Health Sector Shortcomings Associated with Measles Outbreaks in Cape Town, South Africa

Vimbai Chasi, Ailsa Holloway, Christopher Garimoi Orach

Abstract


Measles is viewed mainly as a public health concern constituting an object of study through epidemiological methods. However, the complexity of the risk factors that drive measles outbreaks suggests the need for wider and more inclusive conceptualisation beyond conventional biomedical methods. This prompted the application of a more integrative research approach to measles outbreaks in Cape Town.

The study employed a mixed-methods approach, including an epidemiological analysis of measles cases to identify and characterise measles outbreaks. Qualitative methods were used to identify and differentiate key health sector shortcomings as well as risk governance deficit areas associated with the progression of measles risk.

Results underlined the value of applying an integrated epidemiological and risk governance framework. They included multi-scalar institutional shortcomings that revealed systemic issues in the management of measles outbreaks. These were wide-ranging, and indicated system-wide issues related to monitoring and early detection, reflected at national, provincial and health worker levels.

The research identified recurrent shortcomings at provincial level. These included a focus/investment on mass rather than routine vaccination; as well as, poor mass immunisation planning due to systemic under-estimation of the exposed population (due to use of live births statistics and exclusion of in-migration data, which artificially inflated vaccination coverage). A further limitation was indicated by difficulties in involving key stakeholders in Outbreak Response Immunisation (ORI) and Supplementary Immunisation Activities (SIAs) (especially the Education Department). At health worker level, poor completion of case investigation forms was a recurrent deficit, constraining accurate characterisation of specific outbreaks. An emergent shortcoming following the 2009-2011 outbreak was the failure/delayed diagnosis of the index measles case, which critically delayed intervention, limiting effectiveness of ORI. These findings underline the value of applying an integrative risk lens to the understanding of epidemic risk in urban settings with high levels of population mobility/migration, where public health services face multiple pressures.


Keywords


risk governance, outbreak risk, disaster risk, vaccine, measles, re-emerging infectious diseases, Cape Town

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References


Abdool Karim, S. & Dilraj, A. (1996): Reasons for Under-Reporting of Notifiable Conditions. South African Medical Journal. 86 (1996):834-836. [Online]. URL: http://archive.samj.org.za/ (21 February 2014).

Babbie, E. & Mouton, J. (2001): The Practice of Social Research. South African ed. Cape Town: Oxford University Press Southern Africa.

Bhopal, R. (2002). ‘Cause and Effect: The Epidemiological Approach’. In Concepts of Epidemiology. Integrating the Ideas, Theories, Principles and Methods of Epidemiology. 2nd ed. Oxford.

Barrett, M., Bouley, T., Stoertz, A. and Stoertz, R., 2011. Integrating a One Health approach in education to address global health and sustainability challenges. Frontiers in Ecology and the Environment 9: 239–245.

Biellik, R., Madema, S., Taole, A., Kutsulukuta, A., Allies, E., Eggers, R., Ngcobo, N., Nxumalo, M., Shearley, A., Mabuzane,E., Kufa, E. & Okwo-Bele, J. (2002): First 5 Years of Measles Elimination in Southern Africa: 1996–2000. The Lancet. 359 (9317):1564–68. [Online]. URL: http://www.measlesrubellainitiative.org/wp-content/uploads/2013/06/First-5years-measles-elimination.pdf (21 February 2014).

Biggs, D., Biggs, R., Dakos, V., Scholes, RJ. & Schoon, M. 2011. Are we entering an era of concatenated global crises? Ecology and Society, 16(2): 27. URL: http://www.ecologyandsociety.org/vol16/iss2/art27/ (4 June 2013).

Centers for Disease Control and Prevention (CDC). (1997): Measles Eradication: Recommendations from a Meeting Cosponsored by the World Health Organization, the Pan American Health Organization, and CDC. Morbidity and Mortality Weekly Report (MMWR). 46 (RR-11):1-20. [Online]. URL: http://www.cdc.gov/mmwr/preview/mmwrhtml/00047959.htm (21 February 2014).

Coetzee, D. Metcalf, C. & Coetzee, N. (2007): ‘Outbreak Investigation’. In Epidemiology: A Research Manual for South Africa. Cape Town: Oxford University Press Southern Africa.

Coronado, F., Musa, N., Ahmed El Tayeb, E., Haithami, K., Dabbagh, A., Mahoney, F., Nandy, R. & Cairns, L. (2004): Retrospective Measles Outbreak Investigation: Sudan, 2004. Journal of Tropical Pediatrics. 52(5):329-334. JSTOR URL: http://www.ncbi.nlm.nih.gov/pubmed/16735363 (21 February 2014).

