Wednesday, 22nd of June 2011 |
Will the world's most populous democracy do the right thing?
INDIAN PEDIATRICS 939 VOLUME 46
Accelerating Measles Control in India: Opportunity and Obligation to Act Now
T JACOB JOHN*AND PANNA CHOUDHURY
*Past President, Indian Academy of Pediatrics, and Co-Chair, NTAGI, 439 Civil Supplies Godown Lane, Kamalakshipuram,
Vellore, Tamil Nadu; and President, Indian Academy of Pediatrics (IAP), and Chairman,
IAP Committee on Immunization, DII/M 2753 Netaji Nagar, New Delhi, India. pannachoudhury@gmail.com
E D I T O R I A L
Two major milestones in the history of measles control have recently been achieved. Since November 2002, measles is no longer endemic in the Western Hemisphere(1) and the 2005 goal set by the World Health Assembly (WHA) to halve measles deaths worldwide (compared to 1999 levels) was achieved on time(2). The main intervention that led to these achievements was the tactical scaling-up of measles vaccination.
In May 2005, the WHA welcomed the goal of reducing measles deaths by 90% by 2010 compared to 2000 levels, as part of the Global Immunization Vision and Strategy (GIVS)(3). This global goal was endorsed unanimously by the WHA in May, 2008. This editorial explores the potential impacts of measles control strategies on child survival in India and on the global goal of reduction in measles mortality.
MEASLES IN INDIA
Measles continues to be an important cause of childhood morbidity and mortality in many states in India. At a workshop convened jointly by Government of India (GoI), WHO, and UNICEF on measles, in May 2007, it was estimated that between 100,000 and 160,000 children die from measles in India each year and that over 90% of deaths occur in 10 states – Uttar Pradesh (UP), Bihar, Rajasthan, Madhya. Pradesh, Jharkhand, Assam, West Bengal, Andhra Pradesh (AP), Orissa and Gujarat (preliminary results from a workshop held at National Polio Surveillance Unit, New Delhi, May 2007). A recent (2006) vaccination coverage survey in India showed overall 71% coverage for measles vaccine (given during 9 to 12 months of age) (4).
Accepting 85% vaccine effectiveness for vaccination at 9 months, actual protection was offered to only 60% of annual birth cohorts (71% × 85% = 60%). In other words, 40% remained susceptible to measles. Coverage of measles vaccine was less than 50% in UP, Bihar, Assam and Nagaland and between 50% and 80% in 13 other states(4). Worldwide, of the estimated 26.2 million infants who missed receiving their first dose of measles vaccine by age 12 months through routine immunization services in 2006, 10.5 million were in India (5).
Six states (AP, Gujarat, Karnataka, Kerala, Tamil Nadu, West Bengal) conduct measles surveillance through clinical and laboratory outbreak investigations. In these states, nearly 80% cases occur in children less than 10 years old (data available at National Polio Surveillance Project [NPSP], New Delhi). Even in the states with moderate routine immunization coverage, many under-five children with measles had not been given measles vaccine (e.g. West Bengal 72%, Karnataka 38%, Gujarat 35%). According to the Registrar General and Census Commissioner of India, UP, Bihar and Assam together had 114 million children under 15 years of age, in 2006(6). More than half of them had not received measles vaccine – providing fertile ground for continued intense transmission of measles virus.
Studies in India have shown median case-fatality ratio (CFR) of 3.8% (range: 0% to 30%) among children with measles(7). UP had recorded measles CFR of 4.1% in 1996, through routine reporting(8). Actually the present surveillance method tends to under-report measles deaths. Given the formidable challenges of wide interregional disparities of immunization coverage, a huge unvaccinated child population and the large disease burden, can India reduce its enormous measles morbidity and mortality?
