What happens when vaccine scepticism takes over? Look to the Philippines

After a widely-used vaccine was drawn into question, trust in immunisations plummeted. Now the Philippines is in the grip of multiple severe outbreaks

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By PETER IMBONG  source : Wired

 Monday 30 September 2019

 NOEL CELIS / Contributor / Getty Images

On Friday, September 13, Monalyn Naturan sat on a bed in the emergency ward of a hospital in the Filipino capital Manila. Cradled in her arms was her eight-month-old baby – beads of sweat on her forehead, eyes closed in a slight wince, asleep.

Two days earlier, Naturan had woken up at two in the morning to find her only child with a fever of 39.9 degrees Celsius. At first she wondered if her child was teething, but fearful that the fever could be something more serious, she headed to the emergency ward where they sent her and her child home because it was too early to test for the disease she feared her baby might have. By early Friday morning Naturan was back in the hospital. The diagnosis was as as she feared: her baby had dengue.

In August, the Philippines officially declared that it was in the middle of a national dengue epidemic. Cases of the mosquito-borne virus had risen to unprecedented levels in a span of a few months. Between January and July 2019 there have been 146,062 dengue cases – 98 per cent higher than the previous year. Of that number, 622 people have died.

Six months before the dengue announcement, representatives from the Philippines Department of Health sat in front of the same pool of reporters declaring a measles outbreak in Metro Manila and Central Luzon, regions with a combined population of more than 25 million. In 2005, the Philippines recorded zero measles cases. At the time of the announcement in 2019, it had 12,700 cases and 203 measles-related deaths.

The Philippines and its Department of Health are facing a crisis many countries have never encountered before. After a scandal that prompted widespread mistrust of vaccines, what were once manageable diseases are now tearing through the country’s young population, potentially rolling back the positive results of decades of successful immunisation campaigns.

At the time of writing, there have been 250,000 cases of dengue in the country with more than 1,000 deaths. Five- to nine-year-old children account for almost a quarter of all cases with 39 per cent of them not surviving.

The mosquito-borne viral infection first manifests itself with flu-like symptoms: severe headache, pain behind the eyes, muscle and joint pain, nausea, and vomiting. It can then develop potentially lethal complications called severe dengue, with abdominal pain, persistent vomiting, rapid breathing, bleeding gums, fatigue and restlessness.

Dengue has no specific treatment, but early detection and access to proper medical care can lower fatality rates to below one per cent. It also has four serotypes, which means you can catch it four times with each contraction making you immune to that specific type.

“The current measles outbreak is among the most severe, and the current dengue outbreak is the most severe in the time I’ve been a medical professional – 51 years,” says Esperanza Cabral, a former secretary of the Department of Health. Dengue isn’t actually unusual this time of the year when monsoon rains come and stagnant bodies of water become prime breeding ground for mosquitoes carrying the virus. But the numbers have never been this high.

And while there is no known cure, there is a vaccine that helps prevent dengue. But in 2017 the banning of this vaccine – and the subsequent panic that spread to other vaccines – kicked off a spiral of events that may have accelerated the current outbreak.

In April 2016 the World Health Organisation (WHO) endorsed the first dengue vaccine, Dengvaxia, created by French pharmaceutical firm Sanofi Pasteur. According to the WHO, Dengvaxia is 93 per cent effective against severe dengue and reduces hospitalisations due to the disease by 82 per cent. That same month, the Philippine’s government began a $67 million (£54m) school-based dengue immunisation program. By the end of the year, more than 800,000 children were given the vaccine. The celebrations, however, were short-lived.

In November 2017, Sanofi Pasteur released a statement saying that new analysis had revealed that Dengvaxia is most effective in patients who have already been infected by at least one serotype of dengue. Meanwhile, for those not previously infected by the dengue virus, “the analysis found that in the longer term, more cases of severe disease could occur following vaccination upon a subsequent dengue infection.”

That was enough to trigger the country’s vocal vaccine sceptics to conclude that the vaccine meant to prevent dengue was a cause of the disease. “But that’s not what Sanofi said,” clarifies Edsel Maurice Salvana, director of the Institute of Molecular Biology and Biotechnology at the University of the Philippines Manila. Salvana points out that Dengvaxia doesn’t increase the risk of anyone getting dengue. What it does increase is the risk, for people who have been vaccinated and have never been infected with dengue, that any subsequent dengue infection will progress to severe dengue.

“Dengvaxia, like all other vaccines, carries some risks,” says former health secretary Cabral. “It does not mean that when used properly, it will not benefit patients and the public in general.” In May 2019 the US Food and Drugs Administration licensed Dengvaxia for use in children and teens who have already had one previous dengue infection and live in places where the virus is endemic. Brazil, which had widespread Dengvaxi immunisations, has limited its use to those older than 15. But in the Philippines, the worrying announcement had already sparked widespread mistrust of the vaccine.

By December 2017 the Department of Health suspended the vaccination program following concerns over the risks raised by Sanofi. The sale of the vaccine was stopped, and a senate inquiry followed soon after. That same month, the WHO Global Advisory Committee on Vaccine Safety echoed Sanofi’s statement recommending that Dengvaxia should not be given to individuals who have not been previously infected with the dengue virus.

