Vaccine hesitancy brings whooping cough epidemic to North Macedonia

H. H. Salter, On asthma: chest of an asthmatic. Wellcome Collection. Public Domain Mark. Source: Wellcome Collection.

This article is based the coverage by An edited version is republished here under a content-sharing agreement between Global Voices and Metamorphosis Foundation. 

Between January 1 and February 14, 2024, the Institute for Public Health of Republic of North Macedonia registered 28 cases of whooping cough (pertussis), mostly in unvaccinated babies. This is more than twice the total the number of cases in the previous five years (2019–2022) which amounted to 9.

Epidemiologists warn that children who haven’t been vaccinated should not go to kindergarten to avoid epidemics that threaten the health and life of both children and seniors. They also insist on vaccinating the population, in compliance with the the Commission for Infectious Diseases’ proposal to declare a whooping cough epidemic in the capital Skopje. talked to Professor Nikola Panovski, MD PhD, and Aleksandar Stojanov, MD, who believe that people can be protected only with the DTaP vaccine, which is given five times in childhood.

The vaccine is mandatory

“Children who are not vaccinated should not go to kindergartens. There are also some children in schools who are not vaccinated, but it is deemed that they would overcome the disease easier and therefore they are not as risky. But the babies must be protected,” says Professor Nikola Panovski, who teaches Medical Microbiology at the Medial Faculty of University Sts. Cyril and Methodius in Skopje. “Secondly, quick diagnostics is also a must. If the doctor suspects whooping cough, an antibiotic should be prescribed. It cures slowly, but prevents the spread of the disease.”

According to Panovski, the misinformation and disinformation around vaccines that was rampant during the COVID-19 pandemic brought about the fear of vaccines and lack of trust, which increased the number of anti-vaxxers. “Skopje has the lowest percentage of vaccinations, specifically in the urban municipalities Centar and Karpos. The anti-vaxxers caused a great deal of trouble,” he says.

Panovski's colleague Dr. Aleksandar Stojanov, a retired epidemiologist who used to serve as the head of the Institute for Public Health, warns that the danger of a widespread whooping cough epidemic is real, comparing it with the epidemics of measles and mumps a few years ago.

There were no whooping cough epidemics in the [recent] past. But then the process was good — DTaP was given five times in a lifetime and people were protected. We allowed the anti-vaxxers to shrink the vaccination percentage. It should be 98 percent if we want the population to be protected. If it is below this percentage, it could always return.

‘In the past we were going to the villages to vaccinate’

Stojanov recalls the 2018 measles epidemic, when the first case appeared in a school in Skopje suburb of Radishani.

Once everyone got vaccinated, the situation calmed down. Mumps epidemic broke out in Bair in Bitola and was quickly spreading. Vaccination has always been a problem. However, in the [more distant] past we used to have a good system that worked. We were going to the villages and vaccinated people, we did not wait for them to come to the clinics. Every 45 days we went to the villages, there were regular rounds with set schedules. Now we are waiting for them to come to us, but they are not coming. And the vaccination centers were also downsized, and the number of vaccination teams also decreased. More needs to be done in the field. In the past everyone was vaccinated with DTaP. The problem is in Skopje where the anti-vaxxers are concentrated. In the villages people trust the doctors.

No vaccine has 95% coverage

The recommended coverage above 95 percent has not been reached for any primary vaccine at the national level. The registered primary vaccination coverage is below 90 percent for all vaccines, including those against Hepatitis B, Haemophilus influenzae type B, DTaP/IPV, and MRP, as well as vaccination against HPV, which has the lowest coverage of all vaccines.

According to the latest report from the Institute for Public Health.

The primary vaccination coverage with three doses of the vaccine against HiB, DTaP and IPV for the entire country was 83.9 percent for 2022. Lower than 90 percent coverage was registered in the territories of Veles, Gevgelija, Shtip, Ohrid, Tetovo, Prilep, Skopje, Bitola and Strumica, while the lowest coverage of 53.7 percent was registered in Kumanovo. From the total number of children who should have been vaccinated, 3,322 children were not vaccinated, out of which 41 percent (1,368) are from Skopje and 27.4 percent (910) are from Kumanovo.

Since 2015, the first DTaP revaccination has been constantly declining, reaching the lowest coverage of 66 percent in 2020. A decrease in coverage was also registered in 2022 (69.3 percent) compared to 2021 (72.8 percent). The average coverage for 2017–2021 is 78.1 percent, higher than the registered coverage in 2022.

The revaccination coverage with DTaP/IPV among seven-year-old school children in North Macedonia is 88.5 percent, which is an increase compared to 2020 (87.3 percent) and 2021 (74.7 percent). The revaccination coverage with DTaP/IPV among 14-year-old school children (89.3 percent) shows an increase compared to 2020 (80.3 percent) and 2021 (85.9 percent), but the percentage is still below 90.

Parents should vaccinate their children immediately if a dose is missed

Recently, Kristina Stavridis, MD from the Public Health Institute stated for that the parents should check their children’s vaccination cards and if a dose of vaccine is missed or they have not been vaccinated at all, they should immediately call the vaccination center to vaccinate their child according to the vaccination calendar.

The emergence of pertussis [whooping cough] cases is not unusual, especially now when the region and Europe have registered epidemics and an increasing number of cases. This is especially true in a situation when we are facing reduced vaccination coverage.

The disease can cause brain damage in babies

The Public Health Institute published information related to whooping cough. In the part dealing with complications, the following are listed: pneumonia, inflammation of the middle ear, loss of appetite, dehydration, convulsions, brain damage, hernias, fractures in the chest area, prolapse of the colon, and episodes of respiratory arrest.

Whooping cough causes serious complications and sometimes even death in children under one year of age. One-third of the children under one year of age who get sick with whooping cough need hospital treatment. The most common complications are apnea (life-threatening cessation of breathing), pneumonia (inflammation of the lungs), convulsions, encephalopathy (brain damage), and every 100th patient may die. The complications are less severe in older children and adults, especially those who have previously been vaccinated against whooping cough.

The best way to prevent whooping cough is vaccination with combined vaccines of Hexaxim (DTaP-IPV-HiB-HepB), Pentaxim (DTaP-IPV). Parents of children that had missed some of the five doses prescribed before the age of 7 are advised to contact their pediatricians so they can get the proper immunization.  

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