Ratnesh Murugan, MBBS1; Kristin VanderEnde, PhD2; Veena Dhawan, MBBS3; Pradeep Haldar, MBBS4; Sourabh Chatterjee, MCS1; Deepa Sharma, PhD1; Kevisetuo Anthony Dzeyie, MPH1; Subramanya Balakuntlam Pattabhiramaiah, MBBS1; Sudhir Khanal, PhD5; Fortunate Sangal, PhD5; Sunil Bahl, MD5; Sukarma S.S. Tanwar, MMeD2; Michelle Morales, MD6; Ahmed M. Kassem, MD6 (View author affiliations)
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What’s already acknowledged about this primeic?
In 2019, India adopted the objective of measles and rubella elimination by 2023, a revision of the objective of measles elimination and administration of rubella and congenital rubella syndrome by 2020.
What’s added by this report?
Estimated safety with The primary dose of a measles- and rubella-containing vaccine enhanced from 68Percent to 89Percent in 2021. Estimated safety with the second dose of a measles-containing vaccine enhanced from 27Percent to 82Percent in 2021. All by way of 2017–2021, measles and rubella incidence declined 62Percent and 48Percent, respectively.
What are the implications for public well being apply?
India has made substantial progress in the direction of measles and rubella elimination; pressing and intensified efforts are requipurple To understand elimination goals by 2023.
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In 2019, India, Collectively with completely different nations On the earth Health Group (WHO) South-East Asia Area,* adopted the objective of measles and rubella elimination by 2023,† a revision of the earlier objective of measles elimination and administration of rubella and congenital rubella syndrome (CRS) by 2020§ (1–3). All by way of 2017–2021, India adopted a nationwide stpricegic plan for measles and rubella elimination (4), launched rubella-containing vaccine (RCV) into the routine immunization program, launched a nationwide measles-rubella supplementary immunization exercise (SIA) catch-up advertising campaign, transitioned from outbreak-based mostly surveillance to case-based mostly acute fever and rash surveillance, and Greater than doubled the Quantity of laboratories Inside the measles-rubella internetwork, from 13 to 27. Stpricegies included 1) attaining and sustaining extreme inhabitants immunity with A minimal of 95Percent vaccination safety by offering 2 doses of measles- and rubella-containing vaccines; 2) making sure a delicate and well timed case-based mostly measles, rubella and CRS surveillance system; 3) sustaining an accpurpleited measles and rubella laboratory internetwork; 4) making sure enough outbreak prepapurpleness and speedy response to measles and rubella outbreaks; and 5) strengthening assist and linkages To understand these stpricegies, together with planning and progress monitoring, advocacy, social mobilization and communication, identification and utilization of synergistic linkages of integpriced program efforts, evaluation, and enhancement. This report describes India’s progress in the direction of the elimination of measles and rubella during 2005–2021, with a Think about the yrs 2017–2021.¶ All by way of 2005–2021, safety with The primary dose of a measles-containing vaccine (MCV) administepurple by way of routine immunization enhanced 31Percent, from 68Percent to 89Percent. All by way of 2011–2021, safety with a second MCV dose (MCV2) enhanced by 204Percent, from 27Percent to 82Percent. All by way of 2017–2021, safety with A primary dose of RCV (RCV1) enhanced virtually 14-fold, from 6Percent to 89Percent. Extra than 324 million youngsters acquired a measles- and rubella-containing vaccine (MRCV) during measles-rubella SIAs accomplished in 34 (94Percent) of 36 states and union territories (states) during 2017–2019. All by way of 2017–2021, annual measles incidence decreased 62Percent, from 10.4 to 4.0 circumstances per 1 million inhabitants, and rubella incidence decreased 48Percent, from 2.3 to 1.2 circumstances per 1 million inhabitants. India has made substantial progress in the direction of measles and rubella elimination; by no meanstheless, pressing and intensified efforts are requipurple To understand measles and rubella elimination by 2023.
