The story so far: As the new year dawned, so did a crucial target for India. India had set a target to eliminate measles and rubella (MR) by 2023, having missed the earlier deadline of 2020, due to a variety of reasons, exacerbated by disruptions due to the pandemic. An earlier target that was set for 2015 was also missed. It was in 2019 that India adopted the goal of measles and rubella elimination by 2023, anticipating that the 2020 goal could not be reached.
Why is this target crucial?
The measles virus is one of the world’s most contagious human viruses that kills more than 1,00,000 children every year globally, and rubella is a leading vaccine-preventable cause of birth defects, according to the World Health Organization (WHO). Both measles and rubella can be prevented by just two doses of a safe and effective vaccine. Over the past two decades, the measles vaccine is estimated to have averted more than 30 million deaths globally, as per the WHO’s statistics. In both diseases, the symptoms are a rash and fever. While measles has a high fatality rate, rubella infection in a pregnant woman will have an impact on the foetus, resulting in birth defects.
What happened in 2022?
From October 2022, an outbreak of measles in Maharashtra, particularly Mumbai, had the authorities worried. As per media reports at least 15 children died among several hundreds who contracted the infection. Coming at the cusp of a year in which India had a crucial target to achieve, it perturbed authorities.
Dr. Jacob John, noted virologist who heads the India Experts Advisory Group for eliminating MR, equates it to a phenomenon similar to COVID-19 infections catching up in China end of last year, since they had ‘escaped the previous waves of infection.’ “It is a similar phenomenon, because during the winter months of 2020 and 2021 (November to January when there is the usual spurt in cases of measles) there were no outbreaks,” he said. The 2022 outbreak was like epidemiological compensation. However, experts aver that this outbreak will contribute to ramping up herd immunity in the population which along with a robust vaccination programme will help achieve the necessary targets.
What has India done to achieve targets?
Though the pandemic led to poor immunisation rates, in a paper, Progress Toward Measles and Rubella Elimination — India, 2005–2021, published on the CDC website, Ratnesh Murugan and others explain the paths the country had taken in getting to where it stands now. During 2010–2013, India conducted a phased measles catch-up immunisation for children aged 9 months–10 years in 14 States, vaccinating approximately 119 million children.
Mission Indradhanush was launched in 2014 to ramp up vaccinating the unvaccinated population. During 2017–2021, India adopted a national strategic plan for measles and rubella elimination, and introduced rubella-containing vaccine (RCV) into the routine immunisation programme, besides launching a nationwide measles-rubella supplementary immunisation activity (SIA) catch-up campaign. It also transitioned from outbreak-based surveillance to case-based acute fever and rash surveillance, and more than doubled the number of laboratories in the measles-rubella network.
Is the target to eliminate MR achievable?
“Yes, I would think so,” said Dr. Jacob John. “The main concern is the under one-year population. But if we are able to keep up the tempo of immunisation at 95 % the second dose coverage (which means the first dose coverage has to be higher), it will be possible.”
But the trick, he pointed out, is to do it district by district — give each district a target to achieve the required rate of immunisation, conduct a robust fever and rash surveillance programme, besides testing for MR. He said a well-oiled machinery rests in place, and it is possible to be free of the disease as some other countries have recently demonstrated, including Sri Lanka, the Maldives and South Korea. “My expectation is that 95% will succeed. But what we must remember is that even if 5% miss the target, it is not as if the whole country has failed, we would have indeed achieved significant gains. Besides if we keep monitoring the progress, the districts that are stragglers in implementing the immunisation, can be helped along, with additional inputs,” he contended.
In the process, C.S. Rex Sargunam, paediatrician and president, Tamil Nadu Health Development Association, said it is important to provide full support to the ground level staff who implement the programme — the village health nurses, ASHA (accredited social health activists) workers, anganwadi and ICDS (Integrated Child Development Services) workers. “In fact the only way to ensure a target driven approach is successful is to make sure that the people given the tasks are happy doing their job. We do need to improve their service conditions, and make sure salaries are not pending for months.”
He said that while targets will be easier to achieve in States such as Tamil Nadu and Kerala, thanks to the robust immunisation infrastructure, in the other States, additional efforts should be taken to work towards achieving the target.
The WHO has expressed hope that India could indeed reach the target. “We can reach MR elimination goals in India if we strengthen surveillance by finding, investigating, and collecting and testing a sample for every suspected case, in each district in every State and UT,” said Roderico H. Ofrin, WHO Country Representative to India. Experts underlined the importance of being thorough in public health outreach. As Prabhdeep Kaur, deputy director, National Institute of Epidemiology, ICMR, said: “A threat of infection anywhere is a threat everywhere.”
