-threatening illnesses,” says Dr Otieno. “They protect children by preparing their immune systems to recognise and fight serious, deadly diseases.”

Every month, 600 women deliver and over 1,000 children are vaccinated at JOOTRH, which is the leading referral hospital in western Kenya, but in the wake of the strike those women are seeking care elsewhere, including inside the huts of traditional birth attendants. Some of these mothers, of course, are getting the services from private clinics, where they are getting the necessary vaccination.

Records at the JOOTRH maternity wing tell the story of many other such government hospitals in the country. In May this year, before the strike started, over 600 mothers and 1,000 children were vaccinated at the facility. They were scheduled for a review in June, but unfortunately, that is the month nurses downed their tools.

In June, only 10 per cent went back for the scheduled vaccination, while most pregnant women who were due did not turn up to give birth at the hospital, missing the vaccinations given to infants at birth.

Over 200 women were due to give birth at the hospital in June, but none of them returned. Which means most of them might have given birth at home and those who were fortunate enough, gave birth in private hospitals.

Ms Monica Aloo is one of the women who gave birth at home.

“I went for my check-up on May 12 and was scheduled to go back in June but unfortunately the nurses went on strike,” she told HealthyNation last week from her home in Homa Bay. “I gave birth on July 8 at home aided by a nyamrerwa (community health worker) but my child was never immunised. I am aware of the consequences of not vaccinating my baby, but I do not have that money to do it in a private hospital.”

While Monica is optimistic that her baby boy will survive even if he is not vaccinated, Dr Walter Otieno, a Kisumu-based paediatrician, says the likelihood of the boy dying, or contracting a debilitating disease, before the age of five are very high.

The 2014 Kenya Demographic Health Survey shows that almost eight in 10 children — 79 per cent — aged 12 to 23 months receive all basic vaccinations (BCG, measles, and three doses each of DPT and polio vaccine, excluding polio vaccine given at birth). The other two in every ten receive no vaccines, affecting, later on, the health indicators of the country.

Basic vaccination has improved only slightly since 2008, when 77 per cent of children received all of the basic vaccines. Vaccination was slightly higher in urban than rural areas, at 83 per cent versus 77.

According to the survey, there was a tremendous variation by counties, from 36 per cent coverage in West Pokot to over 95 per cent coverage in Nyamira, Nandi, Kiambu, Kirinyaga, and Tharaka-Nithi.

Basic vaccination coverage increases with a mother’s education and household wealth. Only 57 per cent of children age 12 to 23 months whose mothers have no education have received all basic vaccinations, compared to 87 per cent of children whose mothers have secondary or higher education.

To put it simply, the majority of families in Kenya are opting to have their children vaccinated. But they can only do so when the medical care system is working like a well-oiled engine.

Dr Subiri Obwogo, a local health expert, says vaccination plays are big role in preventing at least 25 diseases, including polio, hepatitis B, whooping cough, measles, diphtheria, measles, tetanus, diarrhoea, pneumonia, and cervical cancers.

Diarrhoea and pneumonia are the two leading killers of children under the age of five in Kenya, and Dr Obwogo says the introduction of their vaccines by the National Immunisation Programme about two years ago was prudent. Together, it is estimated, the two diseases caused two million deaths in 2011 globally.

GOVERNMENT VACCINATION SCHEDULE

A 2013 Lancet publication showed that at least one-third of severe episodes of pneumonia and two-thirds of deaths from the disease are caused by vaccine-preventable vectors.

The report also showed that nearly one-third of the episodes of severe diarrhoea are preventable by vaccination, for example, against rotavirus and cholera.

Unvaccinated children are also at high risk of measles-related deaths, says Dr Otieno, yet a safe and cost-effective vaccine is available. In 2015, the disease killed 134,200 children in the country — or about 367 every day, 15 every hour.

Vaccination resulted in a 79 per cent drop in measles deaths between 2000 and 2015 worldwide, and last year about 85 per cent of the world’s children received one dose of vaccine by their first birthday through routine health services, up from 73 per cent in 2000.

From 2000 to 2015, measles vaccination prevented an estimated 20.3 million deaths globally, making the vaccine one of the best buys in public health management.

The highly contagious disease can quickly spread through an inadequately vaccinated community. It kills children directly or, more often, by weakening their immune systems, making them susceptible to a host of other infections.

Globally, the disease kills nearly one million children every year, 450,000 of them in African countries. In 1980, before widespread vaccination, measles caused an estimated 2.6 million deaths each year.

All crucial vaccinations are administered free of charge in public hospitals and at a fee in private facilities.

At Avenue Hospital in Kisumu, the cheapest vaccination goes for Sh600 while that of rotavirus is charged at Sh4,500. Ante-natal clinic visits here cost Sh2,000.

Nurses have vowed to continue with their strike until their grievances are addressed, saying they will not be cowed by threats to sack them. They have been away from work since June 5, demanding payment of a Sh25,000 monthly allowance, Sh15,400 in risk compensation, and other allowances.

“We need to find a way as a country to mobilise nurses to give these essential vaccinations,” says Dr Dickens Onyango, the Kisumu County Director of Health.

“We are not looking at the bigger impact of missing vaccines and we will have to use a lot of resources in treating these children in future.”

Some of the vaccines administered to children in public hospitals include polio, BCG (to fight tuberculosis), DPT (diphtheria-tetanus-pertussis), Hb (Hepatitis B) and the most recent addition, Hib, which has proven effective in reducing early childhood meningitis in many countries

At birth, infants are injected with BCG on their arms. This is mandatory as stipulated in Kenya’s regular schedule of vaccinations, developed by the Ministry of Health. The vaccine helps protect the newborn against tuberculosis (TB), including TB Meningitis (an infection of the brain) and miliary TB (widespread infection).

The vaccine contains a weakened strain of TB bacteria, which builds up immunity and encourages the body to fight TB if infected with it without causing the disease itself. It gives protection in up to 80 per cent of people for up to 15 years.

Tuberculosis is the fifth leading cause of death in Kenya after pneumonia, malaria, cancer and HIV, and Nairobi became the first capital in the world to launch new child-friendly medicines for treating the disease. About 7,000 children in the country have TB, and the government spends about Sh2 billion annually to treat the disease.

A national survey last year showed that the number of Kenyans with TB has doubled since 2015, with more men than women being affected. There were 558 people with tuberculosis out of every 100,000, up from 233 per 100,000 in 2015. The report notes that there are at least 138,000 new infections every year, with more infections occurring in urban than rural areas.

Another worry is that the tuberculosis-causing bacterium, mycobacterium tuberculosis, is also becoming increasingly resistant to the antibiotics used to treat it

79%

Percentage of children aged 12 to 23 months who receive all basic vaccinations (BCG, measles, and three doses each of DPT and polio vaccine, excluding polio vaccine given at birth). The other two in every ten receive no vaccines, affecting, later on, the health indicators of the country, according to the 2014 Kenya Demographic Health Survey. Basic vaccination has improved only slightly since 2008, when 77 per cent of children received all of the basic vaccines.

Vaccination was slightly higher in urban than rural areas, at 83 per cent versus 77.

15

Number of children killed by measles every hour in 2015, or 367 every day, yet a safe and cost-effective vaccine is available. Vaccination resulted in a 79 per cent drop in measles deaths between 2000 and 2015 worldwide, and last year about 85 per cent of the world’s children received one dose of vaccine by their first birthday through routine health services, up from 73 per cent in 2000.