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Measles
Measles
Measles continues to be a major cause of childhood morbidity and mortality in India. Recent studies estimate that
80,000 Indian children die each year due to measles and its complications, amounting to 4% of under-5 deaths.
Immunization against measles directly contributes to the reduction of under-five child mortality and hence to the
achievement of Millennium Development Goal 4 (MDG 4). The live attenuated measles vaccines are safe, effective and
provide long-lasting protection. The key strategies being followed globally for measles mortality reduction are high
coverage of measles first dose, sensitive laboratory supported surveillance, appropriate case management, and
providing second dose of measles vaccine. Prior to 2010, India was the only country in the world that had not introduced
a second dose of measles vaccine in its National immunization program. We herein discuss the current status of
measles vaccination along with the rationale and challenges of providing a second opportunity for measles vaccination,
and the principles of measles catch-up campaigns.
Key words: Catch-up campaign, Measles, Millennium Development Goal, Prevention, Vaccine.
M
easles is a highly infectious and potentially the Global Immunization Vision and Strategy (GIVS)
fatal viral infection mainly affecting 2006-2015 of the World Health Organization and United
children. Immunization against measles Nations Children’s Fund, is to reduce measles deaths by
directly contributes to the reduction of 90% by 2010 compared to the estimated number in 2000.
under-five child mortality and hence to the achievement World Health Assembly (WHA) has also endorsed the
of Millennium Development Goal 4 [1]. Deaths from same after the review by WHO’s Strategic Advisory
measles occur mainly in infants and young children and Group of Experts (SAGE) on immunization [7].
are primarily due to complications of the infection such as
The key strategies being followed globally for
pneumonia and diarrhea. Measles continues to be a major
measles mortality reduction are:
cause of childhood morbidity and mortality in India.
Although the true burden of measles in India is difficult to • High coverage of Measles 1st dose: Coverage for 1st
quantify, only a small proportion of cases seek treatment. dose measles vaccine must be ≥90% at national level
Infection with measles virus is ubiquitous throughout the and ≥80% for each district in routine immunization.
country.
• Sensitive laboratory supported surveillance: Outbreak
A recent review of published literature from India and case based surveillance fully supported by
shows the median case fatality ratio (CFR) of measles to laboratories for serological and virological
be 1.63% (range: 0%-30.0%) [2]. Malnutrition and classification. An outbreak is considered confirmed if
young age at infection are risk factors associated with measles immunoglobulin M (IgM) is detected in
measles mortality. Recent studies estimate that 80,000 serum from at least two suspected cases.
Indian children die each year due to measles and its
complications amounting to 4% of under-5 deaths [3]. • Appropriate measles case management: Including
The distribution of these deaths is not homogenous but is administration of vitamin A to reduce mortality and
concentrated in states with the poorest performing complications.
immunization programs [4-6]. • Providing 2nd dose of measles vaccine:
Global Goal for Measles Control (a) Single dose in routine immunization - In India, states
The current global goal for measles control, as stated in with ≥80% evaluated coverage for 1st dose of measles
vaccine in Routine Immunization (RI) (DLHS-3) will likely to be susceptible and at risk of being exposed to
have the second dose of measles vaccine in RI with measles virus – for example, to those who are travelling
DPT booster [8]. to areas where measles is endemic. The importance of
vaccinating health workers is underlined by the numerous
(b) Supplementary immunization activity (SIA) for
measles outbreaks occurring in health institutions,
measles through catch up immunization campaigns
affecting both health workers and patients.
and or follow up immunization campaigns: States with
Administration of immunoglobulins or other antibody-
<80% evaluated coverage of 1st dose of Measles
containing blood products may neutralize the effect of the
vaccine in RI (DLHS-3) are conducting Measles Catch
vaccine for 3-11 months, depending on the dose of
up campaigns since 2010 in a phased manner [9].
measles antibody. Following measles vaccination, receipt
MEASLES VACCINES, EFFECTIVENESS AND DURATION of such blood products should be avoided for 2 weeks if
OF PROTECTION possible [7].
Live, attenuated measles vaccines are available, either as Adverse Reactions: Adverse reactions after measles
monovalent vaccine or as measles-containing vaccine vaccination are slight pain and tenderness at injection site
(MCV) in combination with rubella or mumps vaccines. and are transient. About 7 days after vaccination upto 5%
When using the combined measles–rubella vaccine or children may experience fever, occasionally inducing
measles-mumps-rubella vaccine, the protective immune febrile seizures (1:3000 children). Transient rash can
responses to each individual vaccine antigen as well as occur in 2% and thrombocytopenic purpura in 1:30000
vaccine-associated adverse events remain largely and anaphylactic reactions 1:100,000 following
unchanged. Available measles vaccines are safe, effective vaccination [13-15]. Extensive studies in different
and may be used interchangeably within immunization countries have demonstrated that there is no increased risk
programs. of permanent neurological sequelae and no evidence to
support an increased risk of Guillain-Barré syndrome
Following vaccination, the long-term persistence of
following administration of MCVs. There is also no
neutralizing measles antibodies (upto 33 years) and
scientific evidence to support reports that measles
long-lasting protection against measles have been
vaccination may be a risk factor for inflammatory bowel
demonstrated. However, it is not definitively known
disease or for autism [16].
