Women wait to immunize their children at the Kisugu Health Centre in Kampala, Uganda, where free vaccinations take place. The nurse in the foreground is Betty Makakeeto. Credit: Amy Fallon/IPS

By Amy Fallon
KAMPALA, Jun 29 2016 (IPS)

Patience*, a Ugandan maid, planned on taking her three-year-old son for polio immunization during the country’s mass campaigns a year ago, until her landlord’s wife told her a shocking myth.

“The medicine they are injecting them with means the boy when he’s an adult won’t be able to reproduce,” Patience, 32, recalled to IPS what she’d been informed. “She said: ‘Don’t even think about immunization’.”

Patience said that in her neighborhood, the Kyebando slum in Kampala, many families “lied to medical personnel” because they were “terrified” about what this woman had told them.

Earlier this year, the country’s president signed the Immunization Act 2016, prescribing fines, a jail term of six months or both, for parents who don’t vaccinate their children in the age bracket of five days to one year old.“They said the vaccines are made out of pigs, wild animals, (that) our children will behave like wild animals.” -- MP Huda Oleru

The Act also requires the production of an immunization card before admission to day care centres, pre-primary or primary education. It also aims to provide for compulsory immunization of women of reproductive age and other target groups against immunisable diseases.

According to the legislation, passed by Parliament last year, diseases for which immunization is compulsory include tuberculosis, whooping cough, tetanus, hepatitis B, polio and measles.

One in five African children still do not receive all of the most basic vaccines they need, including ones for three critical diseases—measles, rubella and neonatal tetanus – a report issued by WHO at the first ministerial on Immunization in Africa, held in Addis Ababa, Ethiopia, in February.

Uganda was ranked lowest in east Africa for immunization coverage, with one example being the country’s 2014 diphtheria-tetanus-pertussis (DTP3) coverage which was at 78 percent compared to DRC (80 percent) Kenya (81 percent), Tanzania (97 percent) and Rwanda (99 percent).

According to outgoing female MP Huda Oleru, who tabled the private member’s bill in 2011, the biggest obstacle to vaccination in Uganda was the 666 cult made up of more 500 members but “growing” across the country, who refuse to immunize their children.

“They said the vaccines are made out of pigs, wild animals, (that) our children will behave like wild animals,” Oleru told IPS.

Oleru is continuing talks with the groups in eastern Uganda, and said she hoped “in the long-term” they would come around.

But for now the law was the “easiest way” of getting them to immunize their children.

“When I entered Parliament (ten years ago), I realised that we didn’t have an immunisation law, and a law is guidance or directive and it guides us in areas of impunity,” said Oleru.

At least ten members of a Christian group were detained over refusing to vaccinate their children against polio, the Daily Monitor reported last month.

Dr. Henry Luzze, the deputy program manager of the Uganda National Expanded Programme on Immunization, told IPS the government was currently vaccinating against ten diseases. It had submitted an application to GAVI ((the Vaccine Alliance) and received approval to introduce the rotavirus vaccine for diarrhea in children, a “big problem”. They were also looking at introducing a rubella vaccine by 2018 and a second measles vaccination to be given at 18 months.

Measles were still a huge threat, after outbreaks last year in western Uganda, he said.

“We still have some districts and communities that are still below what we want in terms of coverage in the eastern part of the country, areas where there are very high hills and no transport,” said Dr Luze.

Children were also not being vaccinated due to shortages in a number of facilities at a district level, but through recent support from GAVI, Uganda was able to procure solar powered fridges to keep the vaccines in areas prone to power cuts.

The influx of refugees from Burundi, DRC and South Sudan, where immunization rates are low, pose another challenge to Uganda. Late last month at least three cases of yellow fever were confirmed here, with scores of cases suspected.

According to the new Act, “the government shall provide free vaccines and other related services to every Ugandan required to receive vaccination”.

Dr Luzze said the law was good as it was balanced and compels the government to “make sure all the vaccination services are in place”.

“After that, then you commit the parents or the caretakers to make sure all their children are vaccinated,” said Dr Luzze, claiming the legislation “empowers CSOs to challenge the government”, who could be taken to court over shortages.

