Abstract
India has a goal of covering all in-
fants with measles immunisation
between 9-12 months. The present
study was conducted in a resettle-
ment area of east Delhi, with a popu-
lation of nearly onelac, to assess the
extent of measles immunisation and
infection among children aged un-
der three years. All the 21 blocks of
the area were covered and 10%
households were selected by system-
atic random sampling from each of
the blocks to provide 944 households
and 517 under-3 children, who were
individually examined by a doctor.
Two hundred and eighty one chil-
dren aged 12 months or above were
immunised a t or after 9 months giv-
ing a coverage of 74.14%. Among
the immunised children 7.78% and
8.36% were vaccinated before and
after the recommended age-range
(9-12 months) respectively. One
fifth of the children aged 12 months
o r a b o v e were n o t immunised
against measles at all. Among the
surviving under-3 children, no child
suffered measles before 6 months
but 11.86% of the children had mea-
sles between 6-8 months. Six chil-
dren were vaccinated even after
measles episode and seven children
had measles even after ini’mnisa-
tion. Systematic community contact
and special attention to resistant
and hostile parents is important in
order to accomplish 100% coverage.
In view of the sizeable proportion
of measles infection among the age
group of 6-8 months, there is a case
for bringing forward the recom-
mended age for measles immunisa-
tion, if we are to eradicate the dis-
ease. Asia Pac J Public IIealtlt
1998;10(1): 29-32
Kej7,vords: Measles, immunisation,
India.
Address for Correspondence:
Dr. Sanjay Chaturvedi, D-2, U.C.M.S.
Campus, Dilshad Garden, Delhi - 110 095,
INDIA.
Downloaded from aph.sagepub.com at Bobst Library, New York University on May 16, 2015
Measles, lmmunisation and
Disease: Situation Analysis
in a Resettlement Area of
Northern India
Sanjay Chaturvedi, MBBS, MD, RIAMS, FIPHA
Aggarwal OP, MBBS, RID, FIAPSM, FIPHA
University College of Medical Sciences and Guru Teg Bahadur Hospital, Delhi,
India.
Introduction hold and a 10% sample was selected
by systematic random sampling from
Since the eradication of small pox, each of the blocks. The unit of study
measles has been a candidate disease was the under-3 year old child and all
for global eradication, considering the children under-3 years in selected
some of it’s epidemiological analogies households were included in thestudy.
with small pox. In India measles con- Selection of three years of age as a cut-
trol has been an essential ingredient
off point was based on the fact that
of “Universal Immunisation Pro- maximum incidence of measles is seen
gramme” (since 1985-86) and lately in 1-2 years followed by 2-3 years and
of the “National Child Survival and below one year age groups by major-
Safe Motherhood Programme”, where ity of the workers in India.2-l While
the national goal for measles vaccina- increasing the age of cut-off point
tion is 100% coverage of infants be- could have compromised the reliabil-
tween 9-12 months.’ But the commu- ’ ity of recall by mother, decreasing jhe
nity health situation is not simple and
cut off age, on the other hand, was also
there are area specific problems. not feasible considering the phase of
Moreover, simple enumeration of peak incidence.
measles episodes or measles deaths After recording the identification
will be an understatement of the prob- data, the mother of the child under
lem and an incomplete tool to moni- study was interviewed by’a doctor re-
tor the progress of the programme. garding availability of, immunisation
Situation analysis of surviving under- card (Home-available vaccination
3 children about measles vaccination
record for six VPDs), age and place
and the disease fill the gaps left be- of measles immunisation and age of
hind by plain indicators of mortality . the child at the time of-measles epi-
and morbidity. The present study has sode if the child had one in the past.
been conducted for such an analysis .!If the child was immunisation-positive
in eastern Delhi in 1994. and disease-positive also, it was ascer-
Materials and Methods tained which preceded which. If the
child was not immunised against mea-
This community investigation was sles, reasons for the failure of vacci-
conducted in a resettlement colony of nation were also investigated. -Place
eastern Delhi. The study area is sub- and time of immunisation against mea-
divided into 2 1 blocks, and is densely sles was ascertained by the immuni-
populated, with a total population sation card (if available) or by the his-
nearing one lac*. There are 500 to 600 tory obtained from the mother.
