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How Mongolia is handling the measles outbreak

Photo from Mass.mn

By B.Narantsogt

With a faint, howling draft and dim fluorescent lamps, I spent a paradoxically cold mid-May night at the National Center for Contagious Disease (NCCD). I got up from the springy bed next to the nurse’s post in the large alcove off of a corridor. Thinking I shouldn’t have refused the bed in one of the rooms—it got filled soon after—I prepared a bottle of formula for my seven-month-old son, who slept bundled in a thick blanket. It was 3:00 a.m. On May 18, and after four days of second-guessing and misdiagnosing pediatricians and general practitioners, we finally knew what had been making our son sick: measles.
Known as ulaanburkhan or “Red God”, measles usually starts with a fever, cough, runny nose, and red eyes, with the definitive symptom being the almost whole-body presence of red rashes. Because this rash disappears in a few days, or at least it used to in previous occurrences, parents don’t take this disease seriously. But this spring we have seen a major outbreak in Ulaanbaatar, one that required a campaign for additional vaccination and quite heavy media coverage. Why is that?
According to the World Health Organization (WHO), measles is a highly contagious disease that takes a heavy toll on children under 5, even with vaccinations available. It’s been five years since the last outbreak of measles was reported. Mongolia even received a Measles Elimination Verification Certificate from the WHO Western Pacific Regional Office, the qualification for which requires a case-free streak of three years. One of four countries in the region to get this, Mongolians celebrated while the U.S., Japan, and pretty much every other country actively battled it. A friend of mine later said her daughter had measles in 2013, and when she contacted WHO officials, they explained the certificate was for outbreaks and ignored her questions about how many other individual cases were reported.
The first case of measles in this recent outbreak was reported on March 18. Thirteen days later, when the Ministry of Health held a press conference, there had been 333 suspected and 95 confirmed cases, 22 of which were diagnosed in adults. Noting that this particular strain matches a strain identified in China, the Deputy Minister of Health said, after a pause, “Even a few doctors and hospital staff contracted the disease.” Apparently, vaccinated people, children and adults alike, can get it, provided they have weak immunity and other chronic illness. What’s worse, because we hadn’t had an outbreak of measles in five years, the doctors in the health facilities were not accustomed to it. Added to all that, the fact that this was an airborne disease meant the outbreak would be quite costly. The press conference ended with the Ministry of Health promising a nation-wide vaccination between May 15 to 25, with help from the WHO regional office and UNICEF.

Symptoms

My wife looked concerned when I came home on May 11. “Feel his forehead. I think he’s running a temperature,” she said. I placed my hand on my son, who looked happy to see me, albeit a bit tired. Having recently learned to crawl, he’s usually a bit too excited, so his fatigue was overt.
I said, “Feels okay to me,” and picked my son up.
His mother had taken him to a general practitioner in Sukhbaatar District, having read about the measles outbreak and wanting to get a vaccine, just in case, even though the measles vaccine is given at nine months and my boy was only seven months old. But the GP said it was the flu and told my wife our son didn’t need a vaccine. We wondered, was the GP oblivious to the measles outbreak?
The next day, May 12, my son had a high fever. At this point, we didn’t know what it was and we feared he had flu or sore throat. My parents didn’t see measles as a serious disease; they said, “You had it when you were five years old, and after a few days of fever and red rashes it subsided and you had built an immunity.” My in-laws, who were more worried than me and my wife about the complications, urged us to see a doctor.
As of that day, a month and almost two weeks after the Ministry of Health’s announcement, there had been 4,631 suspected and 527 confirmed cases registered by the NCCD. With three days left for the vaccination campaign, the media was giving steadily buzzing warnings. The national immunization consultancy committee had convened and announced that 150,753 children, from six months to ten years and twenty-nine days old, would be vaccinated.

