Fighting measles should be simple: taking just two vaccine shots for children during the ninth and 12th months of life means full immunity from the illness for life.

However, Philippine health authorities have already declared measles outbreaks in at least 6 different areas in the country including Taguig, Davao City, Dumaguete, Zamboanga, Negros Oriental and Autonomous Region in Muslim Mindanao for this year alone.

At least two children have died from measles in Taguig, according to Mayor Lani Cayetano.

• Measles kills 2 in Taguig village

Health Secretary Francisco Duque III said the measles outbreaks show the importance of vaccines despite a health scare over the controversial Dengvaxia anti-dengue vaccine.

"Dapat huwag mawala ang ating tiwala at paniniwala sa ating bakuna ng DOH. Napatunayan na ito ay nagbibigay ng proteksyon laban sa mga sakit," he said.

"We save 3 (million) to 5 million patients from developing diseases, which are otherwise prevented by vaccine."

• After Taguig measles outbreak, health chief reiterates importance of vaccines
• DOH confirms measles outbreak in Taguig village

For former health undersecretary Susan Mercado, fighting measles outbreaks in the country is complicated by a number of factors including the present Dengvaxia scare, a shortage in skilled health workers and even cultural sensitivities in parts of the country.

"You have to educate the mothers so that they understand why they need to get their kids vaccinated. This Dengvaxia controversy simply does not help," she said in an ABS-CBN interview.

In December, the Department of Health stopped its dengue immunization program and pull out Dengvaxia from the market after French drug maker Sanofi Pasteur acknowledged that the drug can cause "severe dengue" when given to children who had never contracted the mosquito-borne disease.

• Philippines suspends dengue vaccine program after Sanofi warns of risks

1 MEASLES CASE EQUALS OUTBREAK

Measles is an infectious disease that can cause death among infants as young as 3 months. Its complications include severe diarrhea, pneumonia and blindness.

Measles can be spread by droplets, a cough can transmit the illness quickly to an unvaccinated child. According to the US Centers for Disease Control and Prevention, 90% of the people close to a person with measles who are not immune will be infected.

Children are given their first measles shot at 9 months because mothers still have antibodies and gives those antibodies to the child, Mercado said. The second shot is given at 12 months.

"Normally, the child is protected from birth until about 9 months when the antibodies go down. So you need the vaccine. If the mother had no antibodies, was never vaccinated, then you have very young children who are at risk from measles. So it is important to get those shots," she said.

"If you get both shots, you get full immunity [from measles] for life. It’s lifelong protection unlike BCG (for tuberculosis), which needs to be repeated, and hepatitis."

Mercado said that after the measles vaccine was introduced, cases of measles in developed countries dropped by 99% due to immunization programs.

Health authorities always declare an outbreak of measles even with just one confirmed case because the illness is very infectious. One case of measles in an area with low immunization rates can spell disaster.

"Just one case of measles gives you reason to be alarmed dahil mabilis siyang kumalat at pwede siyang makapatay ng bata (it spreads fast and can kill kids). Some people think 7 kids [with measles] is not a big thing. For me it is. It's a preventable disease. Dapat wala (There should be none)," Mercado said.

"All you need for an outbreak is a sick patient – patient zero - and a susceptible pool. If you have one sick patient in a community where no one has had vaccination, then an outbreak is likely to occur. But if the sick patient is in a group that has high vaccination, then the illness will not spread," she added.

MEASLES IN DISNEYLAND

In 2014, US health authorities declared a measles outbreak after 147 people were diagnosed with the illness in several US states.

Investigators said the measles virus which originated from the Disneyland Resort Theme Parks in California shared the same genetic characteristics as the type most commonly found in the Philippines.

• US measles outbreak over

Mercado, who was working at the World Health Organization at the time, said the US measles outbreak caused genuine concern since the US had already declared itself measles-free in 2000.

The outbreak also alarmed developing countries. At least 500 measles cases were diagnosed in January 2017 in European countries where immunization rates have dropped.

