|Year : 2010 | Volume
| Issue : 4 | Page : 190-193
Measles elimination goal: Is it feasible for India?
Suneela Garg1, Ananya Ray Laskar2
1 Professor and HOD, Department of Community Medicine, Maulana Azad Medical College, New Delhi and Faculty of Medical Sciences, India
2 Senior Resident, Department of Community Medicine, Maulana Azad Medical College, New Delhi, India
|Date of Web Publication||3-Mar-2011|
Ananya Ray Laskar
Senior Resident, Department of Community Medicine, Maulana Azad Medical College, New Delhi
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Objective : To assess whether measles elimination goal would be feasible for India or not. Methodology: Secondary review of data from WHO Regional Consultative Meet on Measles and Workshop on Rubella. Discussion with stakeholders such as UNICEF experts, PATH, and Government officials. Results: The National Technical Advisory Group of India (NTAGI) has chalked out two broad strategies depending on the routine measles coverage of first dose (MCV1). In 18 states with sustained MCV1 coverage ≥80%, a second routine dose of measles would be given, whereas those states with <80% coverage, supplementary immunization will be introduced in a phased manner. There are many challenges at this juncture-unfinished agenda polio eradication, lack of VPD surveillance system, financial and manpower constraints. However, solutions are possible. Conclusion: Before setting an elimination goal in India, a thorough understanding of the regional situation is required. India should opt for the Measles Mortality Reduction before proceeding to the Elimination Goal by 2020.
Keywords: Catch-up campaign, Elimination, Measles eradication, Mortality reduction, surveillance
|How to cite this article:|
Garg S, Laskar AR. Measles elimination goal: Is it feasible for India?. Indian J Public Health 2010;54:190-3
| Introduction|| |
Despite the availability of a safe, effective, and relatively inexpensive measles vaccine for over 40 years, measles remained a leading cause of childhood mortality in developing countries.  According to global estimates 1,36,000 measles deaths (69%) occurred in countries of WHO South East Asian Region in 2007.  The WHO/UNICEF Global Immunization Vision and Strategy (GIVS) was adopted in May 2005 at the 58 th World Health Assembly. GIVS called upon the member countries to reduce the global measles deaths by 90% by 2010 as compared to 2000 estimates. Followed by this in 2007, the Regional Technical Consultative Group (TCG) endorsed the Strategic Plan for Measles Mortality Reduction in the South East Asian Region.  As already demonstrated in the Region of Americas "measles eradication" is biologically feasible, although implementation challenges remain in each of the remaining five regions.
"Measles eradication" is currently defined as the worldwide interruption of measles transmission and that the simultaneous elimination of measles in all WHO regions would equate to global eradication. Research has demonstrated the need to have homogeneous population immunity of ≥93% to achieve measles elimination. 
| Targets to be achieved for Measles mortality reduction|| |
It has been worked out that in order to bring a mortality reduction ≥ 98% compared to 2000, the immunization coverage has to be stepped up to >90% at the national and >80% at the district level. The surveillance performance would be based on three factors (i) non-measles febrile rash illness ≥ 2.0 cases/100,000, (ii) ≥ 1 suspected measles case detected in each district/year, and (iii) completeness, i.e. district reporting from 100% of districts.
| Situation in the SEARO region|| |
Four countries in the region, namely Bhutan, DPR Korea, Maldives, and Sri Lanka are implementing measles elimination strategies at present. Bangladesh, Indonesia, Myanmar, Nepal, and Timor-Leste are implementing plans for sustainable mortality reduction.  All countries in the Region except India and Thailand have conducted a nation-wide measles catch-up campaign to provide a second dose for susceptible age groups. In addition to conducting a catch-up campaign, Bhutan, DPR Korea, Maldives, and Sri Lanka are providing a second dose through routine immunization in all districts.  The progress in these countries has generated interest in the possibility of setting a global measles elimination goal. 
Recently, countries of the region have seen substantial improvement in detection, investigation, and case management of Measles outbreaks owing to expansion of Acute Flaccid Paralysis (AFP) Surveillance.
At this juncture, the Strategic Advisory Group of Experts (SAGE) drafted few recommendations for Measles Mortality Reduction for the SEARO region which may be considered by India.  These are as follows:
- All children should receive two doses of measles containing vaccine (MCV), either through the routine or supplementary immunization activities.
- Countries with ongoing measles transmission and MCV1 delivered at 9 months of age should administer routine MCV2 at 15-18 months of age.
- In countries with very low measles transmission (those nearing elimination), MCV1 can be administered at 12 months of age. The optimum age for administering MCV2 would be either at 15-18 months or at school entry, depending on whichever strategy results in high coverage.
- The interval between SIAs should be determined through an analysis of the susceptible population. This population would be determined based on routine immunization rates, previous SIA coverage rates, and primary vaccination failures.
- A follow-up campaign has to be conducted when the number of susceptible preschool-age children approaches the size of a birth cohort.
- The criteria for starting routine MCV2 is coverage with MCV1 of ≥ 80% for 3 consecutive years.