MEASLES CONTROL STRATEGIES
Since 2000, almost all countries with high mortality from measles in the past have implemented, under diverse conditions, control strategies recommended by WHO and UNICEF. Although several factors had contributed to high measles mortality, experience with implementing these strategies has taught us that measles deaths can be drastically reduced even in settings of poverty, malnutrition, and overall high
child mortality rates. The current WHO/UNICEF strategy to reduce measles mortality consists of four components:
(i) achieving and maintaining high coverage (>90%) with the first dose of measles vaccine in every district, delivered through regular
immunization services;
(ii) ensuring that all children receive a second dose of measles vaccine delivered either through periodic supplementary immunization activities (SIAs) and/or routine services;
(iii) effective laboratory-backed surveillance (of disease and outbreaks) and monitoring of immunization coverage; and
(iv) appropriate clinical measles case-management, including the provision of vitamin A.
Strategy 1: Strengthening regular immunization system
Strengthening immunization system from the block level up must remain top priority for improved measles control in India. Only 4 states (Tamil Nadu, Kerala, Himachal Pradesh, Goa) and 4 Union Territories (Puducherry, Chandigarh, Lakshadweep, and Daman and Diu) have achieved one-dose measles vaccination coverage of more than 90%. However, improvement in routine immunization alone will not reduce the susceptible pool of older children who had missed measles immunization, owing to underperformance of the system in previous years.
Strategy 2: Providing a second dose of measles vaccine
The average seroconversion rate with measles vaccination at 9 months is 85% (range 70%- 98%)(9,10). Thus, approximately 15% of vaccinated children remain susceptible in spite of receiving one dose. As the level of ‘herd immunity’ needed to significantly impact measles transmission is in the range of 93-95%, even 100% coverage with a single dose of measles vaccine administered at 9 months of age will not prevent the accumulation of a susceptible pool and consequent periodic measles outbreaks. Sero conversion rate improves to >95% when the vaccine is given after one year of age, but the first dose has to be given earlier to protect infants. Field investigations of recent measles outbreaks in developing countries have found that, while some cases occurred in previously vaccinated children (i.e., vaccine failure), most cases occurred in unvaccinated children, indicating that program failure was the predominant reason. For these reasons, WHO and UNICEF recommend that all national immunization programs provide 2 doses of measles vaccine for all children(11). The purpose of the second dose is to protect children who received their first dose but failed to respond. In addition, the second opportunity provides one dose to those who missed the first dose. In settings with low to moderate routine vaccination coverage (<80%), SIAs are the preferred method of delivering the second dose, as they usually achieve coverage levels of >90%. SIAs reach children who lack access to health services, and have been shown to rapidly reduce measles incidence. In settings with high routine vaccination coverage (i.e., ≥80% for 3 SIAs are generally carried out in two phases. An initial, nationwide catch-up SIA targeting 90% of susceptible populations has the goal of eliminating or drastically reducing the susceptible pool. Periodic follow-up SIAs then target all children born since the last SIA. They are conducted nationwide every 2-4 years, with the goal of eliminating susceptibility in recent birth cohorts INDIAN PEDIATRICS 941 VOLUME 46__NOVEMBER 17, 2009 JOHN AND CHOUDHURY ACCELERATING MEASLES CONTROL IN INDIA or more consecutive years), the second dose may be delivered through routine services(12).
Strategy 3: Measles case surveillance with
laboratory confirmation
Effective surveillance system for measles is critical to monitor programme impact and to adopt appropriate immunization tactics to control
outbreaks, if any. Surveillance should be backed by proficient laboratory support. When measles is widely endemic, reporting of aggregated data to track and investigate outbreaks and to identify underserved areas is the appropriate approach. Once the measles incidence is low, for example after conducting an SIA targeting a wide age range (e.g. 1- 14 years), it is appropriate to establish case-based surveillance with investigation and laboratory testing of suspected measles cases and outbreaks(13). In 2006-2007, building on the acute flaccid paralysis reporting sites and laboratory network for polio eradication, the Government of India initiated outbreak-based measles surveillance in six states (named above) with technical assistance from NPSP. This system is already providing essential information needed to define the basic epidemiology of measles in those states. An added function of the laboratory is to support vaccination coverage monitoring through measuring antibody prevalence by age.