whether a single dose of measles vaccine, without natural
boosting by recurrent measles exposure, will result in Routine MCV 1 Coverage
lifelong protection. Studies using IgG avidity
In 1985, MCV1 was introduced in India’s Expanded
measurements to separate primary vaccination failures
Program on Immunization, with a recommended age for
from secondary vaccination failures suggest that
vaccination of 9-12 months. Estimated national routine
secondary failures may occur occasionally [10,11].
MCV1 coverage was 74% among children aged 12-23
However, declining immunity has not been shown as an
months based on UNICEF sponsored national Coverage
important risk factor [12].
Evaluation Survey (CES) of 2009 [17]; state level MCV1
Indications, precautions and contraindications: Mild coverage ranged from 48% to 96%. District level data
illnesses are not a contraindication to vaccination, from the District Level Household and Facility Survey
vaccination should be avoided if the patient is having high conducted during 2007-2008 (DLHS-3) indicated that
fever or having serious disease. Measles vaccine can be MCV1 coverage was ≤90% in 26% of the evaluated
given to adolescent and adults if susceptible or travelling districts [18].
to endemic areas but should be avoided during pregnancy.
SECOND DOSE OF MEASLES CONTAINING VACCINE
Early stages of HIV infection is not a contraindication to
(MCV2)
measles immunization. People with a history of an
anaphylactic reaction to components of the vaccine should With 70% routine measles vaccination coverage and 85%
not be vaccinated. Measles vaccine is also contraindicated vaccine effectiveness with a single dose given at 9 months
in people who are severely immuno-compromised e.g. of age, real protection to measles is only 60% (0.70 ×
severe HIV infection, advanced leukemia or lymphoma, 0.85=0.60) and thus approximately 40% of India’s annual
treatment with high-dose steroids [7]. birth cohort of 26 million children remains susceptible to
measles. At this rate, the accumulation of susceptible
Where no contraindications have been identified,
children in successive annual birth cohorts would reach the
measles vaccine should be given to all infants and young
epidemic threshold level every 2-3 years [19].
children as part of national immunization programmes.
The vaccine may also be offered to teenagers and adults The rationale for providing a second opportunity for
booster doses. However, these campaign doses are not 10. Paunio M, Hedman K, Davidkin I, Peltola H. IgG avidity to
counted and routine vaccination is completed as per the distinguish secondary from primary measles vaccination
schedule. The purpose is to rapidly reach a high coverage failures: prospects for a more effective global measles
around 100% in a short span of time. Furthermore, SIAs elimination strategy. Expert Opin Pharmacother.
2003;4:1215–25.
also provide an opportunity to increase community
11. Pannuti CS, Morello RJ, Moraes JC, Curti SP, Afonso AM,
awareness of immunizations and strengthen routine Camargo MC, et al. Identification of primary and secondary
immunization programs [8]. measles vaccine failures by measurement of
immunoglobulin G avidity in measles cases during the 1997
Challenge for Routine Immunization
São Paulo epidemic. Clinical and Diagnostic Laboratory
Routine vaccination is a critical strategy for achieving high Immunology. 2004;11:119–22.
coverage with MCV1 and MCV2. The government of India 12. Grading of scientific evidence – Table II (duration of
is implementing measures to strengthen routine protection) with key references. Available from http://
www.who.int/immunization/measles_grad_duration.pdf.
vaccination, especially in districts with low coverage.
Accessed on Jan 7, 2013.
Nevertheless, substantial challenges exist, including the 13. Demicheli V, Jefferson T, Rivetti A, Price D. Vaccines for
need for: increasing the number of trained staff at all levels; measles, mumps and rubella in children. Cochrane Database
increasing public demand for and confidence in vaccines; Syst Rev. 2005;4: CD004407.
improving vaccine stock and cold chain management: and 14. Duclos P, Ward BJ. Measles vaccines: a review of adverse
developing a strong reporting and management system for events. Drug Safety. 1998; 19:435–54.
AEFI [23]. 15. Beeler J, Varricchio F, Wise R. Thrombocytopenia after
immunization with measles vaccines: review of the vaccine
Conflicts of interests: None declared; Funding: None. adverse events reporting system (1990 to 1994). Pediatr Inf
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