- The criteria to stop SIAs is MCV1 and routine MCV2 coverage ≥ 90-95% nationally in countries.
| Where does India stand?|| |
India although had outlined a national strategic plan for measles mortality reduction in 2005, it has not yet offered the second opportunity for measles immunization except in some selected cities like Delhi. At present, only 18 states of India comprising of a meager 38% of the population has immunization coverage of more than 80% for the first dose of measles [Table 1].  So a more realistic goal would be 90% reduction in mortality by 2020 compared to 2000 estimates.
In a recently held Regional Consultation, the Government of India expressed its endeavor to introduce second dose of measles vaccine in form of MR (Measles Rubella) vaccine. The National Technical Advisory Group of India (NTAGI) has prepared Strategic Options for Measles Control (2009).  NTAGI has chalked out two broad strategies depending on the routine measles coverage of first dose (MCV1).
i) For states with low MCV1 coverage <80%
SIA targeting 9 month to 10 years with state-wise phasing
Proactive engagement of professional organization and the media required
- By 2010: Rajasthan and Madhya Pradesh will be covered
- 2010-2011: Bihar, Chhattisgarh, Jharkhand, Uttar Pradesh (UP), and Assam will be covered.
ii) For states with sustained MCV1 coverage >=80% (Tamil Nadu, Kerala, Karnataka, Andhra Preadesh, Himachal Pradesh, Punjab, West Bengal, and Orissa)
iii) Second routine dose of measles could be given
Eventually, it is important that all states-high, medium, or low burden-will need to conduct measles SIAs to reach measles elimination.
- 18 states and union territories have already been identified.
- Second opportunity for measles will be offered through UIP (MCV2) before end 2009
| Challenges Ahead|| |
- There are many competing priorities such as the unfinished agenda like Polio eradication or introduction of newer vaccines like Japanese encephalitis in the UIP. High burden measles states, in particular Uttar Pradesh and Bihar, are the focus of continued polio eradication efforts as well. Significant time and resources of health personnel and communities in these states continue to be spent on polio eradication activities. There is an expressed concern of whether measles SIAs could be conducted concurrently or not.
- Setting up and nurturing a surveillance system (with lab support) within integrated disease surveillance project (IDSP) itself would be an enormous task considering the fact that IDSP was not designed as a VPD surveillance system.
- Ensuring availability of Financial, Logistics and Human resources- at both Central and State and sub-state levels would be possible only with a strong political support. Adequate resources (equipment, staff, training and supervision) are needed to be provided to ensure safe injection practices and waste disposal.
- Improving MCV1 coverage through UIP at projected levels may not be feasible in this short span of time. Measles being an injectable vaccine many adverse reactions also need to be addressed.
- Ensure that SIA initiatives (trainings, cold chain support, etc) and strengthen UIP
| Solutions Lie within Our System|| |
The experience with polio eradication in India highlighted the need to expect that difficulties will arise and that the process of measles elimination may be long and complex. In contrast to the popular belief that measles SIAs cannot be planned unless the polio eradication is achieved, experts opine that the existing infrastructure, capacity, micro-plans, and momentum of states conducting regular polio campaigns, will be beneficial in planning measles SIAs. If clear dates and targets are set, measles SIAs can be conducted along with polio campaigns. Focus of SIAs in India needs to initially be on the high priority states (<80% coverage). In states where MCV2 coverage is provided through routine immunization, SIAs could be scheduled in line with the target year of elimination.
A comprehensive analysis of the costs required to scale-up routine immunization to > = 95% in every district is needed. Scaling up routine immunization will reap benefits in the form of improvement in routine immunization for other vaccine preventable disease as well. Thorough assessment of the resources required (financial, human, and materials) is imperative to assess the operational feasibility.
Surveillance and research
High quality of surveillance system that meets surveillance performance indicators needs to be ensured. Laboratory strengthening is an essential component of measles elimination strategies. There is a need for close collaboration and linking laboratory and surveillance data. A system for monitoring and responding to Adverse Events Following Immunization (AEFI) should be put in place. This system is required for vaccine delivered through either routine or SIAs. Research to better understand measles virus and disease in the highest risk settings and refinement of control tools and strategies has to be upscaled.
An advocacy and communication strategy that is tailored to key audiences (general public, politicians, technical experts, etc) would be done on priority basis. This would not only sensitize but also generate strong political and financial commitments to support these activities. There is a possibility of decreased external funding as measles mortality reduction/elimination progresses and hence the need for domestic funding to sustain activities. Forging alliances with the diverse and strong partners to sustain efforts through crisis is needed. Upfront funding commitments from large governments and major donors are needed to ensure sufficient supplies and human resources.
| Conclusion|| |
In the next few years, the efforts toward sustaining measles mortality will include strategies on improving routine immunization services, attaining high quality surveillance integrated with laboratory support, and closing the immunization gaps through supplementary immunization activities. However, before setting an elimination goal a thorough understanding of the regional situation, the relevant activities required, the estimated costs, political commitments, and sustainability issues need to be understood by all stakeholders. India should surely go ahead with the measles mortality reduction goal, but it is too early to say whether India should aim for the measles elimination or not.
| Acknowledgements|| |
The authors like to thank all UNICEF experts, PATH, NTAGI and Government of India officials who present in the WHO Regional Consultative Meeting on Measles and Workshop on Rubella and have given valuable inputs in this paper. They also give special thanks to Dr. G.K. Ingle, Director Professor and Head, for lending his support for conducting the workshop on Rubella in their own institution.
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