Strategy 4: Appropriate treatment including vitamin A
High dose of vitamin A has been shown to decrease severity of illness and CFR in young children hospitalized with measles in developing countries. Therefore WHO currently recommends vitamin A for all children with acute measles. Experience in applying the above strategies in various settings has shown that countries with low to moderate levels of routine immunization coverage can quickly bring down measles mortality through successful catch-up campaigns as observed in 19 African countries and Nepal(14,15). Worldwide, their implementation has resulted in 74% reduction in estimated measles deaths (from 750,000 in 2000 to 197,000 in 2007)(5). The greatest reduction was in African and the Eastern Mediterranean Regions (where measles mortality decreased by 89% and 90%, respectively). WHO estimates that approximately two-thirds of the global burden of measles deaths, namely 136, 000 (range 98,000 to 180,000), occurred in the SEA Region in 2007, with most of them occurring in India. From 2000 to 2007, approximately 613 million children aged 9 months to
14 years received measles vaccine through campaigns in the 47 countries with the highest burden of measles, except in India. Pakistan
completed the catch-up campaign in early 2008. Thus, in 2009, India remains the only country in the world that has not systematically introduced a second dose of measles vaccine.
THE ROADMAP FOR INDIA
The Government of India convened a group of national and international experts (India Technical Advisory Group on Measles, ITAGM) for advice on the most appropriate immunization and surveillance strategies to reduce measles mortality in the country. During its first meeting (2008) ITAGM noted the results of the measles disease-burden workshop (May 2007), especially the finding that ten states in India accounted for over 90% of all measles deaths and the surveillance data indicating that nearly 90% of the measles cases are under 10 years of age. The ITAGM recognized and emphasized the urgency to start accelerated measles mortality reduction activities in India including conducting measles catch-up vaccination campaigns in one or more of the medium to high burden states. In addition, the main ITAGM recommendations called for:
(a) strengthening of immunization services with particular attention to states with low coverage,as this would be critical for sustaining disease reduction that follows catch-up campaigns; and
(b) expansion of the outbreak-based measles surveillance supported by WHO accredited laboratories – to help plan optimum catch-up
campaigns and assessment of their impact. At the June 2008 meeting of the National Technical Advisory Group on Immunization
(NTAGI), the recommendations from ITAGM were INDIAN PEDIATRICS 942 VOLUME 46__NOVEMBER 17, 2009 JOHN AND CHOUDHURY ACCELERATING MEASLES CONTROL IN INDIA discussed and accepted in principle. NTAGI, after reviewing data on measles epidemiology and CFR, has recommended the following:
• A second dose of measles vaccine should be introduced in the Universal Immunization Programme (UIP) at the time of DPT booster
dose (at 18 months of age) in states with ≥80% evaluated coverage with the first dose of measles vaccine;
• Catch-up measles vaccination campaigns should be implemented for children up to age 10 years in states with <80% evaluated coverage with the first dose of measles vaccine and that detailed action plans for these SIAs should be finalized immediately in states with low coverage and high measles mortality burden;
• A study to determine measles CFR in high burden states should be conducted to enable better estimation of the number of measles deaths in India; and
• Measles surveillance should be enhanced in high burden states to assist with planning of catch-up campaigns and to establish baseline data.
The categorization of the states by NTAGI (below and above 80% coverage) was proposed to provide the broad framework on which national and state programme managers can draw up operational plans quickly for the second dose of measles vaccine.
CHALLENGES FOR INDIA
With the defined roadmap for accelerated measles control, what are the barriers (perceived and real) to implementation?
