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Measles-Rubella vaccination campaign: Pandemic as speed breaker

 Dr. D.Y. Patil Medical College, Hospital and Research Centre, Dr. D.Y. Patil Vidyapeeth, Pune, Maharashtra, India

Date of Submission03-Nov-2021
Date of Decision20-Nov-2021
Date of Acceptance29-Nov-2021

Correspondence Address:
Kajal Srivastava,
Dr. D.Y. Patil Medical College and Research Center, Pimpri, Pune - 411 018, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/mjdrdypu.mjdrdypu_868_21


Background: Infectious diseases such as measles and rubella (MR) spread quickly to infect vulnerable populations, especially children below 5 years. Mass vaccination had been implemented to prevent it and its success has been observed through decreasing numbers of cases. The Government of India started MR campaign in February 2017, and Maharashtra was one of the selected states for it. The study was planned to find out the trend of measles cases before and after MR campaign and also to find out the effect of lockdown due to pandemic on vaccine usage. Aim: The aim of this study is to find out the trend of MR cases before and after MR campaign. Materials and Methods: A Descriptive observational study was done in tertiary care center for 2 years. Measles cases from the past 5 years were taken, and the impact of MR campaign was seen. Lockdown due to COVID-19 pandemic had an impact on the vaccination drive. To find out the impact, data for different vaccines were collected from different health centers, and analysis was done in Epi-info. Results: Post MR campaign, there was a sharp decrease in measles cases. Measles mostly targeted children below 6 years, and infants were seen having the longest stay in hospital due to the infection. At the onset of lockdown due to pandemic, vaccine consumption has gone down everywhere in the study. Conclusion: Vaccination is a proven weapon to prevent vaccine-preventable diseases, and measles is no different from other infectious diseases. Lockdown hindered the process of mass vaccination of vaccine-preventable diseases and which has gone down everywhere.

Keywords: Lockdown, measles, measles and rubella campaign, pandemic, vaccination

How to cite this URL:
Chaklader B, Banerjee A, Rathod H, Srivastava K, Lakhute S, Borgaonkar C. Measles-Rubella vaccination campaign: Pandemic as speed breaker. Med J DY Patil Vidyapeeth [Epub ahead of print] [cited 2023 Mar 20]. Available from: https://www.mjdrdypv.org/preprintarticle.asp?id=337100

  Introduction Top

Measles and rubella (MR) infections are considered the most contagious disease in the world. The impact of measles infection was so huge that it was estimated that around 2.6 million children died of it each year in the prevaccination era. After the start of vaccination of measles in 1963, cases as well as deaths due to the same had gone down drastically.[1]

In the past few years, the measles virus was making resurgence in multiple countries which may be due to the inability to reach 95% of the population who required the vaccine, circulation of misinformation about measles, and related vaccines, which further led to an anti-vaccination movement.[2],[3]

Studies in 2013 found out that more than 50% of measles-associated deaths were reported in India.[4] As of 2017, India holds the second position behind Nigeria as the country with the largest number of children unvaccinated with (Measles-containing-vaccine) MCV1 and MCV2.[5] To tackle the above issue, MR campaign was started in February 2017 in India to reduce the number of unvaccinated children.[6]

Maharashtra in November 2018, took the chance of vaccinating children who were below 15 years. Postcampaign measles mortality went down in the campaign states compared to noncampaign states.[7] COVID-19 pandemic had an impact on vaccination all over the world and similar fate was also seen in MR vaccine consumption.[8]

The study was done to find out the overall trend of measles cases in a tertiary care center during pre- and post-MR campaigns. Also had the objective to look at the seasonal variation of measles cases and the overall impact of COVID-19 pandemic on vaccination.

  Materials and Methods Top

A Descriptive observational study was done in tertiary care center for 2 years from May 2019 to May 2021. In this period, measles cases from the past 5 years were taken and the impact of MR campaign, which was launched in February 2017 in India was seen. As the lockdown happened, the vaccination drive which prevented all the vaccine-preventable diseases got a sudden hiccup. To observe the effect, data for vaccine consumption were collected from the urban, rural, and tertiary care centers. Institutional ethics clearance was taken and Research Protocol No is IESC/PGS/2019/19.


