Thousands of babies countrywide are not getting their vaccinations on time, sparking fears that another deadly measles outbreak is imminent.

The main obstacles are vaccine stock-outs at clinics and the incorrect storage of vaccines, which renders them useless.

Recent measles cases were discovered in Johannesburg and Tshwane even amongst children who had been vaccinated – yet there should be no new cases if government’s claim that 100 percent of children were properly immunised in 2012 is true.

While champagne bottles popped on New Year, one-year-old West Rand toddler Adam Liss was struggling.

“He was a fluey, feverish and miserable – he was just a pain,” remembers Adam’s mom, Andrea.

Doctors speculated that Adam had an ear infection until, days later the answer revealed itself in a wave of tell-tale measles spots. Shortly afterwards, Adam’s father, Mathew contracted the virus.

“We just don’t know how the hell Adam or Mathew got it because they were both vaccinated,” says Andrea.

Meanwhile, nine of the 24 children at Matilda Mothapo’s crèche in Soshanguve outside Pretoria also developed measles in late 2014. In Tshwane, about a quarter of children never receive the measles booster shot that helps increase the vaccine’s effectiveness.

Echoes of an outbreak

In 2009 and 2010, South Africa saw a national measles outbreak with an estimated 18 356 measles case, according to the World Health Organisation (WHO).

With the current level of immunisation, measles outbreaks occur every four years, according to health expert Dr Neil Cameron, which means there could be another outbreak this year.

The last outbreak claimed the life of Phumla Tsama’s two-year-old daughter, Hlomani. Hlomani was not vaccinated for measles after being turned away from a North West clinic that was out of stock, Tsama says.

“The clinic told me to come back but to be honest, I didn’t,” said Tsama, who added that she had not known how dangerous measles was.

Hlomani died after almost three painful weeks in hospital. About a quarter of measles cases need to be admitted to hospital for complications like pneumonia and high fever.

As part of a Health-e News Service investigation into vaccinations, we conducted weekly monitoring at five clinics in Gauteng, the Eastern Cape and Limpopo during February.

During this time, there were stock-outs of polio, rotavirus, tetanus and hepatitis B. One clinic in Limpopo’s Vhembe district reported stock-outs of both polio and hepatitis B vaccines. Stock-outs lasted anywhere from one to four weeks.

Additional spot checks of five Limpopo clinics found one had no rotavirus vaccine, which aimed at preventing diarrhoea.

No vaccine is 100 percent effective but if at least 95 percent of South Africans were vaccinated against measles, we would eliminate new cases, according to the WHO.

“If you have a large enough number of people in the community that are immunised, that means if someone comes into that community with the virus, it can’t spread from child to child,” says Cameron.

In 2012, government and the WHO released very different estimates of South Africa’s measles vaccination rates. Government cited 100 percent coverage while WHO estimated that only 79 percent of children had been immunised.

Both estimates are based on problematic data but what is clear is that South African measles vaccines are not reaching the 95 percent of children needed to eliminate new cases.

Stock outs and problematic vaccines’ storage are just some of the hurdles standing between children and vital vaccines.

• Download measles incidence, vaccine coverage estimate data 

Missing the shot

The rural Eastern Cape has some of the lowest child immunisation rates, according to the Health Systems Trust’s latest District Health Barometer. Only 60 percent of children in Alfred Nzo district were fully vaccinated by the age of one, while almost a third of children in the neighbouring OR Tambo district failed to get their second, booster measles vaccination.

Phateka * lives in central Mthatha where she shares a backroom with her young daughter and nieces. She takes the girls to the local Ngangelizwe Clinic for vaccinations where she and others mothers have been turned away due to vaccine stock outs.

The rotavirus vaccine is given to children in two doses, one at six weeks and the second at 14 weeks. Children who miss the second dose have until 24 weeks to be vaccinated as the vaccine does not work on older children.

During a rotavirus vaccine stock-out at Ngangelizwe, Phateka arrived late for her daughter’s second rotavirus dose. As she was close to the cut-off date, nurses advised her to visit a private pharmacy where Phateka paid R300 for the shot.