Corrigall, J., Coetzee, D. & Cameron, N. (2008): Is The Western Cape At Risk of an Outbreak of Preventable Childhood Diseases? Lessons from an Evaluation of Routine Immunisation Coverage. South African Medical Journal. 98(1): 41-45.

Creswell, J. (2009): Research Design: Qualitative, Quantitative, and Mixed Methods Approaches. Los Angeles: Sage Publications.

Cutts, F., Henderson, R. Clements, C., Chen, R. & Patriarca, P. (1991): Principles of measles control. Bulletin of the World Health Organization, 69 (1): 1-7.

Duncan, S., Scott, S. & Duncan, C. (1999): A Demographic Model of Measles Epidemics. European Journal of Population. 15(2):185–198. JSTOR URL: http://download.springer.com/ (21 February, 2014).

Fine, P. 1993. The Interval between Successive Cases of an Infectious Disease. American Journal of Epidemiology. 158(11): 1039-1047. JSTOR URL: http://aje.oxfordjournals.org/content/158/11/1039.full.pdf (21 Februray 2014).

Grais, R., Ferrari, M., Dubray, C. Eds. (2006): Estimating Transmission Intensity for a Measles Epidemic in Niamey, Niger Lessons for intervention. Transactions of the Royal Society of Tropical Medicine and Hygiene. 100(9):867-873.

Holloway, A. (2005): Disaster Risk Science in Soutehrn Africa:Taking it into the academic mainstream. Know Risk. UNISDR. Tudor Rose. 113-114.

Holloway, A. (2009): Crafting Disaster Risk Science: Environmental and Geographical Science sans Frontiers. Gateways: International Journal of Community Research and Engagement. 2(2009): 98–118.

Holloway, A., Fortune G. & Chasi, V. 2010. RADAR (Risk and Development Annual Review) Western Cape 2010. Cape Town: PeriPeri Publications.

Holloway A., Chasi V., de Waal J., Drimie S., Fortune G., Mafuleka G., Morojele M., Penicela Nhambiu B., Randrianalijaona M., Vogel C. and Zweig P. (2013). Humanitarian Trends in Southern Africa: Challenges and Opportunities. Regional Interagency Standing Committee, Southern Africa. Rome, FAO. URL: http://www.riskreductionafrica.org/en/rra-topmenu-docs (21 February 2014).

Hope-Simpson, R. (1952): Infectiousness of communicable diseases in the household (measles, chickenpox and mumps). Lancet, 2: 549-554.

International Risk Governance Council (IRGC). (2010): Risk Governance Deficits Analysis, illustration and Recommendations. Geneva: IRGC.

Köhler, T., Siebert, M. and Hollederer, G. (2008): Disaster Risk Management Contributions by German Development Cooperation, TOPICS 193. Federal Ministry for Economic Cooperation and Development (BMZ). Development Education and Information Division. URL: http://www.riesgoycambioclimatico.org/biblioteca/archivos/DC1059.pdf (18 February 2014).

Kouadio, I., Kamigaki, T. & Oshitani, H. (2010): Measles outbreaks in displaced populations: a review of transmission, morbidity and mortality associated factors. BMC International Health and Human Rights. 10(5):1-10. URL: http://www.biomedcentral.com/1472-698X/10/5 (21 February 2014).

Kruk, M. & Freedman, L. (2008): Assessing health system performance in developing countries: A review of the literature. Health Policy. 85(3):263–276. URL: http://www.ppmrn.net/storage/ppmrn/Margaret%20Elizabeth%20Kruk%20Lynn%20P.%20Freedman.pdf (21 February 2014).

Lopalco, P. & Martin R. (2010): Measles still spreads in Europe: who is responsible for the failure to vaccinate? EuroSurveillance. 15(17):ii-19557. URL: http://www.eurosurveillance.org/images/dynamic/EE/V15N17/art19557.pdf (21 February 2014).

McMorrow, M., Gebremedhin, G., van den Heever, J., Kezaala, R., Harris, B., Nandy, R., Strebel, P., Jack, A. & Cairns, K. (2009): Measles Outbreak in South Africa, 2003 – 2005. The South African Medical Journal (SAMJ). 99(5):314-319. URL: http://www.samj.org.za/index.php/samj/article/view/2750/2349 (21 February 2014).

Mechler, R., (2004): Natural disaster risk management and financing disaster losses in developing countries. URL: http://www.preventionweb.net/english/professional/publications/v.php?id=1266 (21 February 2014).

Morley, D. (1969): Severe Measles in the Tropics-I. British Medical Journal. 1(1969):297-300. URL: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1982195/ (21 February 2014).