Impact on UPI. Concerns have been expressed regarding potential adverse impact of accelerated measles control activities, especially the catch-up campaigns, on UIP. Evidence from experience in other countries showed no such adverse impact. Between 2000 and 2006 — the period of intense measles control activities through catch-up campaigns in the African region, routine coverage with first dose of measles vaccine actually rose from 56% to 73%; in the Eastern Mediterranean region, from 73% to 83%; and in the Western Pacific region, from 86% to 93%. During the same period, coverage in countries of the South East Asian Region other than India, rose from 77% to 85%(16). Will injection safety be compromised during vaccination campaigns? Actually such campaigns in other countries have served as an opportunity for promoting injection safety, including safe waste disposal and management of adverse events following immunization (AEFI), and for raising standards of training of vaccinators and improving the cold chain for vaccine storage and transport. Social mobilization efforts by volunteers have been instrumental for the success of campaigns by providing information to and creating demand from target populations, especially the hard-to-reach and marginalised(14-16). Adverse effects. In 2008, serious AEFI (adverse events following immunization) were reported resulting in death in a few children after giving measles vaccine. So there is apprehension among some in India that campaigns might lead to serious AEFI. Actually death was due to programmatic errors at local level. Careful planning, sound training, close monitoring and an efficient AEFI management system during measles vaccination campaign can effectively mitigate all such risks as demonstrated repeatedly during measles vaccination campaigns in many countries around the world.
Impact on polio eradication. Will accelerated measles control activities now distract attention from the current priority of polio eradication and add to ‘campaign fatigue’? Each of the other remaining polio endemic countries has already implemented measles control strategies; such activities, including campaigns increased community demand for vaccination(16). Many other countries had implemented measles vaccination campaigns during their active phase of polio eradication, taking advantage of the already trained and mobilized work force
with updated maps, local implementation micro-plans, and a functioning monitoring system. Measles vaccination campaigns targeting
millions of children from 9 months to 10 years of age in many states of India will be a huge undertaking. INDIAN PEDIATRICS 943 VOLUME 46__NOVEMBER 17, 2009 JOHN AND CHOUDHURY ACCELERATING MEASLES CONTROL IN INDIA. This will require firm commitment of state
governments, careful advance planning, implementation in manageable phases and full gearing up of the public sector health system at the sub-district, district, state and national levels. If public-private participation is desired, it can be locally designed and managed.
SUMMATION
Without drastic measles mortality reduction in India, the global goal to reduce measles mortality by 90% by 2010 will not be met. Implementation of the NTAGI recommendations for accelerating measles control in India represents an opportunity to rapidly
reduce measles mortality thereby contributing to achievement of the 4th Millennium Development Goal (reduce under-5 child mortality by 2/3 by 2015). It is also an obligation on the part of the Government for the provision of equitable services to the children of all states.
Funding: None.
Conflict of interest: None stated.
REFERENCES
1. de Quadros CA, Olivé JM, Hersh BS, Strassburg MA, Henderson DA, Brandling-Bennett D, et al. Measles elimination in the Americas: evolving strategies. JAMA 1996; 275: 224–229.
2. Wolfson LJ, Strebel PM, Gacic-Dobo M, Hoekstra EJ, McFarland JW, Hersh BS. Has the 2005 measles mortality reduction goal been achieved? A natural history modelling study. Lancet 2007; 369:191-200.
3. World Health Organization. Global Immunization Vision and Strategy Document. Available from: http://www.who.int/immunization/givs/en/ index.html. Accessed on 21 July, 2009.
4. Coverage Evaluation Survey 2005, All India: a Report. New Delhi: Unicef; 2006.
5. World Health Organization. Progress in global measles control and mortality reduction, 2000-2007. Wkly Epidemiol Rec 2008; 83: 441-448.
6. Census of India 2001. Population Projections For India And States 2001-2026 (Revised December 2006). Report of the technical group on population
projections constituted by the national commission on population. New Delhi: Office of the Registrar General & Census Commissioner, India; 2006.
7. Wolfson LJ, Grais, RF, Luquero FJ, Birmingham ME, Strebel PM. Estimates of measles case fatality ratios: a comprehensive review of communitybased
studies. Int J Epidemiol 2009; 38: 192-205
8. Singh J, Kumar A, Rai RN, Khare S, Jain DC, Bhatia R, et al. Widespread outbreaks of measles in rural Uttar Pradesh, India, 1996: High risk areas and groups. Indian Pediatr 1999; 36: 249-256.
9. Cutts FT, Grabowsky M, Markowitz LE. The effect of dose and strain of live attenuated measles vaccines on serological responses in young infants.
Biologicals 1995; 23: 95-106.
