There has been an emergence of measles cases in many states in India. Starting early November 2022, first in Mumbai and its surrounding areas in Maharashtra, and then from districts in Jharkhand, Gujarat and Kerala, the surge in measles cases and a few measles-related deaths have been reported. This is of immense concern as measles is a vaccine preventable disease and two shots of the measles vaccine reduces the risk of disease drastically. A measles vaccine has been available since 1963 and used in India’s universal immunisation programme since 1985. In fact, among all childhood vaccines, measles is one of the most effective vaccines and two shots of the measles vaccine to a child reduces the risk of disease that is close to negligible. The national coverage has increased over time. Globally, there is a consensus to eliminate measles cases and deaths.
India has also set a target of eradicating measles (and rubella) diseases by the year 2023. In fact, it is in this backdrop that the current surge in measles cases is extremely worrying for India and various states. Why should a disease which is targeted for elimination and can be fully prevented continue to spread and cause the death of even a single child?
Though for millennia, measles and smallpox claimed millions of lives, with the availability of the smallpox vaccine in 1798, the smallpox virus was eradicated from the world in 1980. The measles vaccine was first developed in 1963, but soon became part of immunisation programmes and measles cases and mortality had come down drastically. Yet, the disease continues to affect poor and vulnerable populations, in low and middle countries, especially in Asia and Africa. The children who are unvaccinated, undernourished or have Vitamin A deficiency are at higher risk of severe disease.
This raises a question: why is the measles disease spreading again in some Indian states? It was something that was forewarned since the start of the Covid-19 pandemic two years ago. Due to the Covid-19 restrictions and lockdowns, the health services, including immunisation services, had witnessed a major reduction, in nearly all countries across the world. International health agencies had warned all countries that essential health services such as services for pregnant women and vaccination of children should continue. Most countries refused to accept that there was any kind of reduction in essential health services. A global report released in October 2022 has estimated that in 2021, an estimated 40 million children worldwide did not receive either both or one shot of their measles vaccine. The vaccination coverage in all countries have either remained stagnant or fallen in comparison to the pre-pandemic period. The outcome is that the pool of unvaccinated children has increased, which may be leading to a surge and re-emergence, and the outbreak of measles in several countries.
The spread of diseases such as measles -- which are entirely avoidable -- and the deaths of children in Indian states points towards deficiencies in the health system and reduced immunisation coverage. This indicates that the rate of all vaccinations and other health services have declined in India’s states. In fact, people may have become too lax about other diseases as well, such as TB treatment and the treatment of diabetes and hypertension, etc. The impact of this may appear in the years ahead in the form of serious symptoms like heart attacks.
Most of the children affected in the current surge of measles cases come from poor households and the lower socio-economic strata. This is the population group which is worst impacted when government health services and vaccinations falter. Measles is merely a tracer of overall challenges in healthcare. This is an indicator that the situation may not be very different for other vaccine preventable diseases and health services. It calls for strengthening all health services, with specific focus upon underserved localities and population groups.
What should we do now? This requires concerted societal interventions at all levels. At the level of the government, special efforts are needed to immediately strengthen vaccination coverage in every Indian state. The state governments should start vaccination drives and also ensure that health services reach the poor and low-income groups, slums and backward areas especially. Every parent needs to ensure age-appropriate vaccination of their children and also encourage others who have children to get fully vaccinated. Schools should raise awareness about vaccination through special meetings and at parent-teacher meetings. Myths and misconceptions about vaccination and vaccine hesitancy need to be tackled through concerted, credible and timely communications on the science involved. Apart from measles and other vaccines, regular Vitamin A supplementation to young children, nutrition support for underweight children and timely treatment of children with other diseases are essential. Anganwadi and Asha workers have an important role to make all this happen.
The Covid-19 pandemic has made it amply clear that timely disease detection (surveillance), availability of granular data on a regular basis and action based on that analysed data play a vital role in prevention and management of infectious diseases. All these three processes need to be strengthened in India’s states.
Forty years ago, the focus of vaccination was primarily on children. Now, there are vaccines which can protect people in all age groups -- children, adolescents, adults and the elderly -- from various diseases. Yet, the vaccination of adolescents and adults is receiving almost no attention in India. It is time to shift focus of the vaccination programme for children to all age groups -- the life course approach. Only then will we be ready to reduce the impact of Covid-19, measles and other diseases.