Afghanistan: Measles poses deadly risk for malnourished children

Measles - Isolation Ward Boost Hospital | Patient

Afghanistan 2022 © Tom Casey/MSF

“Why is my baby’s foot cold?” Zainab asked a medic, holding the ankle of her one-year-old son, Takberullah. The boy had spent three days in the pediatric intensive care unit (ICU) of the Doctors Without Borders/Médecins Sans Frontières (MSF)-supported Boost hospital in Lashkar Gah, in Afghanistan’s Helmand province. Ten days prior, Zainab’s three children had developed fevers and diarrhea. Takberullah became much sicker than his two sisters and also had a rash, so Zainab brought him to Boost hospital, where he was diagnosed with measles.

His hands and feet were cold because he was in critical condition, suffering from severe pneumonia—a life-threatening respiratory infection—and hypoglycemia, or low blood sugar. “How long will he have to be here?” asked Zainab. “I have other children sick at home, but I don’t know how they are doing.”

The MSF team at the hospital did everything they could for Takberullah, giving him oxygen and antibiotics for the pneumonia and glucose for the hypoglycemia. But despite the intensive care, Takberullah passed away. Zainab returned home to care for her two other children.

Increasing cases, not enough beds

This tragic and preventable story is being repeated across Afghanistan as cases of measles rise precipitously. MSF continues to see high numbers of patients in its projects, more than six months after the Islamic Emirate of Afghanistan (IEA) (also known as the Taliban) took power in Afghanistan. The Afghan health system has been under-funded, under-staffed and dysfunctional for years. Most health facilities in Afghanistan remain under great pressure due to shortages of staff and equipment. It's difficult for many people to access the care they need as many public health facilities are barely functioning and some are closed altogether, while private health care is unaffordable for millions of people.

The number of measles cases has been extremely high in Boost hospital as of late. From December to the end of February, on average, more than 150 children with measles came to the hospital each week. Forty percent of these children had a severe complication such as pneumonia and were admitted for treatment.

In Kunduz city, MSF financed staff and equipment for a new 35-bed measles ward at Kunduz Regional Hospital. The ward opened on February 27 and by the following morning had more patients than beds. 

In Herat, in western Afghanistan, MSF saw almost 800 measles cases in February. “Sixty percent of the measles cases we see arriving at Herat Regional Hospital require hospitalization,” said Sarah Vuylsteke, MSF’s project coordinator in Herat. “Half of those we admit for critical care are also malnourished.”

At the beginning of the year, the hospital had eight isolation beds for patients with infectious diseases like tuberculosis or measles. But that ward quickly became overwhelmed with measles patients, and another 12 beds were added. Work is now underway to transform another building into a 60-bed measles unit to provide intensive care for critical patients and inpatient care for those who are recovering. But even this will likely not be enough to address the rising number of cases.

“In our project in Herat, two children are dying every day due to measles complications,” said Vuylsteke. “I dread to think about what’s happening in other parts of the country that don’t have access to more advanced care. The public health facilities we visited in rural areas have the capacity to handle measles patients with mild complications. But the staff in every single one said they wouldn’t be able to help severe or complicated cases as they don’t have the supplies, staff, or equipment. For children who are very sick—the most vulnerable—there’s very little they can do.”

Weakened immune systems lead to severe illness

The rise in measles cases is particularly alarming as Afghanistan is already facing a nutrition crisis. People struggle to afford sufficient food due to the economic crisis, and persistent drought and displacement caused by the conflict have left people with fewer reserves to last them over the winter.

For months, children receiving treatment in MSF’s feeding centers in Helmand and Herat have often had to share beds as the number of patients exceeds the bed capacity. Across both projects from January until the end of February almost 800 children were admitted with severe acute malnutrition.

“Most children we see in our feeding center and ICU have had measles recently,” said Fazal Hai Ziarmal, MSF’s clinical team leader at Boost hospital. “Measles damages children’s immune systems and makes it harder for them to fight complications such as respiratory infections like pneumonia.”

“If a child is malnourished—as many in Afghanistan are at the moment—their immune system is already very weak and that can lead to a more severe and prolonged measles infection. This in turn damages their immune system even further and makes children very vulnerable. A lot of malnourished children die from post-measles complications,” said Hai Ziarmal.

Low vaccination coverage and crowded living conditions

Measles is preventable through vaccination, but vaccine coverage in Afghanistan is low—one explanation for the rapid rise in cases. “We can increase the number of beds in the places where MSF works but this won’t fix the problem,” said Vuylsteke. “Unless there’s a widespread vaccination campaign, we will continue to see increasing cases for the next six months, putting yet more pressure on an already fragile health care system. In the longer term, the program for regular measles vaccinations should be strengthened so that children can be vaccinated routinely, rather than in response to flare ups in cases.”

In addition, sometimes several families live under one roof, creating perfect conditions for the rapid spread of the disease. Some children recover from measles by themselves while others need simple medication for their complications, but even this can be hard to find in Afghanistan as many health facilities lack sufficient medicines and supplies. This means many parents have to buy the medication from local pharmacies.

“All 12 of my grandchildren got sick but these three are suffering the most,” said Han Bibi, who was waiting in Boost hospital’s measles screening unit with her three grandchildren, who are all suffering from the disease. “We bought some medicine in our village but when the children didn’t improve, we came here. The eldest was crying, saying her chest was painful, and she was vomiting. She’s drinking a lot of water but can’t hold anything else down.”