10. Job JS, John TJ, Joseph A. Antibody response to measles immunisation in India. Bull WHO 1984; 62: 737-741.
11. World Health Organization. Meeting of the Immunization Strategic Advisory Group of Experts, November 2008 – conclusions and
recommendations. Wkly Epidemiol Rec 2009; 84:1-16.
12. World Health Organization. Weekly Meeting of the immunization Strategic Advisory Group of Experts, April 2009 – Conclusions and
Recommendations. Wkly Epidemiol Rec 2009; 84:220-236.
13. WHO Module on best practices for measles surveillance. Available from: http://www.who.int/vaccines-documents/DocsPDF01/www617.pdf.
Accessed on July 29, 2009.
14. Otten M, Kezaala R, Fall A, Mashreasha B, Martin R, Cairns L, et al. Public health impact in the WHO African Region 2000-2003. Lancet 2005; 366: 832-
839.
15. World Health Organization. Progress in Measles Control: Nepal, 2000-2006. Wkly Epidemiol Rec 2007; 82: 346-351.
16. WHO vaccine-preventable diseases monitoring system, 2008 global summary. Available from: http://www.who.int/immunization/documents/
WHO_IVB_2008/en/index.html). Accesssed July
Assessment of Immune Status Against Measles, Mum ...
Assessment of Immune Status Against Measles, Mumps, and Rubella in Young Kuwaitis: MMR Vaccine Efficacy. Madi N, Altawalah H, Alfouzan W ...2017 M&RI Partners Meeting Presentations
The global Measles and Rubella Initiative meeting was held in Washington DC on 7th and 8th Sept. 2017. The meeting which was hosted by American Red Cr ...STORIES OF LIFE IN A CHANGING WORLD Scientists Cr ...
STORIES OF LIFE IN A CHANGING WORLD Scientists Crack a 50-Year-Old Mystery about the Measles Vaccine Worth a little pain? Back in 1990 a school bo ...20 most consulted measles and rubella articles in ...
Dear AllToday we share a review of the year 2016 regarding measles and rubella items posted on our web page. We shared articles on topics ranging from ...Region of the Americas is declared free of measles ...
More information on this great milestone can be found on url link belowhttp://www.paho.org/hq/index.php?option=com_content&view=article&id=125 ...Progress Toward Regional Measles Elimination — W ...
Progress Toward Regional Measles Elimination — Worldwide, 2000–2014 Morbidity and Mortality Weekly Report Best read, with ta ...Health Equity Initiative, New York, NY, 25-26 Febr ...
Health Equity Initiative, Summit, NYC, 25-26 February 2016 For details, consult http://www.healthequityinitiative.org/hei/programs/summit/REQUEST FOR PROPOSAL: MEASLES VACCINATION UNDER 9 ...
1 REQUEST FOR PROPOSAL: Measles Vaccination Under 9 Months of Age APPLICATION SUBMISSION DATE: January 26, 2015 1. In ...CARTOON CHARACTERS JOIN THE FIGHT AGAINST MEASLES
[source] Measles and Rubella Initiative[|source]Thanks to reader Jane Wachira for pointing out the following weblink. Measles eradication consists not ...I LOVE/HATE THIS GLOBAL VACCINATION COVERAGE GRAPH ...
[source]Rosling s FactPod[|source]This video from Hans Rosling explaining what he loves with global measles vaccination coverage trends namely rapid i ...POWER POINT PRESENTATIONS FROM THE 13TH ANNUAL ADV ...
[source]Measles and Rubella Initiative[|source]The Measles and Rubella Initiative has spent much effort fighting for its cause by means of widespread ...CALLING THE SHOTS
[source]PBS Network[|source]"VACCINES -- CALLING THE SHOTS" This TV program, broadcast on the PBS network, looks at the commonest arguments by anti-v ...COMBATING HEALTHCARE CORRUPTION AND FRAUD WITH IMP ...
[source]BMC International Health and Human Rights[|source]Corruption is a serious threat to global health outcomes, leading to financial waste and adv ...CORRUPTION KILLS: ESTIMATING THE GLOBAL IMPACT OF ...
