Measles

Measles is a highly contagious viral disease caused by the measles virus, which belongs to the paramyxovirus family. It is primarily known for causing a distinctive red rash that covers the body. In Nepal, measles is commonly referred to as "Dadura" (दादुरा) in the Nepali language.

Measles is transmitted through respiratory droplets when an infected person coughs or sneezes. The virus can remain infectious in the air or on surfaces for up to two hours. It is one of the most contagious diseases known, with a high secondary attack rate, meaning that if one person contracts the disease, 90% of their close contacts who are not immune will also become infected.

The disease is particularly severe in children under the age of 5 and adults over the age of 20. Complications from measles can be serious and even life-threatening, especially in malnourished children and those with weakened immune systems. Some of the common complications include pneumonia, encephalitis (inflammation of the brain), and diarrhea.

Before the widespread use of the measles vaccine, the disease was a leading cause of childhood mortality globally. However, with the implementation of vaccination programs, the incidence of measles has significantly decreased. The measles vaccine is often combined with the mumps and rubella vaccines, known as the MMR vaccine, and is highly effective in preventing the disease.

Despite the availability of a safe and effective vaccine, measles outbreaks still occur, particularly in communities with low vaccination rates. Ensuring high vaccination coverage is crucial in preventing the spread of the disease and protecting public health.

In the following sections, we will delve into the history and epidemiology of measles, its clinical features and diagnosis, treatment and management, prevention strategies, and the challenges faced in measles control and elimination efforts.

Measles Disease Overview

Symptoms and Transmission

Measles is characterized by a range of symptoms that typically appear 7-14 days after exposure to the virus. The initial symptoms often resemble those of a common cold, including:

High fever (usually above 40°C/104°F)
Cough
Runny nose (coryza)
Red, watery eyes (conjunctivitis)
Koplik's spots (tiny white spots on a red background in the mouth)

After a few days, a characteristic red, blotchy rash appears, usually starting on the face and then spreading downwards to the rest of the body. The rash typically lasts for 5-6 days before fading. Patients are considered infectious from four days before the onset of the rash to four days after its appearance.

Measles is transmitted through respiratory droplets when an infected person coughs or sneezes. The virus can also spread through direct contact with infected secretions or through airborne transmission, where the virus remains suspended in the air for up to two hours.

Complications

While most people recover from measles within 2-3 weeks, the disease can lead to serious complications, especially in children under 5, adults over 20, pregnant women, and individuals with compromised immune systems. Complications may include:

Pneumonia: The most common cause of death from measles in young children.
Encephalitis: Inflammation of the brain that can lead to convulsions, hearing loss, or intellectual disabilities.
Diarrhea: This can lead to dehydration, particularly in young children.
Pregnancy complications: Measles during pregnancy can lead to miscarriage, premature birth, or low birth weight.
Subacute sclerosing panencephalitis (SSPE): A rare but fatal degenerative disease of the central nervous system that can occur several years after measles infection.

Public Health Impact in Nepal

Measles has been a significant public health concern in Nepal, particularly before the introduction of the measles vaccine. In the past, measles outbreaks were common, leading to high morbidity and mortality rates among children.

However, with the implementation of the national measles immunization program, which began in 1979, the incidence of measles has significantly decreased. Nepal has made substantial progress in measles control, achieving the WHO's regional measles elimination target of less than 1 case per million population in 2012.

Despite these efforts, measles outbreaks still occur in Nepal, particularly in communities with low vaccination coverage. In recent years, there have been several reported outbreaks:

In 2019, a measles outbreak in Morang district affected over 80 individuals, mostly children.
In 2020, amid the COVID-19 pandemic, a measles outbreak was reported in Dhading district, with over 50 cases identified.

These outbreaks highlight the importance of maintaining high vaccination coverage and strengthening surveillance systems to prevent and control measles transmission in Nepal. Continued efforts are needed to ensure that all children receive the recommended two doses of the measles vaccine and to address the challenges in reaching marginalized and hard-to-reach populations.

Measles Vaccination in Nepal

Vaccination is the most effective way to prevent measles and its associated complications. In Nepal, the measles vaccine is commonly referred to as the "Dadura ko sui" (दादुरा को सुई) or "Dadura ko vaccination" (दादुरा को भ्याक्सिनेशन), which translates to "measles shot" or "measles vaccination" in English.

Measles-Rubeola Vaccine and MMR Vaccination Program

The measles vaccine is often administered as part of the combined measles-mumps-rubella (MMR) vaccine. The MMR vaccine is a live attenuated vaccine, meaning that it contains weakened versions of the measles, mumps, and rubella viruses that can stimulate an immune response without causing the actual diseases.

In Nepal, the MMR vaccine is part of the national immunization program and is provided free of cost through government health facilities. The vaccination schedule recommends two doses of the MMR vaccine:

First dose: Administered at 9 months of age.
Second dose: Administered at 15 months of age.

The two-dose schedule ensures optimal protection against measles, as well as mumps and rubella. The vaccine is highly effective, with a single dose providing around 93% protection and two doses providing 97% protection against measles.

Development of the Measles Virus Vaccine

The development of the measles vaccine has been a significant milestone in public health history. The first measles vaccine was developed in the 1960s by John Enders and his colleagues, using a live attenuated strain of the measles virus known as the Edmonston strain.