India has Definitely one of many world’s largest immunization packages, concentrating on a delivery cohort of 27 million youngsters yrly (5). In 1985, safety with A primary dose of MCV (MCV1), administepurple at age 9–12 months, was launched into the routine immunization program and MCV2, administepurple at age 16–24 months, was launched in 2011. In 2017, India launched RCV, and measles- and rubella-containing vaccine (MRCV) changed MCV1 and MCV2 Inside the routine immunization schedule.** Administrative vaccination safety (the Quantity of vaccine doses administepurple divided by the estimated goal inhabitants) is reported Annually from all districts in India to the nationwide immunization program, the place knowledge are aggregated and reported to WHO and UNICEF by way of the Joint Reporting Type. WHO and UNICEF use reported administrative safety, nation estimates, and vaccination safety survey knowledge to geneprice annual estimates of vaccination safety by way of routine immunization providers (6). Estimated MCV1 safety enhanced 31Percent, from 68Percent in 2005 to 89Percent in 2021, and estimated MCV2 safety enhanced 204Percent, from 27Percent in 2011 to 82Percent in 2021 (Desk) (Decide 1). Estimated RCV1 safety enhanced 1,383Percent, from 6Percent in 2017 to 89Percent in 2021 (Decide 2). The Fifth National Household Health Survey, carried out nationwide during 2019–2020, estimated the MCV1 safety For youngsters aged 12–23 months to be 88Percent compapurple with the 2005–2007 Third National Household Health Survey–estimated MCV1 safety of 59Percent (7). Estimated safety with The primary MRCV dose (MRCV1) peaked at 95Percent in 2019 earlier than the COVID-19 pandemic; safety declined by 6 proportion factors Through the pandemic to 89Percent in 2020 And A pair of021. Equally, the estimated MCV2 safety declined from 84Percent in 2019 to 82Percent in 2021.
All by way of 2010–2013, India carried out a phased measles catch-up SIA For youngsters aged 9 months–10 yrs in 14 states, vaccinating roughly 119 million youngsters with MCV. In December 2014, India launched Mission Indradhanush (https://www.nhp.gov.in/mission-indradhanush1_pg) as a particular immunization drive to vaccinate unvaccinated and halfially vaccinated youngsters aged <2 yrs dwelling in chosen districts. All by way of 2015–2021, India accomplished 4 Mission Indradhanush rounds (periodic intensification of routine immunization exercise), vaccinating roughly 39 million youngsters who had earlier thanhand missed any doses of vaccines provided by way of routine immunization, together with measles and rubella (the latter during 2018–2021). All by way of 2017–2019, India carried out measles-rubella SIAs in a phased method in 34 (94Percent) of 36 states, vaccinating roughly 324 million youngsters with MRCV. Of The two states That did not halficipate Inside the measles-rubella SIA, West Bengal has scheduled a measles-rubella SIA for early 2023, and Delhi has but To confirm a date for the advertising campaign.
Surveillance Actions and Measles and Rubella Incidence
In 2005, India started using the WHO-assisted acute flaccid paralysis polio surveillance platform for laboratory-assisted measles and rubella outbreak-based mostly surveillance Inside the state of Tamil Nadu. All by way of The subsequent 10 yrs, further states started measles and rubella outbreak-based mostly surveillance,†† which was carried out in all states by 2015, Ensuing in enhanced reporting of rubella circumstances in 2016 (Decide 2). All by way of This period, India lowepurple The sting for investigation of a suspected measles or rubella outbreak by 94Percent, from 20 circumstances per week in 2005 To 5 circumstances per 4 weeks in 2015. All by way of 2005–2015, India’s Joint Reporting Type for measles and rubella circumstances included knowledge from outbreak-based mostly surveillance And further sources. All by way of 2017–2019, India transitioned from outbreak-based mostly to case-based mostly measles and rubella surveillance.§§ Furthermore, in 2021, after a pilot carried out in three states, India transitioned to case-based mostly acute fever and rash surveillance¶¶ in all states (Desk). To assist this scale-up, the internetwork of WHO-accpurpleited laboratories expanded from three in 2005 to 13 in 2017; during 2017–2021, 14 further laboratories have been added to the internetwork, for An complete of 27.