The head of the Public Attorney’s Office, Persida Rueda-Acosta, appeared in front of reporters, together with the parents of children who allegedly died after receiving the vaccine despite providing no clear evidence that Dengvaxia was the cause. Over the next few months, Acosta began a media crusade against Dengvaxia presenting the sobbing parents of dead children whose deaths were allegedly caused by the vaccine, and autopsy reports describing graphic hemorrhaging and organ failure. She’d also invite camera crews to morgues where the children’s bodies lay. Not a medical doctor, but with a flair for the dramatic, she called it the Dengvaxia Death Syndrome.

Acosta became the face of anti-Dengvaxia. Nearly every day on the country’s most popular primetime news programs, broadsheets, and news websites she, together with the director of her office’s forensic laboratory, would explain that while their findings are inconclusive, the symptoms appeared months after the children’s last vaccination, and that was enough. The mere mention of the vaccine’s name in casual conversation would prompt comments about death. And it took down other vaccines with it.

The Philippines was among the first in the world to introduce the Haemophilus influenzae type B vaccine, and one of the earliest countries in the region to introduce the rotavirus vaccine and the pneumococcal conjugate vaccine. In the 1990s there were government-declared immunisation months where millions of children would be vaccinated annually – an effort lauded by the WHO. “And we were able to achieve our millennium development goals of reducing the child mortality rate by two-thirds in 25 years which is credited to vaccination,” explains Lulu Bravo, a pediatrician of 43 years and the executive director of the Philippine Foundation for Vaccines, a non-profit composed of medical professionals and concerned public individuals. “It’s really so frustrating. And now we are starting to lose that edge over vaccination.”

Vaccines may have become victims of their own success, says Salvana. Because people weren’t seeing what the diseases being prevented looked like, they became complacent and immunisation rates started dropping. “The Dengvaxia controversy turned a bad situation worse.” In a 2018 joint report by the WHO and UNICEF, it was revealed that immunisation coverage in the Philippines has been declining since 2008 especially for vaccines addressing tuberculosis, polio, diphtheria, and measles.

The current health secretary, Francisco Duque III called out Acosta for her “baseless claims and accusations” that have resulted in the “decline in vaccine confidence and a rise in cases of measles and other vaccine preventable diseases.” Acosta, meanwhile, has continued to deny a role in the country’s growing vaccine hesitancy. (Acosta’s office did not respond to emails and calls requesting comment.)

“Without any doubt, the Dengvaxia issue caused the chaos and panic among mothers who began to fear vaccination,” says Bravo. “Mothers really shunned it.” She recalls an incident in 2018 when local health workers went house-to-house to campaign for vaccines. “The mothers didn’t want their children to be vaccinated, even throwing stones at the health workers while calling them child killers.”

According to a study by the London School of Hygiene & Tropical Medicine published in the scientific journal Human Vaccines & Immunotherapeutics, in the Philippines, the public's confidence in vaccines dropped after the highly-politicized Dengvaxia crisis. From 93 per cent of their 1,500 participants "strongly agreeing" that vaccines are important in 2015, down to a third in 2018.

The loss of confidence in vaccines has become a global trend already seen in countries like the United States, China, India as well as countries in Europe. In the WHO's 2018 Global Assessment Report of the Global Vaccine Action Plan. It noted that while 2017 had the highest reported number of immunised children, 2018 “starkly illustrates how easily hard-won gains are lost.”

In Manila, some people have taken the dengue epidemic into their own hands. A councilman in the country’s largest city was reported to have released 1,000 cane toads into the city’s sewers hoping they would consume mosquito larvae. But his efforts were immediately followed by criticism, after it was revealed that cane frogs are, in fact, an invasive species and that their skin has toxin glands that are deadly to animals like dogs and cats.

The issue has also become mired in the country’s class tensions. Since the vaccine is no longer available in the country, some scared and wealthy parents have chosen instead to travel to neighboring Singapore or other Southeast Asian countries to have their children vaccinated. Dengvaxia is currently licensed for use in 20 countries including the United States and parts of the European Union. No vaccine-related deaths have been reported in other countries.

“I want to think this is the worse (that could happen) because it’s already pretty bad,” says Salvana. “What gives me some hope is that people came flocking back to vaccines after the measles outbreak. It’s always harder to see the benefit when people aren’t dying because it isn’t an explicit outcome. But we need to remember the past or we are doomed to repeat it.”

In late September, the Department of Health confirmed the re-emergence of polio with two recorded cases since the WHO declared the Philippines polio-free 19 years ago. Two confirmed cases in a polio-free country are enough to declare an outbreak. The first patient, a three-year-old girl, was unvaccinated against polio, said a health department director. According to another health official, the second confirmed case in a five-year-old boy could have been caused by a delay in his vaccination.

“It is unthinkable that a child will suffer from a disease that is highly preventable by vaccination,” the health secretary said in a statement. The agency and its partners are now working on a comprehensive outbreak response, including mass polio immunisation rounds. A few days later, the agency also announced that it is seeing a rise in the number of cases of diphtheria, a bacterial disease that affects the nose and throat. The increase was attributed to low immunisation coverage.

A few hours after Monalyn Naturan’s daughter was diagnosed with dengue at the emergency ward, a nurse dropped by to say that a room was finally being prepared for them. She was relieved. Based on Sanofi and WHO recommendations, when her baby gets better, she’ll now be a prime candidate to receive the Dengvaxia vaccine. That would prevent her from getting any of the three other serotypes of dengue in the future. Would she let her baby be vaccinated then?