Even before the Covid-19 pandemic, the Caribbean had a vaccination problem.
About 10 years ago, childhood immunisation rates began to slip below the World Health Organisation’s recommended 95 percent, leaving the region vulnerable to a potential re-emergence of deadly diseases like polio, measles or mumps.
When the pandemic hit, those rates plummeted further in many countries.
“If you look at the Caribbean as a whole, we find that of the more than 11,000 children younger than one year who live in the Caribbean, almost one in ten did not receive all of their vaccine doses,” Dr. Margherita Ghiselli, an immunisation advisor with the Pan American Health Organisation, told the Caribbean Investigative Journalism Network during a virtual PAHO media briefing in April.
Much of the rest of the Americas faces a similar predicament, which health officials often blame on a Covid double-whammy: First, movement restrictions during the pandemic limited access to routine medical care; and second, misinformation associated with the Covid shot has made people more reluctant to trust any vaccine.
Falling vaccination rates could be deadly at a time when diseases like measles, mumps and polio have started to re-emerge in the Americas.
To fight back, Caribbean health officials are doubling down on education efforts — even in countries that have managed to keep their own vaccination rates relatively high.
Two Countries
Two affected countries are St. Kitts and Nevis and Antigua and Barbuda, both of which face elevated risks associated with tourism industries that attract hundreds of thousands of visitors each year.
In ANB, vaccination rates for eligible children were well below the 95 percent target during the pandemic. The Measles, Mumps and Rubella (MMR) vaccines 1 and 2, for instance, bottomed out at 85 percent and 76 percent in 2021 before recovering to 100 percent last year, according to PAHO statistics.
“There has been an exceptional record of vaccination in Antigua and Barbuda except for the last three years,” Sir Molwyn Joseph, ANB’s Minister of Health, said during the opening of a Vaccination Week observance in April.
In SKN, the rates dipped less dramatically during the pandemic, with MMR 1 and 2 sliding from 99 percent in 2020 to 95 and 93 percent last year — a record that SKN Chief Medical Officer Dr. Hazel Laws said means the country fared much better than many others.
“A coverage rate of greater than or equal to 95 percent was not achieved in 20 countries in the Americas, and St. Kitts and Nevis was not amongst them,” Dr. Laws told CIJN.
A bigger problem in her country, she said, was the decline in recently introduced HPV vaccinations, which hit a rate of 92 percent for HPV 1 and 87 percent for HPV 2 in 2020, the first full year of the rollout.
“We’ve seen a gradual decline over the subsequent two years,” she told CIJN. “But that’s understandable, for that is the Covid period and we didn’t even get the chance to start strong. And now add vaccine hesitancy to that.”
Potential Outbreaks
Now, both countries are sounding the alarm amid concerns that sliding immunisation rates could put them at risk.
“The region of the Americas is facing new measles outbreaks after it was declared measles free in 2016,” SKN Prime Minister Dr. Terrance Drew warned in his Vaccination Week address in April. “Between 2020 and 2021, the vaccination coverage rates of measles, mumps and rubella vaccines (MMR1 and MMR 2) have decreased in this region, and several children are susceptible to measles.”
As of June 6, the United States Centers for Disease Control and Prevention reported 167 cases of mumps in 34 jurisdictions in the United States, with California (11), Illinois (15), New York City (17) and Ohio (20) being areas with the largest spread.
Additionally, Dr. Laws pointed to a case of measles recorded in the US last year and a case of polio in Peru that left a 16-month-old boy with paralysis — even though polio was declared to be eradicated from the Americas in 2001.
Tourism Economics
The threat of vaccine-preventable diseases spreading across the Americas comes as travel is picking up and the Caribbean’s bread-and-butter tourism industry is returning to pre-pandemic levels.
“This situation leaves the Caribbean susceptible to new outbreaks,” Dr. Ghiselli told CIJN, adding, “With such a strong tourism economy as in the Caribbean, the risk of importation is high, which is why it is so important to spread vaccination coverage rates in all countries and territories of the Caribbean, not just St. Kitts and Nevis.”
But that task has not been easy.
