The wise adage, “those who cannot remember the past are condemned to repeat it”, seems to be an all encompassing statement. If we learn nothing from our initial experience, old crises may potentially resurface and once again manifest. With medical maladies however, the fall out from ignorance is often as deadly as it is devastating.
Trouble is, as humans eradicate diseases, it would appear, so too are the memories of its severity and past prevalence.
In kind, the theme for 2019 immunisation efforts is ‘Protected together: Vaccines Work’, a key global campaign aimed at re-focusing attention on vaccination and its absolute necessity in ensuring safer immunised communities world-wide.
With an impressive high vaccine coverage of an estimated 98 percent administered to the populace, Maldives sets a vivid example as a proponent of health care safety, as we have seen through its many years, the eradication of dangerous diseases such as Poliomyelitis, Diphtheria, Neonatal Tetanus, and recently, even Measles.
However, the alarming growth of vaccine hesitancy - a term used to describe the hysteria surrounding vaccines, the reluctance and even refusal to get vaccinated or immunise children - was identified by the World Health Organisation (WHO) as one of the key threats to global health of 2019. As it threatens the number of immunisation coverage worldwide, it thereby puts communities and countries at the risk of dangerous outbreaks and epidemics, and possesses the potential to cause global pandemics.
According to WHO, vaccine hesitancy threatens to reverse the progress made in tackling vaccine-preventable diseases. Revealing that vaccination currently prevents 2-3 million deaths a year, WHO states a further 1.5 million deaths may be avoided if global coverage of vaccinations improved, making vaccines one of the most cost-effective ways of avoiding diseases.
Meanwhile, vaccine hesitancy has already resulted in the resurgence of previously and almost eradicated diseases in countries around the world. Measles cases, for example, increased by 30 percent world-wide, according to WHO, albeit with the disclaimer stating that all cases could not be attributed to vaccine hesitancy.
A vaccines advisory group to WHO identified that “complacency, inconvenience in accessing vaccines and lack of confidence are key reasons underlying hesitancy”.
The issue poses a significant threat to Maldives as well, where, through the circulation of misinformation based on anecdotal ‘evidence’ on social media or via person to person, the vaccine controversy argument is already rampant.
According to the Maldives Demographic Health Survey conducted in 2016 - 2017, based on the vaccination cards and information provided by mothers in the survey, it was found that 77 percent of children under two years received all basic vaccines (a drastic drop from 93 percent in 2009), whereas 8 percent did not receive any vaccines.
In recognition of the grave threat poised to public health care, UNICEF, Health Protection Agency (HPA), Ministry of Health, WHO, doctors and health care providers launched the social media campaign #VaccinesWork, where information is provided readily to the public to invite fact-based discourse on immunisation.
The hashtag is also part of a global initiative to raise money to fund immunisation efforts through the new advocacy partnership between UNICEF, WHO, Gavi, the Vaccine Alliance, and the Bill and Melinda Gates Foundation where, for every like, reaction or share of posts under #VaccinesWork, the foundation will donate USD 1 to UNICEF.
Moreover, Ministry of Health initiated a forum on social media under the moniker of Immunisation.mv, which makes vaccine-relevant informative videos (both originally produced and gathered internationally), reports and news articles accessible to the public.
In an exclusive interview with The Edition, UNICEF Maldives Programme Specialist for Health and Nutrition Shahula Ahmed revealed that the key messages UNICEF will be prioritising for awareness in in 2019 are ‘vaccines are safe’ and ‘vaccines work’, elaborating on the rigorous scientific processes vaccines go through before being approved for use.
According to the leading national public health institute of the United States, Centre for Disease Control and Prevention (CDC), the general development cycle of a vaccine includes stages such as:
- Exploratory stage
- Pre-clinical stage
- Clinical development
- Regulatory review and approval
- Quality control
The CDC describes Clinical development as a “three phase process”, the first of which involves small groups of people receiving the trial vaccine, followed by the administration of vaccine to people identified as having similar characteristics (such as age and physical health) to those for whom the new vaccine is intended. In the final stage, it states, “the vaccine is given to thousands of people and tested for efficacy and safety. Many vaccines undergo Phase IV; formal ongoing studies after the vaccine is approved and licensed.
