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Immunization

Immunization in Afghanistan

next Dr. Agostino Paganini, Principal Advisor, UNICEF Health Section

Q: How did UNICEF respond to the emergency in Afghanistan?

Paganini: When new political will and humanitarian attention was paid to Afghanistan after 11 September [when international action was taken to oust the Taliban], UNICEF immediately realized that the first imperative was to keep people alive while security was set in place and reconstruction started. One of the strategies – together with providing clothes, food and access to clean water – was to provide measles immunization for children. We undertook a major planning exercise with the World Heath Organization (WHO), various non-governmental organizations (NGOs), the interim Afghan authorities and Afghanistan’s Ministry of Public Health (MOPH) to launch a major measles campaign aiming to cover ten million children between six months and 12 years of age.

Q: What obstacles did UNICEF staff face in this campaign?

Paganini: Security and access are two problems in Afghanistan. After two decades of fighting, you have land mines and, of course there are lots of guys with guns. There are also geographic obstacles and large numbers of displaced people. Some children live in remote mountain villages that are hard to reach because the country lacks a transportation infrastructure. There are also gender issues. Even now many women are wary of moving around freely, so we need to be very culturally sensitive.

Q: What were the scope and timeline for this operation?

Paganini: Before this campaign, we had almost 1,000 local people engaged in immunization in Afghanistan. Now there are many more because many NGOs are part of the operation. We mobilized almost 17,000 Afghan staff. The plan was to do the campaign in phases, moving from region to region. We finished our measles vaccination campaign by winter 2002. Winter is really the time when measles epidemics are most serious.

Q: Why does UNICEF immunize children over the age of five?

Paganini: You need to immunize children over five to protect children under five. We have seen that if you immunize only children under five, then the children between five and 15 still contract measles and it keeps going around in the community, catching those below age five who are at risk of dying.

Some 80 percent of those who die from measles -- that is to say, 80 out of 100 children – are in the under-five age group. In a complex emergency situation, up to 30 per cent of children may die from measles. That is a huge amount for a disease such as measles if you consider that an extremely infectious disease such as Ebola kills 60 or 70 per cent.

Q: What happen now that the target has been reached?

Paganini: During this campaign we also put into place regular immunization services so that we don’t accumulate a huge reservoir of unvaccinated children in the future. Before this campaign, we had reports that measles coverage in Afghanistan was somewhere around 20 or 30 per cent and even less than that in some areas. Certain areas of Afghanistan had not had measles immunization in the last 20 years. A good campaign that immunizes up to 90 per cent of the children under the age of 12 will mean that the next four or five years will be measles free. Then it will be time to vaccinate the next generation of children that have not been immunized.

Q: What are the long-term challenges of this campaign?

Paganini: Ultimately, it will all depend on if the security is stabilized, if the civil service is paid and if the donors deliver on the money that they pledged. When you have a destabilized country, you have an economy of war and an economy of peace. If there is no cash going into the communities, to the villages, if we don’t pay the health staff, pay the porters and other support staff, some of these people may work for the warlords.

Q: What other regions are in similar emergency situations?

Paganini: Afghanistan is the only country at the moment that has received the resources to protect all children from measles. The Democratic Republic of the Congo (DRC) is another obscene situation with a totally unacceptable mortality. In our language, mortality is perceived as catastrophic if there is more than one dead for 10,000 people, per day. In the DRC, we have 10 times that indicator and it has been going on for the last two or three years.

These are incredible numbers. But when we say we need $350 million to stop this mortality, which is about $10 for each Congolese, people laughed at us and said, “You are crazy.” We need $350 million dollars because we have to do measles immunization. We have to do malaria control. We have to do diarrhoea control. We have to have antibiotics for respiratory infections, not to mention sleeping sickness that has returned to Kinshasha. We have started measles immunization in the DRC, but we don’t have the money to cover half the children we need to cover.

Expert Opinion: Immunization in Emergencies