Ambalavao, Madagascar – Children cry while a nurse tries to reassure mothers who have come to vaccinate their children against a measles epidemic that has killed more than 1,200 people in this island nation where many are desperately poor .
Madagascar faces its largest outbreak of measles in history, with cases well in excess of 115,000, but resistance to vaccinating children is not the driving force behind the increase.
Measles cases are increasing in the United States and elsewhere, partly due to misinformation that prevents certain parents from receiving a vaccine. New York is trying to stop an outbreak by ordering mandatory vaccinations in a Brooklyn neighborhood.
In Madagascar, many parents want to protect their children, but face immense challenges, including lack of resources.
Only 58% of people on the main island of Madagascar have been vaccinated against measles, an important factor in the spread of the epidemic. With measles one of the most infectious diseases, immunization rates must be between 90% and 95% or more to prevent outbreaks.
On a recent day, the hall of appearance of the center of Iarintsena was full, with mothers sitting on the floor and others waiting outside in the oppressive heat. Two volunteer nurses and a midwife tried to meet the demand.
Nifaliana Razaijafisoa had walked 15 kilometers (9 miles) with her 6-month-old baby in her arms.
"He has a fever," he said. "I think it's measles because there are these little pimples that appeared on his face."
The nurse quickly confirmed this.
"I'm so scared for him because everyone in the village says he kills children," Razaijafisoa said.
The epidemic has mostly killed children under the age of 15 from the beginning of September, according to the World Health Organization.
"The epidemic unfortunately continues to expand", although at a slower rate than a month ago, said Dr. Dossou Vincent Sodjinou, epidemiologist at the WHO in Madagascar. In mid-March, 117,075 cases had been reported by the health ministry, which covered all regions of the country.
Some cases of resistance to vaccination exist because of the influence of religion or traditional health professionals, but they are isolated, he said.
This outbreak is complicated by the fact that almost 50% of children in Madagascar are malnourished.
"Malnutrition is the bed of measles," said Sodjinou.
The child of Razaijafisoa weighs only 5 kilograms (11 pounds).
"This is the case of almost all the children with measles who have come here," said Lantonirina Rasolofoniaina, a volunteer at the health center.
Simply reaching a care clinic can be a challenge. Many people in Madagascar cannot afford to see a doctor or buy medicine, and health centers are often understaffed or have low-skilled workers.
As a result, information on health problems can be unreliable. Some parents are unaware that the vaccines are free, at least in public health centers.
Four of Erika Hantriniaina's five children had measles. He had mistakenly believed that people could not be vaccinated after nine months of age.
"It is my 6-year-old daughter who had the measles first. She had a lot of fever," he said. "I called the doctor but it was Friday. He had already gone to the city. I went to see another doctor who told me that my daughter had an allergy. … This misdiagnosis was almost fatal."
The girl had diarrhea and vomiting and could not eat, Hantriniaina said, adding that she survived by a hair.
Measles, a highly infectious disease spread by coughing, sneezing, close contact or infected surfaces, has no specific treatment. The symptoms are treated instead.
"Vitamin A is given to children to increase their immunity. We try to reduce fever. If there is a cough, we give antibiotics," said Dr. Boniface Maronko, sent by OMS in Madagascar to oversee efforts to contain the epidemic. If the disease is not treated early enough, complications appear that include diarrhea, bronchitis, pneumonia and seizures.
The Ministry of health of Madagascar has sent free medicines to the regions most affected by the epidemic. Maronko reminded the heads of health centers in the Ambalavao region not to pay their parents, saying he had seen some doctors ask for money. He told the Associated Press that he feared that the medicines would not be enough.
The country's capital, Antananarivo, a city of 1.3 million, has not been spared.
Lalatiana Ravonjisoa, a seller of vegetables in a poor neighborhood, grieves for her 5-month-old baby.
"I had five children. Everyone had measles. Last time, I didn't go to the doctor because I had no money," he said. "I gave my child the residual medicine from his older brother to bring down the fever."
For a few days he did not worry: "I felt like he was cured". But one morning he realized he had trouble breathing. Later he discovered that his feet were cold.
"Look at my baby," he told his mother.
"He hugged him for a long time and she said nothing. Then he asked me to be strong. He was gone."
Ravonjisoa said he blames himself, "but I didn't imagine for a moment that he would die." At the hospital, a doctor confirmed that her baby died from measles-related respiratory complications.
At the end of last month, the WHO launched a third mass vaccination campaign in Madagascar with the overall goal of reaching 7.2 million children from 6 months to 9 years.
"But immunization is not the only strategy for responding to this epidemic. We still need resources for assistance, monitoring and social mobilization," said Sodjinou, epidemiologist of the WHO.