Ngcobo, N. & Cameron, N. (2010): Introducing new vaccines into the childhood immunisation programme in South Africa. South African Journal of Epidemiology Infection. 25(4):3-4.

Ngcobo, N. (2008): The impact of the immunisation programme on vaccine-preventable diseases in South Africa: A review of progress over a 10- to 15-year period. The Southern African Journal of Epidemiology and Infection. 23 (1): 9-13.

Ngcobo, N. (2008): The impact of the immunisation programme on vaccine-preventable diseases in South Africa: A review of progress over a 10- to 15-year period. The Southern African Journal of Epidemiology and Infection. 23 (1): 9-13.

Pharoah, R. (2009): Fire Risk in Informal Settlements in Cape Town, South Africa. In Pelling, M. & Wisner, B. Eds. 2009. Disaster Risk Reduction: Cases from Urban Africa. London: Earthscan. pp105-125.

Program for Monitoring Emerging Diseases (ProMED). (2010a). 447 Cases of Measles in Western Cape Province. International Society for Infectious Diseases. [Online]. Available: www.promedmail.org [2010, October 18].

Program for Monitoring Emerging Diseases (ProMED). (2010b). Measles Cases Fill Wards. International Society for Infectious Diseases. [Online] Available: www.promedmail.org [2010, October 18].

Renn, O. (2008): Risk Governance: Coping with Uncertainty in a Complex World. London: Earthscan.

Smith, K. & Petley, D. (2009): Environmental Hazards-Assessing Risk and Reducing Disaster. London: Routledge.

Szusz, E., Garrison L. & Bauch C. (2010): A Review of Data Needed to Parameterize a Dynamic Model of Measles in Developing Countries. BioMed Central (BMC) Research Notes. 3:75. URL: http://www.biomedcentral.com/content/pdf/1756-0500-3-75.pdf (21 February 2014).

Toole, M., Steketee, R., Waldman, R. & Nieburg, P. (1989): Measles Prevention and Control in Emergency Settings. Bulletin of the World Health Organization. 67(4): 381-38. URL: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2491262/pdf/bullwho00062-0040.pdf (21 February 2014).

United Nations International Strategy for Disaster Reduction (UNISDR). (2004): A Global View of Disaster Reduction Initiatives. Geneva: United Nations ISDR. URL: http://www.unisdr.org/files/657_lwr1.pdf (21 February 2014).

United Nations International Strategy for Disaster Reduction (UNISDR). (2013): From Shared Risk to Shared Value –The Business Case for Disaster Risk Reduction. Global Assessment Report on Disaster Risk Reduction. Geneva, Switzerland: United Nations Office for Disaster Risk Reduction (UNISDR).

Varvasovszky, Z. & Brugha R. (2000): Stakeholder Analysis - A Review. Health Policy and Planning. 15(3): 239-246. URL: http://heapol.oxfordjournals.org/content/15/3/239.abstract (21 February 2014).

Wisner, B., Blakie, P., Cannon, T., Davis, I. (2004): At Risk Natural Hazards, People’s Vulnerability and Disasters. 2nd ed. London and New York: Routledge.

World Health Organisation Regional Office for Africa (WHO/AFRO). (2004): Guidelines for measles surveillance. Geneva: World Health Organisation Regional Office for Africa (WHO AFRO).

World Health Organization (WHO). (1999): WHO Guidelines for Epidemic Preparedness and Response to Measles Outbreaks. Geneva: World Health Organization (WHO). URL: http://whqlibdoc.who.int/hq/1999/WHO_CDS_CSR_ISR_99.1.pdf (21 February 2014).

World Health Organization (WHO). (2009): Measles and Rubella Surveillance and Outbreak Investigation Guidelines. New Delhi: World Health Organization, Regional Office for South-East Asia.

World Health Organization (WHO). (2010): Global Immunization Data. October 2009. URL: http://vaccineindia.org/index.php?option=com_content&view=article&id=408%3Aglobal-immunization-data&Itemid=189 (21 February 2014).

World Health Organization Regional Office for Europe (WHO/EU). (2010): Seven Key Reasons why immunization must remain a priority in the WHO European Region. European Immunization Week Prevent. Protect. Immunize. The Regional Office for Europe of the World Health Organization. URL: http://www.euro.who.int/__data/assets/pdf_file/0017/84302/Seven_Key_Reasons.pdf (21 February 2014).

Young, H., Borrel, A., Holland, D. & Salama, P. (2010): Public Nutrition in Complex Emergencies. The Lancet. 364 (2004): 1899–909.