Vaccination in Sri Lanka
- Samantha White
- Mar 19, 2015
- 6 min read
Over December 2014 and January 2015, I spent 4 weeks in Sri Lanka on a medical placement at the Panadura Base Hospital and Kuthumathi Women’s Hospital. I spent time in Emergency Medicine, Internal Medicine, Surgery, Paediatrics, and Obstetrics. Utilising this time in the health care system of a developing country, I decided to further explore the role of vaccination in Sri Lanka and how it differs to Australia. To obtain this information, I had discussions with doctors and patients in Sri Lanka, and conducted online research around the topic.
The Vaccine Schedule
With a glance at the National Immunisations Schedules in Sri Lanka and Australia, there are some obvious differences. Some of these are due to varying disease prevalence, and others are due to economical differences.
BCG
Australia has relatively low rates of TB at 6.2 new cases per 100,000 population in 2011, with 88% of notifications being from the overseas-born population [1]. TB is more prevalent in Sri Lanka, with an incidence of 66 per 100,000 in 2013 and a prevalence of 103 per 100,000 [2]. BCG vaccination rates are very high in Sri Lankan children [3, 2], and GFATM has been providing financial assistance for strategies to control TB, including vaccination [60 years]. Australia continues to report a small number of multi-drug resistant TB (MDR-TB) of which all are derived from overseas [1]. Based on these statistics, Australia’s prevention strategy continues to be centralised national TB reporting and surveillance without a need for routine vaccination.
Pentavelent DTP-HepB-Hib
Sri Lanka uses the combination “five-in-one” vaccine for diphtheria, pertussis, tetanus, hepatitis B, and Haemophilus influenzae type b (Hib). This vaccine is cheaper than Australian version (which also includes the IPV), as GAVI/WHO subsidises this vaccine for particular countries. To meet this criteria for WHO/GAVI subsidisation the vaccine must be safe, high-quality, and affordable [4]. By the end of 2010, 61 countries were approved to receive the GAVI-subsidised vaccine, and that number is now up to 73 countries. Increased supply and competition between manufacturers for this large market has also helped drive prices down. As of 2013, a dose of the five in one vaccine costs $1.1 [5].
OPV
The oral polio vaccine is a live attenuated poliomyelitis virus, which is delivered orally. This vaccine is not only simple to administer, but is also low cost and highly effective and also provided intestinal immunity, making it an excellent choice for developing countries with higher prevalence of polio. Australia uses the IPV (inactive polio vaccine), which is found in the combination vaccines given at 2 months, 4 months, 6 months, and 4 years of age. Routine vaccination with IPV alone should only be conducted in countries with low risk of polio and high vaccination coverage (>90%) [6].
Japanese Encephalitis
JE is present in almost all SE Asian countries, and transmission is most commonly via an infected mosquito [7]. In Sri Lanka, JE is endemic countrywide, and transmission occurs all year round. There were 60 reported cases in 2012 [8]. Most JE infections are asymptomatic and only ~1% of cases are serious, however of these 20-30% of cases are fatal, and 30-50% of survivors suffer from permanent neuropsychological sequela such as parkinsonian symptoms, seizures and flaccid paralysis [7]. WHO recommends vaccination in all regions where JE is recognised public health problem [9]. Rates of JE have been decreasing in Sri Lanka, largely due to vaccination, however the virus is not transmitted between humans and therefore there is no heard immunity effect from vaccination and all non-vaccinated people are at risk [10].
Rubella in pregnancy
Most Sri Lankan women have no reliable vaccination records and so rubella boosters are given to all pregnant women to prevent congenital malformations associated with rubella infection during pregnancy.
Tetanus toxoid vaccine in pregnancy
Maternal TT vaccines are administered routinely in Sri Lanka based on WHO recommendations for all women in countries at high risk of maternal and neonatal tetanus infection (Clostridium tetani) to receive the vaccine [immunisation 2006 WHO]. Vaccinating mothers means that the antibodies will cross the placenta and protect the baby for the first few months of life, until they are given their tetanus vaccine as part of the schedule [11]. TT vaccines are also given free of charge in the hospital when a person has a deep wound putting them at risk of tetanus infection; this is consistent between Sri Lanka and Australia.