Data for measles cases were collected from the Department of pediatrics and it was entered in Microsoft Excel. Data for vaccine consumption in tertiary care center were collected from the immunization outpatient department (OPD). Data for vaccine consumption were collected from the urban and rural health training centers. An in-depth interview was conducted to find out the reasons behind the present trend of vaccine consumption from parents who were in health-care center for vaccination purposes.

Statistical analysis

Data analysis was carried out using Epi-infoTM statistical software (developed by the Centres for Disease Control and Prevention in Atlanta, Georgia). Categorical data were presented as numbers and percentages. Ninety-five percentage of confidence interval (CI) is given.

  Results Top

2015–2017 saw lesser cases getting reported compared to 2018, where measles case toll was highest in the past 5 years. 2019 and 2020 had only one case of measles each. Before MR campaign, there were 99 measles cases and after MR campaign, only two cases were reported. Measles cases were mostly seen in January to April as 58 measles cases were reported at that time frame [Table 1].
Table 1: Of 100 measles cases, 76 cases were having age below 6 years, 21 were infants, 9 were toddlers and 35 were preschool going children, 60 were males, and the rests were females

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The majority of measles cases had a stay of 1-3 days in hospital, children with the age group of 0-12 months had to stay more in hospital compared to other age group children [Figure 1].
Figure 1: Stay of measles cases in hospital (days)

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Male children had to stay more in hospital due to measles infection compared to female children [Table 2].
Table 2: Number of days of stay in hospital

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There had been 80.4% reduction of PENTAVAC consumption in a span of 5 months that is from December 2019 to April 2020 in tertiary care center. 43.75% fall of consumption in tertiary care center was seen in April alone. From the previous low, there had been more than four times increase in demand for the same vaccine within a span of 2 months that is from April 2020 to June 2020. Later, there was a fall of 67.18% in consumption within a span of 7 months from October 2020 to April 2021. 95% CI of PENTAVAC consumption in tertiary care center is 76.68–109.5. Similar trend was also followed in other centers also [Figure 2].
Figure 2: Trend of PENTAVAC consumption

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98.2% fall of consumption in MR vaccine was seen in a span of 5 months (December 2019 to April 2020) in tertiary care hospital. Within a span of month (March 2020), there was 67% decline of demand for MR vaccines. Later, when the first wave had reached its peak, the consumption increased manyfold. The second wave had 75% decline in consumption within a span of 4 months (January 2020 to April 2021). 95% CI comes out to be 27.88–39.49 [Figure 3].
Figure 3: Trend of measles and rubella vaccine consumption

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A fall of 83.1% in consumption of oral poliovirus vaccine (OPV) was recorded within 3 months (February 2020 to April 2020). Following months reported manyfold increase in demand. As the COVID-19 cases peaked, the demand of OPV reduced by 66.9% within a time frame of 3 months (August 2020 to October 2020). There was 60% decrease in OPV consumption in 4 months in tertiary care center (January 2021 to April 2021). Ninety-five percentage of CI comes out to be 133.18–277.70 [Figure 4].
Figure 4: Trend of oral poliovirus vaccine consumption

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Overall, downtrend of all the vaccine consumption was seen from January 2020 and it touched the lowest point on April 2020. The number of vaccine taker increase with increase in COVID-19 cases and both peaked at the same time in 2020. Another downtrend was seen when the second wave came and halted the vaccine drive.

In-depth interview with parents coming for vaccination of their child brought out issues such as lack of transport, strict lockdown implemented by police in different areas, and fear of spreading the infection to old and young ones living in the same house haunting them during the lockdown due to which they decided to stay away from the idea of getting their child vaccinated during that time.

