Academic journal article Bulletin of the World Health Organization

Adding Interventions to Mass Measles Vaccinations in India/ Ajout D'interventions Aux Vaccinations De Masse Contre la Rougeole En Inde/Adicion De Intervenciones a Las Vacunaciones Antisarampionosas En Masa En la India

Academic journal article Bulletin of the World Health Organization

Adding Interventions to Mass Measles Vaccinations in India/ Ajout D'interventions Aux Vaccinations De Masse Contre la Rougeole En Inde/Adicion De Intervenciones a Las Vacunaciones Antisarampionosas En Masa En la India

Article excerpt

Introduction

Measles vaccination made an important contribution to the millennium development goal to reduce under-5 mortality (MDG4), (1) accounting for 23% of the estimated worldwide decline in all-cause child mortality from 1990 to 2008. (2,3) A cornerstone of the strategy was that all children be offered a second opportunity to receive a dose of measles-containing vaccine, either through routine immunization services or through mass vaccination campaigns (known as supplementary immunization activities). (4) Supplemental immunization targets all children, to reach those who have been missed by routine services and also those who may have failed to develop an appropriate immune response after vaccination. (4) The strategy has been widely implemented in sub-Saharan Africa over the last decade, with measurable success in reducing mortality. (5) India delayed implementing supplementary immunization, and this may have contributed to the slower decline in measles mortality as compared with sub-Saharan Africa. India's share of global measles mortality increased from 16% of 535 300 deaths (95% confidence interval, CI: 347 200-976 400) in 2000 to 47% of 139 300 deaths (95% CI: 71 200-447 800) in 2010. (6)

In 2010, India introduced a second opportunity to receive measles-containing vaccine through routine immunization programmes in states with 80% or higher coverage of the first dose of measles-containing vaccine, and elsewhere through supplementary immunization activities. India's first supplementary mass measles vaccination campaign took place from 2010 to 2013 in 14 states (7) containing 59% of India's 113 million under-5 children (authors" calculations based on census data). (8) These 14 states have relatively weak health systems compared with the national average (9) and poorer progress towards MDG4. (10) The supplementary immunization activity reached 119 million children aged nine months to 10 years, achieving 91% coverage of the target population of 130 743 905. (11) India's first round of supplementary mass measles vaccination delivered only a measles-containing vaccine dose. Planning is underway for a larger measles-rubella vaccine introduction campaign targeting children aged 1-15 years. (12)

Campaign-style delivery has two key advantages over routine services; it can achieve high coverage even in areas where the reach of routine services is weak (2) and it reduces access barriers. On the other hand, a weakness of campaign delivery is that it represents a one-time or cyclic event. Some countries have made strategic use of mass vaccination campaigns to offer additional health interventions such as vitamin A supplements, insecticide-treated bednets and deworming medicines. (2) Therefore, vaccination campaigns could serve as an important platform to extend the reach of health services to underserved groups and improve maternal and child survival.

To date, India has largely not included add-on interventions with its mass vaccination campaigns and Indian health planners have expressed concerns over the potential challenges of implementing these, while agreeing that add-ons could be beneficial in principle. (9) To inform the design of future supplementary immunization activities in India and elsewhere we aimed to project the impact on mortality of a hypothetical set of technically feasible, high-impact interventions for maternal and child survival, delivered during India's 2010-2013 mass measles vaccination campaign.

Methods

For states participating in the supplementary immunization activity, we conducted a mathematical modelling study to quantify: (i) the number of lives saved by a supplementary immunization activity delivering measles-containing vaccine alone, and (ii) the number of lives that could be saved by a supplementary immunization activity package delivering measles-containing vaccine plus a set of six hypothetical add-on interventions. The analysis baseline reflected existing coverage levels for all interventions offered through routine services. …

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