households in each of the blocks. All The diagnosis and time of mea-
the 21 blocks were covered by the sles episode was made on the basis of
study. Sampling unit was the house- history given by the mother. In all
* 1 Inc = 100.000
29
 suspected cases-of measles, a second Table 1. Age and sex wise distribution of the children studied
opinion from another doctor and a fac-
ulty member was taken to confirm the Age in completed months Male (%) Female (%) Total (%)
diagnosis. While evaluating the his-
tory of measles episode, help .was Less than 9 43 (8.31) 29 (5.61) 72 (13.92)
taken from standard case definition of 9-1 1 36 (6.96) 30 (5.80) 66 (12.76)
“National Child Survival and Safe 12-14 39 (7.54) 26 (5.03) 65 (12.57)
Motherhood Programme: Conduct 15-23 63 (12.18) 59 (11.41) 122 (23.59)
Disease Surveillance,”s adapted from 24-35 105 (20.31) 87 (16.82) 192 (37.13)
WHO module. Total 286 (55.32) 23 (44.68) 5 17 (100.00)
In the immunisation pro-
grammes, the aim and meaning behind x2 = 1.86, d.f. = 4, p > 0.75
recommending 9-12 months as age Table 2. Age at measles immunisation
range for measles vaccination is to
immunise the child before her/his first Age at immunisation
birthday. In the present study, the age (completed months) Male (%) Female (%) Total (%)
of the child was recorded in completed Less than 9 17 (4.90) I0 (2.88) 27 (7.78)
months, so in the results, this recom- 9-1 1 161 (46.40) 130 (37.46) 291 (83.86)
mended age range is represented as 9- 12-14 16 (4.61) 7 (2.01) 23 (6.63)
1 1 months. 15-23 2 (0.57) 4 (1.15) 6 (1.73)
Results 24-35 0 (0.00) 0 (0.00) 0 (0.00)
Of the 1054 selected households, 944 Total 195 (56.20) 152 (43.80) 347 (100.0)
households (89.56%) responded. The x2
= 5.56, d.f. = 4, p > 0.10
non-response of 10.44% was mainly
because either these families were Table 3. Reasons for non-inimunisationin children aged 12 months or above
away for a long duration or they re- ~~

fused to respond. Four hundred and Reason Male (%) Female (%) Total (%)
eighty three (5 I . 17%) of the 944 stud-
ied households had one or more un- Health fiinctionary did not immunise 3 (3.95) 6 (7.89) 9 (1 1.84)
der-3 children, providing a total of 5 17
,
because the child had already
under-3 children for the study. Table suffered with measles
1 shows the agehex distribution of Mother/guardian did not permit 4 (5.26) 2 (2.63) 6 (7.89)
these children. Not taken to centre, in time, though 10 (13.16) 12 (15.79) 22 (28.95)
There were 347 children who had contacted by health functionary
received measles vaccine, and of these Taken to centre, in time, but denied 5 (6.58) 3 (3.95) 8 (10.53)
291 children (83.86%) were immu- vaccination for some reason
nised between 9-1 1 months, the rec-
ommended age range for measles im- Neither contacted by health 13 (17.11) 18 (23.68) 31 (40.79)
munisation. Onlya minority of them functionaries nor the
(8.36%) were vaccinated between 12- mother/guardian was concerned
23 months-and there was no child in Total 35 (46.05) 41 (53.95) 76 (100.00)
the sample who was inimunised after
24 months of age; However, 7.78% x2= 0.39, d.f. = 2, p > 0.75
of the immunised children were given
measles vaccine before they reached Table 4. Age at measles episode
the recommended age for measles
immunisation (Table 2). The immu-
Age at measles episode .‘
(completed months) Male (%) Female (%) Total (%)
nisation card was available for 64.02%
of the total studied children. Less than 6 0 (0.00) 0 (0.00) 0 (0.00)
There were 76 un-immunised 6-8 5 (8.47) 2 (3.39) 7 (11.86)
children aged 12 months or above, and
for 11-84% of them, the health func- 9-1 1 12 (20.34) 8 (13.56) 20 (33.90)
tionary did not vaccinate since the 12-14 12 (20.34) 10 (16.95) 22 (37.29)
child had already been infected with 15-23 3 (5.08) 4 (6.79) 7 (11.86)
measles. For the rest of the children,
it was the failure of the programme for 24-35 0 (0.00) 3 (5.08) 3 (5.08)
various reasons as noted in Table 3. Total 32 (54.24) 27 (45.76) 59(100.00)
Of the 517 surviving under-3
children, 59 had n history of measles x2 = 1.53, d.f. = 1, p > 0.10
30
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episode. Of these, 33.90% and
37.29% of tlie children had measles
between 9-1 1 months and 12-14
months, respectively. Only 11.86%
and 5.09% children had measles be-
tween 15-23 months and 24-35
months. However, 1 1.86% of these
