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ORIGINAL ARTICLE
Year : 2021  |  Volume : 65  |  Issue : 5  |  Page : 5-9  

Measles outbreak among children ≤15 years old, Jaintia Hills District, Meghalaya, India, 2017


1 Epidemic Intelligence Service Officer, Integrated Disease Surveillance Programme, National Centre for Disease Control, Delhi, India
2 Deputy Director, Epidemiology Division, National Centre for Diseases Control, Delhi, India
3 Public Health Specialist, Division of Global Health Protection, Centers for Disease Control and Prevention, Delhi, India
4 Entomologist, Integrated Disease Surveillance Unit, Shillong, Meghalaya, India
5 Resident Advisor, Division of GLobal Health Protection, Centers for Disease Control and Prevention, Delhi, India
6 National Programme Officer, Integrated Disease Surveillance Programme, National Centre for Disease Control, Delhi, India

Date of Submission29-Jul-2020
Date of Decision19-Oct-2020
Date of Acceptance06-Dec-2020
Date of Web Publication29-Jan-2021

Correspondence Address:
Dipu Lowang
Room No. 6, Third Floor, Talo Apartment, Barapani Down Colony, Naharlagun, Papum Pare - 791 110, Arunachal Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijph.IJPH_960_20

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   Abstract 


Background: Of 1115 measles outbreaks during 2015 in India, 61,255 suspected measles cases were reported. In 2016, a measles outbreak was reported at East and West Jaintia Hills districts in Meghalaya State, India. Objectives: The outbreak was investigated to describe the epidemiology, estimate vaccination coverage and vaccine effectiveness (VE), determine risk factors for the disease, and recommend control and prevention measures. Methods: A measles case was defined as new-onset fever with maculopapular rash occurring between May 1, 2016, and January 21, 2017, in a resident of East and West Jaintia Hills. Cases were identified by active and passive surveillance. Serum and urine samples were collected from cases with laboratory diagnosis for confirmation. A retrospective cohort study was conducted to estimate vaccination coverage, VE, and risk factors for the disease. Results: We identified 382 cases (51% female). The attack rate was 24% with three deaths. The case fatality rate was <1%. The median age was 4 years (range: 3 months–12 years). Among children 12–60 months, 128 (56%) received measles-containing-vaccine first-dose (MCV1), 85 (37%) received measles-containing-vaccine second-dose (MCV2), and 80 (35%) received Vitamin A. VE for MCV1 was 78% and for MCV2 94%. Being unvaccinated for MCV1 (relative risk [RR] = 9.7, 95% confidence interval [CI] = 4.6–20.5) and MCV2 (RR = 17.4, 95% CI = 4.3–69.4) were both strongly associated with illness. Conclusions: Poor vaccination coverage led to the measles outbreak in East and West Jaintia Hills districts of Meghalaya. Strengthening the routine immunization systems and improving Vitamin A uptake is essential to prevent further outbreaks.

Keywords: India, measles vaccination, retrospective cohort study, risk factors, Vitamin A


How to cite this article:
Lowang D, Dhuria M, Yadav R, Mylliem P, Sodha SV, Khasnobis P. Measles outbreak among children ≤15 years old, Jaintia Hills District, Meghalaya, India, 2017. Indian J Public Health 2021;65, Suppl S1:5-9

How to cite this URL:
Lowang D, Dhuria M, Yadav R, Mylliem P, Sodha SV, Khasnobis P. Measles outbreak among children ≤15 years old, Jaintia Hills District, Meghalaya, India, 2017. Indian J Public Health [serial online] 2021 [cited 2021 Mar 5];65, Suppl S1:5-9. Available from: https://www.ijph.in/text.asp?2021/65/5/5/308314




   Introduction Top


Measles, a vaccine-preventable disease, has affected an estimated 9.7 million children and resulted in 134,200 deaths in 2015 globally.[1],[2] India is residence to half of the global measles deaths that occurred in 2010, despite vaccine administration at 9 months and 16–24 months.[3] 61,255 suspected measles cases were reported from 1115 measles outbreaks in India in 2015.[3] The sporadic cases of measles are reported from different parts of Meghalaya, highest being reported from East and West Jaintia Hills districts from 2009 to 2016, and only a few outbreaks were reported, as per the Integrated Disease Surveillance Programme, Ministry of Health and Family Welfare, New Delhi.

