Measles in Nigeria Vs The United Kingdom - The role of healthcare and its capacity for positively promoting health

Introduction – Global Trends

According to the World Health Organization (WHO) (2019), measles is a virus-borne disease that is exceedingly contagious and dangerous. Until the introduction of the measles vaccine in 1963 and widespread immunization, major epidemics occurred every 2–3 years, killing an estimated 2.6 million people each year. Measles is caused by a paramyxovirus virus that is transmitted through direct touch and the air. After invading the respiratory tract, the virus travels throughout the body. Measles appears to be a human disease that does not infect animals. Measles mortality have decreased dramatically as a result of increased vaccine campaigns (WHO, 2019; NHS, 2022). Measles is a highly contagious viral disease that is particularly harmful to children and can result in severe diarrhea, ear infections, blindness, pneumonia, and encephalitis (swelling of the brain). Some of these issues can result in death (UNICEF, 2022; National Center for Immunization and Respiratory Diseases, 2020).

Image Credit: Tessa Davis on Twitter

Despite the availability of a safe and cost-effective vaccine, more than 140 000 people died from measles in 2018, the majority of whom were children under the age of five. Between 2000 and 2018, vaccination lowered global measles deaths by 73 percent (from an estimated 536,000 cases in year 2000 to 142,000 cases in 2018). Around 86 percent of the world's youngsters had received one dose of measles vaccine through routine health care by their first birthday, up from 72 percent in 2000. Measles vaccination avoided an estimated 23.2 million deaths between 2000 and 2018, making it one of the best investments in public health (WHO, 2019; Centers for Disease Control and Prevention, 2022).

The number of reported worldwide measles cases increased by 79 percent in the first two months of 2022 compared to the same time the previous year. The fact that the highly contagious virus and other vaccine-preventable diseases are becoming more widespread is a serious signal (UNICEF, 2022). According to UNICEF (2022), a lot of factors are coming together to create a "perfect storm" for measles spread. Pandemic disruptions, greater vaccination access discrepancies, and a shift in resources away from routine immunization are all challenges. Many children nowadays are not immune to measles and other vaccine-preventable diseases. As a result, there is a greater danger of large-scale epidemics. 23 million children will have missed all of their childhood immunizations by 2020. This is the greatest level since 2009, and it represents a 3.7 million increase over 2019. Many communities have lifted social segregation measures imposed during the pandemic's peak, raising the risk. This facilitates the spread of the measles virus in unprotected locations (UNICEF, 2022; CDC, 2022).

Vaccination has significantly reduced measles mortality over the last two decades. Measles vaccine is thought to have avoided nearly one-fifth of all child fatalities since 1990, when the disease killed 872,000 individuals. Public Health England estimates that 20 million illnesses and 4,500 fatalities have been prevented in the UK since the measles vaccine was introduced in 1968. Adults who have not been vaccinated, particularly young individuals aged 15 and older who did not receive MMR vaccination as children, account for the bulk of measles cases in the UK. Approximately 30% of those who have been affected have been admitted to the hospital. (University of Oxford, 2022; Public Health England, 2018).

According to research, more than one in ten school-aged children in England are at danger of contracting measles because they have not received their vaccinations. Measles is a more contagious sickness than Covid and can be fatal. When a kid turns one, the MMR vaccine is free on the NHS, with a second dose available around three-and-a-half years old, before they start nursery or school. In the United Kingdom, it is never too late for children, teenagers, and young adults to obtain their MMR vaccine, and they can get a second dose even if the first was years ago. When a large percentage of the population is protected by vaccination, it becomes more difficult for the disease to spread (Roberts, 2022; NHS, 2020; UK Health Security Agency, 2019).

While outbreaks were probable, the World Health Organization proclaimed the United Kingdom measles-free in 2017, indicating that the disease was not widely circulating and spreading. Measles is still more frequent in certain other countries, which means it might return to the UK and infect unvaccinated people if given the chance. In 2018, the UK lost its eradication status when new instances emerged, with 991 cases verified in England and Wales, up from 284 in 2017. During the Covid outbreak, measles cases dropped dramatically due to social isolation and reduced travel (Roberts, 2022; WHO, 2019).