When Health-e visited Ngangelizwe Clinic, mothers also reported that nurses refused to immunise their children unless their “Road to Health” cards were covered with plastic.

Vaccines travel a long road to get from factories to clinics and making sure that they are stored at the correct temperatures is a challenge.

[quote style=”boxed” float=”right”]”Nurses were immunising children with these frozen vaccines… moms that were going through the trouble of getting their children vaccinated (were) given a false sense of security…”

Six of the 11 clinics visited had storage problems. One Limpopo clinic’s fridge was twice as hot as the recommended storage temperature, another had a broken door and kept opened measles vaccines for longer than recommended. One did not have a thermometer to monitor fridge temperatures.

Monique Lines is a pharmacist who until recently worked in the OR Tambo district, which was worst hit by the last measles outbreak.

Lines says some nurses struggle to understand storage requirements, as she discovered on a visit Pumalanga Gateway Clinic, which had stored vaccines at minus 10 degrees instead of between two and eight degrees.

“I called the clinic manager in to explain the problem and it became blatantly obvious that neither the clinic manager nor her nurses were able to accurately read a thermometer,” says Lines.

The district had to write off R 100 000 worth of vaccines rendered useless due to freezing.

“The sad thing is that the nurses were immunising children with these frozen vaccines and signing their Road to Health cards. Moms that were going through the trouble of getting their children vaccinated (were) given a false sense of security,” says Lines.

• View data on national vaccine spending

A matter of time

Dr Karl le Roux, the principal medical officer at Zithulele Hospital, is currently following 480 babies born in OR Tambo district last year as part of the Zithulele Birth Follow-up Study.

A significant proportion of babies in the study are not getting vaccines at the right ages, mainly because of clinic stock-outs.

“If we are to deliver proper healthcare to all South Africans, we have to get the basics right and there is nothing more basic than doing childhood immunisations properly,” says Le Roux, who is also an executive member of the Rural Doctors Association of SA (Rudasa).

“We need to ensure that every baby gets its immunisations on their first clinic visit and that every clinic has a functioning fridge that is checked every month.”

A few months ago, Nomvuyiseko Valelo (20) and her son, Lonyaku, were turned away from Mapuzi Clinic in Coffee Bay when he was nine months because the clinic had no measles vaccine.

However, a visit to Mapuzi Clinic revealed one extremely overwhelmed professional nurse, Zola Willie, having to deal with around 60 patients a day – 20 of whom were babies that needed immunisations.

Many vaccines, like the measles vaccine, also need to be reconstituted – or mixed with another liquid – before being administered. However Lusikisiki nurses report that packers at the Mthatha medicines depot often do not pair the right reconstituting liquid with the right vaccine.

But there is hope for school-going children. As part of government’s efforts to strengthen primary healthcare, it is reintroducing nurses in schools – and one of their primary tasks is to ensure that all pupils are up to date with their immunisations.

The National Department of Health’s Expanded Programme on Immunisation undertook to urgently investigate the stock outs.

Meanwhile, government is also working to reintroduce school nurses as part of its primary healthcare revitalisation programme. One of the main aims of the nurses is to ensure that all children are fully vaccinated.

* Not her real name.

Reporting by Kerry Cullinan, Laura Lopez Gonzalez, Sibongile Nkosi, Tshilidzi Tuwani, Ziyanda Masinyane, Tandeka Hlongwane, Ndivhuwo Musetha, Mtshana Mvlisi and Lusanda Ngcaweni

An edited version of this story first appeared in the 10 March edition of The Star newspaper. This work was supported by a grant from the African Story Challenge.

Read more from Health-e’s investigation into vaccination in South Africa “Shots in the dark?” as part of the African Story Challenge:

• Shots in the dark? Snapshots of Health-e investigation
• Stock-outs, low awareness stymie immunisations
• Vaccinations are everyone’s business in Shoshanguve
• Film: Shots in the Dark? A look at vaccines in the Eastern Cape
• Missing babies, missing booster shots in the Eastern Cape
• What is measles?