Diagnosis

The first hospital we went to was a respected, private hospital in Khan-Uul District. As we were explaining that we didn’t have an appointment, our son vomited up his breakfast, so we paid 70,000 MNT to immediately see the pediatrician. Her diagnosis was a sore throat, the rashes behind his ears were explained as allergies, and along with an assortment of medicines, the doctor advised us to run a hot bath for our child, which would “help with the fever”. In hindsight, this misdiagnosis, along with the advice to take a bath- which has adverse effects for measles-afflicted patients, seemed to have exacerbated my son’s sickness and led to several complications. Again, we wondered, was the pediatrician oblivious to the measles outbreak?

Progression

As of May 15, the fever worsened and our boy started vomiting more often, not eating or drinking much. We went to the district’s health center, an overloaded facility where almost everyone goes without bothering to go through a GP. The doctor there advised us to check with the NCCD lest it be measles.
We drove into the gated compound of the NCCD on that dry day, the multiple entrances were teeming with patients – some masked, some not – in long lines. Most of them adults, especially college students. As a group in line explained, apparently, when these students were toddlers, they were given a bad batch of the measles vaccine. That’s why they were coming down with fevers and rashes.
After cutting a line with a baby amongst grown-ups, we entered one of the examination rooms. The gray room with blue tiles looked like a squalid, Soviet-style cafeteria. The NCCD doctor, who had a blinking facial tic from sleep deprivation, listened with a stethoscope and checked our son’s throat. He refused us, saying the rashes were not symptomatic of the measles. I was suspicious that this was an allergy, and I was happy to hear it wasn’t measles. But having been in the vicinity of all those other patients outside, I thought our son probably caught it anyway. It was inevitable at this point.
Two days later, our boy woke up with red rashes all over his face and torso, and six hours later he was finally admitted to the NCCD.
The measles isolation ward is a central building of the labyrinthian, Khrushevka-style compounds. The plaque in the front says, “Hepatitis Clinic”, which shows how makeshift this measles situation has become. Our floor had 11 rooms, which had two to five beds for patients, mostly babies, but with some adult patients. All the patients on the floor had to pass us by when they needed the nurse. In the evening, mothers walked the halls with their crying infants, much to my annoyance, but when my son brayed after midnight, he kept the whole ward awake. The breeze in the alcove made my son cough all night, even in his sleep.
May 18, two months after patient zero’s case, the vaccination campaign was in full swing. It was day three and 66,616 children had been vaccinated. They reported that enrollment was at 17.7 percent. There were 345,968 children aged 0 to 4 and 271,346 children of 5 to 9 years vaccinated in 2014, according to the NSO. With this year’s newborns, the number must be about 700,000.
On this day, my son, irritated with the many medicines I had forced into his mouth, hadn’t been drinking much formula or broth, and coughed and wheezed, and had increasing diarrhea. That morning, the resident doctor, Dr. Enkhjargal, checked on my son, and to my surprise, ordered an X-ray appointment. With a fast talking manner and bold vibe, Dr. Enkhjargal still sounded neutral when she told me the results, and confirmed my fear: my son’s measles had developed a complication of pneumonia. After the X-ray, I had read on the Internet that pneumonia combined with measles was one of the deadliest complications. As I let that sink in, my son cooed and poked the edge of the desk with his little finger. I cried for the next half hour, despite the nurses coaxing me to stop the hysteria, that there were children with worse conditions, some even in comas in the intensive care unit. My wife, who hadn’t gotten much sleep, worried about our boy, came to the hospital. My parents, who were calling me once a day about the baby and said he’d recover soon, also came.
On May 22, my son was checked out of the NCCD. At this point, the hospital had treated his pneumonia and his rashes were disappearing. With plenty of help coming in, especially from my in-laws, our son had timely and tireless support, something I fear is not available for other parents in a similar situation. We ended up buying all the medicines that each doctor prescribed and a humidifier (the NCCD’s humidifier was broken), and I wondered if everyone else was able to manage the aftercare. With some relief, we continued with more medicines and waited for our son’s diarrhea to subside.