Nigeria is one of 45 countries responsible for 94 percent of measles deaths worldwide (WHO/UNICEF, 2017). In the past year, the most measles outbreaks have occurred in Nigeria, Afghanistan, Ethiopia, Somalia, and Yemen. There had been 21 severe and disruptive measles outbreaks in the year leading up to April 2022. And the actual number of cases is very certainly far higher. Because surveillance systems have been disturbed by the epidemic, significant underreporting of cases is possible (UNICEF, 2022). The high prevalence of measles in the Nigeria emphasizes the necessity for targeted interventions. Polio resources are heavily used in the measles program (Jean Baptiste et al., 2021).

Figure 1: Measles Statistics (Number of Reported Cases) in Nigeria and the UK from 2012 to 2021

Source: World Health Organization (WHO) (2022).

National and global public health measures relating to measles in United Kingdom and Nigeria

The World Health Organization defines measles eradication as the absence of circulating measles in places where vaccination rates are high and case detection procedures are in place. Isolated cases with minimal community transmission may still occur in nations where the illness has been eradicated. The various steps taken in the United Kingdom and Nigeria to reduce the incidence of measles is discussed below.

a.     Measles in The United Kingdom

Measles is still prevalent in many parts of the world, and there are numerous big outbreaks in Europe right now due to low MMR vaccine uptake. Measles virus importations will continue to rise into the UK until the disease is eradicated internationally, and maintaining high coverage of two doses of the MMR vaccine in the population is vital to limiting transmission within the UK. In locations where vaccine uptake is low, measles outbreaks are common. Young, unvaccinated adults who were not immunized as children are also at danger. While the UK has achieved the WHO target of 95% coverage for children aged five, only 87.4% of children have received the second dosage. Because measles is such a common disease, even slight reductions in vaccination rates can have a big impact. Anyone who has not received two doses of the MMR vaccine is at danger, especially those going to areas where big outbreaks are currently occurring. We must concentrate our efforts on increasing MMR vaccination coverage as part of a routine childhood immunization program, as well as catching up older children and young adults who have missed out earlier (UK Health Security Agency, 2019).

While there has been an increase in measles cases in the last three years, it's crucial to remember that, thanks to the MMR vaccine, measles is still uncommon in the UK. Until the measles vaccine was introduced in 1968, hundreds of thousands of cases were reported each year. To combat measles outbreaks and promote MMR vaccine uptake across the health system, a lot of good work is being done. In terms of protection, herd immunity is vital. When a high proportion of the population is immunized against a disease, it becomes more difficult for the disease to spread between unvaccinated people. While not everyone can be vaccinated, those who can help protect others who cannot. 95 percent of the population must be safeguarded in order to achieve herd immunity (UK Health Security Agency, 2019).

As part of the NHS Long Term Plan, a number of efforts to maintain and improve MMR dose uptake are included. These include a thorough review of the GP contract for vaccination and immunisation, as well as improved local coordination to promote increased vaccine coverage in each area, which can help target low-uptake populations. For youngsters aged 10 and 11, the GP contract recently added a screening for MMR status. The current Government Green Paper on prevention urged a vaccine approach in addition to implementing the existing Measles and Rubella Elimination Strategy. The Department of Health and Social Care, in cooperation with PHE and NHS England, will deliver this comprehensive strategy in the autumn (UK Health Security Agency, 2019).

Public Health England recommends that anyone who has missed a vaccine make an appointment as soon as possible, and we're launching a public-facing campaign called Value of Vaccines to help distribute vaccination messages and information, particularly MMR. Elimination can only be maintained by maintaining and boosting MMR vaccination coverage. The loss of elimination status serves as a stark reminder that everyone who is eligible for vaccination must get it. It's an opportunity to educate people about the dangers of measles, the necessity of vaccination, and the importance of reporting suspected cases as soon as possible to prevent the disease from spreading (UK Health Security Agency, 2019).

b.     Measles in Nigeria

In Nigeria, measles infections tend to increase in the first half of the year due to the warmer temperatures. In Nigeria, vaccination coverage is low, with just slightly more than half of children receiving the vaccine, but children in conflict-affected areas are particularly vulnerable. Malnourished babies with weakened immune systems are at a higher risk. As a result of the fighting and subsequent displacement, more than 4.4 million children in Nigeria require humanitarian assistance, with an estimated 450,000 children at risk of Severe Acute Malnutrition in 2017. The immunization program, which is being carried out in collaboration with the Nigerian government, the World Health Organization, and various non-governmental organizations, also includes vitamin A supplements and deworming tablets. The Measles and Rubella Initiative provided the majority of the campaign's funding (UNICEF, 2017; UNICEF 2022).