But there has already been some criticism from Ugandans that the law is too harsh, and during a recent mass polio campaign, held in March, there were reports that about 2,000 children below the age of five missed out on immunizations in Karamoja, northeastern Uganda, according to the country’s Daily Monitor newspaper.

The Act also creates the establishment of an Immunization Fund, house by the ministry of health, to “purchase vaccines and related supplies, cold chains, and funding of immunization outreach activities”.

Sources will be made of up monies appropriate by Parliament for the fund and donations.

“GAVI has been supporting this country so much and they’re still giving, but the challenge is GAVI has its criteria,” said Oleru. “Soon we might become a middle-income country, then we shall not be eligible (for support) under GAVI.”

Luzze said he believed the law would be easy to enforce because “the president, the ministers, the parliamentarians, religious leaders” all supported it.

President Yoweri Museveni was “aggressive” about promoting immunization because he believes it saves “families from spending too much money and time caring for sick members”, among other reasons, said his spokesperson Lindah Nabusayi.

Dr Moses Byaruhanga, the director of medical and health services for Uganda’s police, told IPS the authorities would go on radio talk shows to talk about the law, but would be strict on it.

“Police will be able to find out if (parents) did not take their kids for immunization,” he said, adding health workers, local leaders and schools would be the eyes and ears of the community.

International immunization experts such as Mike McQuestion, director of sustainable immunization financing at Sabin Vaccine Institute in the US, have praised the new legislation as a “textbook example of good governance”.

“The way the Ugandans created this law was itself impressive,” he told IPS. “Several public institutions had to work together to write it, vet it and push it through.”

In late March, about two weeks after it emerged the law had passed, Patience had her son immunized against polio, during a door-to-door mass campaign.

“It was very easy, they just put a drop in the mouth, then a mark on the finger,” she said, adding it took only three minutes.

Patience admitted she had been “partly” worried about going to jail under the new law, and that was the reason she’d chosen to vaccinate her son. But she said the nurse had told her “you shouldn’t not vaccinate him because you’ll be arrested, but because he can get sick”.

“I think now he is free from becoming sick,” said Patience.

*Patience’s name was changed for personal reasons.

“In situations where there is a higher mortality and morbidity, people very often still see on a day to day basis the impact of vaccination.” Jos Vandelaer, UNICEF. Credit: Adil Siddiqi/IPS

By Lyndal Rowlands
UNITED NATIONS, Feb 5 2015 (IPS)

Measles remains one of the leading causes of death for young children worldwide, even though a safe vaccine is available.

Most of the 145,700 people who died from measles in 2013 were children under the age of five, according to the World Health Organization (WHO)."These kids face a double whammy, in that if they don’t get immunised and they fall sick their chance of getting treatment is also lower than an average kid.” -- Jos Vandelaer of UNICEF

However, immunisation has also saved many children from death and serious illness. The WHO estimates that 15.6 million deaths were prevented between 2000 and 2013, because of increased access to the measles vaccination.

Jos Vandelaer, prinicipal advisor on immunisations for UNICEF, the United Nations children’s agency, told IPS that the children most at risk of missing out on vaccinations are among the world’s most vulnerable and disadvantaged, including children from minority backgrounds and displaced or refugee children in temporary accommodation.

“These are the very same kids who also don’t have access to health care, to clean water, to hygiene, to school, and so on,” he said.

“So these kids face a double whammy, in that if they don’t get immunised and they fall sick their chance of getting treatment is also lower than an average kid.”

In light of the recent outbreak of measles in the United States, Vandelaer spoke to IPS about some of the differences in communicating the importance of vaccination in developed and developing countries.

“In situations where there is a higher mortality and morbidity, people very often still see on a day to day basis the impact of vaccination. If you still have a lot of measles around, people will understand that vaccinating the child will protect the child,” Vandelaer  explained.

“That is probably less visible in situations where you have higher coverage and the diseases are less prevalent. People start to see less of the benefit of immunisation, because they don’t see the disease anymore,” he said.

“What we start seeing, as has also been in the press here in the United States, or in some European countries, these are often the people who are higher educated who are having objections against immunisations, it is not a matter of not being informed, but it is a matter of being misinformed,” he said.

Vaccines protect the group not just individuals

Vandelaer also spoke about the importance of herd immunity.

