Tanzania - Background - Combatting Antivaccination Rumours: Lessons Learned from Case Studies in East Africa

Tanzania

• Well documented link between Philippines rumours and Tanzania
• Opposition to TT centered around a single mission hospital in mainland Tanzania, with some antivaccination activity on Tanzania's offshore islands
• Lab testing required to disprove the alleged association between TT and contraception
• Medical missionary now won over to WHO/government position

In the United Republic of Tanzania, anti-vaccination rumours against tetanus toxoid (TT) emanated from a Catholic mission hospital in the southern part of the country whose medical director read about anti-TT rumours through a Philippine NGO. She took the rumours to a regional meeting in 1994 where she raised questions about whether tetanus vaccine was laced with human chorionic gonadotrophin (hCG). She opposed vaccinating women of child bearing age until she had an independent laboratory attest to the purity of TT vaccine being used in Tanzania. She now supports vaccination of children and of women of child bearing age.

Tanzania's Ministry of Health launched the Expanded Programme on Immunisation in 1975. EPI made a substantial increase in immunisation coverage in the 1980's. By 1988, coverage was more than 80 percent, two years ahead of the 1990 global target for reaching 80 percent coverage.

Vaccination coverage rose from 50 percent in 1984 to 80 percent in 1989, but started to fall in the early 1990's. The proportion of children fully immunised by 12 months of age fell from 72 percent in 1989 to under 60 percent in 1991, 1992, 1993, and 1996. The post-1990 fluctuations were more closely linked to patterns of donor support than to rumours or to social factors.

Tanzania has been working toward the goal of polio eradication since 1988, when the World Health Assembly chose the target year of 2000 for global eradication. With the support of WHO and other international organisations and agencies, Tanzania implemented its first rounds of National Immunisation Days in 1996. NIDs were synchronised with those of Kenya, Zambia, and Uganda. The technical report on NIDs and EPI, quoted in the following box, calls attention to a major constraint in social mobilisation.

The report does not give any other information regarding the rumour, including where it was being spread and exactly which communities were affected. It does note, however, in the Lessons Learnt section that "religious leaders are a potential for community mobilisation and their timely involvement is crucial." Strategic planning for the following year included efforts to engage mass media to reach the community and disseminate correct promotional messages to support the campaign and not create fear.[3]

Reports on the 1998 NIDs note other rumours about OPV, including many doses of OPV will cause side effects, OPV would cause sterility, and OPV was associated with the malaria epidemic in the Muleba District. Additional social mobilisation activities were supported with funding from UNICEF, especially during the time between the first and second rounds of NIDs, to counter the rumours.[4]

In 1998 the Tanzania Ministry of Health reported that national levels of polio coverage reached 97 percent for the first round of NIDs and 100 percent for the second round with an overall average above 90 percent. The report attributes low coverage in some (unspecified) districts to the rumours. The last reported cases of polio occurred in 1993.

An annual Tanzania EPI evaluation meeting in April 2000 highlighted some of the milestones of the past 25 years, including continued strong national political support and some improvements in technology. Yet Tanzania faces many health challenges, particularly a fluctuating immunisation coverage and an increase in infant and under age five mortality rates.[5] Health sector reforms have been a challenge to operationalise. In addition, Tanzania has had an influx of refugees fleeing conflict-torn countries on its borders.

Source: Msamanga, Dr. Gernard. A Review of the Situation of Expanded Programmeme on Immunisation in Tanzania. February 2000. Prepared for the Ministry of Health and WHO Office. Dar es Salaam.pp. 36 – 38.

The antigen with the lowest overall rate of immunisation is tetanus toxoid, the one given to women of childbearing age. Thus, Tanzania faces two challenges: raising the immunisation coverage of all children for all antigens, and raising the level of TT vaccinations among women of childbearing age.

Tetanus Toxoid Vaccinations

The WHO webpage gives a detailed account of the epidemiology and prevention of tetanus. Neonatal (newborn) tetanus is the most common form of tetanus in developing countries. The disease is caused by contamination of the umbilical stump following childbirth through cutting the cord with an unsterile instrument, or by applying animal dung to the cut cord. Three to 14 days after birth, the infant suddenly fails to suck properly and becomes irritable; convulsions occur with increasing frequency and intensity. Case fatality is very high.

WHO Policy on TT

WHO policy calls for prevention of tetanus in all age groups.

In all countries protection against tetanus begins with immunisation in the newborn period, followed with reinforcing doses at older ages. A reinforcing dose of TT at approximately 6 months to one year after the third dose is given in a number of countries.

EPI in Tanzania would require every female between 15 and 45 years to get five doses of TT to ensure lifetime immunity. Yet the majority of women got only prenatal vaccinations. While it is widely believed by many health officials that rumours may have affected the rate of coverage, since the coverage for TT is low all over the country, other factors may play a role in stopping women from getting vaccinated except during their pregnancies. For example, in some interviews, health workers said that it is often difficult for young women 15 or 16 years of age to come alone to get TT.

While there may be some constraints, health workers also noted that mothers do not question whether TT contains contraceptives. TT cannot sterilize them if they are already pregnant, and they have seen many women who have received TT and become pregnant again.

Source: Ministry of Health, EPI Annual Report, 1993

The 1993 EPI report notes that the dropout rate from first to second tetanus toxoid dose rose between 1992 and 1993. This could have been a result of a rumour "alleging that the strategy of vaccinating women of childbearing age is associated with attempts to enforce involuntary contraception." The report makes no reference to the source of the rumour.

2 First National Immunisation Days in Tanzania 10-11 August and 14-15 September, 1996: Process, Results and Lessons Learnt Technical Report. March 1997. Compiled by Khadija Msambichaka and Peter Kilima for the Ministry of Health. Dar es Salaam. P.6.

3 First National Immunisation Days in Tanzania 10-11 August and 14-15 September, 1996: Process, Results and Lessons Learnt Technical Report. March 1997. Compiled by Khadija Msambichaka and Peter Kilima for the Ministry of Health. Dar es Salaam. P.17.

4 Technical Report: Tanzania National Immunisation Days 1998. 1998. Compiled by Caroline Akim and Peter Kilima for the Ministry of Health. Dar es Salaam.

5 Report of EPI Annual Evaluation Meeting Held in Dar es Salaam Msimbazi Centre. April 2000. Ministry of Health Department of Preventive Services. Dar es Salaam.