However, with the advent of social media and the internet, the voices of those advocating for the anti-vaccine movement grow louder in opposition.
Shahula observed that, although the entire scientific community, academia, doctors and health care providers all advocate for vaccination, the pushback went ‘viral’ because, “a lot of times on social media, without actual proof or scientific backing, if you have an opinion and you add some anecdotal links to your life which you feel correlate, a person reading it presumes it is fact”.
She noted that the vaccine hesitancy is especially fuelled when well known public figures and celebrities express sentiments against vaccination, creating and adding to existing doubts.
“We are living in a fact-resistant world, that sets a dangerous precedent, because it is happening here in Maldives as well,” asserted Shahula.
Testament to Shahula’s claim, vicious arguments have sparked online recently across Maldivian Twitter circles with anti-vaccine proponents adamantly stating their claims. Certain local health bloggers have also begun advocating against vaccinations as well.
Although various different channels corroborate the existence of anti-vaccine groups amongst the general populace, official statistics pertaining to any such groups are not available.
However, experts ascribe much of the fear surrounding vaccines to their alleged link with autism, while controversy is particularly levelled against the Measles, Mumps and Rubella (MMR) vaccine.
In 1998, Andrew Wakefield published a case study in the medical journal the Lancet, suggesting that the MMR vaccine may predispose children to behavioural regression and development disorders. The ultimately retracted study received publicity despite the fact that Wakefield’s sample size consisted of only 12 young males. According to National Centre for Biotechnology Information (NCBI), the study was uncontrolled in design, and the conclusion speculative in nature.
A series of studies followed, but the most damning counter argument was presented in an investigation by the name of ‘Measles, Mumps, Rubella Vaccination and Autism: A Nationwide Cohort Study’ published in the Annals of Internal Medicine, where researchers studied the connection between the MMR vaccine and autism in a nationwide cohort of all children born in Denmark to Danish-born mothers from 1999 to 2010. Studying kids from age one through the end of August 2013, they examined data on 657,461 children, of which 6,517 were diagnosed with autism.
The examination strongly supported that MMR vaccination does not cause autism, even in highly susceptible kids - who have siblings with the disorder. Specifically, the results of the study stated that “no increased risk for autism after MMR vaccination was consistently observed in subgroups of children defined according to sibling history of autism, autism risk factors (based on a disease risk score) or other childhood vaccinations, or during specified time periods after vaccination”.
Investigations into Wakefield’s original paper revealed that he had distorted the data and acted unethically. His medical license was revoked, and his study has since been debunked multiple times. Despite this, he is hailed as an activist and his paper is cited by anti-vaccine groups to this day.
Consultant in Paediatrics at Medica Hospital Dr Nazla Musthafa affirmed in an interview that contrary to anti-vaccine beliefs, “It has been proven multiple times there’s no link between vaccines and autism. If you don’t vaccinate, you’re more likely to develop issues; Measles is a disease that can cause brain swelling, brain infection, or possibly permanent brain damage.”
The doctor highlighted that the timing when most parents recognise signs of autism being exhibited coincides with the time when vaccines are administered. However, she added that as autism is a development disorder, with the proper know-how parents could identify it sooner by noting “little differences between your child from other children. For example, the child may not make eye contact”.
It is a well-documented psychological fallacy that correlation between two variables implies causation between the two variables. Dr Nazla emphatically stated that there are multiple scientific research done that proves definitively that there are no links between vaccination and autism.
