Measles vaccine holding back India’s immunisation

The poor coverage of measles vaccination and later doses of basic vaccines like those for polio, diphtheria, pertussis and tetanus (DPT) are pulling down the proportion of fully immunised children. This indicates a poor mechanism to track children already registered in the immunisation system despite a Mother and Child Tracking System (MCTS) being in place since 2009.A recently released NSO report on health for 2017-18 shows that from over 94 per cent coverage for the BCG vaccine given at birth, coverage fell to just 67 per cent for the measles vaccine, given between 9-12 months, the poorest coverage among all basic vaccines needed for a child to be counted as being fully immunised.Similarly, from 94 per cent coverage of the oral polio vaccine’s (OPV) birth dose, the coverage went down with every subsequent dose to reach 80 per cent by the third dose. The DPT vaccine coverage went from 91 per cent coverage for the first shot given at six weeks to 78 per cent by the third shot at 14 weeks. This meant that India’s proportion of fully immunised children remained at around 60 per cent in 2017-18, not much different from the National Family Health survey of 2015-16, which found it to be around 62 per cent.While this was a huge improvement from just 44 per cent in 2005-06, the budget allocated for immunisation has also jumped from Rs 473 crore in 2005-06 to approximately Rs 2,000 crore allocated for the Universal Immunisation Programme (UIP) excluding shared costs such as staff salary, establishments etc.India’s immunisation coverage has remained low relative to its neighbours. In Sri Lanka 99 per cent of children are fully immunised. In Bangladesh, the coverage for DPT-3 was 98 per cent and for measles was 93 per cent in 2018, according to the World Health Report 2020. In Nepal, the coverage for the third shot of DPT was 91 per cent and that for measles was 69 per cent.A child is considered to be fully immunised if she has received BCG, three doses of OPV, three shots of DPT vaccine and the measles vaccine. All these, if delivered on schedule, are within the child’s first year, with measles being the last. There are booster shots and vaccines for other diseases, but they do not count for considering a child fully immunised.The central government’s Mission Indradhanush launched in December 2014 set the goal of ensuring full immunization for children up to two years of age and pregnant women. The govt identified 201 high focus districts across 28 states that had the highest number of partially immunized and unimmunized children. The government said the increase in full immunization coverage was just one percentage point per year earlier, but had increased to 6.7 percentage points per year through the first two phases of Mission Indradhanush.A 2017 district-level study on routine immunization in Haryana led by Dr Shankar Prinja of the community medicine department in PGIMER, Chandigarh noted that the challenge of decreasing dropouts and enrolling the ones with no immunization at all had become ever more daunting as the country added a pool of 12.5 million partially immunized children each year. According to the NSO survey 3 per cent of children received no immunisation at all. Considering that the survey was looking at children under six, even 3 per cent would amount to millions of children. This proportion was as high as 7-8 per cent in some states.“Initially, Mission Indradhanush went off very well with an 18 per cent increase in coverage in 190 districts. But states insisting on doing it in all districts instead of focusing on identified laggard districts has diluted its impact over time. As fatigue sets in, the mission becomes routine and that means children who were to be covered under routine immunisation get covered under the mission instead of the mission being to mop up children missed by routine immunisation,” explained Dr Anish Sinha of the Indian Institute of Public Health in Gandhinagar adding that this was happening because the routine immunisation system had not been adequately strengthened.“The weakest link in the routine system are the health workers who are paid very poorly. A very motivated ASHA gets Rs 4,000 per month at best, including all incentives. It’s almost impossible to find anyone for that salary in urban areas where even a domestic help gets almost double that. Even in rural areas this is too little,” said Dr Sinha.The mother and child tracking system and various other tech platforms and mobile-based applications launched to track data have been unsuccessful. Public health researchers point out that any technology is only as good as the people operating it and the data entered into it and thus it all boils down to the health workers expected to enter the data.

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