Accelerated measles control measures began in the WHO African Region (AFR) in 2001, and the region adopted the 2020 measles elimination target in 2011 (WHO Regional Office for Africa, 2015). African Region Member States conducted periodic supplemental immunization activities (SIAs) to reach unimmunized children missed by routine vaccination services, improving measles case management, and establishing a case-based measles surveillance system to supplement routine immunization coverage and reduce immunity gaps (Postolovska, Helleringer, Kruk & Verguet, 2018).

In 1978, Nigeria included measles vaccination in its standard immunization program for children aged 9 months and up (WHO/UNICEF, 2017). In 2006, case-based measles surveillance was implemented during the early stages of measles control (Weldegebriel, Gasasira, Harvey et al., 2011). During the early stages of implementing measles control activities, Nigeria conducted an initial "catch-up" campaign in late 2005 (target age: 9 months to 15 years; administrative coverage: 96.0 percent) and a "follow-up" campaign in 2008 (target age: 9 months to 4 years; administrative coverage: 112.0 percent). Due to routine MCV1 coverage of less than 50.0 percent, a high incidence rate, and the persistence of measles outbreaks, the government has been conducting statewide mass immunization campaigns every two years. MCV1 vaccination coverage in Nigeria was 33% in 2000, 44% in 2006, and 41% in 2007. In Nigeria, vaccination coverage grew dramatically from 53 percent in 2008 to 56 percent in 2010 (WHO, 2020; Jean Baptiste et al., 2021).

UNICEF's larger emergency health response in three Nigerian states in the northeast includes this effort. In conjunction with Nigerian authorities, UNICEF has given primary health care services to both internally displaced individuals and vulnerable host communities where they have sought refuge. Over 4.2 million individuals have benefited from services such as routine vaccination, antenatal care, and midwifery support, as well as treatment for common ailments like malaria, diarrhoea, pneumonia, and measles (UNICEF, 2022).

UNICEF has educated nearly 1,000 health workers in emergency primary health care, engaged 60 nurse-midwives, and dispatched six doctors to help strengthen health services in areas where humanitarians have only recently gained access. The situation in northeast Nigeria remains dire, with over 1.6 million people displaced as a result of the violence. UNICEF's response effort is hampered by a lack of financing, despite great progress in delivering healthcare, malnutrition treatment, drinkable water, sanitation and hygiene services, education, and child protection to children and their families. In 2017, UNICEF requested US$150 million to address the urgent humanitarian needs in northeast Nigeria, down from US$51 million in 2016 (Jean Baptiste et al., 2021).

Measles Outbreak Management in the UK (Public health actions coordinated by Public Health England)

In the United Kingdom, recent measles outbreaks have highlighted the disease's pervasiveness. GPs are likely to be the first point of clinical contact in a variety of scenarios. Prompt suspicion of diagnosis and subsequent procedures are critical for preventing additional infection and protecting vulnerable contacts. As the major suppliers of MMR vaccine, which is the most effective way of avoiding outbreaks, GPs, in partnership with PHE, play a crucial role in helping to manage measles in the UK. On alerted cases, the local HPT conducts a risk assessment and provides relevant recommendations (as shown in Figure 2) (Moten, Phillips, Saliba, Harding & Sibal, 2018).

Figure 2: Primary care management flowchart for a suspected measles case showing the key actions taken by GPs in conjunction with PHE. CCGs = clinical commissioning groups. ECDC = European Centre for Disease Prevention and Control.MMR = measles, mumps, and rubella vaccine. PEP = post-exposure prophylaxis. PHE = Public Health England. WHO = World Health Organization.

PHE collaborates with GPs to prevent the spread of the disease in the following ways:

a)     Information gathering,

b)     Identification of contacts,

c)     Subsequent actions (depend on the individual situation, but may include providing ‘warn and inform’ letters and post-exposure prophylaxis (PEP) for exposed contacts),

d)     MMR vaccination (measles is easily preventable: two doses of MMR vaccine are given at 12 months and 3 years 4 months of age, and are around 95% effective).