Senior Consultant in Paediatrics and Head of Department of Child Health at Indira Gandhi Memorial Hospital (IGMH) Dr Niyasha Ibrahim elaborated, “MMR is given after 1 year of age, in some countries directly at 1 year of age, but in Maldives at 18 months of age. You have autism features that are exhibited before 1 year of age. It is just a matter of awareness of parents and health care providers to detect autism”.
Infact, “because there is more awareness, the autism detection rate is becoming better in Maldives”, the doctor clarified.
National Autistic Society of United Kingdom attested their position that it is “‘clear that there is no link between autism and MMR vaccine”’, as evident from a comprehensive review named ‘Vaccines are not associated with autism: An evidence-based meta-analysis of case-control and cohort studies’, which they provided online of all available studies on the disproven causal links between autism and vaccines in 2014, based on data from more than 1.25 million children.
Regardless of the overwhelming evidence that most life-saving vaccines are safe, the controversial argument against immunisation surely fails to account for the numerous lives saved by vaccines.
Dr. Niyasha stated, “Maldivians today are growing up without seeing a single case of Poliomyelitis in their lives, because we have not had a single case of Poliomyelitis in 35 years. Some of the older generations, aged 60 or 70 years old, have witnessed cases of Poliomyelitis here, they witnessed Diphtheria, Neonatal Tetanus and other diseases that no one even remembers now.”.
This in itself, may potentially be a leading cause of contention surrounding vaccination.
Following the obsolescence of an increasing number of dangerous diseases through the advent of immunisation, the current populace is afforded the privilege of living without concerning themselves about the severity of such illnesses. This it turn, gives rise to complacency, negligence and even ignorance.
In 1974, Japan had a highm 80 percent coverage rate for whooping cough vaccines. With only 393 cases of whooping cough and zero-related deaths in the year, the country came close to eradication. However, complacency set in and by 1979, only 10 percent of children were vaccinated, resulting in 13,000 cases and 41 related deaths that year. Recognising the threat, Japan reinvigorated efforts to vaccinate, and disease rates dropped again.
On the matter in Maldives, Dr Niyasha emphasised, “People are not seeing the diseases, that is why they can’t even imagine what happens when these diseases are around”.
Before the introduction of the measles vaccine in 1963, major epidemics occurred every 2-3 years and caused an estimated 2.6 million deaths each year. With the availability of safe, effective and affordable vaccines, the number of deaths dropped by 80 percent in less than two decades.
However, currently, there is an alarming increase in measles cases worldwide, even in countries where it was eliminated - or were close to doing so. Several countries such as Brazil, Madagascar, the Philippines and Ukraine experienced outbreaks in the previous two years, as did in countries such as the United States, where measles was previously eradicated.
Over 100,000 people succumbed to measles in 2017, threatening to undo decades of progress, even in countries where the vaccines is available.
Describing the contagious nature of measles Dr. Nazla said, “if someone afflicted with it were in a room and then they leave, for two hours it will be suspended in the air. Measles, chicken pox and tuberculosis are the three most contagious diseases. They are more contagious than influenza, so even if you travel in the same flight, you might contract it”.
Hence, though WHO recognised Maldives in 2017 as one of the first countries in the WHO South East Asia Region to have successfully eliminated measles, this is not by any means a reason for complacency.
“For a disease to be eliminated, a high percentage of vaccine coverage for the entire country is necessary—at least over 90 percent. So if you have a 90 percent coverage of vaccines for measles, that would be the only way to rid the country of the disease. Then even the 10 percent who are not vaccinated would be protected through herd immunity”, offered Dr Niyasha.
Herd immunity is a form of indirect immunisation where, when a certain percentage of the populace are vaccinated, they prevent the infectious disease from spreading so that even individuals that are not - or cannot be (such as newborn babies, or individuals with compromised immune systems) - vaccinated gain a measure of protection. Those that are vaccinated essentially acts as a protective barrier around those that are not.
Conversely, if the number of people vaccinated were to falter (such as the case seen world-wide and according to the DHS survey, in Maldives as well) herd immunity would not be achieved and such diseases would again become commonplace.
