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Strong health systems, as well as immunization efforts, are essential for combating diseases around the world.
By Andrew Schroeder
Measles, a common childhood killer disease declared "eliminated" in many parts of the world, including the United States, Canada and Europe almost two decades ago, is now part of global health. Measles cases worldwide increased by nearly 300% in the first quarter of 2019 compared to the first quarter of 2018, according to surveillance data covering 190 countries released last week by the World Health Organization.
More than 112,000 cases would have started this year, compared to just over 28,000 from the beginning of 2018. This year was also marked by a significant gain over 2017. Even if the shocking levels of the mid-20th century Were not yet close, tens of millions of children were infected and millions died, the tendency to the occurrence of new measles infections seems to be inexorably and frustrating on the rise.
This trend places children under the age of 10, especially in poor and conflict-affected areas, at an increasingly preventable level of risk.
The global resurrection of the seas
One of the most common explanations in the media about the resurgence of measles is linked to a set of beliefs encouraging reluctance to continue childhood vaccinations. Earlier this year, WHO described this emerging reluctance as one of the "top ten" global threats to health.
The spread of misinformation about child immunization is causing a wave of what the World Health Organization calls "vaccine hesitancy." ". Over time, the downward trend of implementing evidence-based public health recommendations may threaten effective long-standing practices in child health since the mid-20th century.
In some areas of California, New York and Washington, for example, it has been proven that relatively small epidemics have been correlated with reduced immunization rates due to poor immunization information combined with poor immunization. new introduction of the virus, often through travelers.
However, how to explain the resurgence of the disease on a global scale? There is no doubt that the world must remain vigilant about the possibility that the consensus around childhood immunization will be compromised over time by "growing hesitation about vaccines". However, a large number of people in the world still do not have access to the vaccines they both want. and need.
FISH, CONFLICT AND HEALTH SYSTEMS
In addition to the effect of reluctance to immunize, there is no need to look beyond WHO-specific data on the location and trends of measles growth.
Almost all of the huge increase in the number of measles cases from 2017 until the beginning of this year is attributable to a few places. This year, nearly two thirds of all measles cases reported worldwide are attributable to only two countries: Ukraine and Madagascar. These two countries are very enlightening as to the real reasons why we should be paying attention to measles as a "canary in the mine" in the face of the underlying weaknesses of public health systems.
Let's start with Ukraine, which may seem, at first glance, the most confusing.
Why would a middle-income country located on the outskirts of Europe, endowed with a historically reliable and almost universal public health system, suddenly become a kind of poster for the unrestrained spread of diseases? Infectious Infants for whom vaccination exists? The answer is quite simple: conflict.
Before 2014, Ukraine maintained a measles vaccination rate of 95%, generally considered the ideal reference level for herd immunity. Then a conflict broke out between Ukraine and Russia. As a result, the budget of the Ukrainian Ministry of Health was frozen and measles vaccine purchases virtually ceased until the end of 2015. In 2016, the vaccination rate in Ukraine dropped to 41%, one of lowest rates on the planet.
In the following years, the vaccination rate in Ukraine has returned to a level close to its pre-conflict levels, with coverage of about 91% achieved last year. But the damage was done. A multi-year cohort of Ukrainian children has lost immunity to the disease. Combined with widespread disruption of the primary health care system and the physical effects of conflict in many communities, measles quickly took root and began to spread.
Part of the measles migration from the Ukrainian epidemic has apparently gone international, with cases in New York, Israel and elsewhere being directly attributed to reported cases of travelers from Ukraine.
Elsewhere, from Yemen to Nigeria, one can also detect the extremely negative impact of conflict on the capabilities of basic health systems and rates of measles infection. Lessons from the measles epidemic in Ukraine, as in the case of these other countries, are not only that it does not take much to fundamentally disrupt a functioning health system and produce an otherwise preventable epidemic. Disruptions in health systems in a country, due to high levels of global mobility due to air transport, can quickly be felt in many parts of the world.
The danger of poor health care
The current situation in Madagascar, to which Direct Relief continues to react with local partners, including the Ministry of Health, is very different from that in Ukraine. Madagascar is one of the least developed countries with an index of human development (HDI) ranking 161 out of 189 countries. Its public health budget has been under constant pressure for many years simply because of the trade-offs needed to manage the multiple emerging threats to the health of rapidly changing communities. As a result, the measles immunization rate in Madagascar has fallen to one of the lowest in the world, at 58%.
Vaccination is not the only element of the health system that increases the risk of measles contagion. Poor nutrition leads to a weakening of the immune system of children and a decrease in their ability to resist infections. This is one of the main reasons why Direct Relief helped distribute vitamin A in high doses to strengthen the immune system of vaccinated and unvaccinated children.
The weakness of primary care systems also presents difficulties in ensuring that all children are regularly examined by a doctor and that suspected cases of measles are promptly identified and treated. Combined with low immunization rates and persistent under-nutrition, inadequate primary health care and disease surveillance can allow cases to multiply well before it is possible to identify and d & # 39; intervene.
The kind that triggers an outbreak
Measles is well suited to epidemics given these weaknesses in the system. The rate of measles reproduction, the number used by epidemiologists to measure the likelihood that an infected person will infect other people in the absence of countermeasures, is very high.
A systematic review of The Lancet in 2017 confirmed an average reproductive rate of 18, with considerable observed variance based on contextual factors, including poverty and health system vigor. This means that a single measles infection can usually produce at least 18 new infections in the absence of corrective measures. Similarly, measles is contagious for 7 days before the person becomes symptomatic, which means that infections can easily spread without being detected. This impressive rate of transmission, including the challenges of early detection, is constantly threatening to transform measles epidemics into exponentially growing epidemics.
In addition to defending the fundamental value of public health and the practice of mbad immunization, we still have a long way to go to achieve a truly universal access to vaccines, as well as the related interventions of the United States. health systems that maximize the chances of children's resistance to infectious diseases. This lack of equitable access threatens especially the most vulnerable of these countries. But it also threatens communities far from their borders, given the fluidity of trade and global travel.
The weakness of primary health systems, whether born of conflict, poverty or, as often, a combination of both, remains one of the greatest threats to human health.
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