• WHO warns of measles outbreak across Europe

Data from the Department of Health in 2014 also showed that almost all Philippine provinces had one case of measles for the year. As a result, health authorities rolled out a supplemental measles vaccination campaign nationwide for all children between 6 months and 59 months.

As a result, the number of lab-confirmed and epi-linked measles cases went down dramatically in 2015.

Mercado said one way to prevent measles outbreaks is to map out "pockets of low vaccination rates."

"If you have pockets of low vaccination rates, that’s where you go. You have to map it. Dapat babalikan at liligawan. (You have to go there and woo them). Dapat ang LGU nakakaintindi, ayaw din naman nila na maraming nagkakasakit (the local government unit must be understanding. They don't want their people to get sick)," she said.

BAD INFO, CULTURAL SENSITIVITY

One challenge in the fight against measles outbreaks is simply bad information.

In 2015, the government's immunization campaign in the Autonomous Region in Muslim Mindanao was delayed due to resistance from parents.

DOH-ARMM Sec. Dr. Kadil Sinolinding Jr. said parents refused to have their kids vaccinated after 300 kids were rushed to hospitals due to vomiting and stomach ache after taking deworming tablets.

• Why immunization campaign in ARMM is delayed

During the Senate hearing on Dengvaxia, Duque said some groups are intentionally spreading wrong information to instigate fear of other government vaccination programs.

"Certainly, there's an effort to create this hysteria or fear if not panic among parents... This is fanned unnecessarily by systemics that come from certain quarters," he said.

• Amid Dengvaxia scare: Vaccination coverage drops 30 pct in some areas, says Duque

Another challenge in the fight against measles outbreaks is cultural sensitivities in some parts of the country.

Mercado said there are groups that simply do not like vaccines. For example, she said some Aetas do not want to go to barangay health centers “kasi kapag pumunta ka sa hospital, ibig sabihin mamamatay ka na."

(For Aetas, when you go to a hospital, it means you are at the point of death.)

"Tapos ayaw nilang magpa-swero (they don't want to have an IV), so what we had to do was put the IV drip on ourselves to show that we were okay. It is something they have never seen...The cultural part is very important," she added.

In the measles outbreak in Zamboanga, she said the DOH had to tap Tausug and Badjao nursing students to go to those areas with suspected measles cases because people have to know the language.

"As you go down, the information has to be very localized. At the end of the day, it is still about the mother allowing the vaccination of the child," she said.

Another issue complicating the measles problem is migration. Areas where there are a lot of transients also need to monitor for possible measles cases, Mercado said.

WANTED: HEALTH WORKERS

Complicating the problem further, she said, is the lack of health workers that can carry out vaccination or supplemental immunization activities.

In Zamboanga City, she said health authorities had to immunize 120,000 children starting February 19 after diagnosing 287 suspected measles cases "and they only had 100 workers."

To solve the problem, the Red Cross asked 3 nursing schools to mobilize another 100 to 200 workers to help with the immunization program.

"It’s a problem when we don’t have enough appropriate health care workers distributed in the right places. We need to have more. Pwedeng may supply pero kulang nang tao. (You could have enough supply but lack workers.) Unless you fix that problem, you could have health facilities with not enough people staffing," Mercado said, adding that the problem of lack of health workers is not unique to the Philippines.

"All countries have that problem. Health is a very human resource intensive industry," she said.

However, the health expert also noted that at least 1,725 children in Zamboanga failed to receive vaccines after their parents refused "because of Dengvaxia, or because they simply don't want immunizations."

This, she said, shows the complex mix of challenges that need solving to completely eliminate measles outbreaks in the Philippines.

More than just supplying health workers and vaccines, Philippine health authorities must also convince people that vaccines are good for them.

"You have to look at each area and pinpoint what the problem is because it is a system problem. In problem solving for an outbreak, it is like an investigation. What caused this and what do you do next? There’s really no general answer. It can be many different things - lack of syringes, outpost delivery, transport, etc."

"There’s the supply side: the need for health workers and the stock of vaccines. But there's also the campaign, the demand side. Mothers have to want the vaccines and get their kids immunized... It's a no-brainer. It's a preventable disease that has a solution that is doable, affordable, safe, effective," she added.