In recent years health officials have been concerned by the fact that communicable diseases have surged to the extent they could soon overtake non communicable diseases. To prevent this dangerous trend the Health Ministry has set in place several strategies. The Expanded National Immunisation Program (EPI) is one.
Total health care service free of charge is the goal of this Program, and services are free, as the cost of the vaccines and implementation is borne by the Ministry of Health. Yet, despite this offer, there still remain instances where mothers are reluctant to get their children immunised due to myths and false beliefs surrounding the vaccination program.
Consultant Epidemiologist, Ministry of Health Dr Deepa Gamage tells the Sunday Observer why immunising children is important and the adverse health effects on children and the general public if they are not immunised or are delayed until complications set in.
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Q. Now that the new school term has begun and children are likely to be exposed to various infectious and preventable diseases, a program like the Expanded Immunisation Program is timely. When was it first begun and by whom?
A. Vaccination of children has evolved over the years from the early 1960s and it has become a National Immunization Program to be delivered to children as an organized program through the public health care system. The initiation of the vaccination goes far back to the Smallpox vaccination and eventually, vaccination against Poliomyelitis, Diphtheria, Whooping cough, Tetanus and Tuberculosis (for prevention of milliary tuberculosis) were added, to reach all the children in the country through the EPI in 1978.
Thereafter, measles vaccination was added to the EPI schedule in 1985 when the country was at a high endemic stage. Rubella vaccination was then included for the reproductive-age women after the detection of high cases of Congenital Rubella Syndrome (CRS) and for babies, in 1996, with a view to prevent CRS cases.
Q. So the EPI program has benefited not only children but the public as well, and most importantly eliminated some of these infectious diseases. Can you mention some of them?
A. Considering the vaccine-preventable diseases, the last case of Poliomyelitis was reported in the country in 1993 but the country was certified polio-free or declared polio eliminated in 2014. Maternal and Neonatal Tetanus elimination status was achieved in 2016 with the last neonatal tetanus case in 2009. Measles elimination was targeted to be achieved by 2020 but the country has achieved endogenous measles elimination certification in 2019, a year ahead of the national targeted year. We are targeting the elimination of Rubella and CRS by this year with the last confirmed CRS case in 2014.
Q. Rubella is one of the diseases covered by the EPI. I understand it’s a disease that affects mostly newborns if contracted by the mother during pregnancy. What are the health impacts of rubella?
A. Rubella is a disease of fever and maculopapular rash, somewhat similar to measles but milder. But, if the country is endemic with rubella, it is likely that a woman can get rubella during pregnancy, in which case abortions can occur or a baby born with severe congenital abnormalities in the heart, eyes, ear and other organs in the body. Parents have to suffer throughout their life with social and health impacts due to this easily preventable disease through a vaccine.
Q. That is good to hear indeed. What factors brought about these remarkable achievements?
A. All these achievements were possible with the effective vaccination program delivered to the public in an equitable manner, with committed, motivated health care staff at the curative and preventive sectors to provide quality assured vaccination services and well-educated parents in the community to accept vaccines confidently at appropriate ages through the life cycle approach.
Q. To get a better understanding of the program tell us how it operated then. Did you have a team of doctors and nurses who carried out the immunisations?
A. The service delivery is usually through the public health care infrastructure of the Medical Officer of Health (MOH), in which Public Health Midwives and Public Health Inspectors are involved in field clinic and school clinic vaccinations, under the guidance of supervisory categories including Public Health Nursing Sisters and the MOH.
The Regional Epidemiologist at district level is working as a technically competent expert to provide guidance and monitor the Immunization Program and Vaccine-Preventable Diseases (VPD). In addition, immunization service provision is available in hospitals where Consultant Paediatricians are present.
Q. Have the immunisation schedule changed in recent years to achieve specific objectives? What are the most recent changes?
A. The National authority for the National Immunization Program is the Epidemiology Unit, Ministry of Health. The vaccination is considered as an effective prevention strategy for communicable diseases and delivered through the concept of life cycle approach in an equitable manner with easy access to all citizens. However, the immunization schedule is changed from time to time to achieve the program’s objectives. The addition of Live JE vaccination to the immunisation program in 2009, replacing the Measles-Rubella vaccine with Mumps-Measles-Rubella (MMR) vaccine in 2011, the injectable inactivated polio vaccine in 2015 are some of the recent changes done in the National Immunization Schedule. In addition, HPV vaccination has been started for girls in Grade 6 in school as a strategy of preventing cervical cancers.