Within any society there are always a small number of people who cannot be immunised, including the very young and children with compromised immune systems from cancer or other illnesses. These children rely on what is called herd immunity to protect them from vaccine-preventable illnesses.

As Vandelaer explained, “If you get above a certain threshold with immunisation, you protect a large number of kids, and if you do that and you manage to be above that threshold, you have enough children protected to make life for the virus difficult enough to find the few kids who are not protected.

“A virus will hop from one person to the next, but if a person is protected the virus can’t go any further. If you have enough of these people who are protected and the virus is hopping around and it hops onto a protected person, it can’t go any further,” he said

“When there are very few un-immunised children they are actually protected by the children around them. That is why it is important to vaccinate, not just to protect individuals, but also to protect the group.”

Elder explained that governments voice their concerns about the high prices of vaccines at the World Health Assembly every year.

Governments of the world’s poorest countries can access vaccines through the GAVI Vaccine Alliance, of which UNICEF is a member. These governments are required only to make a small copayment, and GAVI covers the rest of the cost, through donated funds.

However many of the world’s poorest people now live in middle-income countries, and their governments usually purchase vaccines directly from manufacturers, in a market shrouded in secrecy.

While compiling their latest report, MSF Access contacted governments and vaccine producing companies to ask for information about how much vaccines cost.

Elder said that none of the vaccine producing multinational corporations MSF Access contacted provided any data on how much they charged for vaccines and that they actually “[took] great lengths to conceal whatever price information possible”.

The companies did all tell MSF Access that they used a tiered pricing structure, so theoretically this should mean poorer countries pay less than richer countries to access vaccines.

Elder explained that one of the reasons MSF Access believes that vaccine prices should be made publicly available is because the data they did receive from governments did not necessarily reflect the tiered pricing structure that the vaccine manufacturers claim to use.

“When you actually look at the [limited] data, and look at the prices governments are paying vis-à-vis their economic level there isn’t this classic line,” Elder explained.

Another issue effecting vaccine supply is having a healthy market, preferably without monopoly or duopoly situations. MSF Access report that there is currently only one manufacturer (Serum Institute of India) who produce 80 percent of the supply of the measles vaccine and who are also the only WHO prequalified manufacturer of the MR vaccine (the combined measles and rubella vaccine).

This has actually resulted in a price increase for the MR vaccination, which the WHO now recommends as part of the basic vaccination package, and places a worryingly heavy reliance on a single manufacturer.

While UNICEF and the United States government both publish what they pay for vaccines, they are rare exceptions. Elder says that greater transparency is needed across the board so that taxpayers from the donor countries who support GAVI and middle income countries who buy their vaccines directly, know how much vaccines are costing their governments.

Edited by Kitty Stapp

Ali Khalil and his son, Diar, pose by the coffins they have just arranged for burial. Credit: Karlos Zurutuza/IPS

By Karlos Zurutuza
SEREKANIYE, Syria, Nov 3 2014 (IPS)

The walls of the Association for the Martyrs of Serekaniye are covered with the portraits of those fallen in combat in this northern Syrian town. Ali Khalil has buried everyone and each of them with the help of Diar, his 13-year-old son.

Inside this building west of Serekaniye, 680 kilometres northeast of Damascus, Khalil invites IPS to hear some of the stories behind the myriad of pictures. The first one is that of his brother, Abid.

“He dreamed of being a journalist but he was hit by a sniper in November 2012. He was the first one I buried, and I have done the same with the rest ever since,” recalls this former merchant in his late thirties, before resuming his account.

“These three arrived completely charred; this one was beheaded, the same as those two further up” … Khalil points with his finger at just half a dozen among more than a hundred portraits staring at infinity.“5.5 million children have been directly affected by the war [in Syria], one in ten has become a refugee in a neighbouring country and around 8,000 of the latter crossed the border without their parents” – UNICEF

It was precisely the death of his brother which led him to set up this committee to support the families of the deceased. He is one of the ten members in charge.

“Other than arranging the burial, we assist families with money, food or blankets for the winter,” explains Khalil. The aid, he adds, comes from the Kurdish provisional government in northern Syria

After the uprising of 2011 against the Syrian government, the country’s Kurds opted for a neutrality that has forced them into clashes with both government and opposition forces.