India is striving to eliminate measles and control rubella by 2020 and timely outbreak investigations, and rapid response to outbreak is an important measure to attend its elimination. On December 6, 2016, surveillance units from East and West Jaintia Hills districts, Meghalaya State, India, reported 36 suspected measles cases. We investigated the outbreak to describe the epidemiology, estimate vaccination coverage and vaccine effectiveness (VE), determine risk factors for the disease, and recommend control and prevention measures.


   Materials and Methods Top


Case finding

We defined a case as new-onset fever and maculopapular rash between May 1, 2016, and January 21, 2017, in a resident of East or West Jaintia Hills districts, Meghalaya. We defined a measles-related death as a death that occurred within 1 month of onset of measles irrespective of associated illness. We searched for measles cases and deaths in the districts through passive surveillance via reporting from district health facilities and outpatient, inpatient, and emergency department registers in district hospitals. We actively searched for cases in Byrwai village in East Jaintia Hills district.

Retrospective cohort study

We conducted a retrospective cohort study in Byrwai village, the most-affected village, in East Jaintia Hills district to determine risk factors, including determining the coverage of measles-containing-vaccine first-dose (MCV1) and measles-containing-vaccine second-dose (MCV2) and access to Vitamin A. We defined the cohort as all children ≤15 years old in Byrwai village. Illness within the cohort was defined as reported acute-onset fever and maculopapular rash with one of the following symptoms: cough, coryza, or conjunctivitis between August 28, 2016, and January 21, 2017. Every household was identified using the house number, and every house that participated in the survey was marked to avoid duplication. We interviewed mothers/caregivers using a semi-structured questionnaire about sociodemographics, symptoms, complications, treatment, access to Vitamin A, health-seeking behavior, and illness outcome. All houses found locked were revisited the following day and were marked. For children 12–60 months old, we assessed vaccination status using vaccination cards; if no card was available, we prompted the mother/caregiver to recall the date of vaccination or reasons the child had not been vaccinated for MCV1. We assessed the risk of getting measles with exposed (vaccinated) or unexposed (nonvaccinated) to MCV1, MCV2, or Vitamin A supplement in children of 12–59 months old. We defined exposed to measles vaccination as those among the 12-59 month cohort who received both MCV1 and MCV2.

Children either completely or partially vaccinated for other antigens before 9 months of age but not vaccinated for MCV1 were interviewed for reasons for nonvaccination. We calculated VE for MCV1 (one dose only vs. no dose) and MCV2 (two doses vs. no dose) using the formula:



We calculated proportions, case fatality rate (CFR), attack rate, and relative risk with 95% confidence interval using Epi Info version 7.2.1 release Feb 2017 (Centers for Disease Control and Prevention in Atlanta, Georgia, USA).

Immunization system assessment

We assessed administrative coverage for the affected areas and visited Pamra Paithlu Primary Health Centre (PHC) and Sohkymphor Sub-Centre (SC) of East Jaintia Hills district that covers Byrwai village to assess micro plans for measles vaccination, cold chain maintenance, supplies, and vaccination practices based on a checklist of observations and key informant interviews.

Laboratory investigation

We collected five serum and two urine samples from seven cases within 7 days from the date of onset of rash from Byrwai village. The serum and urine samples were tested at the Guwahati Medical College Hospital, Assam, for anti-measles IgM by enzyme-linked immunosorbent assay and measles RNA by reverse transcriptase-polymerase chain reaction, respectively.

Ethical considerations

The investigation was a public health response to an outbreak as part of the India Epidemic Intelligence Service Program, undertaken with the purpose to identify the source of spread for immediate control of outbreak and intended for benefit of the community at large. Ethical approval is not applicable as part of public health response. The investigation did not involve any human laboratory sample collection for research purpose, and there were no invasive investigations or medical interventions/experiments. All Government of India ethical principles and guidelines were adopted during the outbreak response: the investigation was aimed at achieving public good (beneficence) and collective welfare (solidarity); no harm was done to any individual (nonmaleficence); fair, honest, and transparent (accountability and transparency); and participants' data were de-identified prior to analysis (confidentiality).