[source]PLoS One[|source]Many countries still have high levels of child mortality, particularly in sub-Saharan Africa and South Asia, and in recent ye ...READY OR NOT: RESPONDING TO MEASLES IN THE POSTELI ...
[source]Annals of Internal Medicine[|source]Opnion Paper Although endemic measles was eliminated in the United States in 2000, two concurrent measle ...RUBELLA AND CONGENITAL RUBELLA SYNDROME CONTROL AN ...
[source]Morbidity and Mortality Weekly Report (MMWR)[|source]In 2011, the World Health Organization (WHO) updated guidance on the preferred strategy f ...PROGRESS TOWARDS MEASLES ELIMINATION – EASTERN M ...
[source]Weekly Epidemiological Record (WER)[|source]During the period 2008–2012, regional progress towards measles elimination stagnated, and th ...THE IMMUNIZATION PROGRAMME THAT SAVED MILLIONS OF ...
[source]Bulletin of the WHO[|source]In the world vaccination week, the Bulletin of the World Health Organization outlines the history, status and impa ...HEALTH SYSTEM COST OF DELIVERING ROUTINE VACCINATI ...
[source]Bulletin of the WHO[|source]On the eve of the 40th anniversary of launching of the Expanded Programme on Immunization (EPI) in 1974, during th ...World Immunization Week
[source]WHO/IVB Publication[|source]Never miss another jab, The slogan for World Immunization Week 2014 is “Immunize for a healthy future: Know ...Measles: know the risks, check your status, protec ...
[source]WHO/IVB Publication[|source]Measles is a highly contagious, serious disease caused by a virus. In 1980, before widespread vaccination, measles ...THE RIGHTS OF THE UNVACCINATED CHILD: THE LEGAL FR ...
[source]Los Angeles Times[|source]In light of what s starting to look like a surge of measles cases spread by unvaccinated carriers, Hasting ...Consultants: Measles and rubella control/eliminati ...
[source]Technical Network for Strengthening EPI[|source]Announcement solicits interest from potential candidates to act as consultants for WHO through ...PUBLIC HEALTH OFFICIALS MARK 50TH YEAR OF MEASLES ...
[source]Journal of American Medical Association[|source]Until the 1960s, measles was a rite of passage for US children; nearly all had the disease bef ...THE TOLL OF THE ANTI-VACCINATION MOVEMENT, IN ONE ...
[source]Los Angelos Times[|source]Aaron Carroll today offers a graphic depiction of the toll of the anti-vaccination movement. It comes from a Council ...“Can we use $30 of the taxes you’re already pa ...
[source]Annual Letter of BMGF[|source]If you were asked this question today, what answer would you give? Bill and Melinda Gates ask, "Would you check ...REACHING HARD-TO-REACH INDIVIDUALS: NONSELECTIVE V ...
[source]American Journal of Epidemiology[|source]Source: American Journal of Epidemiology The World Health Organization guidelines for response to me ...Rubella and Congenital rubella syndrome control an ...
[source]Weekly Epidemiological Record (WER)[|source]Full text record of Rubella and CRS control/elimination are available at http://www.who.int/wer/20 ...Measles Press Conference at CDC: 50th Anniversary ...
[source]CDC Media Release, 5th Dec[|source]Full text, video and question and answer session for journalists all avalable at http://www.cdc.gov/media/r ...A bibliometric analysis of childhood immunization ...
[source]BMC Medicine[|source]During the past four decades national EPI programs have developed or adapted and implemented a broad range of strategies ...Lessons from the tragic measles outbreak in Samoa
Monday, 9th of March 2020 |
Characterisation of diversity of measles viruses in India: genomic sequencing and comparative genomics studies.
Monday, 9th of March 2020 |
The elimination of measles in Iran
Monday, 9th of March 2020 |
Measles-containing vaccines in Brazil: Coverage,
Monday, 9th of March 2020 |
Measles-containing vaccines in Brazil: Coverage, homogeneity of coverage and associations with contextual factors at municipal level.
Monday, 9th of March 2020 |
Website Views |
47455242 |