59 children had already suffered mea-
sles before they could reach the eligi-
ble age for vaccination that is, nine
months. However, none of them had
a measles episode before six months
of age (Table 4).
In all of the above four areas of
consideration (Table I-4), girls were
statistically comparable to the boys.
Table 5 illustrates the overall
situation of the surviving under-3 chil-
dren in the sample. Using children
aged 12 months or above as denomi-
nator, the coverage of measles vaccine
given at or after 9 months was 74.14%.
Of the 59 children who liad measles
episode, seven (1 1.86%) suffered with
tlie disease even after getting immu-
niscd, and of the 347 immunised chil-
dren, six (I .73%) were vaccinated af-
ter having suffered with measles.
Discussion
In tlie present sample, more than 25%
of the surviving under-3 children who
Iiad crossed 12 months of age, were
not vaccinated against measles at the
recommended age. This is far from
satisfactory since we have adopted a
goal of immunising all children
against measles before they reach one
year of age.] The condition may not
be better in other parts of the country.
According to UNICEFAVHO data, the
picture is better but they also report
that only 82% of one year old children
were immunised against measles, at
the national level, as late as in 1993.6
However, intensive measles immuni-
sation campaigns conducted in1995
onwards to attain 100% coverage, with
apparently good results, should have
improved the situation. But these ef-
forts will have to be sustained.
With regards to tlie age at mea-
sles immunisation, 8.36% of tlie im-
munised children received the vaccine
at or after 12th completed month. This
could have been predated to make it
more effective. On the other hand,
7.78% of the immunised children were
vaccinated before the recommended
age of nine months. Tho~igliit might
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Asia-Pacific Journal of Public Health 1998 Vol. 10. No. 1
Table 5. Status of measles iminunisation and infection of under-3 children
A. Total children studied 517
B. Children aged I2 months or above 379
C. Total children immunised against measles 347
D. Children aged 12 months or above who 303
were immunised against measles (* % of B) (* 79.95)
E. Children in item D, immunised at or after 9 months 28 1
(* % of B = Vaccination coverage) (* 74.14)
F. Children immunised before 9 months 27
(* 7.78) (* 8.36)
G. Children immunised at or after 12 months 29
(* % of C) ($: 8.36)
H. Children aged 12 months or above who
were not immunised against measles at all 76
(* % of B = Programme failure) (* 20.05)
I. Surviving under-3 children who had measles 59
(* % of A, not the incidence) (* 11.41)
J. Children who had measles before 9 months 7
(" % of I) (* 11.86)
K. Children who had measles before 6 months 0
(* % of I) (* 0.0)
7
L. Children who had measles even after immunisation
(* % of I) (* 11.86)
M. Children who were vaccinated after measles episode
(* % of C) 6(* 1.73)
have benefited the recipients since we dren ( I .73% of immunised children)
are using' E-Z (Edmonston-Zegreb) received vaccine though they had al-
strain' which is quite effective even ready suffered with measles. On the
before nine it was mainly other hand, when reasons for non-im-
because of omission, since we have yet munisation were analysed it was ob-
to make any policy change in vacci- served that in 113 4 % of the un-im-
nation schedule. Workers from India9- munised children aged 2 12 months,
have been active participants in the the health functionary did.not.vaeei-
global debate on optimal age for mea- nate because of positive history of
sles va~cination.'~-'~ Though some measles. Denying vaccination on the
researchers have even suggested to basis of positive history of natural in-
combine it with the third dose of DPT fection has certain operational disad-
vaceine,ls tlie most widely recorn'- vantages, especially in consideration
mended age range for measles immu- of other eruptive fevers. On the other
nisation for developing countries re- side of tlie issue, exposing children to
mains as 9-12 months. However, a .dive measles virus twice (vaccination
high prevalence of measles in in- after natural infection),-without a dis-
fancyIg and its attending niorbidity'O tinct advantage, is also not advisable.