Measles and rubella surveillance system indicators estimate sensitivity, timeliness, And efficiency. All by way of 2017–2021, the discarded nonmeasles and nonrubella circumstances price,*** a measure of surveillance sensitivity, enhanced 5fold, from 0.30 to 1.81 per 100,000 inhabitants, and The share of districts with a discarded case price ≥2 enhanced thirteenfold, from 3Percent to 42Percent. The timeliness of case investigations (≤48 hours of notification) enhanced from 83Percent in 2017 to 92Percent in 2021, and 100Percent of suspected circumstances with enough specimens have been examined in a WHO-accpurpleited laboratory. In 2021, 94Percent of patterns have been examined ≤4 days of receipt by the laboratory; by no meanstheless, solely 72Percent of laboratory end outcomes have been submitted to the immunization program within 4 days of specimen receipt, probably delaying public well being movement.
All by way of 2017–2021, the incidence of measles decreased 62Percent, from 10.4 to 4.0 circumstances per million inhabitants, and the incidence of rubella declined 48Percent, from 2.3 to 1.2.††† All by way of This period, Amongst The numerous laboratory-confirmed and epidemiologically linked measles circumstances, 71Percent of sufferers had acquired no MCV doses or had an unacknowledged vaccination historic previous. Equally, 81Percent of particular persons with laboratory-confirmed and epidemiologically linked rubella had acquired no RCV doses or had an unacknowledged vaccination historic previous. In 2021, Amongst The numerous laboratory-confirmed and epidemiologically linked circumstances, 42Percent of measles and 58Percent of rubella circumstances have been reported in youngsters aged 9 months–4 yrs.
Amongst isolates from sufferers during 2017–2021, measles virus genotypes detected and reported included B3, D4, and D8; D8 accounted for 1,623 (95Percent) of 1,703 isolates reported. Rubella virus genotype 2B was detected and reported from 43 sufferers during 2017–2021. However, genotype information Is out there for a small proportion of measles (3Percent) and rubella (0.4Percent) circumstances during This period.
All by way of 2005–2021, India made substantial progress in the direction of measles and rubella elimination. Through implementation of nationwide and regional stpricegies, together with Mission Indradhanush and two SIAs carried out in phases during a number of yrs every (2010–2013 And A pair of017–2019), to strengthen each routine and supplementary immunization, estimated MCV1, MCV2, and RCV1 safety enhanced 31Percent, 204Percent and 1,383Percent, respectively. Reported measles and rubella incidence declined by 62Percent and 49Percent, respectively, during 2017–2021.
Regardless of this progress, India continues to face challenges in its objective To understand measles and rubella elimination by 2023. All by way of the COVID-19 pandemic, nationwide routine MRCV1 safety decreased from a peak of 95Percent in 2019 to 89Percent in 2021, and MCV2 safety decreased from a peak of 84Percent (2019) to 82Percent (2021). As properly as, the surveillance indicators demonstpriced declines in sensitivity of measles and rubella surveillance from 2019 to 2020. India initiated numerous measures to mitigate the influence of the pandemic on immunization supply and surveillance, together with the dissemination of up So far steperiodge for the continuation of immunization and surveillance, As properly as to state-diploma considers To debate challenges and monitor progress. All by way of the second half of 2021, the placeas persevering with To answer the COVID-19 pandemic, India educated roughly 240,000 particular persons in fever and rash surveillance at workshops by way ofout the nation. In 2021, 42Percent of districts reveryed the surveillance efficiency goal of two or more discarded nonmeasles and nonrubella circumstances per 100,000 inhabitants, An enhance Of roughly 280Percent from 11Percent of districts in 2020. To deal with challenges with knowledge extreme quality and laboratory and surveillance reporting delays, India is transitioning to A mannequin new, exact-time, integpriced Vaccine-Preventable Illness Surveillance Information Management System.
