The prospects of Measles Elimination in INDIA

1. Department of Community Medicine

2. Learning Objectives
By the end of this lecture you will know:-
 Difference between Control, Elimination & Eradication
 Why we need to eliminate Measles !
 Factors favouring the elimination & Challenges
 Current strategies

3. Basic concepts
 Control : Reduction of incidence & prevalence to a locally
acceptable level.
 Elimination : Eradication from a large Geographic region or
political jurisdiction.
 Eradication : Termination of all transmission by extermination
of agent through Surveillance & containment.

4. Measles (Rubeola)
 An acute highly infectious viral disease of childhood
 Caused by RNA virus of family Paramyxovirus
 Fever with Cough, coryza or conjunctivitis (3Cs) followed by a
typical RASH
 Koplik’s spots
 Transmission by person‐to‐person via aerosolised droplets.
 Complications

5. Clinical Presentation
 PRODROMAL STAGE
 ERUPTIVE STAGE
 POST MEASLES STAGE
 COMPLICATIONS

6. Why Measles ?
 Global: 122000 Deaths in 2012 (330/day).
 Disproportionate burden in developing countries.
 India: 56000 Deaths 2011 or 156/day.
 MDG 4, one indicator is (%) infants received primary dose.
 Very severe in malnourished children (400 times).
 Epidemic during winter & early spring.

7. Factors favoring Elimination
1) Virus: Only one antigenic type & cannot survive outside body
2) Reservoir : Human case
3) Source of infection: Aerosolised droplets
4) Transmission: Person to person
5) Communicability: 4 days before to 4 days after rash
6) Isolation: 1 week from rash
7) Secondary Attack Rate : Rare
8) Vaccine: Gives lifelong immunity but with TWO doses

8. Challenges for Elimination
 Weak Immunization system
 Highly infectious nature
 Inaccessible population
 Refusal by some population
 Changing Epidemiology of Measles
 Catch–up to > 130 Million children
 Gaps in Human & Financial resources at multiple levels

9. Rationale for 2nd Dose
 Effectiveness 85% at 9 months & 95% at >12 months
 DLHS-3 (2007-08) Measles 1st dose 69.6%.
 Actual protection at 9 months to only 60%
 (70% Coverage × 85% Efficacy = 60%).
 40% remained susceptible to measles.
 2nd opportunity ≥ 1 year will give double benefits.

10. Measles control - Strategies
Mortality
Reduction
Elimination
1st dose coverage >90% >95%
2nd Opportunity >90% >95%
Surveillance
Aggregate or case-
based
Case-based
Case Management
Vitamin A Supportive
Rx
Vitamin A Supportive
Rx
 Targets for 2015
 Routine MCV1 >90% National, >80% every district
 Incidence < 5 case / million
 Mortality reduction by >95 % (from 2000 level)

11. What has been done....
 2nd dose Measles introduced in India 2010 under UIP
 21 states MCV 1 coverage > 80% by RIA
 14 states MCV1 < 80% coverage targeted all children 9mt-10yr
by SIA then introduced in RIA after 6 months
 Phase I: 2010-11, Phase II:2011-12 & Phase III:2012-13
 Mission Indradhanush (All under 5 by 2020 for 7 VPD)

12. Global Activities
 1980 WHO & UNICEF: Accelerated measles mortality reduction
strategy
 2 dose of MCV to all through RI & SIA and improve surveillance
 63rd WHA 2010 set targets for 2015
1. Achieve at least 90% measles vaccination coverage nationally
and 80% coverage in all districts.
2. Reduce measles cases to <5 per million.
3. Reduce measles mortality by 95% compared to 2000 levels.
 Global Measles & Rubella strategic plan 2012 – 2020
 Close the Immunization Gap, 6 targets for 2015