   Results Top


Descriptive epidemiology

We visited 12 health facilities and collected reports from 29 other weekly disease reporting units. We identified a total of 382 cases and three measles deaths (CFR <1%) in East Jaintia Hills (n = 260 cases) and West Jaintia Hills (n = 122 cases) districts, Meghalaya, during May 2016 to January 2017. Half of the cases (192/382) were from Byrwai village in East Jaintia Hills. Among the 334 cases with available data, the median age was 4 years (range: 3 months–12 years) and 51% were female. Of 382 cases, 125 (33%) received Vitamin A. Cases began in early June in East Jaintia Hills district and spread to West Jaintia Hills district by the end of June with a peak of 34% (112/334) of cases in August 2016 [Figure 1].
Figure 1: Cases of measles by week of illness onset, East and West Jaintia Hills districts (n = 334), and Byrwai village, East Jaintia Hills (n = 192), Meghalaya, India, June 2016 to January 2017.

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Retrospective cohort study

We interviewed 190 mothers, four fathers, 12 grandmothers, and 28 other caregivers of 813 children ≤15 years old in 234 households of Byrwai village through a house-to-house survey. Our survey's response rate was 96%. More than 99% (799) of the cohort followed the Niamtre religion. The median age of the cohort was 7 years (range: 1 month–15 years). The median number of household members was 8 (range: 1–33). Among the 813 children (50% female), we identified 192 cases with an overall attack rate of 24%.

Cases began by the end of August 2016 and continued through January 2017 [Figure 1].

In addition to fever and rash reported by all cases, cases frequently reported conjunctivitis (94%), cough (93%), and coryza (64%). Complications were reported among 56 (29%) cases who most commonly noted diarrhea (29, 52%), pneumonia (18, 32%), and croup (4, 7%). During illness, 110 (57%) cases visited a private health-care provider, 26 (14%) a government health-care provider, and 56 (29%) did not seek medical care. Out of 813 children, 229 (28%) were 12–59 months old. There were 61 (27%) cases evenly distributed across the age group. Among children 12–59 months old, based on vaccination card (48%) and mother recall for those without vaccination cards (52%), the overall vaccination coverage was 15% for MCV1 only, 32% for both MCV1 and MCV2, and 53% were not vaccinated at all. Approximately 35% had received Vitamin A [Table 1].
Table 1: Vaccination coverage by both vaccination card and mother recall for measles-containing-vaccine 1 and 2 in a cohort of children aged 12-59 months, Byrwai village, East Jaintia Hills, Meghalaya, India, January 2017 (n=229)

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The most common reasons reported for nonvaccination of MCV1 were lack of awareness among mothers about vaccination (60%), fear of injection (24%), and lack of time (12%) [Table 2]. Among children 12–59 months old, the attack rate among those who received MCV1 was 9% as compared to 46% for unexposed, 3% among who received MCV2 as compared to 46% unexposed to MCV2, and 6% having received Vitamin A supplement as compared to 27% unexposed to Vitamin A supplement. VE of MCV1 was 80% and MCV2 was 92% [Table 3].
Table 2: Reasons for nonvaccination of measles-containing-vaccine 1 in a cohort of children aged 12-59 months, Byrwai village, East Jaintia Hills District, Meghalaya, India (n=122)

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Table 3: Risk factors for measles in a cohort of children aged 12-59 months, Byrwai village, East Jaintia Hills District, Meghalaya, India, January 2017 (n=229)

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Immunization system assessment

In 2016, East and West Jaintia Hills districts reported 73% and 98% administrative coverage for fully immunized children, respectively. MCV1 and MCV2 coverages in East and West Jaintia Hills were 74% and 101%, respectively. West Jaintia Hills reported 77% MCV1 coverage and 80% MCV2 coverage. Sohkymphor SC, which included Byrwai village, reported administrative vaccine coverage of 69% for MCV1 in 2016. Sohkymphor SC did not report MCV2 coverage in 2016. In Byrwai village, national vaccination campaign coverage was 27% for MCV1 and 8% for MCV2 during Mission Indradhanush, a Government of India initiative to vaccinate all unvaccinated or partially vaccinated children conducted from October 2015 to January 2016.[4]

At Pamra Paithlu PHC, routine immunization micro plans were incomplete. There were no lists of children to be vaccinated or vaccination session plans. All vaccines were in usable condition and within expiry date. Cold chain temperature monitoring was available and in order. Immunization registers, vaccination cards, syringes, and Vitamin A were available.

At Sohkymphor SC, routine immunization micro plans were missing lists of children to be vaccinated, session plans, and vaccinators. The SC had no cold-chain storage; vaccines were collected from Pamra Paithlu PHC every session day. Immunization registers, vaccination cards, syringes, and Vitamin A were available.

Laboratory investigation

All five serum samples were positive for anti-measles IgM, and the two urine samples were positive for measles RNA.


