Caracas Chronicles

Malyn, mother of two teenage boys and an 18 month old baby, tells me this is the first time she has had to struggle to immunize a child at a public facility. She earns less than minimum wage, so paying for vaccines is a non-starter for her.

Her pediatrician gave her an unexpected alternative: go to “Villa del Rosario, Colombia.”

“I’ve been to Colombia many times before, but my money’s not good there,” she tells me, after realizing her baby’s vaccination program was dangerously behind. She braved two hours by bus to the border, crossing the Simón Bolívar bridge with her child in her arms.

She arrived at the Villa del Rosario Vaccination Center. “They hand out a hundred numbers for Venezuelan children on Mondays, Wednesdays and Fridays. I arrived at 6 am and got number 80.”  

They fed both her baby and her, full breakfast and lunch, while they waited for their turn. Her baby got his vaccination program updated, after 8 hours, but it didn’t bother Malyn at all. “They treated us so well. They explained everything I needed to know about my baby’s vaccination program.” They gave her baby all pending vaccines, including chickenpox and hepatitis A.

The EPI – the Expanded Program on Immunization (Spanish acronym “PAI”) – is a strategy developed jointly by the World Health Organization (WHO) and the Pan-American Health Organization (PAHO), to provide 100% vaccine coverage against all biological agents of importance to public health. As a member state of PAHO and WHO, Venezuela established its own PAI in 1974.

In 2004, Venezuela joined PAHO’s Fondo Rotatorio de Vacunas (or Revolving Fund for Vaccine Procurement). The country allegedly adheres to PAHO/WHO recommendations, but incomplete PAI schedules have become increasingly common. The crisis has reached what was probably the last functioning program of our hollowed out, outdated health system, and the seams are showing.

“A lot of children didn’t receive the vaccine against tuberculosis last year,” says Huníades Urbina Medina, president of the Venezuelan Society of Child Care and Pediatrics. “The Venezuelan PAI is outdated. Vaccines against HPV (human papillomavirus), chickenpox and hepatitis A are not included in the program.”

That means that the only way to get these vaccines is by going to private medical facilities, where prices are often astronomical. Dr. Urbina also claims that, in Bolívar, the coverage of the diphtheria vaccine is only 50%.

We asked for the prices at a private clinic. For rotavirus… and the hexavalent… they asked for Bs.1,400,000” – ten times today’s minimum wage.

This is the struggle of folks like Ana, mother of a two month old baby girl.

“My baby’s vaccine schedule is not complete. After birth, we paid for the vaccines she needed. They weren’t available anywhere I asked, so we went to a private pediatrician. Both vaccines were Bs.190,000.”

That was about two times the minimum wage at the time.

Then came the time for the two month old vaccines: “We asked for the prices at a private clinic. For rotavirus (for viral diarrhea) and the hexavalent (for polio, diphtheria, meningitis and other ailments) they asked for Bs.1,400,000” – ten times today’s minimum wage. “We found a public outpatient clinic that had the pentavalent (the hexavalent minus polio), but our pediatrician advised against it; he has concerns about the safety of publicly available vaccines.”

Ana’s worry is permanent now.

“I was carrying my baby the other day and this lady approached us. My first thought was that she was too close to us,” she tells me. “I’m exposing my baby to so many things, and she doesn’t have her vaccines. It’s nerve racking.”

She’s not alone. Yesma, mother of a gorgeous 14 month old baby, has gone through hell trying to vaccinate her kid.

“You complete a dose, then worry about getting the next one.”

When her baby turned one, she called the private clinics and found the viral trivalent vaccine (against measles, parotiditis, rubella). She could afford it, but chickenpox and hepatitis A were $160 each, in cash. No-can-do.

“I heard a story about a doctor charging for saline solution as if it was an actual vaccine. I used to have faith in private doctors, but now, when I leave a private consultation, I feel like it’s an act of faith. I don’t know if it’ll work, I don’t even know where the meds come from.”

Vaccination in numbers

According to WHO data, some of the 2016 vaccine coverage numbers in Venezuela are way below where they should be. Let’s take a look:

Rotavirus

The coverage for the past four years has been consistently below the recommended 95%. Rotavirus is the most frequent cause of serious acute diarrhea in small children.

Diphtheria, pertussis, tetanus

Bacterial trivalent, which protects against diphtheria, tetanus, and whooping cough, also has been consistently below the recommended 95%. This data represents the vaccine coverage throughout the country; in some states, coverage is even lower.

According to the last Epidemiology Bulletin published (the first one since 2015), 324 cases of Diphtheria were diagnosed, mostly in Bolívar, a state that borders with Brazil. Epidemiologists say the first case came from abroad, but now we have autochthonous cases of a vaccine-preventable deadly disease.

The Bulletin also reports 370 cases of whooping cough, also a preventable disease causing serious respiratory infection, possibly lethal. 160 of those cases were diagnosed, again, in Bolívar.

BCG (tuberculosis)

The coverage of the BCG is excellent. 3,817 cases of tuberculosis were diagnosed in 2016.

Other coverages like polio, Hib (Haemophilus influenzae, which causes meningitis and pneumonia), measles and hepatitis B are somewhere in the 80% range.

And this year?

Since no official data on vaccination coverage for 2017 has been available to date, we can only guess. According to a PAHO/WHO statement, 5.3 million doses of vaccines for diphtheria were purchased after the outbreak started. The organization says Venezuela spent about $24 million on vaccines last year; and, according to this other note, Venezuela planned to purchase 20 million doses of immunobiological products for 2017.  

So, why the struggle? Infrastructure is probably to blame. This piece by El Pitazo details numerous complaints by local public institutions; in Bolívar, the Public Health office says it didn’t have the number of vehicles needed for the job. They also lack refrigerators and cold rooms.

Then there’s corruption. Venezuela gets most of its vaccines through the Revolving Fund and contracts with countries like India and China. But, in 2010, the Comptroller General’s office issued a statement declaring they found no receipts backing the vaccines allegedly purchased from Cuban labs between 2005 and 2010. PAHO/WHO provides information on how the Revolving Fund works and how much money it costs, but it doesn’t reveal the exact transactions by each country.

Where the Venezuelan government gets its vaccines from and how the money is allocated remains a mystery.

The hard road ahead

As put by Dr. Silvana Vielma, professor of the Department of Infectious Diseases at ULA’s School of Medicine, “The PAI program is beaten.”

She had a post-vaccinal reaction (an adverse reaction linked directly to vaccination) in her practice, and when she checked for the manufacturer in the patient’s EPI card, she found only the date when the shot was given.

“There isn’t a way to follow up on a lot of biological products,” she says.

If a clinic doesn’t have a power plant… biological products are at risk of losing effectiveness

That particular vaccine was part of the latest government attempt at improving vaccine coverage – the “Plan Nacional de Vacunación ¡Intensificando la protección!”

“The issue here is the conservation of the biological product” she says. “After the many power cuts we deal with on daily basis, how does the public network manage to keep the refrigeration and proper storage for vaccines?”

Concern is also for private practitioners. “If a clinic doesn’t have a power plant, or a way to make sure the cold chain is sustained, biological products are at risk of losing effectiveness.”

Bottom line

You can’t blame a mother for not trusting public administered vaccines. If on top of dealing with shortages, parents are also concerned about the safety of the shots and chose not to comply with the vaccination programs, we might have a potential disaster in our hands. The Health Ministry needs to campaign, big time, bring more transparency to the vaccine acquisition process and make it difficult for parents and physicians to doubt their safety.

As it should be.