In July 2012 they took over the areas where they form a majority, in Syria’s north. Today they rule over three enclaves in the north: Afrin, Jazeera and Kobani, the latter being known worldwide for the brutal and still on-going six-week siege at the hands of the Islamic State.

Redur Xelil, spokesman for the YPG (Kurdish acronym for People’s Protection Units), the militia defending the territory, told IPS that after Kobani, the battle in Serekaniye has been the bloodiest front for the Kurds in Syria.

A burial in Serekaniye for fighters fallen in combat against ISIS. Credit: Qadir Agid

Mahmud Rashid, 37, also volunteers at the martyrs´ house. He has two sisters and nine brothers, “all of them fighting, including a 60-year-old one.” He adds, however, that one of them, Brahim, fell into the hands of the Islamic State five months ago, and that they have had no news from him ever since.

“His wife showed up four days ago to get help. We handed her clothes for her seven children, blankets and 10,000 Syrian pounds [about 48 euros],” Rashid told IPS.

“I will be a soldier”

The conversation is interrupted by the arrival of the truck carrying the last two coffins commissioned by the association. After they are taken into the room, Khalil and his son start to wrap them in the regular red cloth, to which they will add the yellow banner of the YPG and a crown of plastic flowers.

They proceed with the precision conferred by a two-year routine so it barely takes them more than ten minutes. Shrouding the bodies, Khalil explains, is “much more laborious.” But he´s not alone.

“Diar helps me with everything and does whatever is needed. We are hand in glove,” the volunteer explains proudly, posing his hand over his son’s shoulders. Khalil has another son, Rojdar, who is 11 but cannot join them because he suffers from chronic hepatitis and never leaves the house.

In a report on the impact of three years of war on the health of Syria’s children released this year, Save the Children warns of the serious deterioration of sanitary conditions in the country. According to Save the Children, 60 percent of hospitals in the country have been destroyed and the production of drugs has decreased by 70 percent.

To these figures has to be added the fact that half of the doctors in the country have left. Of the 2,500 that a city like Aleppo needs, only 36 remain, says Save the Children. With representation in 120 countries, it is calling for “urgent action” so that children receive basic vaccination.

Meanwhile, it is far from easy to get a word from Diar. “Why don´t you want to talk now,” Khalil asks his son. “Tell him how much you loved your uncle; tell him you would spend the day together at the Internet café.”

Diar admits he has not much to do other than helping his father. “A majority of the children have left the city and the few remaining don´t dare to leave home because of the fighting,” explains the boy, without looking up from the ground.

For those who left, reality is far from bearable either. As noted by UNICEF in its 2014 report titled Under Siege: The devastating impact on children of three years of conflict in Syria, 5.5 million children have been directly affected by the war, one in ten has become a refugee in a neighbouring country and around 8,000 of the latter crossed the border without their parents.

Other than the most visible effects, the psychological sequels are equally devastating: “Many Syrian children are in pure survival mode”, says UNICEF child protection specialist Jane MacPhail, who spends her days working with child refugees in Jordan. “They have seen the most terrible things and forget normal social and emotional responses.”

“Tell the journalist what you used to say during the days when the shelling lasted day and night: ‘You can throw as many bombs as you want but we will never leave’,” Khalil insists with his son, while the boy concentrates on carefully centring the crown of flowers on the second coffin.

Diar stands up only to say that he will join the ranks of the YPG as soon as he is 18. The war in Syria may be over after five years but that does not seem to matter to him.

“I will be a soldier,” Diar repeats, with his eyes still fixed on the ground. Until then, he says, he will help his father.

(Edited by Phil Harris)

A poster to promote rotavirus vaccination. Credit: Monde Kingsley Nfor/IPS.

By Monde Kingsley Nfor
YAOUNDÉ, May 7 2014 (IPS)

The growing number of child deaths from diarrhoea in Cameroon has necessitated the introduction of a new vaccine (RotaTeq) designed to protect babies under five against common types of rotaviruses that cause diarrhoea. But growing skepticism over new vaccines, and lack of potable water and proper hygiene could thwart such public health efforts, experts say.