   Discussion Top


The measles outbreak that occurred in Byrwai village in East and West Jaintia Hills district included 382 cases and three measles deaths from May 2016 to January 2017. The two districts had lower actual vaccination coverage than reported by administrative coverage. Coverage was likely low because of weak immunization service delivery, combined with lack of awareness of vaccination and fear of injections among mothers.

Although the vaccine storage and monitoring of the cold chain appeared to be maintained, the health facilities visited lacked complete and comprehensive micro plans, a key to delivering vaccines to children and maximizing vaccination coverage. The Mission Indradhanush failed to address the poor vaccination coverage in Byrwai village.[4] Achieving and sustaining high vaccine coverage is the only way to achieve measles elimination by 2020.[4],[5],[6] Recent measles outbreak in North East India from April 2014 to May 2015 also revealed that >90% of under-five children were not vaccinated for measles-containing vaccine, thereby accumulating susceptible population and also indicating that the existing routine immunization needs strengthening.[7] A similar finding was reported from the measles outbreak investigation in Rajasthan, where about 90% of cases were not vaccinated for the measles-containing vaccine.[8] Cold chain and vaccine storage were meticulously maintained at the vaccine storage points, and VE was good, indicating that vaccine failure is not likely the cause of the measles outbreak in Byrwai village.[9],[10]

Missed opportunities to vaccinate children due to lack of mothers' awareness about the importance of vaccination and fear of adverse reactions following immunization were additional reasons for low vaccination coverage.[11],[12] Creating immunization awareness campaigns that involve caregivers and communities might help address awareness and education gaps. Parents, who were laborers and depended on daily wages, reported not having time to take their children to the health center for vaccination. Organizing vaccination outreach sessions on Sundays or during nonworking hours or late in the evenings in Byrwai village would increase vaccination opportunities and might increase vaccination coverage among children of laborer populations.

One additional factor that might explain low vaccination coverage might be religion. This measles outbreak occurred in a community that follows the Niamtre faith. Followers believe that rashes are a divine gift. They believe in allowing the natural course of disease to progress and abstain from treatment. An Austrian community also opposed childhood vaccination because they believed that measles infection was beneficial to the child.[11],[12],[13],[14] Health education, including vaccination promotion among traditional faith healers from the Niamtre community, could help to encourage positive parental attitudes toward vaccination.

There were limitations to this outbreak investigation. First, the actual vaccination status of the children and history of illness could have been affected by recall bias as we interviewed mothers/caregivers more than a month after the onset of illness. In addition, validation of measles vaccination status and Vitamin A supplementation could not be confirmed due to lack of records in the health center.

This outbreak demonstrates the importance of a multifaceted community approach to achieve measles elimination targets. Emphasis should not only be given to boosting coverage during special vaccination programs. Targeted strategies to strengthen routine immunization service delivery systems, create awareness about vaccine benefits, and appropriate health education messaging for religious communities are all needed to increase measles vaccination among children and prevent future outbreaks.

Acknowledgment

We would like to thank Dr Ekta Saroha, US Centers for Disease Control and Prevention (CDC); Dr C. S Agarwal, former Head, Department of Epidemiology, National Center for Disease Control (NCDC), Delhi; and Dr S Venkatesh, former Director, NCDC, Delhi, for their constant support and feedback during the outbreak investigation. We are also grateful to Dr H. J Uriah, District Surveillance Officer, East and West Jaintia Hills, Dr Lamim Fernandez, Medical Officer Pamra Paithlu PHC and all the staff of Department of Health and Family Welfare, Government of Meghalaya, India for their support in this investigation.

Financial support and sponsorship

This public health activity was conducted by India Epidemic Intelligence Service (EIS) program of National Centre for Disease Control at the request of the Government of Meghalaya. The National Centre for Disease Control receives funding support for the India EIS Program through cooperative agreement No. NU2GGH001904GH10-1001 from the U.S. Centers for Disease Control and Prevention, Center for Global Health, Division of Global Health Protection. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

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Hutchins SS, Escolan J, Markowitz LE, Hawkins C, Kimbler A, Morgan RA, et al. Measles outbreak among unvaccinated preschool-aged children: Opportunities missed by health care providers to administer measles vaccine. Pediatrics 1989;83:369-74.  Back to cited text no. 11
    
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Bbaale E. Factors influencing childhood immunization in Uganda. J Health Popul Nutr 2013;31:118-29.  Back to cited text no. 13
    
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