Another vaccine not on the schedule but that I witnessed being administered multiple times per day, was the rabies vaccine. This was given to a patient following an animal bite, usually from a stray or domesticated dog, or less frequently, a stray cat. The vaccine was administered in conjunction with rabies anti-sera injections at the site of the wound and IM (in the buttocks for example). The rabies vaccine and anti-sera were given free of charge to patients at the hospital. This vaccine is not commonly seen administered in Australia, as we do not have many stray animals on the streets, and most areas of the country are rabies free. Something that shocked me upon my arrival to Sri Lanka was the huge number of stray dogs on the streets, which can transmit diseases and cause injury through bites. Sri Lanka is a developing country, and thus not many people spend money on taking their animals to the vet to sterilise and vaccinate them. So rather, the animals reproduce in large numbers and the offspring get abandoned on the streets, as the people cannot afford to look after them. It was very sad to see so many starving animals on the streets, and also to see so many people coming to the Emergency Department with bite wounds requiring sutures and vaccination for rabies.
Benefits of Vaccination
The differences of vaccines administered between Sri Lanka and Australia not only reflect the varying prevalence of disease in these countries, but also the economic variance. Both Australian and Sri Lankan people are fortunate to have governments that prioritise public health and preventative health programs, and that the vaccines on the national schedule are provided to people free of charge (government funded). This speaks to the fact that vaccination is one of the most cost effective preventative health strategies worldwide.
As a developing country aiming to improve health standards, Sri Lanka has recognised the impact of infectious disease on public health and how vaccination against certain diseases can reduce morbidity, mortality, hospital admissions, time of school or work, and cost of medications. Developing countries such as Sri Lanka are at increased risk of infectious disease due to poorer living conditions, so it is wise for the government to fund these vaccinations for children, providing both economical and health benefits.
Vaccination coverage
Maintaining adequate vaccination coverage is an ongoing challenge in Australia. Falling vaccination rates have been mostly due to public controversy surrounding certain vaccines and an increasing number of people with naturalist beliefs. Sri Lanka has excellent vaccine uptake, and attitudes towards doctors and modern medicine is very different to that in Australia. Many Sri Lankan doctors I spoke to liken the attitudes of the Sri Lankan people to “the old days” in Western countries when “doctors were gods in white coats”, as patient’s in Sri Lanka listen and adhere to anything the doctors tell them. This can be a good thing in the context of important public health measures like vaccination, however also poses problems in other areas of medicine such as ethical practice and patient centred care. These aspects of medicine have been given priority in our teaching in the UWA MD course, and my experiences in the Sri Lankan health care system made me realise how important communication skills and ethical practice are to me as a future doctor. I am now aware that empowering patients to control their own health care and illness experience is one of my values as a healthcare professional.
So not to confuse respect for doctors with ignorance, it is important to comment on Sri Lanka’s literacy and life expectancy. Sri Lanka has an average life expectancy of 75 years [2] (Australia 81) and a school enrolment rate of >95% [12]. This is excellent, and compares well to other WHO listed developing countries. Such a high school enrolment rate is reflected in their literacy. Conversations with my host mother (senior house officer at Kethumathi Women’s Hospital) revealed that most Sri Lankan people are very literate, being able to communicate verbally with their doctors very well and follow written instructions. A major difference between Australians and Sri Lankans is their access to the Internet and social media. Anti-vaccination campaigns run wild in these forums, influencing people in Western countries to doubt the safety and efficacy of vaccination. Sri Lankan people source their information from doctors and health professionals they speak with and are therefore taught that vaccination will protect them and their families from the communicable diseases in their community – which is 100% fact. Whilst in Sri Lanka I did not see a single case of a vaccine preventable disease (VPD), which surprised me at first, but I think this is owed to the National Immunisation Schedule and the excellent uptake of vaccination by the Sri Lankan people.
References
2. http://www.who.int/entity/gho/countries/lka.pdf?ua=1
3. Wijesinghe PR, Palihawadana P, Alwis SD, Samaraweera S. Annual risk of tuberculosis infection in Sri Lanka: a low prevalent country with a high BCG vaccination coverage in the South-East Asian region. WHO SE Asia Journal of Public Health. 2013; 2(1):34-40.
4. http://www.who.int/features/2013/vaccine_prequalification/en/
5. http://www.who.int/pmnch/media/news/2013/20130506_gavi/en/
6. http://www.who.int/ith/vaccines/polio/en/
7. http://wwwnc.cdc.gov/travel/yellowbook/2014/chapter-3-infectious-diseases-related-to-travel/japanese-encephalitis
8. http://apps.who.int/gho/data/node.country.country-LKA
9. http://www.who.int/immunization/research/development/japanese_encephalitis/en/
10. http://www.who.int/ith/diseases/japanese_encephalitis/en/
11. http://www.babycenter.in/x1023109/why-and-when-is-the-tetanus-toxoid-tt-vaccine-given-during-pregnancy
12. http://data.unicef.org/education/literacy
Another excellent WHO resource: http://www.who.int/immunization/sowvi/en/
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