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COMMENTARY
Year : 2022  |  Volume : 66  |  Issue : 1  |  Page : 71-73  

Measles elimination by 2020 – Current status and future challenges in India


1 Final MBBS Student, Department of Community Medicine, Grant Government Medical College and Sir J.J. Group of Hospitals, Mumbai, Maharashtra, India
2 Professor and Head, Department of Community Medicine, SMBT Institute of Medical Sciences and Research Center, Nashik, Maharashtra, India
3 Professor and Head, Department of Pediatrics, SMBT Institute of Medical Sciences and Research Center, Nashik, Maharashtra, India
4 Professor, Department of Community Medicine, SMBT Institute of Medical Sciences and Research Center, Nashik, Maharashtra, India

Date of Submission27-Mar-2021
Date of Decision21-Aug-2021
Date of Acceptance15-Nov-2021
Date of Web Publication5-Apr-2022

Correspondence Address:
Manas V Pustake
230, Apna Boys'Hostel, JJ Hospital Campus, Byculla, Mumbai - 400 008, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijph.ijph_963_21

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   Abstract 


India, as a member of the World Health Organization South-East Asia Region, had committed to measles elimination by 2020. Efforts to increase immunization coverage, special immunization activities, and case-based surveillance have been implemented rigorously over the last 7 years, but India has not been able to eliminate measles. Multiple factors led to this namely inadequate vaccination coverage and COVID pandemic and others. The pandemic added its contribution in disruption of vaccine delivery services under Intensified Mission Indradhanush preventing the achievement of the elimination target, in stipulated time. India may need to think beyond strengthening the routine immunization activities and increasing the geographical coverage under Intensified Mission Indradhanush. Promising the future in the measles vaccine delivery system in the form of Measles-Micro-Array-Patches is seen on the horizon may prove to be a game-changer for targeting measles elimination, in the current decade.

Keywords: Elimination, India, measles, microarray patch


How to cite this article:
Pustake MV, Padhyegurjar MS, Mehkarkar NS, Padhyegurjar S. Measles elimination by 2020 – Current status and future challenges in India. Indian J Public Health 2022;66:71-3

How to cite this URL:
Pustake MV, Padhyegurjar MS, Mehkarkar NS, Padhyegurjar S. Measles elimination by 2020 – Current status and future challenges in India. Indian J Public Health [serial online] 2022 [cited 2022 Jul 4];66:71-3. Available from: https://www.ijph.in/text.asp?2022/66/1/71/342603



Measles is one of the most infectious diseases in humans.[1] Previously, measles were believed to cause 5–8 million deaths a year before the introduction and mainstream use of the measles vaccine.[2] The elimination of measles has been the subject of many debates since the 1960s when measles vaccinations were first approved. In 1997, the Dahlem Conference on Disease Eradication stamped eradication as the permanent decrease to zero of the worldwide incidence of disease caused by a specific pathogenic organism as a consequence of purposeful efforts, leading in the termination of the need for interventions.[3],[4] In the 1980s, shortly after the eradication of smallpox, the concept of managing and eliminating measles emerged.[5],[6] The eleven member states of the World Health Organization South-East Asia Region, at its 66th session of the WHO Regional Committee, in 2013, pledged to eliminate measles by 2020.[7]

Global coverage for Measles Containing Vaccine-1 (MCV1) stayed at 85% from 2015 to 2019, while that of Measles Containing Vaccine-1 (MCV2) increased from 63% to 71% for that timeframe.[8] In India, for 2018, coverage of MCV1 was 86% and that of MCV2 was 73%, as per the data, which far low when compared with the targets for elimination. In India in 2017, 2.9 million children were missing out on MCV1, and 6.1 million were missing out on MCV2. In the world, India is the second, only to Nigeria when it comes to the number of unvaccinated infants for MCV1 and MCV2.[9] The number of confirmed measles cases in the world set a new record in 2019. Measles cases jumped approximately to 869,000 worldwide in 2019 the most since 1996, all across WHO regions. Global measles deaths in 2019 climbed by 50% from 2016, losing an estimated 270,000 lives in 2019 alone, which should have been avoided.[10] The primary cause of the rising measles cases and deaths is believed to be the failure to vaccinate children early and often with the 2 doses of measles-containing vaccines viz. MCV1 and MCV2 leading to immunity gaps, later compounded by COVID-19 pandemic. Even though measles cases have been reduced in 2020, required COVID-19 prevention measures have disrupted vaccination and hampered efforts to prevent and reduce outbreaks.[10],[11] On February 5th, 2017, India launched one of the world's largest immunization campaigns against measles and rubella. Now the MR vaccine is used in routine immunizations, replacing the measles vaccine, which is administered at 9–12 months and 16–24 months of age.[12]

From a global viewpoint, a study conducted in the United States in 2020 with “Stay-At-Home-Orders” found a 50% reduction in measles-containing vaccine administration (base case) over 2 months in Spring 2020. With no catch-up vaccination, it was expected that vaccination coverage for children born in 2019 will drop from 90% to 82% for the first dose of MCV.[13] Vaccination programs were suspended or postponed in 37 countries during the CoVID-19 pandemic, potentially affecting more than 117 million children in these nations.[14] Specifically talking about the measles vaccine in India, it is thought that more than 3 million children missed their first dose of the measles vaccine. In 2020, 23 million children missed out on fundamental vaccines because of disrupted routine immunization services, up 3.7 million from 2019.[15]

Most of these children – up to 17 million – are unlikely to have gotten even a single vaccine during the year, worsening already large vaccine access gaps.[16] There have been major disruptions in vaccination service provision in several regions of the world because of numerous resources and employees being redirected to support the COVID-19 response.