The findings On this report are topic to A minimal of three limitations. First, safety estimates are based mostly on administrative knowledge And will be inaccuprice As a Outcome of of errors in recording doses administepurple or in estimating the goal inhabitants. Second, surveillance knowledge might underestimate exact disease incidence because surveillance sensitivity was low: youngsters who had measles or rubella Will not have been launched in for care And by no means all circumstances in sufferers who sought care Could have been reported. Lastly, given the small Quantity of patterns sequenced, genotype knowledge Will not mirror the ppurpleominant circulating genotypes.
In September 2022, recognizing the pressing and intensified work requipurple To understand measles and rubella elimination by 2023, India adopted a “Roadmap to Measles and Rubella Elimination in India by 2023” (8). Given subnationwide variations in immunization safety and surveillance sensitivity, the roadmap consists of an movement plan To intensify and monitor progress in the direction of measles and rubella elimination with a Think about district-diploma implementation, monitoring, and program consider. With an annual delivery cohort of 27 million youngsters in India, the measles and rubella elimination program recurrents a distinctive alternative To sprime demise and sickness from these illnesses.
Immunization and surveillance program staff members in India On the Ministry of Health and Household Welfare, World Health Group’s National Public Health Support Community, and completely different halfner enterprisees.
1World Health Group Country Office for India, New Delhi, India; 2Center for Worldwide Health, Division Of worldwide Health Protection, CDC India, New Delhi, India; 3Ministry of Health and Household Welfare, Authorities of India, New Delhi, India; 4JSI, New Delhi, India; 5Immunizations and Vaccines Development, World Health Group South-East Asia Areaal Office, New Delhi, India; 6Worldwide Immunization Division, Center for Worldwide Health, CDC.
- World Health Group, Areaal Office for South-East Asia. SEA/RC66/R5 – measles elimination and rubella/congenital rubella syndrome administration. New Delhi, India: World Health Group, Areaal Office for South-East Asia; 2013. Accessed November 10, 2022. https://apps.who.int/iris/deal with/10665/128273
- World Health Group, Areaal Office for South-East Asia. Measles and rubella elimination by 2023. New Delhi, India: World Health Group, Areaal Office for South-East Asia; 2019. Accessed November 10, 2022. https://apps.who.int/iris/deal with/10665/327923
- Khanal S, Kassem AM, Bahl S, et al. Progress in the direction of measles elimination—South-East Asia Area, 2003–2020. MMWR Morb Mortal Wkly Rep 2022;71:1042–6. https://doi.org/10.15585/mmwr.mm7133a2 PMID:35980874
- Ministry of Health & Household Welfare, Authorities of India. National stpricegic plan for attaining and sustaining measles and rubella elimination in India. New Delhi, India: Ministry of Health & Household Welfare, Authorities of India; 2019. https://nhm.hp.gov.in/storage/app/media/uploaded-information/MRPercent20StpricegicPercent20PlanPercent20India.pdf
- Ministry of Health & Household Welfare, Authorities of India. National well being mission: immunization. New Delhi, India: Ministry of Health & Household Welfare, Authorities of India; 2022. Accessed November 10, 2022. https://nhm.gov.in/index1.php?lang=1&diploma=2&sublinkid=824&lid=220
- Burton A, Monasch R, Lautenbach B, et al. WHO and UNICEF estimates of nationwide toddler immunization safety: methods and course ofes. Bull World Health Organ 2009;87:535–41. https://doi.org/10.2471/BLT.08.053819 PMID:19649368
- Worldwide Institute for Population Sciences. National Household Health Survey, India. Maharashtra, India: Worldwide Institute for Population Sciences; 2022. Accessed November 10, 2022. http://rchiips.org/nfhs/
- Ministry of Health & Household Welfare, Authorities of India. Roadmap to measles and rubella elimination in India by 2023. New Delhi, India: Ministry of Health & Household Welfare, Authorities of India; 2022.
