Quicker reaction to measles could have saved lives

Samoa and the Pacific region should have responded faster to a potential measles outbreak last year, given the situation in New Zealand at the time, the World Health Organisation (W.H.O.) has said.

In the recently released report of a virtual meeting on measles, rubella and polio eradication in May, W.H.O. said while the region reacted quickly after the measles outbreak was detected in Samoa, it was still not fast enough.

“Timeliness of these activities should be improved when risk of importation is high from countries outside the sub region, such as from New Zealand.”

In 2019, New Zealand recorded its first cases of a new measles outbreak in January and cases continued to climb throughout the year with a major peak occurring in mid-September.

By the end of December, there had been over 2000 cases with 756 hospitalisations, with two official outbreaks finally over by mid-January 2020. 

In September, the W.H.O. Strategic Advisory Group of Experts (S.A.G.E) sounded the alarm for Samoa, with member, Dr. Nicola Turner, saying the country is at “real risk of quite large amounts of disease.

“It only takes one measles virus to arrive on the plane and it would spread very rapidly through the Samoan community, within weeks and months, so Samoa is at high risk of a measles outbreak,” she said, on 02 September.

The following day, Director General of Health Leausa Dr. Take Naseri held a press conference to dispel fears of a local measles outbreak after a returning participant of a Methodist conference in New Zealand tested positive for measles.

“So far, Samoa does not have an outbreak of measles. That is a fact,” he said on 03 September, while there were several cases reported to surveillance, according to the Ministry of Health’s own data finally released mid-November.

Meeting in May, five months after the end of Samoa’s measles epidemic which lasted four months, infected 5707 people and killed at least 83 people (though the W.H.O. reports 86 in their meeting report), the sub regional committee on eliminating measles and rubella in the Pacific reflected on the regional health crisis that was.

The Committee members are Ulugia Dr. Tito Kamu, the head of the paediatrics unit at Tupua Tamasese Meaole Hospital, Tonga’s Dr. George Siaosi, Fiji’s Dr. Iliasapeci Vereti Tuibeqa, Dr. Jean-Paul Grangeon of Wallis and Futuna and Dr. Jean-Marc Ségalin from French Polynesia. 

They attributed the widespread infection rate of the 2019 measles epidemic in Samoa to the M.M.R. programme being suspended after the death of two infants who received an incorrectly mixed vaccine.

When the vaccine programme was restarted again nine months later, anti-vaccination messaging “may have contributed to decreased uptake of vaccination,” they said.

“Samoa’s 2019 experience demonstrates the rapid accumulation of susceptible children when an immunization programme is interrupted, as we are currently experiencing due to the coronavirus disease 2019 (COVID-19) outbreak.”

The high case fatality rate was partly a result of the health system being overwhelmed, which led to a massive international effort, but also by a shortage of Vitamin A, the committee said.

One problematic area was Samoa’s inability to test for measles using a polymerase chain reaction (P.C.R.) test, a capacity the country has only now acquired due to the COVID-19 pandemic.

Instead it sent samples to New Zealand for confirmation, which was dealing with its own measles outbreak and forwarded those samples to Regional Reference Laboratory in Australia. 

“The laboratory in New Zealand does not have reference laboratory status for measles and was overwhelmed by domestic specimens for measles testing,” the committee said. 

In total the Australian laboratory received 391 samples from 377 patients for measles testing (it is not clear how many of these were from Samoa).

As well as reviewing the situation, the committee also makes several recommendations for how to handle measles and rubella in the future by intensifying surveillance and catching up children who missed their vaccines due to the COVID-19 pandemic.

They also call on countries to review their vaccine schedule and change the timing of the second dose of the measles and rubella vaccine to be given to two year olds, instead of waiting until they turn five.

The same meeting included the sub regional committee on the elimination of polio, which reports that the Pacific Islands have successfully been maintaining polio-free status.

However, low levels of surveillance and patchy vaccine coverage means the outbreak risk is still high.

Despite the major success of officially eradicating wild polio across Africa, there continue to be new cases in Pakistan and Afghanistan which means the importation risk continues.

Immunisation coverage in four Pacific Islands, namely Samoa, Commonwealth of the Northern Mariana Islands, the Federated States of Micronesia, and the Marshall Islands has been “suboptimal” in 2019, the committee reports.

“Further, it was noted with concern that American Samoa had not submitted coverage data since 2011 despite repeated follow-up.”

In 2018 Samoa’s coverage rates for polio-containing vaccine fell dramatically from 71 per cent coverage to 31 per cent. 

In 2019 that was recovered only slightly by reaching 55 per cent. Official figures place that number closer to 70 per cent. 

Both years were the lowest coverage rates since 2008. What’s more, surveillance rates for acute flaccid paralysis (the clinical case definition for polio) is seriously lacking in the region and there are not enough stool samples being sent to reference laboratories for testing. 

The committee is urging the region to get polio coverage up to 90 per cent nationally, and for surveillance to radically improve. 

They also recommend countries to go over old medical records to look for possibly missed or unreported cases of acute flaccid paralysis, and to keep collecting stool samples from new cases “irrespective of current national and international travel restrictions.”

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