Many barriers prevent us from achieving high population immunity against measles and successfully getting measles eliminated. These include disagreement on various issues at the level of policymakers, under-immunization, a lack of public trust, insufficient political will, and non-availability of funds, misconceptions regarding vaccinations, and adverse effects of the use of social media.

Although the targets of 95% (MCV1) and 90% (MCV2) coverage in some countries have been met, there has been substantial inequity in subnational coverage of MCV1 and MCV2 which has contributed to the outbreaks of measles. Equity in subnational coverage is equally important.[17]

Measles is a sensitive indicator of inequity; in areas where the measles virus has recently been transmitted, a full description of children's communities and socio-economic conditions would aid advocacy for complete elimination, particularly among disadvantaged and vulnerable populations. As advised by the WHO, one way of doing this is using a GPS device (GPS-enabled mobile phones can be used) to mark the location of the case and the area where an active search has been conducted so that it can be displayed on a map.[18]

Disrupted services due to COVID-19 are to be brought on the track

India needs to consider re-establishing the immunization programs. In situations where immunization services must be cut or discontinued, the state health authorities can reinstate and reinvigorate immunization services as soon as possible to close immunity gaps, until local COVID-19 virus spread has been decreased and primary health care services can resume. If opportunities for catch-up immunization are restricted, outbreak-prone VPDs such as measles should be prioritized. To allay worries, reinforce community relations, and re-establish community demand for vaccination, the state should adopt successful engagement campaigns and connect with communities.[19]

Measles surveillance, in India, should be case-based in the elimination mode. Active surveillance of health services, such as a regular audit of clinic logbooks for missed care, is necessary so that no cases are missed. Measles surveillance should be conducted in combination with rubella and incorporating other rash-causing diseases such as dengue into this surveillance framework, considering the limited concept of case identification for measles.[17],[20]

Carefully performed basic case-based surveillance is imperative for detecting high-risk locations and monitoring population progress towards elimination. As with other diseases, however, since measles is a different ailment, they may need to be educated in case identification as well as epidemiological investigations, including reviews of prior outbreaks.[21]

Another important method is serological surveillance by using laboratory confirmation, which started in India in 2013.[22],[23] Once India accelerates its case identification and case-based surveillance programs, more serum samples can be analyzed for laboratory confirmation of measles and will boost much-needed surveillance.

A new delivery system for vaccines, the microarray patch, is being studied in a clinical trial for use in 2020–2021 to administer the measles-containing vaccine. It will significantly increase coverage and equity if this system for the non-injectable vaccine were shown to be advantageous to promote better equity and high coverage, the development of innovative tools (e.g., microarray patches) should be prioritized, thus leading to progress toward elimination.[17] There are many barriers to achieving high coverage of the measles vaccine, some of which may be solved by emerging vaccine delivery technologies. Microarray array patches (MAPs) are single-dose devices used for transcutaneous administration of molecules, including inactivated or attenuated vaccines that penetrate the outer stratum corneum of the skin and deliver antigens to the epidermis or dermis [Figure 1]. MAPs to deliver measles vaccines can be transformative technologies to meet elimination targets across the globe. When used in vaccine delivery, MAPs can provide some possible operational benefits, including thermostability, better acceptance, a reduction in risk of infection, reduction in trained manpower, ease of administration, lower supply chain needs, reduction in medical waste, and dose saving. Besides, measles MAP can be used in “house-to-house” campaigns and temporary or fixed post sites for vaccination.[24],[25]
Figure 1: Measles-Microarray Patch for Measles vaccine delivery.[24]

Click here to view


Potentially favorable product characteristics of microarray patches (MAPs, also known as microneedle patches) make them of considerable interest in the delivery of measles vaccines, especially in low-and-middle-income countries (LMICs), including India. MAPs are thought to have operational advantages that could help increase equitable coverage and vaccine administration in difficult-to-reach areas, especially if they include a thermostable vaccine.[25]

Although tangible progress has been made in the reduction of confirmed measles cases, related morbidity, and mortality, reaching closer to the target of measles elimination, India has not been able to achieve the target in time. In addition to routine measures, reinforcing equitable coverage for measles vaccine, case-based surveillance, serological surveillance, India needs to get the routine immunization back on track which was disrupted during the COVID-19 pandemic. This is a challenge as the health workforce is burdened with the priority-based pandemic-related workload on one side and logistic difficulties on the other. The usage of innovative technologies like GPS technology for case surveillance and reporting should be promoted. Furthermore, innovative vaccine delivery system like Measles-MAP (Measles-Micro-Array Patches) have shown great promise in preliminary studies.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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