Measles epidemic continues in Sri Lanka due to poor health and social conditions
18 April 2000
A measles outbreak that started in Sri Lanka last September is continuing and spreading, reaching epidemic proportions in the most impoverished areas. Officially, about 6,000 cases have been reported, resulting in several deaths, but doctors and health officials insist that the real casualty rates are far greater.
Measles is a preventable disease, largely eradicated in countries with comprehensive vaccination programs. But in Sri Lanka, poor living conditions and deteriorating health and sanitation facilities have combined to cause a contagion. This is aggravating an already festering situation produced by outbreaks of malaria, dengue fever, hepatitis-A, leptospirosis, cholera and other diarrheal diseases.
Up to the end of the third week of February, 5,915 measles cases were reported to the Health Department's Epidemiological Unit. According to one of the Unit's senior officers, the numbers may be several times higher. Most patients admitted to government hospitals with notifiable diseases like measles are not reported to the Unit or Medical Officers of Health (MOHs) due to government doctors' increased workloads and the lack of any proper guidance for them to do so.
In addition, the statistics do not count people who use indigenous medicine, obtain private health care or fail to seek any treatment. And cases are not reported at all from the northern and eastern provinces because of the war against Tamil separatists. Other medical workers told the WSWS that lack of funds and official indifference are preventing accurate reporting of death rates where patients die from complications linked to measles.
Nearly 2,000 measles cases have been reported from the capital, Colombo, which is the most densely populated region, where many live without basic sanitary facilities. Since measles is a highly contagious disease, spreading by droplets from person to person, most cases have emerged from overcrowded shanties, slums, lodges and dormitory-style rooms that lack proper sanitation and ventilation. Colombo has the highest population density—3,453 persons per square kilometre compared to the national average of 288.
High infection rates have also been reported in Sabaragamuwa, Northwestern and Uva provinces, as well as Mannar district—a southwestern border area of the war-torn north—which has several war refugee camps.
Measles can cause death and severe disability. Globally, the disease kills in 10 percent of cases, according to the World Health Organisation (WHO). Among children who survive, the results include blindness, deafness, brain and lung damage, and stunted growth and development.Vaccination crisis
Where countries have well-developed and planned vaccination programs, measles outbreaks are short-lived. In Sri Lanka, however, about 35,000 babies are born annually who are not vaccinated. This represents 10 percent of births, pediatrician Dr. Sujeeva Amarasena said at a recent public lecture.
Moreover, the national average figures mask the even lower rates in poorer regions. In some provincial health service areas, the official vaccination rate for nine-month-old infants falls as low as 55 percent. A recent Epidemiological Unit survey revealed that the vaccination coverage in the Colombo urban area is just 84 percent.
No system of follow-up vaccination exists, even though protection is only partial with a single dose at the age of nine months. The Epidemiological Unit recommends a second vaccination dose before the age of 10. No outbreak-response immunisation (ORI) programs have been introduced in Sri Lanka either. WHO research shows that ORI is effective in ending measles outbreaks, preventing high morbidity and minimising complications such as pneumonia and diarrhea.
There is also a vaccine with proven effectiveness against measles, mumps and rubella. But in Sri Lanka it is only available to the rich who can afford to buy doses from the private sector for 435 rupees ($US7) each.
Many adolescents and adults are vulnerable in Sri Lanka because vaccination of infants only began in 1984, with coverage beginning at 20 percent and then spreading very slowly. The current epidemic has affected a large number of teenagers. According to reports, scores of children could not sit for General Certificate of Education exams due to measles.
A significant proportion of vaccinated people have also caught the infection. Some doctors who talked to WSWS raised suspicions about a vaccination failure. Epidemiological Unit officials said a refrigeration disruption due to power failures, transport problems and bad storage conditions could have led to vaccine failure in some cases. (To ensure quality, the vaccine must be kept at a certain temperature from manufacture to administration.)
Medical Officers of Health have started random vaccination programs among low-income families who live in shanties and slums. They have not been provided with enough vaccines to carry out genuine vaccination programs island-wide, however.Health institutions spread the disease
Combating a contagious disease like measles is more difficult since most government hospitals in Sri Lanka do not have facilities for isolating the patients with infectious diseases and separate staff to take care of them. This has led to cross infections in the overcrowded wards.
These conditions are causing complications such as encephalitis, pneumonia, diarrhea and conjunctivitis. Most of the health institutions lack the necessary antibiotics and other drugs to treat patients, as well as investigation facilities such as laboratory testing, X-rays and ECG.
Colombo's Infectious Disease Hospital (IDH) is the only hospital reserved for patients with infectious diseases. It has only two wards for measles patients, each with 15 beds—far too few to cope with the present epidemic. “When the specific wards are over-crowded patients are sent to some other wards,” one IDH nursing officer said.
The hospital illustrates how recent health cuts have affected the public health institutions. A nursing officer explained: “We don't have enough medical investigation facilities and essential drugs. Even a small investigation like X-ray and ECG is not available. We have not received the measles antibody test results sent to the Medical Research Institute. We lack facilities to protect ourselves from infectious diseases. But we have to face epidemics, one after another. Earlier it was cholera and hepatitis-A and now it is measles.
“If an inward patient is in a bad condition he should be transferred to a hospital with more facilities. But if the ambulance driver goes on leave or the only ambulance breaks down we have to arrange an ambulance from a nearby hospital, so it takes a lot of time to transport the critically-ill patients.”
The WHO reports that 0.9 million people die from measles each year around the world. Yet only a few deaths have been reported this time in Sri Lanka. None of the patients who die from encephalitis, pneumonia and diarrhea are examined to investigate a link to measles. Even where a patient had an earlier history of measles, the possible link is ignored because there are no proper investigation facilities.
One doctor working at the National Hospital told the WSWS: “We had two patients in January with clinical evidence of measles. One girl was admitted with a history of bronchitis following measles and another 18-year-old boy with high fever and lower respiratory tract infection following recovery from measles. In both these cases we wanted to confirm whether these were due to complications of measles. We sent blood samples to Medical Research Institute (MRI) for measles antibody tests. A month later we had not received the results.”
An Epidemiological Unit officer said: “The dismantling of the health system has jumbled everything. The notification of infectious diseases has dwindled and been jeopardised. Patients who die from possible complications of measles are not properly investigated.”
Measles antibody blood tests can confirm the disease better than diagnosing it clinically but these tests cost 900 rupees ($US13) in the private sector. The MRI has failed to issue the results of requested blood tests. When the WSWS met the MRI director and asked why the test results were not issued, she refused to answer saying that a recent government circular had instructed officials not to give information to the media. Another person working in the MRI, however, said that 1,290 out of the 1,790 measles tests during the last quarter of last year were positive.
Measles can be eliminated, according to the WHO. It advocates the following measures to reduce the spread of the disease:
* Lower the vaccination age from nine months to six, with a second dose after nine months, during outbreaks.
* Check the immunisation status of all children attending any health facility.
* Ensure adequate measles immunisation status among hospitalised patients.
* Isolate fever and rash cases upon arrival to health facilities.
None of these strategies have been introduced in Sri Lanka and instead the social and health conditions are worsening. The resulting epidemic is an indictment of the private profit system and the six years of rule by the Peoples Alliance government.