By Pranay Lal
Post-COVID, governments the world over are rushing to regain lost ground in their fight against diseases. The pandemic has devastated programmes and has undone hard-earned progress. Diseases like polio and measles, once near elimination, have made a worrisome comeback.
Measles, an enduring global health crisis, inflicts substantial harm, particularly on children under five. With 6 million infections and 300 daily casualties, urgent action is imperative. In November 2022, 30 times more measles cases emerged in Europe as a perilous consequence of declining vaccination rates. Reports streamed in from former Soviet states, and later from Britain, the Netherlands and the US. Infectious disease specialists had long warned of the potential for a massive resurgence with declining vaccination rates. The real threat of measles mortality persists in low-income countries, with a 43% year-on-year increase in global measles deaths, primarily in sub-Saharan Africa, where pandemic-disrupted vaccination efforts have exacerbated the situation. The urgency lies in addressing these global disparities rather than fixating solely on the resurgence in more developed nations. Despite a 73% reduction in global measles deaths from 2000 to 2018 through vaccination, recent outbreaks have exposed persistent challenges. Developed countries now stare are measles numbers similar to some developing countries. A near 100% vaccination coverage depends on a scaffold of robust health systems and public health practices. Even minor weaknesses and oversights in health systems allow highly infectious diseases like measles to re-emerge. Some countries especially the UK, suffer from a misgivings of the fraudulent 1998 Lancet paper which falsely linked the MMR vaccine to autism. This paper had triggered anti-vaccination sentiments, disrupting programmes and causing measles resurgence in multiple countries. Vaccine hesitancy emerges as a stumbling block, fuelled by distrust in communities, echoing the historical impact of misinformation on vaccination efforts, especially in UK and some European countries currently grapple with strong measles outbreaks. UK and Europe are case studies, emphasizing the enduring impact of misinformation.
India’s struggle with a surge in measles cases reflects the challenges of the Measles-Rubella (MR) 2020 program, initially aiming for elimination by 2020 but revised to 2023 due to the disruptive force of COVID-19. The fifth round of the National Family Health Survey (NFHS-5) data from 2019 to 2021 reveals sobering vaccination coverage gaps, worsened by manpower shortages, communication lapses, cold chain maintenance issues, and vaccine hesitancy. The vaccination protocol, with doses at 9–12 months and 15–18 months, necessitates 95% coverage for herd immunity. However, NFHS-5 indicates only 56% of children received the recommended two doses by age 3. Despite a massive 2017-2019 immunization campaign targeting 410 million children, pandemic disruptions since February 2020 left at least 2.6 million Indian infants without their first measles vaccine dose. Intensified Mission Indradhanush 3.0 in 2021 attempts to address the aftermath but has yet to fully curb the ongoing outbreak. Government of India data suggests that measles and rubella incidence declined by 62% and 49% from 2017 to 2021. The aftermath of disrupted vaccination efforts in 2020, compounded by routine immunization gaps, has led to a resurgence of measles in four major Indian cities. India faces the grim reality of missing its 2023 elimination deadline, necessitating robust political support for elimination efforts. Urgent efforts are needed to meet the 2023 elimination goals, with a focus on district-level implementation and monitoring. In the recently announced interim budget, the Union Finance minister Smt. Nirmala Sitharaman proposed the roll out of a newly designed U-WIN platform to strengthen immunization and advance efforts under Mission Indradhanush. U-WIN has adopted good practices and learnings from the Covid-19 vaccine management system (Co-WIN). It has been piloted in two districts of each of the 30 states and union territories for registration and vaccination of pregnant women and births, with follow up on immunization of a child up to the age of 13 years.
The problem is not entirely rural in India. Mumbai’s stark illustration of routine immunization dropping below 65% in 2022, contributing to over 400 reported cases and eight deaths, emphasizes the colossal challenge of vaccinating India’s 1.4 billion population. Ghaziabad in Uttar Pradesh, a large urban sprawl also encountered a large outbreak in October 2021. Measles experts emphasize that even in communities with high vaccination rates, certain individuals may retain sub-optimal immunity against measles, rendering them susceptible to future outbreaks. The persistence of measles in populations underscores the risk of resurgence when vaccination rates decline. Sero-surveillance (a means to estimate antibody levels against infectious diseases in a population and informs about population-level immunity) plays a pivotal role in monitoring vaccine-preventable diseases, offering early indications of populations requiring supplementary vaccinations to forewarn against potential outbreaks. Beyond vaccination, surveillance especially among families of migrant workers and pregnant women, demand urgent attention for effective outbreak response. As India navigates these challenges, the missed 2023 deadline serves as a poignant reminder of the uphill battle. Vulnerable undernourished children, constituting 45% of under-5 mortality, pose an additional barrier to vaccination success. Malnutrition not only jeopardizes health but dampens immune response, making these children more susceptible to infections. Direct benefit transfers (for example for tuberculosis patients) and nutrition programmes targeted at children have so far had mixed results. While vaccines like OPV, pneumococcal polysaccharide, Haemophilus influenza, and rabies exhibit a normal response, measles and rotavirus vaccines show lower efficacy in undernourished children.
Addressing these challenges requires a multifaceted strategy, including increasing vaccine coverage, fortifying outbreak preparedness, and bolstering surveillance. In the broader context of childhood vaccination in India, socioeconomic disparities persist. While overall vaccination coverage has improved, the benefits are more pronounced in certain regions, creating a nuanced tapestry of progress. Socioeconomic factors continue to influence vaccination rates, necessitating targeted interventions to uplift disadvantaged and underserved groups. New communication strategies that build trust and dissipate misinformation are urgently needed. India’s quest to become measles-free will require it to address the interplay between malnutrition, improving vaccination coverage, and strengthening health systems. The evolving narrative of vaccination, especially among undernourished children, serves as a call to action for all agencies and urging all programmes to unite with an unwavering commitment to leaving no child behind.
(The author is a biochemist and works as senior advisor to Health Systems Transformation Platform (HSTP) on climate change, infectious diseases and health. Views expressed are personal and do not reflect the official position or policy of the FinancialExpress.com.)
