Measles remains a mass killer as immunisation flounders

Measles is an important cause of childhood morbidity and mortality in many states killing thousands of children each year. More than 90 per cent of mortality occurs in 10 states — Uttar Pradesh, Bihar, Rajasthan, Madhya Pradesh, Jharkhand, Assam, West Bengal, Andhra Pradesh, Orissa and Gujarat.

Epidemiological data on measles in India are rather limited. This probably happened due to the misconception of considering measles as a non-serious disease because of which many parents do not take their kids to a hospital.

The government admits that only some measles cases with complications reach public sector hospitals and in turn reported in official figures, which does not reflect the reality. The incomplete reporting grossly underestimates the actual incidence of measles cases and deaths.

But it is indeed a major health threat. Despite the availability of a safe and effective vaccine, globally, measles killed over 5,30,000 and 1,82,000 in south east Asian region alone as reported in 2003. Public health officials estimate that between 1,00,000 and 1,60,000 children die from measles in India each year.

Under the Universal immunisation Programme started in 1985, all states give a dose of measles vaccine to children aged 9-12 months. While the reported coverage is more than 80 per cent since 1990, the evaluated coverage in 2000-01 was found to be about 56 per cent.

Barring polio, the immunisation scene did not improve much in the last eight years in the public sector. At a recent consultation on measles organised by the Public Health Foundation of India, it was found that UIP coverage is as low as 52 per cent in some of the key states.

According to the Union health ministry, about 11 million children each year are added to the group of children not protected from measles. Since 2000, almost all countries with high measles mortality implemented control strategies recommended by WHO and UNICEF.

Worldwide, their implementation resulted in 74 per cent reduction in estimated measles deaths (from 7,50,000 in 2000 to 1,97,000 in 2007)). The greatest reduction was in African and the eastern Mediterranean regions where measles mortality decreased by 89 and 90 per cent respectively.

Following the global trend, the National Technical Advisory Group on immunisation (NTAGI) reaffirmed in 2004 that children should be vaccinated for measles between 9 and 12 months. It was also recommended to immunise the un-immunised at the earliest contact up to 59 months of age.

In 2005, the government readied an action plan, which set out a target of reducing the measles mortality by two-thirds by 2010, compared to the 2000 estimates. It emphasised on achieving at least 90 per cent coverage in a majority of the districts by 2009. But not much seems to have happened in the last four years.

Surveillance crucial

Since an effective surveillance system for measles is critical to monitor the programme’s impact, the Centre in 2006-07 exploited the acute flaccid paralysis (AFP) reporting sites and laboratory network for polio eradication in six states to initiate measles surveillance, which would have generated some data before introducing the second dose of measles vaccine in states with better immunisation records.

Few years back, the Centre convened an expert group — National Technical Advisory Group on immunisation (NTAGI) for advising the government on immunisation and surveillance strategies to reduce measles mortality.

Last year NTAGI recommended, second dose of measles vaccination in 18 states with better routine immunisation record along with supplementary immunisation activity (SIA) in states with poor vaccination record and expansion of measles surveillance.

The SIA campaign was to be launched in Rajasthan, Madhya Pradesh and Orissa in 2009-10 and in Bihar, Chhattishgarh, Jharkhand, Uttar Pradesh and Assam in 2010-11. Since preparations for the campaign take seven-eight months, the first 2010 target will definitely not be met.

The recommended second dose of measles vaccine was effective in the 47 countries with the highest burden of measles in Asia and Africa including India’s neighbours like Nepal and Pakistan.

In 2009, India remains the only country in the world that has not systematically introduced a second dose of measles vaccine, two veteran public health researchers T Jacob John and Panna Choudhury wrote in a commentary in the latest issue of the ‘Indian Journal of Pediatrics’.

Even though the Centre has not identified the states where the second measles shot will be administered, according to the public health officials states with first dose measles coverage of more than 80 per cent as per the coverage evaluation survey of UNICEF 2006 qualifies for second dose.

The 18 states and Union territories, which suit the criteria are: Andhra Pradesh, Delhi, Goa, Himachal Pradesh, Jammu & Kashmir, Karnataka, Kerala, Orissa, Punjab, Tamil Nadu, West Bengal, Sikkim, Andaman and Nicobar, Chandigarh, Dadra Nagar Haveli, Daman and Diu, Lakshadeep and Pondicherry.

“This is NTAGI recommendation, usually followed by the government. But no formal decision has been taken as yet,” Choudhury said.

Failure to adhere to the NTAGI recommendations suggest that India would not be able to achieve the 4th Millennium Development Goal of reducing under five child mortality by two-thirds by 2015.