The impact of measles immunization campaigns in India using a nationally representative sample of 27,000 child deaths

  1. Benjamin KC Wong  Is a corresponding author
  2. Shaza A Fadel
  3. Shally Awasthi
  4. Ajay Khera
  5. Rajesh Kumar
  6. Geetha Menon
  7. Prabhat Jha  Is a corresponding author
  1. St Michael's Hospital, Canada
  2. King George's Medical University, India
  3. Government of India, India
  4. Postgraduate Institute of Medical Education and Research, India
  5. National Institute of Medical Statistics, Indian Council of Medical Research, India

Abstract

India comprises much of the persisting global childhood measles mortality. India implemented a mass second-dose measles immunization campaign in 2010. We used interrupted time series and multilevel regression to quantify the campaign's impact on measles mortality using the nationally representative Million Death Study (including 27,000 child deaths in 1.3 million households surveyed from 2005–2013). 1–59-month measles mortality rates fell more in the campaign states following launch (27%) versus non-campaign states (11%). Declines were steeper in girls than boys and were specific to measles deaths. Measles mortality risk was lower for children living in a campaign district (OR 0.6, 99%CI 0.4–0.8) or born in 2009 or later (OR 0.8, 99%CI 0.7–0.9). The campaign averted up to 41,000–56,000 deaths during 2010–13, or 39%–57% of the expected deaths nationally. Elimination of measles deaths in India is feasible.

Data availability

Under legal agreement with the Registrar General of India, the MDS data cannot be redistributed outside of the Centre for Global Health Research. To request MDS data access procedures or to set up a data transfer agreement, please contact the Office of the Registrar General, RK Puram, New Delhi, India (rgoffice.rgi@nic.in). The public census reports can be found at http://www.censusindia.gov.in/vital_statistics/SRS_Statistical_Report.html. Source data files have been provided for Figures 1,2,3,4, Figure 1 - figure supplement 1, and Table 2. National survey data (from Figure 5) can be obtained free of charge from the following websites: http://rchiips.org/nfhs/NFHS-4Report.shtml (NFHS-4); http://rchiips.org/nfhs/report.shtml (NFHS-3); http://rchiips.org/DLHS-4.html (DLHS-4); http://rchiips.org/prch-3.html (DLHS-3); and http://rchiips.org/state-report-rch2.html (DLHS-2).

Article and author information

Author details

  1. Benjamin KC Wong

    Centre for Global Health Research, St Michael's Hospital, Toronto, Canada
    For correspondence
    wongbenja@smh.ca
    Competing interests
    No competing interests declared.
    ORCID icon "This ORCID iD identifies the author of this article:" 0000-0002-7745-6271
  2. Shaza A Fadel

    Centre for Global Health Research, St Michael's Hospital, Toronto, Canada
    Competing interests
    No competing interests declared.
    ORCID icon "This ORCID iD identifies the author of this article:" 0000-0002-2336-6254
  3. Shally Awasthi

    Department of Pediatrics, King George's Medical University, Lucknow, India
    Competing interests
    No competing interests declared.
  4. Ajay Khera

    Ministry of Health and Family Welfare, Government of India, Delhi, India
    Competing interests
    No competing interests declared.
  5. Rajesh Kumar

    School of Public Health, Postgraduate Institute of Medical Education and Research, Chandigarh, India
    Competing interests
    No competing interests declared.
  6. Geetha Menon

    Department of Health Research, National Institute of Medical Statistics, Indian Council of Medical Research, New Delhi, India
    Competing interests
    No competing interests declared.
  7. Prabhat Jha

    Center for Global Health Research, St Michael's Hospital, Toronto, Canada
    For correspondence
    jhap@smh.ca
    Competing interests
    Prabhat Jha, Senior editor, eLife.
    ORCID icon "This ORCID iD identifies the author of this article:" 0000-0001-7067-8341

Funding

Canadian Institutes of Health Research (FDN154277)

