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Diphtheria epidemic in former Soviet Union |
Brisbane-based Allan Bass, from the Australian Centre for International and Tropical Health and Nutrition at the University of Queensland, returned recently from Moldova in the former USSR. He was there to oversee the implementation of a diphtheria vaccination program to counter the effects of an epidemic that has ravaged the region in the last four years, but which finally seems to be under control.
With the collapse of the Soviet Union in 1990 and subsequent economic and political upheavals, the health care system broke down and the standard of living fell dramatically. Over the autumn and winter of 1994-1995, diphtheria , a disease that kills about one in 20, infected 50,436 people. To illustrate just how quickly the disease took hold, no cases of diphtheria had been reported in 1985-86.
The old Soviet system had an elaborate, cumbersome immunisation schedule in place, with multiple doses of vaccine (as many as 13 doses of BCG by the time a child was 16) and problems with storage. A cold chain system did not exist.
To make matters worse, Russia, which produced vaccines for the region, was demanding hard currency from the NIS (Newly Independent States) as payment. With no hard currency to buy vaccines, immunisation rates in the NIS quickly fell. And with travel restrictions lifted, the spread of diphtheria was assured.
In 1992, USAID sponsored the delivery of the first large international shipment of vaccines to the central Asian republics of the NIS. Since then, the Red Cross, UNICEF, and the EU have contributed vaccines. Their mission was to ensure the immunisation of all children younger than one year of age.
Since then, Mr Bass said there had been a rationalisation of the immunisation schedule and that, between 1992 and 1995, the situation improved slowly. The most dramatic decline began in November last year when the mass immunisation campaign and the use of antibiotic prophylaxis of contacts of cases began to have an effect. However, it had been a hard slog, Mr Bass said, not least changing the mind set of service providers, who were used to working off several pages of contraindications.
\"About one third of diphtheria cases - a crude estimate - are in contraindicated children,\" Mr Bass said. \"For example, [in] institutionalised children with disabilities ...[vaccination is] contraindicated simply because they are disabled. Now most of the cases occurring are in institutions.\"
Cases of diphtheria had been rising dramatically when school started each autumn and again between January and March. School has just started in the NIS, but so far, the numbers of reported cased are low. Health authorities are predicting a continuation in the decline of diphtheria cases this northern winter.
Diphtheria is one of the vaccines that is damaged by freezing and this is a common problem in the cold climate of the NIS. For the future, an indicator is being developed that will show at a glance if the vaccine has been frozen. However, it would be a while before it was introduced, Mr Bass said. After all, it took 10 years to develop and introduce the heat sensitive label used on UNICEF-acquired oral polio vaccines.
The diphtheria epidemic in the former USSR provides an example of how the breakdown of the immunisation system can quickly lead to outbreaks of disease that were thought to be virtually a thing of the past, particularly in developed countries.
This article was published in GPSpeak in October 1996.
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