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An Important Milestone in Health-Related Efforts and Progress (Part II)

By :- Dr. Fikrejesus Amahazion

Editor’s note: this is the second article in a two-part series related to Eritrea’s national measles and rubella vaccination campaign.

The first article of this two-part series, published in the last edition of Eritrea Profile (Wednesday April 24), highlighted Eritrea’s commitment to its people and how the country’s long-run success in reducing child mortality has been rooted in a combination of several factors, including vaccination. The following article takes a closer look at the topic of vaccination, quickly reviews progress on measles and rubella, and briefly outlines the significance of vitamin A supplementation.

 A simple, cost-effective intervention

Human beings have benefited from vaccines for more than two centuries, while the history of inoculation can be traced back even further. Briefly, vaccines train the body’s immune system to create antibodies, just as it does when it is exposed to a disease. However, because vaccines contain only killed or weakened forms of germs like viruses or bacteria, they do not cause the disease or put one at risk of its complications.

Although closely linked and sometimes (incorrectly) used interchangeably, inoculation, vaccination, and immunization are actually distinct. Inoculation refers to implanting a disease agent, pathogen, or antigen in a person, animal, or plant to produce a disease for study or to stimulate resistance. On the other hand, in terms of vaccination and immunization, the former represents an action and the other is an effect. To be more precise, vaccination involves introducing a vaccine into the body in order to stimulate the body’s own immune system to protect the person against subsequent infection or disease. Moreover, vaccines are usually administered through needle injections, but can also be administered by mouth or sprayed into the nose. By contrast, immunization is the process by which a person becomes protected – or in other words, immune or resistant – against a disease through vaccination.

Routine childhood vaccination is an important health intervention that helps prevent serious illness, disability, and death in children caused by a range of dangerous diseases, including diphtheria, tetanus, pertussis (whooping cough), influenza, pneumonia, and as targeted in Eritrea’s current national campaign – measles and rubella. Today, around the world vaccination is widely recognized to be among the most simple, cost-effective, and successful ways to reduce child mortality and promote children’s general health and well-being.

Since its independence, Eritrea has made tremendous leaps in terms of national routine vaccine coverage. In 1991, there were only six vaccines available for children and the overall coverage rate stood at less than ten percent. (Some of the vaccines provided at independence included the Bacille Calmette-Guérin vaccine, along with the vaccines for diphtheria, tetanus, and pertussis, among others.) Over subsequent years, however, the national routine vaccination schedule in Eritrea steadily grew and it has progressed to provide young children with an array of vaccines that help to protect against a variety of serious or potentially fatal diseases.

Notably, Eritrea’s progress has been recognized and celebrated by regional and global organizations. For example, in November 2009, Eritrea garnered recognition from Gavi, a public-private global health partnership, for its outstanding performance in improving child health and immunization. One of 17 countries to be recognized at the ceremony held in Vietnam, Eritrea won the award for the “Best Immunization Performance”. In 2016 and 2017, Eritrea received back-to-back awards from UNICEF’s Eastern and Southern Africa Regional Office for effective vaccine management practices, while in September 2018 the country received another award from UNICEF in recognition of improvements in its national vaccine store.

As was highlighted in Part I of the present series, during a working visit to Eritrea in late 2021, Mohammed Malick Fall, UNICEF Regional Director for East and Southern Africa, explained that he was, “struck by the level of immunization [of children],” before going on to note that there, “are many advanced countries that have a hard time reaching [those coverage levels]” (Fall 2021).

At present, Eritrea administers a total of 14 vaccines to young children. Collectively, these protect against several dozen diseases and overall coverage rates are above 90 percent. Through the Ministry of Health and the National Immunization Programme, a total of around 300 health facilities in the country provide routine vaccination services six days per week. In addition, vaccination service is provided at about 450 outreach sites nationwide, while nomadic groups and those residing in extremely remote or difficult to reach areas receive service through mobile health units, barefoot doctors, and mass vaccination campaigns organized in close cooperation with community coordinators, volunteers, and local contacts.

 Targeting measles and rubella

Caused by a virus, measles is a highly transmissible, serious disease which usually results in a high fever and rash, but can also lead to blindness, encephalitis, or death. The disease remains one of the leading causes of death among young children globally, especially in the developing world (particularly in parts of Africa and Asia), but with outbreaks in developed countries also common.

The measles vaccine, first made available nearly 60 years ago, has proven to be an extremely safe, highly efficacious, and very inexpensive way to reduce measles incidence and mortality in many parts of the world. While the measles vaccine is available in monovalent formulation, it is commonly incorporated with other vaccines, thus allowing for shared delivery and administration costs. It is equally effective in the single or combined form. One of the vaccines that it is frequently combined with is the vaccine against rubella, a contagious viral infection that occurs most often in children and young adults. Rubella is the leading vaccine-preventable cause of birth defects, while rubella infection in pregnant women may cause fetal death or serious congenital defects.

Over the years, Eritrea has maintained high coverage for measles vaccination, making substantial progress toward measles elimination. (While Eritrea has made significant strides in moving towards measles elimination, it still must complete several steps in order to achieve formal certification of complete elimination.)

For many years, children in Eritrea were provided one dose of the measles vaccine at around nine to 12 months of age. While a child is considered adequately immunized against measles after receiving one dose of vaccine, in 2009 the WHO recommended that reaching all children with two doses of measles vaccine should be the standard for all national vaccination programs, in order to further decrease incidence and mortality from measles and make progress toward elimination. In particular, two doses help ensure immunity and prevent outbreaks, as a large percent of vaccinated children – perhaps up to approximately 15 percent – may fail to develop immunity after receiving the first dose.

In 2012, not long after the WHO’s global recommendations, Eritrea introduced a second dose of the measles vaccine into the national routine vaccination schedule. Since 2018, Eritrean children have received two doses of the combined measles-rubella vaccine. In 2022, measles vaccine coverage for the first and second doses was 93 and 85 percent, respectively, with both figures considerably higher the continental and global averages. Notably, the coverage for first dose is well above what it was in 2000 – 76 percent – and also nearly three times more than the figure in 1993, when it was about 34 percent.

In terms of incidence, in 2022 there were 28 reported measles cases and 19 cases of rubella nationwide, reflecting continued progress on prevention and control. Comparatively, around the world there were well over 205,000 measles cases and 18,000 rubella cases.

 Not to be overlooked: Vitamin A supplementation

As a part of the national measles and rubella vaccination campaign, Eritrea has also been conducting vitamin A supplementation. This is significant for several reasons.

Deficiency in vitamin A is the leading cause of preventable childhood blindness, can contribute to hearing loss, and increases the risk of death from common childhood illnesses such as diarrhea. According to the WHO, the highest rates of vitamin A deficiency are in Africa and South Asia. Importantly, vitamin A supplementation is a proven, low-cost intervention and has been shown to help maintain strong immune systems in children, reduce the incidence of diarrhoea and measles, prevent blindness and hearing loss, and significantly help reduce mortality.

Eritrea has recognized the benefits of this key child well-being and survival intervention, and over the years has taken steps to strengthen and expand its program for vitamin A supplementation. Hundreds of thousands of children nationwide have benefited from supplementation, ultimately improving their well-being and improving their chances of survival.

In 2021, coverage stood at approximately 81 percent – 80 percent is globally regarded as the effective coverage threshold needed to improve child survival – up from just 39 percent in 2001 and effectively non-existent at independence.

Crucially, despite these tangible steps forward, the country is working to make further progress by better targeting and monitoring the most vulnerable children and systematically identifying and addressing the obstacles to reaching them.

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