|All circumstances, no.||13,854||20,925||10,485||5,497||5,697|
|Laboratory-confirmed*||3,487 (25)||5,795 (28)||4,829 (46)||2,572 (47)||1,863 (33)|
|Epidemiologically linked†||9,569 (69)||13,470 (64)||3,291 (31)||629 (11)||448 (8)|
|Clinically suitable§||798 (6)||1,660 (8)||2,365 (23)||2,296 (42)||3,386 (59)|
|Measles genotypes, no.||D4 (4), D8 (204)||D4 (1), D8 (333)||B3 (2), D4 (5), D8 (553)||B3 (4), D4 (64), D8 (510)||D8 (23)|
|Age group of sufferers with laboratory-confirmed and epidemiologically linked measles|
|<9 mos||602 (5)||1.140 (6)||752 (9)||357 (11)||166 (7)|
|9 mos–4 yrs||5,255 (40)||7,579 (39)||2,840 (35)||1,371 (43)||981 (42)|
|5–9 yrs||5,144 (39)||7,449 (39)||2,177 (27)||743 (23)||552 (24)|
|10–14 yrs||1,466 (11)||1,944 (10)||960 (12)||295 (9)||291 (13)|
|≥15 yrs||589 (5)||1,153 (6)||1,391 (17)||435 (14)||321 (14)|
|Unacknowledged or lacking||NA||NA||NA||NA||NA|
|MCV doses acquired by sufferers with laboratory-confirmed and epidemiologically linked measles|
|≥2||1,619 (12)||3,467 (18)||1,319 (16)||700 (22)||876 (38)|
|1||1,926 (15)||1,923 (10)||995 (12)||406 (13)||321 (14)|
|0||6,073 (47)||7,978 (41)||3,311 (41)||1,019 (32)||382 (17)|
|Unacknowledged||3,438 (26)||5,897 (31)||2,495 (31)||1,076 (34)||732 (32)|
|All circumstances, no.||3,097||2,381||3,487||1,397||1,681|
|Laboratory-confirmed**||888 (29)||1,032 (43)||2,088 (60)||1,293 (93)||1,636 (97)|
|Epidemiologically linked††||2,209 (71)||1,349 (57)||1,399 (40)||104 (7)||45 (3)|
|Rubella genotypes, no.||2B (9)||2B (9)||2B (19)||2B (6)||NA|
|Age group of sufferers with laboratory-confirmed and epidemiologically linked rubella|
|<9 mos||115 (4)||92 (4)||169 (5)||109 (8)||82 (5)|
|9 mos–4 yrs||742 (24)||629 (26)||1,277 (37)||665 (48)||977 (58)|
|5–9 yrs||1,198 (39)||874 (37)||1,098 (32)||330 (24)||283 (17)|
|10–14 yrs||652 (21)||457 (19)||513 (15)||164 (12)||151 (9)|
|≥15 yrs||390 (13)||328 (14)||430 (12)||129 (9)||188 (11)|
|Unacknowledged or lacking||NA||1 (0)||NA||NA||NA|
|RCV doses acquired by sufferers with laboratory-confirmed and epidemiologically linked rubella|
|≥2||64 (2)||108 (5)||187 (5)||157 (11)||345 (21)|
|1||74 (2)||52 (2)||489 (14)||342 (24)||464 (28)|
|0||1,801 (58)||1,323 (56)||1,882 (54)||608 (44)||524 (31)|
|Unacknowledged||1,158 (37)||898 (38)||929 (27)||290 (21)||348 (21)|
|Surveillance and program implementation|
|States with case-based mostly or fever and rash surveillance|
|Case-based mostly surveillance§§||6 (17)||17 (47)||29 (81)||32 (89)||0 (0)|
|Fever and rash surveillance¶¶||0 (—)||4 (11)||4 (11)||4 (11)||36 (100)|
|WHO-accpurpleited measles and rubella laboratories, no.||13||17||21||20||27|
|States ending measles-rubella SIA||10 (28)||26 (72)||34 (94)||34 (94)||34 (94)|
|Surveillance efficiency indicators|
|No. of discarded NMNR circumstances***||3,581||7,196||14,514||11,039||25,654|
|No. of discarded NMNR circumstances per 100,000, nationwide diploma (goal ≥2)||0.3||0.5||1.1||0.8||1.8|
|Districts with NMNR discard price ≥2||20 (3)||20 (3)||107 (15)||84 (11)||321 (42)|
|Percent of suspected circumstances enoughly investigated††† ≤48 hours after notification (goal ≥80)||83||89||87||89||92|
|Percent of suspected circumstances with enough specimens§§§ examined for measles and rubella in a proficient laboratory¶¶¶ (goal ≥80)||100||100||100||100||99|