Dr Niyasha linked the growth of the anti-vaccine movement everywhere with the increasing potential for the resurgence of many vaccine-avoidable diseases.
“If we continue on this trajectory, these diseases will become common. We can observe this in foreign countries as well; there was a big measles outbreak in New Zealand recently, and previously, there were measles and diphtheria outbreaks in US and European countries. This is because anti-vaccine groups are rising up and many children are unvaccinated”.
With the amount of congestion, the overcrowding crisis and tourist arrivals in the millions, it stands to reason that Maldives is particularly vulnerable as a potential hotbed for viral infections if the percentage of immunisation were to drop.
“Previously, people were living in small isolated islands without a lot of contact but that has changed” said the doctor. “Now we have outbreaks of diseases such as influenza, diarrhoea and dengue all the time. If vaccination levels drop, we are very susceptible to these diseases”.
Immigration and the booming travel sector further raise risk, as foreigners from countries with lower vaccine rates may interact very closely with Maldivian communities, which can result in imported diseases.
“We are not safe,” said Dr. Niyasha. “We get people coming from other countries as tourists and as labourers. We also travel a lot. Many Maldivians go to countries where the diseases are endemic. Measles is not eradicated in Sri Lanka or India. Pakistan and Afghanistan are countries where polio is not eradicated, and when Maldivians go on Hajj and Umrah, they might contract diseases from people who hail from these countries as well”.
While anti-vaccine proponents often proclaim that it is their individual right to exercise whether to vaccinate or not, it is a failure to comprehend that not only do they put themselves at risk, but also their children, entire families and communities.
“The right becomes quite blurred as it impacts other children, stressed Shahula. “By exercising your right to not vaccinate, the child’s right to education is jeopardised as in classrooms with other children, they will also become exposed”.
“The fundamental right to keep your child healthy and safe should be considered very holistically. By vaccinating, you are ensuring that the child is protected from harmful illnesses, as is the right of the child”, she said.
Dr Nazla added, “It is the right of the other person that they should have a safe environment and it is critical for them. So even if a baby is born in the same house and they cannot be vaccinated yet, it is the right of the baby to be protected. An innocent person is put at risk because someone else decides to not be vaccinated. Isn’t it the right of the others that the community protects them?”
With the 2019 World Immunisation Week, it is a key objective of the campaign for UNICEF to demand governments to take action to provide equal access to life-saving immunisation to fulfil the right of every child to health, in line with the international law on childhood known as the Convention on the Rights of the Child.
Governments world-wide have recognised the threat of vaccination levels dropping and are taking countermeasures to enforce immunisation, for instance, Germany now imposes fines of €2,500 for failure to vaccinate children, teachers and healthcare professionals.
In Maldives, it is mandatory for a child to be vaccinated - unless a doctor’s order specifies that they have a contraindication to vaccines - for enrolment into grade one of primary school.
Health workers remain the most trusted advisor and influencer of vaccination decisions, and they must be supported to provide trusted, credible information on vaccines.
With the campaigns launched in 2019 World Immunisation Week, Maldivian health workers are all urging the populace to learn about the absolute importance of vaccination and engage in fact-based discourse on immunisation from credible sources rather than spread misinformation on social media.
While outbreaks are on the rise elsewhere, Shahula emphatically stated, "We do not have to wait for such an unfortunate thing to happen to our country”.
Although Maldives is fortunate to have as high a vaccine coverage as it does, its aforementioned vulnerabilities pose a perilous situation if that coverage were to dwindle.
As surmised by a warning from Dr Niyasha: “There will come a day, if we continue on this trajectory, that these diseases will become common”.
It is quite revealing that all the evidence leads to the same premise agreed upon by the three interviewed health workers; that the situation is dire, and if nothing were to be done, nationwide catastrophe would not be just plausible, but an inevitability.