Since the start of the pandemic, there have been growing concerns over vaccines, their efficacy, how they were produced, and whether they were rushed in the manufacturing process. In much of the world, those concerns have been greatly magnified by the misinformation and disinformation that has circulated widely online.“During the Covid-19 pandemic, anti-vaccine beliefs have been at an all-time high, and vaccine hesitancy has become a major threat to public health,” according to the 2022 research paper “Misinformation and Covid-19,” published by the US-based National Institutes of Health.
In small island states like SKN and ANB, such misinformation — which caused the WHO to declare an “infodemic” — has spread quickly via social media.
Dr. Shivon Belle Jarvis, head of the Paediatric Department at the Mount St. John Medical Center
in ANB, has seen the effects first-hand.
“We recognise that we had several cases of incomplete immunisations,” Dr. Belle Jarvis told CIJN. “And this would have occurred for several reasons: one, vaccine hesitancy, because some persons perceived, … ‘They are giving my child the Covid-19 vaccine,’ even though they’re told that they’re given the regular childhood vaccinations. So the whole issue of hesitancy and trust became an issue.”
Additionally, she said, the pandemic kept people at home, precluding regular child healthcare visits.
Eulana Weekes, a mother of three in SKN, described an information vacuum in her country that she believes has allowed misinformation to flourish.
“It is a requirement that my children should be vaccinated, so I take them to the health centre to get that done,” she said. “However, I do not think that enough is being done to ensure that parents really understand the importance of their children being vaccinated. You take them to the health centre and the nurse administers the vaccine, but the understanding is not there.”
Former SKN Chief Medical Officer Dr. Patrick Martin suggested that SKN is “a victim of its own success,” whereby residents have fallen victim to complacency owing to the robust efforts to combat various ailments in children over the years.
Education
It is against that backdrop that the governments in both countries are now embarking on campaigns to educate the public about vaccinations, especially at the early childhood level.
Dr. Laws said that the SKN Ministry of Health will continue to educate young mothers about the importance of having their children vaccinated in order to minimise the likelihood of any outbreaks.
But she noted that more education is needed and the media also has a role to play in spreading the word, especially when it comes to the new HPV vaccine.
Dr. Laws also underscored her ministry’s efforts during Vaccination Week in the Americas, which included partnerships with clinics where community health nurses undertook to get out and promote vaccinations.
And for children who missed their appointments, Nurse Nekesha Hazel said they made home check-ups.
Balancing Health and the Economy
Because SKN and ANB are both heavily tourism-dependent, a major outbreak of a vaccine-preventable disease could once again have them struggling to balance between the health of the nation and the economy.
During the Covid pandemic, that balancing act had dire effects across much of the region.
SKN largely played it safe, implementing stricter restrictions than many other Caribbean countries.
Partly as a result, its gross domestic product contracted 14.5 percent in 2020 and another 0.9 percent in 2021 before rebounding about nine percent in 2022, according to the International Monetary Fund.
Despite the turnaround, the country’s tourism recovery last year was still “lagging the [Eastern Caribbean Currency Union] and other Caribbean peers because of stricter and longer-lasting Covid restrictions,” the IMF found.
Visitor numbers tell the story as well: SKN port officials reported 1,107,000 arrivals in 2019, dropping to 301,400 in 2020 and 122,600 in 2021 before recovering somewhat last year to 537,300. The increase accelerated after the government lifted Covid travel restrictions last September.
ANB, meanwhile, took a less strict approach. It closed its borders early in the pandemic, but it began to substantially ease restrictions before much of the rest of Caribbean.
During the height of the pandemic in 2021, for instance, the Cabinet agreed to remove some of the travel restrictions that had been implemented under State of Emergency Orders. All measures were then removed last year.
GDP numbers suggest that the ANB economy recovered faster than SKN’s, but still took a big hit. The country’s GDP contracted by 17.5 percent in 2020, but grew 6.6 percent in 2021 and 8.5 percent in 2022, according to the World Bank.
Any future outbreak of a vaccine-preventable disease would likely trigger similar effects as developed nations issue advisories that prompt travellers to postpone or cancel their trips.
As Caribbean countries learned during the pandemic, such advisories can shut down a tourism industry virtually overnight.