Measles Outbreak Management in the Nigeria

The official guideline for responding to measles outbreaks in Nigeria offers two methods for limiting the outbreak: "selective" and "nonselective" outbreak response immunization (ORI). Measles vaccination is delivered through routine service sites under selective ORI to all unvaccinated children aged 6-9 months or an age group based on measles epidemiology. When a measles outbreak is discovered (five cases of probable measles reported in a health facility or district in one month), "selective" ORI is advised (Isere & Fatiregun, 2014).

Figure 3: Flowchart for suspected measles outbreak response

Source: World Health Organization (2020)

During "selective" ORI, the following activities should be carried out:

a)     inform affected communities about the suspected outbreak and provide instructions,

b)     vaccinate all children presenting at health facilities and immunize children aged 6 months to 5 years without a history of measles vaccination.

c)     Re-vaccinate all children who received measles vaccination before the age of nine months,

d)     Reinforce routine immunization services to quickly identify priority locations within the affected district to remedy program weaknesses (as shown in Figure 3).

Roles of the healthcare of the United Kingdom and Nigeria and their capacity for positively promoting health.

Despite the fact that there is a safe and effective vaccine to prevent measles, it remains one of the leading causes of death among children under the age of five worldwide. There is no specific antiviral treatment for the measles virus. Malnourished young children, especially those with weakened immune systems, are more likely to have serious cases. In populations with severe levels of malnutrition and poor health care, measles can kill up to 10% of people. Around 119 million children were vaccinated against measles in 31 countries during mass immunization campaigns in 2016. By or before 2020, all WHO Regions have set goals to eradicate this preventable disease (Pan American World Health Organization, 2022).

The World Health Assembly set three targets for future measles eradication in 2010, all of which must be achieved by 2015 which includes; increase routine coverage of the first dose of the measles-containing vaccine (MCV1) to more than 90% nationwide and more than 80% in each district, reduce annual measles incidence to less than 5 cases per million and reduce estimated measles death by more than 95% from year 2000 estimates. The World Health Assembly endorsed the Global Vaccine Action Plan in 2012, with the goal of eradicating measles in four WHO areas by 2015 and five by 2020 (WHO, 2019).

By 2018, the global vaccine coverage program reduced mortality by 73 percent. According to the Measles & Rubella Initiative and Gavi, the Vaccine Alliance, measles vaccination saved 23.2 million lives between 2000 and 2018, with the bulk of deaths occurring in Africa and countries supported by the Gavi Alliance. If attention is not maintained, hard-won advantages may be lost. When children are not immunized, outbreaks occur. Due to insufficient coverage nationally or in pockets, significant measles outbreaks occurred in multiple locations in 2018, resulting in numerous deaths. The WHO Strategic Advisory Group of Experts on Immunization (SAGE) concluded that measles elimination is in jeopardy, based on current trends in vaccination coverage and incidence, and that the disease has resurfaced in a number of countries that had previously achieved or were on the verge of achieving it (WHO, 2019).

In 2001, the Measles & Rubella Initiative (M&R Initiative) was launched. This is a global partnership led by the American Red Cross, United Nations Foundation, Centers for Disease Control and Prevention (CDC), UNICEF and WHO. The Initiative is dedicated to preventing measles deaths and congenital rubella syndrome. The Initiative assists countries in planning, funding, and evaluating efforts to eradicate measles and rubella (WHO, 2019).

Recommendations

Measles vaccination campaigns have been disrupted all around the world due to the coronavirus outbreak. As we recover from the epidemic, it's vital that we commit to improving health systems and ensuring that every child obtains the necessary vaccines. More skilled healthcare professionals, more vaccination facilities in underserved areas, more thorough health data, and effective vaccine messaging are all examples of stronger health systems. Public health practitioners in the UK and Nigeria should strive for high compliance and best practice in case-based surveillance and outbreak response during measles outbreaks as they play a vital role in preventing further spread of the disease. Face-to-face communication between communities and providers is essential for vaccination promotion in the fight against measles. Service providers must find ways to connect with and learn more about the communities they serve in order to create and maintain trust.

Reference

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HOW TO REFERENCE THIS ARTICLE

Ademola, V. D (2022). Measles in Nigeria Vs The United Kingdom - The role of healthcare and its capacity for positively promoting health. Retrieved from https://www.youdread.com/2022/11/measles-in-nigeria-vs-united-kingdom.html