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Indian Journal of Community Medicine

Measles Outbreak in a Rural Area Near Shimla

Author(s): B.P. Gupta, S. Sharma

Vol. 31, No. 2 (2006-04 - 2006-06)

Introduction

World Health Assembly in 1989 resolved to reduce measles mortality and morbidity by 90% and 95% respectively by 1995, compared with the number of cases during the prevaccination era1. In 1990, the world summit for children adopted a goal to vaccinate 90% of children against measles by 2000.2 In 2002, WHO established a regional network of national measles laboratories with standardized testing procedures for IgM antibodies to measles in all South East Asian Region (SEAR) countries. Five to ten samples are tested during each outbreak to confirm the diagnosis of measles.3

The major factors that determine the epidemic spread are the accumulation of the susceptible and new arrivals that have not suffered from disease in a community and the inevitable exposure to infection. It is unfortunate that outbreaks of measles still go unreported and unrecognized in our country at a time when developed countries are exploring the feasibility of eradicating measles globally and dreaming of a world free of measles by 2015. The present study is an account of outbreak of measles in a remote village of Himachal Pradesh,.

The place is situated about 60 km from Shimla and 15-20 km from CHC, Suni. There is no proper approach road to the village, making access difficult. Half the distance from CHC Suni to Dumehar village is approachable by road and rest of the distance has to be covered on foot.

Material and Methods

Information about occurrence of cases of fever and rash in village Dumehar was given by the Multipurpose Health Worker to the Medical Officer, CHC Suni on June 2, 2004 which was conveyed telephonically to the Department of Community Medicine I.G. Medical College, Shimla on 3rd June, 2004. A team of doctors from the Department of Community Medicine, I. G. Medical College, Shimla went to investigate, help and guide the local health authorities in managing the outbreak.

A house-to-house survey was carried out to collect information regarding the outbreak, examine the patients, note details about their illness and treat the sick children. The diagnosis of measles was made using the case definition for "suspect measles".

The criteria for diagnosing measles were as follows:

  1. Fever with rash (generalized maculopapular non- vesicular), and
  2. Either cough / coryza (running nose) or conjunctivitis (red eyes).

In order to know the vaccination status of children we had to rely heavily on parental recall. Vaccination cards were not available for most of the children; an attempt to retrieve the immunization records was possible only for the last four years, which were also not properly kept and maintained.

To serologically confirm the epidemic, 5 single sera from five patients were collected and sent to NICD, New Delhi to detect IgM antibodies against measles virus.

Results

A total of 1360 population was surveyed of which 425 (31.3%) were children below 15 years of age. Total 69 (16.2%) children suffered from measles. The youngest was 4 years old and the oldest was 14 years old. The age and sex distribution of measles cases and attack rate is presented in Table I.

Table-I: Age and sex distribution of measles cases and attack rate

Age
Group
(Years)
Males Females Total
Total Affec-
ted
Attack
rate(%)
Total Affec-
ted
Attack
rate(%)
Total Affec-
ted
Attack
rate(%)
0-4* 98 2 2.0 79 1 1.3 177 3 1.7
5-9 74 12 16.2 55 13 23.6 129 25 19.4
10-15 72 24 33.3 47 17 36.2 119 41 34.5
Total 244 38 15.6 181 31 17.1 425 69 16.2
* No case amongst infants

The attack rate amongst boys and girls was 15.6% and 17.1% respectively. The difference was not statistically significant (p > 0.05) No infant and no adult were found to be affected with measles. The 5-15 years age group contributed 95.7% of cases. No death due to measles was reported in the surveyed population.

The index case was a 12-year-old male child, who accompanied his mother to attend some function at Karsog in Distt. Mandi, about 40 Km away from Dumehar village on 12.5.2004, where he came in contact with a case of similar illness. He developed fever and rash on 22.5.2004. During the prodromal period, many children of his class contracted the disease as 17, 10-15 year old students of the same school developed measles during 8-14 days of the index case. The last case was reported on 27.7.2004. All 69 cases were below 15 years of age. Peak incidence was reported between 2nd to 5th weeks of occurrence of index case.

Among 69 cases of measles, 47 (68.1%) cases reported one or more post-measles complications. Diarrhoea was the commonest (51.1%) followed by respiratory infection (46.8%). 2.1% cases developed otitis media. 19.2% cases had both diarrhoea and respiratory infection. No case of encephalitis was reported. Four of the five samples were positive for IgM antibodies against measles. Samples were collected in the month of July, 2004 from convalescing patients, 5-6 days after the appearance of rash.