  Discussion Top

Measles being an airborne infection, spreads very quickly to infect many more, especially the younger ones, who are below 5 years.[9] In the study, it was found that the majority of measles cases were below 6-year-old age group. Another research paper presented that 15% of cases were below 12 months, 20% were between 1 and 4 years old.[10] Other data from metropolitan areas showed that the median age of cases was 24 months.[11] More than half of the measles cases were males. Other research articles found out that excess mortality among the females was 4.2% in the age group of 0-4 years, 10.9% for all female measles cases who belong to 5-14 years. This excess female mortality was 20.9% in Middle East, 6.2% in North America, 5.9% in Far East Asia, 4.3%, and 3% in Latin America and Europe, respectively.[12]

There was a lesser number of measles cases at the beginning of the study (2015) but because of the increase in number of measles cases reporting, the count went up during 2018 calendar year. Following year had only one case of measles. Reason for such a low case count may be due to MR campaign. There had been a common consensus about the trend of measles cases in the world that there was a downtrend of cases. India saw a 43% drop in measles cases in 2016 compared to 2015, and it was expected to eliminate measles by 2020.[13]

Measles cases were mostly seen in starting first few months of the year. In general, it was found that there might be an increase in the number of measles cases before and after a cold spell. A study done for the incidence of measles in Guangzhou, southern China, showed that hot and cold temperatures resulted in a decrease in the incidence of measles and 18°C–20°C was considered most dangerous for infection transmission. It was also observed that relative humidity was inversely associated with the incidence of measles.[14]

Children below 12 months were staying more in hospital due to measles infection. Stay in hospital due to the infection reduces with increase in age. Few males had a longer stay compared to females.

PENTAVAC protects against diphtheria, tetanus, whooping cough, hepatitis B and hemophilus influenza type B, OPV protects from polio, and MR vaccine protects from Measles and Rubella infection. All the above vaccines went down on the basis of consumption at the onset of widespread lockdown to protect general people from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Reports from other sources found out that around 200,000 children missed their pentavalent vaccine doses.[15] As the severity of lockdown reduced, people came out and vaccinated their children. A number of children getting vaccinated was below par compared to the previous year. As COVID-19 cases peaked in the first wave, there was a fear of further increase in number of cases and deaths which lead to fear and panic, driving the consumption of vaccines lower. Later, when the second wave came, the consumption of vaccines for vaccine-preventable diseases went down to a level almost equivalent to the initial lockdown period. The result of a poll suggested that 64% of country's routine immunizations had been disrupted or even suspended as of April 2020.[16] According to a model study published in the Lancet, 2020's coverage of vaccination was likely to fall below a level not seen over a decade in a few regions. Another estimate shows that double the number of children may have missed doses of each vaccine than expected due to pandemic disruptions in high-income countries such as Central Europe, Eastern Europe, Central Asia, North Africa, and Middle East. Through articles, authors warned about the resurgence of vaccine-preventable diseases unless a required effort is taken to get routine immunization services back to normalcy.[17]

2019 saw nearly 14 million children missing out on vaccines such as measles and DPT-3. Thirty measles vaccination campaigns were either canceled or on the verge of cancellation due to SARS-CoV-2 outbreaks in different parts of the world. According to a survey conducted by the WHO and GAVI pulse, almost 75% of participating countries (82) reported COVID-19-related disruptions in their immunization programs. The study found out few facts which made parents not to go out during lockdown for vaccination; similar facts were also observed in other studies that is, people were reluctant to leave their home, transport interruptions, economic hardships due to loss of job, and restrictions on movement were few reasons for reduced number of vaccination. It was predicted that the likelihood of a child born today and later getting fully vaccinated by the time they reaches the age of 5 years is <20%. In countries such as Brazil, Bolivia, Haiti, and Venezuela, immunization coverage has gone down to a level which is equivalent to 14% less than the 2010 level.[17] Reports suggest that there has been a massive decline in routine vaccination such as measles, mumps, and rubella vaccination which has gone down by 69% during the initial phase of lockdown in India.[18] This study also showed a 67% reduction in demand of MR vaccine in tertiary care center in the initial phase of lockdown.