“Diarrhoea is one of the top killers of children under five in Cameroon, responsible for more than 5,800 deaths in children under five yearly,” Desire Noulna of the Expanded Programme on Immunisation (EPI) told IPS.There is suspicion and mistrust of vaccines among different communities in Cameroon.

According to GAVI, a public-private alliance to boost immunisation, rotavirus kills more than 600 children every day in Africa, and thousands more are hospitalised or require clinic visits.

Globally, rotavirus is the most usual cause of severe gastroenteritis in children, accounting for an estimated 2.4 million hospital admissions and 527,000 deaths each year. About 85 percent of these deaths occur in developing countries, mainly in South Asia and sub-Saharan Africa.

In June 2009, based in large part on clinical trials in Africa that demonstrated vaccine efficacy in impoverished, high-mortality settings, the World Health Organisation (WHO) recommended that rotavirus vaccines be included in all countries’ national immunisation programmes.

Cameroon introduced the rotavirus vaccine last month after ten other countries in Africa: Botswana, The Gambia, Ghana, Malawi, Morocco, Ethiopia, Rwanda, Tanzania, South Africa, and Sudan.

According to WHO, South Africa, the first African country to introduce rotavirus vaccines into its national immunisation programme in 2009, experienced dramatic decreases of 54 to 69 percent in rotavirus hospitalisations in both rural and urban settings within two years.

In Ethiopia, the introduction of rotavirus vaccines is estimated to save 3,700 lives, and 800,000 dollars in household expenditures annually. In Ghana, rotavirus vaccines are predicted to save 1,554 lives annually, and 53 percent of treatment costs.

Cameroon will hold a national immunisation campaign in the coming months. But some experts argue that the sanitation problem in Cameroon presents a major challenge to the effectiveness of this vaccine.

“There are some neighbourhoods in our major cities that for months go without potable water. Even when supplied, the quality is very doubtful,” says Obed Fung, health expert at the Foretia Foundation that supports development in Cameroon.

According to the African Development Bank (ADB), only about 45 percent of the rural population has access to drinking water against 77 percent in urban areas. An estimated 13.5 percent of rural people have access to proper hygiene and sanitation compared to 17 percent in urban areas.

Women and girls shoulder the largest burden in collecting water; 15 percent of urban and 18 percent of rural populations have to rely on improved drinking water sources more than 30 minutes walk away. It is mostly girls and women who have to fetch the water.

“Poor access to water and sanitation could hinder the success of this campaign but it is important that we focus on water-borne illnesses especially diarrhoeal diseases and seek ways of curbing outbreaks,” Noulna said. “While the country may be facing water scarcity and poor hygiene, there is a need to avoid the worst case scenario of a sudden outbreak.”

But there is suspicion and mistrust of vaccines among different communities in Cameroon.

“The national immunisation programme in Cameroon now administers nine different vaccines for children and the public think that this treatment is exaggerated. It is always the case because they do not understand the public health risk of having just one victim with a viral attack,” Dr. Paul Onambele at the district hospital in capital Yaounde told IPS.

Rumours have been circulated that public health officials were administering vaccines to sterilise women, Onambele said.

A study by the EPI found that 33 percent of families are opposed to vaccination of children and pregnant women due to religious and traditional beliefs.

“These controversies over the efficacy, safety, and morality of immunisation have continued to impede vaccination efforts in Cameroon, most especially in the northern part of Cameroon which is greatly influenced by beliefs stemming from Nigerian communities against vaccination,” Onambele said.

Haman Alima, a nursing mother in a Yaounde neighbourhood says: “I grew up and we never used to be vaccinated but we are all fine. I only vaccinate my child because I cannot refuse while in the hospital.”

Such attitudes are dangerous. “Our country is in turbulent times with a drop in immunisation coverage, inequality in coverage among districts and cities, and most importantly, the recent resurgence of polio,” Clarisse Loe Loumou from GAVI told IPS.

According to EPI, 62 percent of the health centres do not involve local associations and NGOs in the promotion of vaccination.

However, GAVI and EPI intend to achieve a 90 percent level of involvement by increasing efforts already made by using civil society platforms to reach communities and give local people ownership over vaccination.