What is really killing the children of Tripura Para?
At the time of writing this article (Monday, July 24), another child has died in the measles outbreak in Tripura Para, raising the death toll to 10. Three-year-old Nipa Tripura passed away at nine o'clock in the morning, after battling bronchopneumonia and septicaemia for several hours in the ICU of Chittagong Medical College Hospital (CMCH). She had been hospitalised at the Bangladesh Institute of Tropical and Infectious Diseases (BITID), along with 99 other children between the ages of one and 12, including her sisters Rita, 5, and Laxmi Rani, 2, but was taken to CMCH in the night of the 23rd when her condition was not improving. She was given oxygen, but there was nothing more that could have been done for little Nipa. Laxmi Rani is also in the ICU, but Rita, says Chittagong Civil Surgeon Dr Azizur Rahman Siddique, is on the mend.
Nipa's death comes almost two weeks since nine children died untreated in an unexpected measles epidemic in the remote neighbourhood of Tripura Para of Sonacchari Union in Sitakunda Upazila. While talking to Star Weekend earlier in the afternoon of the 24th, Dr Azizur Rahman had been all reassurances. "All the children are on the path to recovery. Of the 99 children who had been originally hospitalised at BITD, 65 were sent to CMCH, and 29 have been treated and sent home. 21 of the 78 children at CMCH have also been sent home," he informed. A total of 112 children have been hospitalised between CMCH and BITID, and exactly half of them still remain there, fighting for their lives.
These children fare a far better chance than Rupali and Shimal Tripura, two of the children who died on the 12th of this month, before the disease had even been identified. They had not been taken to the hospital.
"We took her to a man who practices homeopathy. He lives two kilometres away. He had given her some medicines," said Suman Kumar Tripura, father of three-year-old Rupali. Sitakunda Upazila Health Complex is 15 kilometres away.
Two-year-old Shimal was also taken to a local man who practices homeopathy. The two-year-old had been suffering for six days, the usual span of time fevers run their course.
According to the Directorate General of Health Services (DGHS), there should be one community clinic for every 6,000 people within a limited radius. By those standards, Sonaicchari, which has a population of over 38,000, should have at least six, and Sitakunda at least 55. But the union has only one. Furthermore, there is less than one doctor per 3000 people in Bangladesh, suggesting an alarming shortage of doctors to provide adequate services. Why accessing healthcare was so difficult for the families of Tripura Para becomes abundantly clear. If they were able to avail timely assistance, the grim fates of their children could have been wholly avoided.
Primary treatment aside, the people of Tripura Para had not been visited by health workers in the past seven years, telling a very different tale from what many local authority members and healthcare providers continue to claim. The Civil Surgeon stuck to the story that the families refused to get their children vaccinated when Star Weekend spoke to him, while Abdul Khalek, Mirsarai Upazila Health and Family Planning Officer (UHFPO) and head of the probe body that investigated the outbreak, said the guardians had a misconception that "vaccines would kill their kids" and "they hardly interacted with outsiders".
Somacharan Tripura's eldest daughter Ratna, 14, was vaccinated around 10 years ago. Speaking to The Daily Star, he said health workers used to visit the area on a regular basis, but they stopped coming here so his four-year-old son Uzwal who fell sick with a fever, rash, and breathing problems, could not be vaccinated. Pradip Kumar Tripura's eldest son Anil Tripura, 16, was also vaccinated when he was a child, but his other two brothers Saiken, 9, and Munna Babu, 7, were never vaccinated.
"We live in an extremely remote area. If the health workers don't come to us then how could we know about the dates and procedures of the government's vaccination campaigns?" said Pradip to our Chittagong correspondent.
Asked whether there was any superstition among the locals about vaccination, he said, "It's false. Tell me if it was true then how could so many children in this area have been vaccinated and why had such an incident not happened before?"
Indeed, Dr Alauddin Majumder, director (health), Chittagong, echoed the families' views. "I think it's a case of sheer negligence by the field-level health workers. They did not visit the area at all," he said. What is horrifying is that the six health workers who have since been transferred from their posts had been working in the Sitakunda area for 10-12 years, according to Sitakunda UHFPO, Dr S. M. Nurul Karim. Those transferred are Heath Inspector Khaled Md Humayun Kabir, Assistant Health Inspector Reba Mahajan, and four Health Assistants Nilufa Akhter, Badrunnesa Begum, Tafura Begum and Nurul Karim. Asked how often they are supposed to report to him, Dr. Nurul Karim says, "Health workers are supposed to report on their vaccination activities every month, including where they have visited, who they have vaccinated, and so on." Absurdly, the six workers make up the entire chain of command of Upazila health services, headed by none other than the UHFPO. While the UHFPO is changed periodically, these workers were purportedly from the local Bengali community and have been stationed here for over a decade, showing how deeply entrenched this public health debacle truly is.
While Bangladesh brags about its impressive measles vaccination coverage and its nationwide mega-campaigns, we have failed to reach our target of measles elimination status by 2016. According to the 2016 research Evaluation of impact of measles rubella campaign on vaccination coverage and routine immunisation services in Bangladesh, the lowest household asset quintile or the poorest households have only 87.4 percent coverage, but for measles elimination, you need 90-95 percent coverage. While this might not seem like a big difference, the equilibrium is a delicate one. Experts warn that if measles vaccination coverage in a single community drops below the threshold of 90-95 percent, so called "herd immunity" is eroded, increasing the risk of outbreaks. A study in the US found that even a five percent drop in the uptake of measles, mumps, and rubella (MMR) vaccine among children could result in a threefold increase in measles cases.
The measles outbreak in Sitakunda isn't the first in recent years. Although unreported by the media, last year the number of confirmed measles cases increased, with 21 outbreaks in Sylhet Division and Cox's Bazar District, according to the World Health Organisation (WHO). Overall, 972 confirmed cases were reported. Although the break-out in Cox's Bazar has been linked to the entry of unvaccinated Rohingya refugees, 56 percent of all districts in Bangladesh have not met surveillance performance targets either.
Also, there is always the issue of infants not yet old enough to receive the vaccine or unvaccinated adults. For example, in Bangladesh, the measles and rubella vaccines (MR 1 and 2) are given at 38 weeks and 15 months. Any child younger is at risk of the two diseases, while women, if infected by rubella, may pass on the infection to her unborn child, resulting in miscarriage, death or congenital defects.
Like Tripura Para, there are many remote pockets of the country at risk of outbreaks. The 2014 MR vaccination campaign promised to mobilise special teams to cover hard-to-reach locations, including haor and char areas, large market places, rice mills, brick fields, brothels and places where working mothers live with their children. But the events of the past month throw into question these promises. A simple solution for Sitakuna and similar marginalised communities would have been to employ members of that very community as healthcare providers, thereby turning a hard-to-reach area into a completely accessible one. Instead, infants of women who cannot avail formal neo-natal care continue to fall out of the vaccination schedule. In fact, 17 percent of caregivers of children who went unvaccinated in the 2014 drive did not even know about the campaign.
With two satellite clinics set up in the tin houses of Birendra Tripura and Mogram Tripura, children are now regularly being vaccinated, and given vitamins, while their parents are being taught about health and nutrition. There are also plans to set up a permanent health camp within the next three months. But the Civil Surgeon informs us they are yet to find a suitable plot of land and the poor weather is making it difficult to begin work. Until the rains let up, there will be no healthcare cenre for the 85 families of Tripura Para.