Of 425 children below 15 years, 303(71.3%) were unvaccinated and 122(28.7%) were vaccinated. Of the 122 (28.7%) vaccinated, all were aged less than 9 years and had received one dose of measles vaccine at around 9-12 months of age. Of 303(71.3%) unvaccinated, 28(9.2%) were not eligible for vaccination (age less than 9 months), 275(90.8%) were not vaccinated due to various reasons (non availability of services, lack of concern for measles, ignorance). None of the cases (n = 69) had received vaccination against measles. In response to outbreak the following containment measures were implemented:

Treatment of Cases, IEC to prevent further spread of infection and to prevent malnutrition, Vitamin A administration to all children and mass immunization of all children between the ages of 9 months to 5 years and who were not immunized previously and who had not suffered from measles this time. However in view of the outbreak, 8 children in the age group of 6-9 months, not immunized previously, were also immunized and advised revaccination at 9-12 months of age.

Discussion

This unusual outbreak that remained confined to children between (5-15) years is an example of lacunae in the strategy and implementation of Measles control programme, which led to a whole generation of children who missed the routine immunization.

In the present study, only 122 (28.7%) children were immunized, though coverage improved in the area during the past 5 years due to establishment of a sub-centre and posting of a health worker (who reported about the occurrence of measles cases). About 77.8% in 9-12 months, 72.9 % in 1-4 years, 10.1% in 5-9 years and none in 10-15 years were vaccinated. It was the accumulation of unvaccinated susceptible children in this remote isolated area, due to non availability of health services 5 years back, which probably are the determinants contributing to this outbreak. Escape of under-five children in this outbreak is contrary to the earlier measles outbreak reports from other parts of the country where most of the cases occurred in children below six years.6,7,8

It may be possible that due to non availability of health services and lack of concern for measles immunization, a pool of susceptible children accumulated in the village. Further the policy to vaccinate only between (9-12 months) and not beyond that probably deprived vaccines to young children thus precipitating this outbreak. The findings in the study are consistent with the view that the availability of health care facility is a critical factor, which affects the risk of measles in any area. Not only the provision of health services, but also their accessibility, quality and utilization are important in reducing measles outbreaks.

There was no measles associated fatality in this outbreak. 47 cases (68.1%) reported one or more post measles complications. It was probably due to active and timely efforts by the Deptt. of Community Medicine along with local health authorities that led to better treatment of sick children thus averting any fatality. Similar findings have been observed by some other authors where no mortality was reported thus representing mild nature of the disease, while very high case fatality rates have been reported by others during epidemics8,9. Measles per-se is rarely fatal and it is only the secondary bacterial complications that are primarily responsible for measles related deaths. Measles immunization may shift the age at the time of infection towards higher age groups even in endemic situation; measles is less likely to be fatal in older children and adults4. Some countries are now experiencing an upward shift of natural measles infection10, and one of the reasons for this may be decline of antibody titers to such low levels where there are unable to afford protection against measles infection several years after vaccination or due to primary vaccination failure (no immunological stimulation after vaccination). Increasing and sustaining high measles routine coverage (i.e. >90%) is essential for achieving a sustainable reduction in measles mortality15.

Strengthening routine vaccination is a corner stone of measles control in our country. Measles surveillance needs to be strengthened because it is critical for documenting the changing epidemiology of measles and for evaluating the impact of vaccination activities.

References

  1. CDC Measles Control -South- East Asia region, 1990-1997. MMWR 1999; 48: 541-545.
  2. CDC Progress towards global measles control and regional elimination, 1990-1998. MMWR 1998; 47:1049-54.
  3. CDC Progress toward sustainable Measles Mortality Reduction - South- East Asia Region, 1999-2002. MMWR 2004; 53: 559-562.
  4. Cutts F. Measles control in the 1990's: Principles for the next decade. Expanded Programme on Immunization. WHO Document WHO /EPI/GEN/90.2.1990.
  5. Desai VK, Kapadia SJ, Kumar P, Siddharth N. Study of measles incidence and vaccination coverage in slums of Surat city. Indian Journal of Community Medicine 2003; 28: 10-15.
  6. John TJ, Joseph A, George TI, Radhakrishanan Singh RPD, George K. Epidemiology and Prevention of measles in rural South India. Indian J Med Res 1980; 72:153-8.
  7. Pereira SM, Benjamin V. Measles in a South Indian Community. Trop Geogr Med 1972; 24: 124-9.
  8. Risbud AR, Prasad SR, Mehendal SM, Mawar N, Saikh N, Umrani UB, Bedekar, SS, Banerjee K. Measles outbreak in a tribal population of Thane district, Maharashtra. Indian paediatr 1994; 31:543-51.
  9. Gupta BP, Swami HM, Bhardwaj AK, Vaidya NK, Sharma CD, Kaushal RK. An outbreak of measles in remote tribal area of Himachal Pradesh. Indian J Comm Hith 1989; 5: 25-8.
  10. Cutts FT. Principles of Measles Control. Bull of the WHO 1991; 69: 1-7.

Deptt. of Community Medicine I.G. Medical College,
Shimla 171 001, HP
Received: 2.09.2004

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