|Percent of patterns examined ≤4 days after specimen receipt in laboratory (goal ≥80)****||89||39||85||84||94|
|Percent of end outcomes acquired by program ≤4 days after specimen receipt (goal ≥80)††††||67||22||47||53||72|
|Percent of weekly surveillance mannequins reporting to nationwide diploma on time (goal ≥80)||92||92||94||94||93|
FIGURE 1. Quantity of reported measles circumstances,* estimated proportion Of youngsters who acquired their first and second doses of measles-containing vaccine,† and supplementary immunization activities, by yr§,¶ — India, 2005–2021
Abbreby way oftions: MCV1 = first dose of measles-containing vaccine in routine immunization; MCV2 = second dose of measles-containing vaccine in routine immunization; SIA = supplementary immunization exercise.
* All by way of 2005–2016, India’s Joint Reporting Type for measles and rubella included knowledge from outbreak-based mostly surveillance And further sources. All by way of 2017–2019, circumstances included knowledge from outbreak-based mostly surveillance and case-based mostly measles and rubella surveillance. All by way of 2019–2021, circumstances included knowledge from cased-based mostly measles and rubella surveillance and acute fever and rash surveillance.
† Vaccination safety knowledge have been from World Health Group and UNICEF estimates of nationwide immunization safety; MCV1 was launched into routine immunization in 1985, and MCV2 was launched in 2011.
§ Measles catch-up SIA focused youngsters aged 9 months–10 yrs, carried out in three phases in 14 states: 2010–2011, 2011–2012, And A pair of012–2013.
¶ Measles-rubella catch-up SIA focused youngsters aged 9 months–15 yrs, carried out by state during 2017–2019 in 34 of 36 states and union territories.
FIGURE 2. Quantity of reported rubella circumstances,* estimated proportion Of youngsters who acquired their first dose of rubella-containing vaccine,† and supplementary immunization activities, by yr,§ — India, 2012–2021
Abbreby way oftions: RCV1 = first dose of rubella-containing vaccine in routine immunization; SIA = supplementary immunization exercise.
* All by way of 2012–2016, India’s Joint Reporting Type for rubella circumstances included knowledge from outbreak-based mostly surveillance And further sources. All by way of 2017–2019, circumstances included knowledge from outbreak-based mostly surveillance and case-based mostly measles and rubella surveillance. All by way of 2019–2021, circumstances included knowledge from cased-based mostly measles and rubella surveillance and acute fever and rash surveillance.
† Vaccination safety knowledge have been from World Health Group and UNICEF estimates of nationwide immunization safety; RCV1 was launched into routine immunization in 2017.
§ Measles-rubella catch-up SIA focused youngsters aged 9 months–15 yrs, carried out by state during 2017–2019 in 34 of 36 states and union territories.
Suggested citation for This textual content material: Murugan R, VanderEnde K, Dhawan V, et al. Progress Toward Measles and Rubella Elimination — India, 2005–2021. MMWR Morb Mortal Wkly Rep 2022;71:1569–1575. DOI: http://dx.doi.org/10.15585/mmwr.mm7150a1.
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