  • Prabhat Jha

Bill and Melinda Gates Foundation

  • Prabhat Jha

National Institutes of Health (R01TW05991-01)

  • Prabhat Jha

External funding is from the Canadian Institutes of Health Research (http://www.cihr-irsc.gc.ca, Grant FDN154277), the US National Institutes of Health (https://www.nih.gov, Grant R01TW05991-01), and the Bill and Melinda Gates Foundation. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Reviewing Editor

  1. Mark Jit, London School of Hygiene & Tropical Medicine, and Public Health England, United Kingdom

Ethics

Human subjects: Ethics approval for the MDS was obtained from the Post Graduate Institute of Medical Research, St. John's Research Institute and St. Michael's Hospital, Toronto, Ontario, Canada. Consent procedures have been published earlier (Gomes et al., 2017; Jha et al., 2006a; Registrar General of India, 2016).

Version history

  1. Received: November 3, 2018
  2. Accepted: February 15, 2019
  3. Accepted Manuscript published: March 5, 2019 (version 1)
  4. Version of Record published: April 16, 2019 (version 2)

Copyright

© 2019, Wong et al.

This article is distributed under the terms of the Creative Commons Attribution License permitting unrestricted use and redistribution provided that the original author and source are credited.

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  1. Benjamin KC Wong
  2. Shaza A Fadel
  3. Shally Awasthi
  4. Ajay Khera
  5. Rajesh Kumar
  6. Geetha Menon
  7. Prabhat Jha
(2019)
The impact of measles immunization campaigns in India using a nationally representative sample of 27,000 child deaths
eLife 8:e43290.
https://doi.org/10.7554/eLife.43290

Share this article

https://doi.org/10.7554/eLife.43290

Further reading

  1. Measles vaccination campaigns have saved the lives of about 50,000 Indian children in three years.

    1. Epidemiology and Global Health
    Sean V Connelly, Nicholas F Brazeau ... Jeffrey A Bailey
    Research Article

    Background:

    The Zanzibar archipelago of Tanzania has become a low-transmission area for Plasmodium falciparum. Despite being considered an area of pre-elimination for years, achieving elimination has been difficult, likely due to a combination of imported infections from mainland Tanzania and continued local transmission.

    Methods:

    To shed light on these sources of transmission, we applied highly multiplexed genotyping utilizing molecular inversion probes to characterize the genetic relatedness of 282 P. falciparum isolates collected across Zanzibar and in Bagamoyo district on the coastal mainland from 2016 to 2018.

    Results:

    Overall, parasite populations on the coastal mainland and Zanzibar archipelago remain highly related. However, parasite isolates from Zanzibar exhibit population microstructure due to the rapid decay of parasite relatedness over very short distances. This, along with highly related pairs within shehias, suggests ongoing low-level local transmission. We also identified highly related parasites across shehias that reflect human mobility on the main island of Unguja and identified a cluster of highly related parasites, suggestive of an outbreak, in the Micheweni district on Pemba island. Parasites in asymptomatic infections demonstrated higher complexity of infection than those in symptomatic infections, but have similar core genomes.

    Conclusions:

    Our data support importation as a main source of genetic diversity and contribution to the parasite population in Zanzibar, but they also show local outbreak clusters where targeted interventions are essential to block local transmission. These results highlight the need for preventive measures against imported malaria and enhanced control measures in areas that remain receptive to malaria reemergence due to susceptible hosts and competent vectors.

    Funding:

    This research was funded by the National Institutes of Health, grants R01AI121558, R01AI137395, R01AI155730, F30AI143172, and K24AI134990. Funding was also contributed from the Swedish Research Council, Erling-Persson Family Foundation, and the Yang Fund. RV acknowledges funding from the MRC Centre for Global Infectious Disease Analysis (reference MR/R015600/1), jointly funded by the UK Medical Research Council (MRC) and the UK Foreign, Commonwealth & Development Office (FCDO), under the MRC/FCDO Concordat agreement and is also part of the EDCTP2 program supported by the European Union. RV also acknowledges funding by Community Jameel.