and mortality2'.22keep the issue unset- Though it is generally advised that
tled. The fact that 10-15% ofthe total health functionaries should vaccinate
episodes of measles occur before 9 all infants above nine months irrespee-
months"." and tlie availability of E-Z tive of the history of measles, there is
strain make a case for advancing the a need for a clear cut and stated policy
age for immunisation. With our ex- in this regard.
isting schedule, we are constantly ne- While reviewing tlie reasons for
glccting this important pool of infec- non-immunisation, it was evident that
tion. parental apathy and lack of Informa-
In the present sample, some chil- tion, education and communication
support were the two main factors be-
hind this failure. Despite a visible
growth of electronic mass-media and
its access by the people, health func-
tionaries continue to play a central role
in IEC support. As the programme
progresses, a systematic community
contact by health workers with iden-
tification and special attention to re-
sistantlliostile parents attains impor-
tance in order to accomplish 100%
coverage.
Another important thing in this
regard was that a sizeable number of
eligible children were denied vacci-
nation though they were brought to
the health-centres on time. The rea-
sons behind such denial include non-
availability of vaccinehyringes or the
health staff. Such instances must be
minimised and if the situation is be-
yond the control of the health centre,
because ofproblems at superior level,
these cases sh-ould be specially reg-
istered, subsequently contacted and
covered during next session. What-
ever be the reason, all cases of non-
vaccination should be taken as cases
of programme failure. The impact of
this failure is significant since most
of these children are going to suffer
with natural infection, considering
the high incidence and secondary at-
tack rate in unprotected children.
Since it was an assessment of
the status of measles iininunisation
and infection among surviving chil-
dren, nothing specific can be said
about morbidity and mortality. How-
ever, it is evident that measles con-
tinues to be a significant pediatric
disease despite national efforts. In the
present investigation, though there
was no measles episode occurring
before age six months, the trend in
surviving under-3 children shows that
more than a tenth of the total inea-
sles cases occurred in the age group
of 6-8 months, before the children
could reach the eligible age for mea-
sles vaccination. The situation ap-
pears to be similar in inany of the
south-Asian countries and a regional
strategy needs to be developed to pre-
vent infection in this age group, if we
are to eradicate the disease. The fact
that a significant proportion of mea-
sles episodes occurred in the age
group of 9-1 1 months reinforces the
32
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suggestion that even within the ex-
isting age range for immunisation,
children should be vaccinated as soon
as they reach eligibility.
In the present sample, seven
children suffered with measles even
after immunisation. The reasons be-
hind this can be many, and are beyond
the scope of this study. In India 10-
15% of infants fail to seroconvert
even if vaccinated at or after nine
month^,'^,'^ so it can be a part of ex-
pected phenomenon. Nonetheless,
such cases may provide an area to be
explored further to find out'deficien-
cies in the immunisation programme.
Acknowlcdgcmcnt
Authors gratefully acknowledge the
contribution of the interns, posted in
the Department of Preventive and So-
cial Medicine, University College of
Medical Sciences, Delhi, during July
to September 1994, in data collection
for this study.
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