Mothers outside a primary health care center in Ranomafana, Madagascar, wait for their children's turn to receive their standard childhood immunizations, which include the measles vaccine. Image: PIVOT
As the world faces a measles outbreak, even countries with high rates of vaccine coverage have not been spared an uptick in cases. Though a cause for concern anywhere, the emergence of three cases of measles in the United States or Europe does not often evoke a sense of crisis. But when the same number appear in Madagascar, as happened in October, the fragile state of the health system means the situation can escalate to a widespread emergency very quickly.
According to the UN, since the first cases were recorded last fall, the outbreak in Madagascar has infected over 76,000 and claimed the lives of at least 926 individuals to date—a magnitude that the country has not seen in decades.
Currently, however, measles outbreaks are cropping up around the globe, capturing international attention due to the threat they pose to communities in such unexpected places as the United States. In some areas, the uptick in cases is a result of a movement among people who opt out of having their children vaccinated despite the relative ease and affordability of doing so.
By contrast, the people of Madagascar are in urgent need of vaccines—the only measure proven effective against measles. The outbreak has been fueled by a nationwide shortage of these lifesaving immunizations.
“The Madagascar measles outbreak is a particularly precarious situation because many of the districts have weak health infrastructure and systems to begin with, which is now exacerbated with a shortage of vaccines,” said Michael L. Rich, HMS assistant professor of medicine in the Brigham and Women’s Hospital Division of Global Health Equity and chief clinical advisor at PIVOT, one of the international organizations partnering with the Madagascar Ministry of Health to respond to the outbreak. Without a reliable supply of vaccines, strong supply chains or facilities adequately staffed with trained personnel, an end to Madagascar’s ongoing measles crisis is difficult to foresee, Rich said.
PIVOT has roots at Harvard Medical School. The organization’s co-founders include Rich and Matthew Bonds, assistant professor of global health and social medicine in the Blavatnik Institute at HMS and scientific director of PIVOT.
PIVOT has been working to strengthen integrated health systems in Madagascar since 2014. Through a combination of health system strengthening, clinical care delivery and biosocial research, the organization seeks to improve health in one region in rural Madagascar and to provide solutions for the challenges of delivering quality health care everywhere.
In many ways, the story of Madagascar’s measles outbreak is familiar. With a weakened public health system and one of the world’s highest poverty rates, the country’s largely rural population is highly vulnerable to epidemics, including diseases such as plague that have been reduced or eliminated in countries with stronger health systems.
PIVOT’s mission is to ensure that the public health system in Ifanadiana District is strong, resilient and accessible so that caregivers there can manage outbreaks whether caused by measles, plague or malaria. However, even with a good health system in place, without adequate vaccinations the people in the region are extremely vulnerable to measles.
This outbreak, so closely following the pneumonic plague epidemic that occurred roughly a year ago, is reinforcing the importance of PIVOT’s mission to ensure a functional public health system—the key to containing and preventing outbreaks.
“This is an alarming situation,” says PIVOT country director Ali Ouenzar. “Preventive measures must be accelerated to stop the spread of the epidemic.”
In Ifanadiana District, PIVOT has been working with the MoH to ensure that necessary supplies are rapidly available to address all measles cases, providing treatment kits to all health centers in the district and training clinicians in measles case management. So far, 105 cases have been reported in the district with zero resulting deaths. Alongside the MoH, PIVOT has made strides over the past five years to achieve a 73 percent vaccination rate in the communities PIVOT supports compared to 49 percent in the rest of the district.
But PIVOT’s leaders acknowledge that 73 percent is still a long way from the 95 percent vaccination rate required for a community to be considered “immune” to measles, according to the U.S. Centers for Disease Control and Prevention.
To achieve this, PIVOT and the MoH are launching a weeklong campaign against measles throughout Ifanadiana District with the explicit goal of vaccinating at least 95 percent of those most susceptible to contracting measles: children between the ages of 6 months and 9 years. With roughly half of children in Madagascar at increased risk of illness due to malnutrition, this age group comprises the majority of the rising death toll nationwide.
Alongside partners from the MoH, Ouenzar said PIVOT anticipates immunizing 65,000 children before the end of February. Teams will travel by motorbike and on foot, crossing rivers and climbing hills to reach families and children in every corner of a district that is roughly the size of Delaware.
"The situation is urgent," Rich said. "We're calling upon the global health community to mobilize resources to curtail the present outbreak in Madagascar and to invest in the health system so that future outbreaks can be prevented."