  Conclusion Top

Vaccination is a must to get protection from measles, and for which MR campaign was launched in the last quarter of 2018, following which measles cases count had gone down. One year later, when everyone was dealing with pandemic, vaccination programmers were seen suffering the most as there were very few takers of vaccines during the lockdown. Vaccine consumption went up but to go down later due to the second wave of COVID-19. During the pandemic, it was observed that everyone was trying to prevent SARS-CoV-2 transmission, and other communicable and noncommunicable diseases were made to take a back seat. This further lead to an increase in collateral damages mostly seen due to the lack of proper tuberculosis treatment increased maternal and infant mortality due to the lack of Accredited Social Health Activist workers (ASHA) who were doing COVID duty, and an increase in heart disease, diabetes, and psychiatric cases due to reduced number of specialized functional OPD during pandemic.[19] In the future, thought should be given in advance to prevent vaccine-preventable diseases before reserving beds for paediatrics.

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Conflicts of interest

There are no conflicts of interest.

  References Top

WHO. Newsroom/Facts in pictures/Detail/Measles; December 05, 2019. Available from: https://www.who.int/news-room/facts-in-pictures/detail/measles. [Last assessed on 2021 Oct 20].  Back to cited text no. 1
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UNICEF. Worldwide Measles Deaths Climb 50% from 2016 to 2019 Claiming Over 207,500 Lives in 2019; November 12, 2020. Available from: https://www.unicef.org/press-releases/worldwide-measles-deaths-climb-50-2016-2019-claiming-over-207500-lives-2019. [Last assessed on 2021 Oct 20].  Back to cited text no. 3
Shrivastava SR, Shrivastava PS, Ramasamy J. Measles in India: Challenges & recent developments. Infect Ecol Epidemiol 2015;5:27784.  Back to cited text no. 4
CDC. Mortal M. Wkly Rep 2020;69:1706-10. Available from: https://www.cdc.gov/mmwr/volumes/69/wr/mm6945 [Last assessed on 2021 Oct 20].  Back to cited text no. 5
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Wong BK, Fadel SA, Awasthi S, Khera A, Kumar R, Menon G, et al. The impact of measles immunization campaigns in India using a nationally representative sample of 27,000 child deaths. Elife 2019;8:e43290.  Back to cited text no. 7
WHO. Newsroom/Fact sheets/Detail/Immunization Coverage; July 15, 2021. Available from: https://www.who.int/news-room/fact-sheets/detail/immunization-coverage. [Last assessed on 2021 Oct 20].  Back to cited text no. 8
CDC. Measles (Rubeola); November 05, 2020. Available from: https://www.cdc.gov/measles/symptoms/signs-symptoms.html. [Last assessed on 2021 Oct 20].  Back to cited text no. 9
Chen SS. How does the Incidence of Measles Vary by Age? Medscape; June 06, 2019. Available from: https://www.medscape.com/answers/966220-87105/how-does-the-incidence-of-measles-vary-by-age. [Last assessed on 2021 Oct 20].  Back to cited text no. 10
Singh J, Datta KK. Epidemiological considerations of the age distribution of measles in India: A review. J Trop Pediatr 1997;43:111-5.  Back to cited text no. 11
Garenne M. Sex differences in measles mortality: A world review. Int J Epidemiol 1994;23:632-42.  Back to cited text no. 12
Dey S. Measles Cases in India Dropped by 43% in a Year: WHO. Times of India; September 25, 2019. Available from: https://timesofindia.indiatimes.com/life-style/health-fitness/health-news/measles-cases-in-india-dropped-by-43-in-a-year-who/articleshow/60476283.cms. [Last assessed on 2021 Oct 20].  Back to cited text no. 13
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Explained: How Pandemic Disrupted DTP, Measles Vaccination of Kids. The Indian EXPRESS; July 16, 2021. Available from: https://indianexpress.com/article/explained/how-pandemic-disrupted-dtp-measles-vaccination-of-kids-7406813/. [Last assessed on 2021 Oct 20].  Back to cited text no. 17
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