It’s being seen as the paradox of the pandemic, as routine childhood immunisation backslides over the last two-odd years, from reasons including the diversion of attention and resources to getting Covid-19 vaccinations in place.

The message hit home hard, when a joint report from the World Health Organization and the United States Centers for Disease Control and Prevention estimated, a staggering 40 million children had missed a measles vaccine dose, globally, in 2021.

The report comes even as measles cases (and deaths) are reported from India, in states including Maharashtra, Kerala, Gujarat and Jharkhand.

In fact, global public health voices had cautioned such a situation could arise, due to pandemic-linked lockdowns and realignment of resources to roll-out Covid-19 vaccines and support. And while measles is not alien to India, doctors caution, the spike in measles cases could signal similar worrying trends on other childhood diseases, as well.

Early warning

The measles outbreak is a “tracer” (or “early warning” of sorts) on other vaccine-preventable diseases, says Dr Chandrakant Lahariya, epidemiologist and health systems specialist. The very fact that measles has picked up, indicates that immunisation has gone down. Measles being highly transmissible gets detected, he adds.

In just 45 days, at least 150 cases of measles had been seen and 20 had been lab-confirmed, says paediatrician Dr Vipin Vashishtha, speaking of the Bijnor district (Uttar Pradesh), and the insight it gives on the ground situation possibly across the country. Measles is an air-borne virus, and occurs largely in infants, he says, adding that the mortality risk was high in those less than nine months.

While measles occurs round the year across the country, in the North, it is usually seen between November and March, says Vashishtha, former national convener with the Indian Academy of Paediatrics — committee on immunisation. Further, “Measles is more contagious than Covid-19,” he points out, in that one child could infect about 18 others, unlike Covid, where it is in low single digits. Despite having good vaccines in the country, with high efficacy when both doses are given, the present day surge is because attention was on Covid-19 vaccination and management, he said, making an observation that mirrors the warnings from several pubic health voices.

Young doctors

Adding to the observation that doctors need to be mindful of other childhood diseases that could crop up, he points to instances of whooping cough that he is seeing again, after some six-odd years. Symptoms to identify these childhood diseases are taught in med-schools. But thanks to a successful universal immunisation programme in the country (that brings these conditions under control), young doctors may not have seen actual cases in their practice, he says. Young doctors will need to be alert to conditions like diphtheria etc, as they may not be familiar with it, says another virologist in agreement.

In July 2020, early days of the pandemic, the WHO and Unicef had said, that their 2019 vaccine coverage estimates showed that that improvements such as the expansion of the HPV vaccine (against cervical cancer) to 106 countries , was in danger of lapsing. Preliminary data for the first four months of 2020, showed a substantial drop in the number of children completing three doses of the vaccine against diphtheria, tetanus and pertussis (DTP3). “This is the first time in 28 years that the world could see a reduction in DTP3 coverage – the marker for immunization coverage within and across countries,” it had said.

Global paradox

In 2021, there were an estimated 9 million cases and 128 000 deaths from measles worldwide. “Twenty-two countries experienced large and disruptive outbreaks. Declines in vaccine coverage, weakened measles surveillance, and continued interruptions and delays in immunization activities due to COVID-19, as well as persistent large outbreaks in 2022, mean that measles is an imminent threat in every region of the world,” the latest WHO/CDC report said.

“The paradox of the pandemic is that while vaccines against Covid-19 were developed in record time and deployed in the largest vaccination campaign in history, routine immunisation programmes were badly disrupted, and millions of kids missed out on life-saving vaccinations against deadly diseases like measles,” said WHO Director-General Dr Tedros Adhanom Ghebreyesus.

Better surveillance

Doctors say it is unacceptable to have deaths from vaccine-preventable diseases like measles, when there is a steady supply of the vaccine, especially so in India. The few states that are reporting cases and death do so, due to better surveillance and reporting systems, the doctors say, adding that it can be assumed that other regions are also witnessing similar spikes, from low vaccine coverage, malnourishment and clusters or close living conditions.

India has a high incidence of measles, given that it has the highest birth numbers (about 26 million odd births) annually, explains Lahariya. The need now is to revive the immunisation programme and ensure that it reaches its beneficiaries, he says, adding that the vaccines, human resources and a well-oiled machinery for childhood immunisation is all in place and has been for many years now.