EC Health dismisses study highlighting NHI vaccination failures

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Immunisation rates at a National Health Insurance pilot project in the Eastern Cape are considerably below targets, mainly because of stock-outs, and indicate inadequate provision of basic primary care, finds a study in the SA Medical Journal. EC Health has dismissed the findings.

The study monitored the vaccinations of 470 children between April 2013 and May 2015 in the OR Tambo district. The 470 children were born at Zithulele Hospital in Mqanduli and 10 clinics, and homes in the area. The OR Tambo district is one of the pilot districts for the NHI project, aimed at providing essential healthcare to all citizens despite their socio-economic status.

The researchers write: “Immunisation coverage of children is a cornerstone of primary healthcare (PHC) and an important gauge of the quality of the health service in a country, but is also a good indicator of how far a country is from preventable disease outbreaks, such as the measles outbreak that occurred in South Africa in 2010.

“SA’s immunisation schedule has been significantly expanded since 1994, with the recent addition of the pneumococcal (PCV) and rotavirus (RV) vaccines in 2009, and is the most comprehensive in Africa.

“As part of the 2010 ‘Re-engineering of Primary Health Care’ policy, the South African National Department of Health (NDoH)has emphasised the importance of doing the basics of PHC right. However, there has been disagreement about how well the schedule has been implemented on the ground and the NDoH has disputed low WHO/UNICEF immunisation coverage figures.

“After the 2011 census provided revised estimates of the number of children under
the age of 1 year, the NDoH immunisation indicators were adjusted downwards, but were still significantly higher that WHO/UNICEF estimates. The quality of NDoH immunisation data gathered through the District Health Information System (DHIS) is poor and apart from one study there are limited data on immunisation coverage in rural areas of SA and, to the best of our knowledge, nothing about coverage in rural Eastern Cape.

“In this study we assessed immunisation coverage of the South African Expanded Programme of Immunisations (EPI-SA) during the first 2 years of life and the timeliness of immunisations in the first year of life. The study formed part of the Zithulele Births Follow-up Study (ZiBFUS), a prospective, longitudinal cohort study, initiated in January 2013.

“The NDoH has set ambitious targets for immunisation rates in the Health Ministry’s Annual Performance Plan 2014/2015-2016/7, with the stated aim of 95% coverage for immunisations by 1 year and 85% coverage for measles second dose (MCV2).

“The ZiBFUS demonstrates that in rural areas, clinics are falling short of national targets for immunisation coverage, even in an NHI pilot district with a well-functioning district hospital. The ZiBFUS data show 1-year immunisation coverage of 73.3%, in comparison with the target of 95%, and measles second dose coverage of 79.4%, as compared with the 85% target. It is encouraging that 96.3% of babies had received at least one measles immunisation by 2 years. However, MCV 1 immunisation coverage still falls well below the NDoH target of 95% at 1 year, which is also the level required for the development of herd immunity.

“It is important to note that we were only able to assess immunisation status on children who had RtHCs available. Although RtHC availability was high – 96.4% at 3 months and 89.4% at 24 months – we are probably underestimating immunisation coverage slightly, as children without RtHCs are less likely to have been immunised, as clinic nurses require them for vaccinations to be given.

“As a point of comparison, and not unexpectedly for an underserved rural area, our figures for 1-year immunisation coverage are lower than the NDoH national estimates for 2012/13, which vary between 94% (Annual Performance Plan) and 83.4% (2014/15 District Health Barometer).

“Interestingly, our figures are higher than WHO/UNICEF national estimates for 2012/3, which indicate that immunisation coverage was around 69%.

“In light of the prevention imperative of immunisations and the risk to herd immunity due to poor coverage, it is notable that stock-outs of immunisations had affected nearly 50% of the all the women and children participating in the study by the 6-month interview, necessitating one or more subsequent visits to ensure adequate coverage.

“Furthermore, 56% of women whose children did not have up-to-date immunisations attributed this to stock-outs, while only 19% of women indicated that they had not yet gone to their clinic for the required routine vaccinations.

“There may be some reporting bias here, in that women might try to justify their children’s incomplete immunisations by blaming nurses or clinics. However, the fact that 45% of the women who said they had been asked to return to the clinic at least once had children whose immunisations were all up to date indicates that stock-outs are not simply being used as an excuse, but that this is indeed an extensive problem. There is a tendency for healthcare workers to blame mothers for incomplete immunisations, but our data indicate that nearly three-quarters of missed immunisations were due to a health system failure – either a stock-out (56%) or lack of information to women about their baby’s immunisations being incomplete (16%).

“Furthermore, the knock-on effect of stock-outs, which delay routine immunisations and therefore cause other scheduled immunisations to also be delayed, is well demonstrated, with 38%-50% of the 14-week immunisations given more than 1 month late.

“This finding, coupled with the difficulty that many mothers have in accessing rural clinics, means that young infants are left potentially vulnerable to dangerous preventable diseases, and resultant malnutrition and developmental delay.

“Our data cannot be generalised to the whole of SA, but gives an indication of the immunisation coverage and timeliness of routine childhood immunisations in poor rural communities. It is clear that, despite SA’s impressive immunisation policies and the emphasis on the basics of PHC under the ‘Re-engineering of Primary Health Care’ strategy, immunisations are not always available to infants in the rural Eastern Cape. This places an unnecessary burden on rural women and their children and puts poor rural communities at risk of preventable disease outbreaks.”

 

A Daily Dispatch report says that provincial health spokesperson Sizwe Kupelo dismissed the research. “We would like to get a copy of the study. To assess the validity of the claim one has to evaluate the methods used, sample population and what data was collected. As the department, we use the district health barometer as credible sources of the immunisation coverage. We reject the claim that patients do not get vaccinated because there are no vaccines. The national department of health provided sufficient vaccines to cover over 85% of the estimated cohorts, which is the required level ….”

The journal said women who travelled to the hospital from outside the targeted areas for the study were excluded because of a lack of resources for regular follow-ups of women further afield. “A total of 493 women fulfilled the inclusion criteria. There were nine sets of twins but the second twin was excluded from this analysis … 470 mother-infant pairs were evaluated,” the report said. “The age range of the women was from 14 to 52, and 77 of the women were under 18 years old.”

The report said journal’s study was conducted by researchers from universities around the world, including South African and US institutions. The team aimed to examine the successful and timely delivery of immunisation to children during the first two years of life in a deeply rural part of the Eastern Cape.

SAMJ article
Daily Dispatch report


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