Vaccinations

At the end of the campaign, on May 25, the number of children vaccinated in the national campaign had reached 163,216. Ch.Urtnasan, the chief of Public Relations at the NCCD, reported they were treating 811 patients, with 312 caregivers, exceeding their capacity to admit only 530 patients. The suspected cases had reached 8,945, coming from all districts of the city, even Nalaikh.
An NCCD spokesperson said the enrollment rate was at 87.1 percent, and they were extending the vaccination until June 5 to enroll children who missed the campaign. A key revelation that made things worse was that it took 30 days for the inoculated children to build full immunity, and that exposure to measles during this period often resulted in contraction. The fact that some adults contracted the disease didn’t help.
The season wasn’t ideal for isolating the outbreak either. As the end of the academic year saw high school and college students going to the countryside for vacation or to visit family, the provinces declared defensive protocols. Children’s Day on June 1 was coming up, and the NCCD held a press release (because there’s no such thing as a public service announcement in Mongolia) with as much media as possible present to ask parents to celebrate the holiday with their children indoors and avoid public gatherings.
Children’s Day is a time when every child is almost entitled to go out to the National Amusement Park and get sundry sweets in a gift bag. City Hall, which had planned about 145 million MNT for this celebration, stated that the activities they were organizing were outdoors. Yes, they were aware of the measles outbreak, but this was what health officials had advised.

Aftercare

Despite our vigil for recovery and additional medicines, my son’s diarrhea worsened and he was losing weight fast. So, on May 25, we went to a private hospital in Bayangol District. After numerous antibiotics, rehydration drips, and physical treatments, the diarrhea stopped and we checked out of the hospital on the morning of Children’s Day.
It was about 10:00 a.m., but on our way home, we saw very few cars and people, much less children. The traffic was mild and a few kids were at the playground in front of our apartment. Previously, when I was coming and going to and from the hospital, while my wife was there with my son, I had felt bad when I saw the gamboling children and new mothers who held their infants on my way to the entrance. I thought I was carrying an infection that could be transmitted to these children. But on Children’s Day, we didn’t feel any remorse. Infection was everywhere anyway, and if there were children playing outside, they were probably immune. That’s how we rationalized it anyway. My son has recovered and that’s all that matters.

Recovery

On June 2, the NCCD posted a new bulletin, reporting the status of the measles outbreak:
“Nationwide, there are 12,458 suspected cases. [Although, knowing the secret stage of measles and the way the NCCD refuses to admit patients until the rashes actually appear, I suspect there are even more out there.] These are counted from the districts of Songinokhairkhan, Bayanzurkh, Bayangol, Sukhbaatar, Khan-Uul, Baganuur and Nalaikh; provinces of Uvurkhangai, Umnugobi, Darkhan-Uul, Dornogobi, Khuvsgul, Bulgan, Selenge, Bayankhongor, Zavkhan, Dundgobi, Gobi-Altai, Bayankhongor, Khentii and Bayan-Ulgii. There are 540 cases confirmed with lab results and 1,984 cases tracked with an infection-spread study. Five-hundred and forty-nine patients are being treated at NCCD with a diagnosis of a severe case.”
Soon, this outbreak will subside, it might even disappear overnight, leaving everyone exhausted and bitter—just like “The Andromeda Strain”. But unlike its fictional counterpart, this is a disease we have long known. History is full of viral diseases like measles and smallpox, which at some point decimated the Native American population in the 16th century. It’s been 52 years since the measles vaccine has become available. Given the endemic nature of the disease (meaning the disease revisits a community after a few years), it baffles me why we have a period of bad vaccine distribution and why the public and health officials were not well-prepared for this.
I wonder if measles would be extinct if everyone in the world was vaccinated. But then, I read that if more than 95 percent of the community is vaccinated, an outbreak doesn’t happen. Countries with malnutrition and a lack of adequate healthcare get as much as a 10 percent mortality rate during an outbreak. From personal experience, I’ve seen how we’re handling the outbreak, and this is not enough. Unlike in the USA, where delusional mothers skip their children’s vaccination on purpose, we have bad batches and inadequate health care system. If we can reach 95 percent of vaccination, measles could really become a thing of the past.

B.Narantsogt writes for sowhymongolia.com and cracked.com.

Short URL: http://ubpost.mongolnews.mn/?p=15084

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