Q. What is HPV vaccination and how is the vaccine acceptance in the school today?
A. It is given at the age of 10 for girls identified in Grade 6, to be vaccinated with 2 doses with a minimum of a six-month gap between the doses, for adequate immune development. The vaccine demand and acceptance are very high at the moment.
Q. What are the age groups that get the vaccination for these deadly diseases?
A. BCG vaccination is given at birth to prevent milliary Tuberculosis, and is usually continued at community-based immunisation clinics. At the age of two, four and six months Pentavalent vaccine (Hib,DPT,HepB) , and polio vaccination (OPV and IPV), at nine months MMR vaccine 1st dose, at 12 months Live JE vaccine, at 18 months DPT vaccine, at three years MMR 2nd dose and at five years DT vaccine are being given.
The HPV vaccine is given in school for girls in Grade 6 and adult Diphtheria-Tetanus vaccine booster dose is given at Grade 7. In preventing neonatal tetanus, the tetanus vaccination is given to pregnant women. This shows the life cycle approach in preventing deadly communicable diseases in the country.
Q. Are they free of charge?
A. Yes, all vaccines given through the National Immunization Schedule are free of charge. The government invests a significant amount in procuring vaccines, cold chain equipment and other logistics for vaccine implementation.
Q. How do you assure the quality of vaccines delivered through the National Immunization Schedule?
A. All the vaccines delivered through the National Immunization Program are World Health Organization prequalified vaccines, which means they are high quality assured vaccines. All vaccines are stored at expected temperature, ranging from 2-80C from manufacturing until it is administered to the child. For this purpose, a special refrigerator called Ice Lined Refrigerator (ILR) is provided to all MOH offices. Refrigerator temperature is closely monitored using minimum of 2 devices of a thermometer and special equipment called ‘Fridge Tag.’
All vaccine storing refrigerators throughout the country are supported with thermo-stabilizers and backup power supply generators to ensure the provision of uninterrupted power supply. All these measures ensure provision of high-quality vaccines through the National Immunization schedule.
Q. How do you maintain the quality of the vaccination services carried out in the MOH area?
A. All public health midwives, public health inspectors and nursing officers involved in the vaccination are well-trained and regularly updated on the procedure. The MOH examines each child before vaccination to identify eligibility and ensure safe vaccination.
All precautions are taken during the vaccination to minimize adverse effects following immunization. All vaccinated children and women are kept under observation for nearly 20-30 minutes in the same vaccination clinics to observe any adverse effects.
Q. With the emergence of the coronovirus disease (CoViD19) is the Epidemiology Unit and the Ministry of Health ready to face the challenge of controlling the disease and preventing its spread? Is there a possibility of preventing it through a vaccine in future?
A. Coronavirus disease started in China, and later experienced in other countries including one case in Sri Lanka, is a new disease condition in which the exact epidemiology of the disease is not fully explained. Based on the currently known scientific evidence it transmits from human to human through droplet infection.
Adhering to proper hand washing practices, respiratory etiquette, avoiding unnecessary handling of nose, mouth and eyes can prevent most of the transmission. The Epidemiology Unit and other Units of Quarantine, Disaster Management, Laboratories and hospitals are making maximum efforts of surveillance, early detection, diagnosis and treatment to face the global challenge.
However, still there is no vaccine available but some global efforts are ongoing to identify the possibility of developing a vaccine.
Q. Your message to all those vulnerable to preventable diseases that could be minimized through vaccination
A. It is the responsibility of all parents to vaccinate their children at the recommended appropriate age to prevent these deadly and debilitating vaccine-preventable diseases.
The Ministry of Health has taken all measures to ensure the provision of safe quality vaccines.
Easy access to services is assured through making immunization services available through community based Immunization clinics conducted by the MOH offices and in immunization clinics in hospitals.
Q. Your message to parents and the general public on preventing communicable diseases through immunisation?
A. Providing vaccination to children will not only protect their own child but other children as well in the community.
These deadly diseases are low in the country at the moment because of the vaccination. However as these diseases are still circulating in some other countries, and could enter the country by visitors carrying with them the live bacteria , it could endanger your child.