Kolkata, WEST BENGAL — When 24 year old Aparna Bera walked to the health sub centre in south Choto-Rakkhaskhali, an island in the Sundarbans, for a booster dose of the diphtheria vaccination for her 16 month old daughter, she found the sub-centre was closed.
“I was told by the Asha workers that due to an outbreak near the sub-centre, vaccination is postponed,” Bera said.
Four people in the village had contracted the novel coronavirus, prompting a closure of the sole public health facility on the island, and the suspension of the immunisation programme for infants. (Asha workers, or Accredited Social Health Activists, are a vital part of rural India’s public health system.)
Bera’s experience is far from unique. Across the world, the novel coronavirus pandemic and the consequent lockdowns, have disrupted national immunisation programmes putting an estimated 80 million children in 68 countries at risk of contracting diphtheria, polio and measles according to WHO and UNICEF.
In India, Priti Mahara, Director, Policy Research and Advocacy, Child Rights and You (CRY) said India’s immunisation programme had suffered a massive setback since March this year.
“A whopping 63% of the surveyed households in the northern states reported the lack of access to immunisation services, followed by West with 39 per cent; while less than a third of the respondents reported inaccessibility to immunisation from other regions,” Mahara said, adding that CRY’s survey found that one in four respondents said healthcare for children was inaccessible during the lockdown.
“Most of it was reported from the North (31%), followed by the South (21%). In other regions, lack of access to regular healthcare facilities was experienced by less than 20% of the parents,” Mahara said.
In India, interviews with parents, health workers, government officers and public health experts in West Bengal, Delhi, Bihar, Uttar Pradesh, reveal that the covid-related disruptions to the country’s immunisation and vaccination programmes has created a real risk of a measles outbreak — suggesting a nightmare scenario of overburdened public health systems trying to cope with simultaneous outbreaks of measles and covid-19.
“Sadly we are trying to combat a virus which does not have a vaccine while we are unable to pay adequate attention to ailments with known vaccines in this difficult situation,” said Dr Kaninika Mitra, Health Specialist for UNICEF in West Bengal.
Children who do not get their Measles-Rubella vaccine on time might develop weaker immunity to the disease than their peers who get the immunised on time.
“Over the last few years, it’s been a hard won battle to put immunization and ANC delivery in place – it has taken effort, resources, finances as well as building community habits”
If sessions are missed and children do not get MR vaccine, there is always a risk of measles outbreak, especially in pockets, where immunization coverage is already low, Dr. Mitra said.
Dr Ajay Chakrabarty, the Director of Health Services in West Bengal, admitted that measles was “a challenge.”
“That is one precise reason why the health workers are told that if one vaccine can be administered then it should be the vaccine to combat measles. I would say 90% will be covered,” Dr. Chakrabarty said.
For other vaccinations administered between 9 to 16 months, Dr. Chakrabarty said, “the window is bigger and the problem is not acute as parents are very aware in Bengal.”
CRY’s Mahara feared the covid related disruptions could have caused lasting damage to India’s child immunisation efforts.
“Over the last few years, it’s been a hard won battle to put immunization and ANC delivery in place – it has taken effort, resources, finances as well as building community habits,” Mahara said. “But it has taken just a few months for much of the achievement to go undone.”
HuffPost India spoke to health workers in four states to understand how the coronavirus affected India’s infant immunisation programme. Much of the confusion seems to have stemmed initially from absence of clear guidelines from the Union Health Ministry.
“Immunization was part of essential services from day one but we were also grappling with many questions. What to do, how to do, measures to prevent the spread of the pandemic, the efficacy of the measures, were some of the questions,” a senior West Bengal government official told HuffPost on condition of anonymity.
A Ministry of Health and Family Welfare guideline — ‘Immunisation Services during and post COVID-19 outbreak’ — has actually added to the confusion, by offering seemingly contradictory advice.
“No active mobilization to the health facility be carried out” the guidelines say, but also advise that “Every opportunity is to be utilized for vaccinating beneficiaries if they have already reported at the facilities.” The health activists say these two sentences contradict each other.
A senior Health Ministry official in Delhi said that despite problems the health centres were “kept open for a reason.”
“A CRY-supported survey of two slums in New Delhi – VP Singh Camp and Nardaan Basti – found that the immunisation process was suspended in March, and is yet to resume in local anganwadi centres.”
“If COVID vaccine is invented tomorrow, we can administer it quickly through health centres,” he explained.
Health workers told HuffPost India that the hectic contact tracing, testing, and quarantining demands placed by the pandemic had made it almost impossible to find the time for the immunisation programme.
“We had a schedule of 16 hours considering that we had to attend calls after reaching home as our numbers were locally distributed,” said Anjana Basu, a health supervisor at a primary health centre in the Rajpur-Sonarpur municipality in Bengal’s 24 Parganas district, describing the chaos. ’People were calling us for ambulances and services and then even shouting at us.”
Basu said health workers in her municipality had to attend everything from door to door pandemic awareness campaigns, conduct surveys, provide antenatal care to immunization.
In Bihar, Makeswar Raut, a senior health worker, said burdening health workers came with its own complications.
“Same health worker was engaged to combat COVID and administer vaccines to the children as Bihar has severe ANM shortage. It is not wise at all,” he said.
In Bihar, Raut said, the migration crisis prompted by India’s punitive national lockdown had likely meant that the children of migrant workers had probably missed their measles-rubella vaccinations. The recent floods in several of the state’s districts has further complication immunisation efforts.
“The supply was halted,” Raut said, a common complaint of health workers in several states.
In Uttar Pradesh Mohammed Raihan, area coordinator of child-advocacy group Child Rights and You (CRY), said the Antenatal Care programme, which helps pregnant mothers deliver healthy babies, was the worst hit.
“In antenatal care, the health workers need to touch the mothers physically, which they did not fearing corona contraction. This is no less an issue,” Raihan said.
A CRY-supported survey of two slums in New Delhi – VP Singh Camp and Nardaan Basti – found that the immunisation process was suspended in March, and is yet to resume in local anganwadi centres. The study found that at least 300 children had missed their vaccinations in these two slums alone.
Matri Sudha, a NGO supported by CRY, noted that once Delhi’s lockdown eased, mothers were asked to take their children to public hospitals for their vaccine shots.
Interestingly in at least two states of north east – Arunachal Pradesh and Assam – both vaccination and ANC process was claimed to be smooth.
“We have had no problem and the sessions ran on time,” said Tonu Bam, a senior ANM of Arunachal’s main public health facility, Tomo Riba Institute of Health and Medical Sciences. Assam-based health worker Utpal Medhi said vaccinations were on schedule and the situation was “by and large under control.”
Dr Abhijit Chowdhury, a hepatologist and a member of the West Bengal government’s advisory board, said Asha workers across the country were under duress.
“In a top down system, the ASHA workers are at the bottom, shouldering the entire workload. It was necessary to distribute the responsibility involving self-help groups, Panchayats etc but it never happened, exposing a deep crack in the country’s health care system,” said Dr Chowdhury.
Covid Care Network (CCN), a civil society initiative to support Covid positive patients, plans to work with the grass root level health workers,
“ASHA workers are physically stretched and emotionally stressed, CCN hopes to stand by them,” said Dr Chowdhury.
“We too have our family and fear,” said Kamala Manna, an Asha worker in Satuipara village in South 24 Parganas
“We maintain 16 writing pads,” she said, explaining the breadth of her work. “We work throughout the day, even in normal times; try to protect the children and the mother and finally take the blame for everything,” she said.