Over time, the measles vaccine has undergone improvements to enhance its safety and effectiveness. The current measles vaccines used worldwide are based on further attenuated strains derived from the original Edmonston strain, such as the Schwarz strain and the Moraten strain.

In Nepal, the measles vaccine used in the national immunization program is procured through UNICEF and meets the quality standards set by the World Health Organization (WHO). The vaccine is supplied as a lyophilized (freeze-dried) powder that needs to be reconstituted with a diluent before administration.

Challenges and Strategies for Measles Vaccination

Despite the availability of an effective vaccine, achieving and maintaining high vaccination coverage remains a challenge in Nepal. Some of the barriers to measles vaccination include:

Limited access to health services in remote and hard-to-reach areas.
Lack of awareness about the importance of vaccination among some communities.
Vaccine hesitancy and misconceptions about vaccine safety.
Inadequate cold chain maintenance and vaccine storage in some areas.

To address these challenges, Nepal has implemented various strategies to improve measles vaccination coverage, such as:

Conducting mass measles vaccination campaigns to reach unvaccinated children.
Strengthening routine immunization services through outreach and mobile clinics.
Engaging with communities to promote vaccine acceptance and dispel misconceptions.
Improving vaccine management and cold chain maintenance at all levels of the health system.

By continuing to prioritize measles vaccination and addressing the barriers to coverage, Nepal can make further progress toward the goal of measles elimination and protect its population, particularly children, from this preventable disease.

Measles Immunization Strategy in Nepal

Nepal has made significant strides in measles control through its national immunization program, which aims to protect children against vaccine-preventable diseases, including measles. The measles vaccine, known as the "Dadura ko sui" (दादुरा को सुई) or "measles injection," is a crucial component of this program.

National Immunization Program and Measles Vaccine Inclusion

Nepal's national immunization program was established in 1979 and has gradually expanded its scope to include a range of vaccines. The measles vaccine was first introduced into the program in 1989, initially targeting children aged 9 months to 2 years. Over time, the program has evolved to adopt the WHO-recommended two-dose schedule for measles vaccination.

Currently, the national immunization program in Nepal provides the measles vaccine free of cost to all children through government health facilities, outreach clinics, and vaccination campaigns. The program is supported by various international organizations, such as UNICEF, WHO, and Gavi, the Vaccine Alliance.

Impact on Measles Incidence Rates

The inclusion of the measles vaccine in Nepal's national immunization program has had a remarkable impact on reducing measles incidence and mortality. Before the introduction of the vaccine, measles was a leading cause of childhood morbidity and mortality in Nepal, with frequent outbreaks occurring throughout the country.

However, with the implementation of the measles vaccination program and the achievement of high vaccination coverage, Nepal has seen a significant decline in measles cases. In 2012, Nepal reached the WHO's regional measles elimination target of less than 1 case per million population, a testament to the success of its immunization efforts.

Despite this progress, measles outbreaks still occur in Nepal, particularly in areas with low vaccination coverage or among marginalized communities. Maintaining high vaccination coverage and strengthening surveillance systems remain crucial to preventing and controlling measles transmission.

Measles Injection Schedules in Nepal

The Ministry of Health and Population in Nepal follows the WHO-recommended vaccination schedule for measles. The measles vaccine is administered as part of the combined measles-mumps-rubella (MMR) vaccine, and the recommended schedule is as follows:

First dose of MMR vaccine: Administered at 9 months of age.
Second dose of MMR vaccine: Administered at 15 months of age.

The two-dose schedule is designed to provide optimal protection against measles, as well as mumps and rubella. The first dose is given at 9 months of age because maternal antibodies, which provide protection to infants, start to wane around this time. The second dose is given at 15 months to boost the immune response and ensure long-lasting protection.

In addition to the routine immunization schedule, Nepal also conducts supplementary immunization activities (SIAs) to reach children who may have missed their routine vaccinations. These SIAs often involve mass vaccination campaigns targeting specific age groups or geographic areas to close immunity gaps and prevent outbreaks.

By adhering to the recommended measles injection schedules and ensuring high vaccination coverage through both routine immunization and SIAs, Nepal continues to make progress toward the goal of measles elimination. Sustained efforts and commitment from the government, health workers, and communities are essential to maintain the gains made and protect future generations from this vaccine-preventable disease.

Measles Control in Nepal

While Nepal has made significant progress in measles control, several challenges remain in ensuring widespread access to the measles vaccine and achieving the goal of measles elimination. However, through concerted efforts and partnerships, Nepal continues to work towards overcoming these challenges and protecting its population from this vaccine-preventable disease.

Challenges in Measles Virus Treatment and Prevention

One of the main challenges in measles control in Nepal is ensuring high vaccine coverage, particularly in remote and hard-to-reach areas. Factors such as geographical barriers, limited health infrastructure, and inadequate cold chain maintenance can hinder the delivery of vaccines to these areas. Additionally, some communities may have limited awareness about the importance of vaccination or may hold misconceptions about vaccine safety, leading to vaccine hesitancy.

Another challenge is the timely identification and response to measles outbreaks. Nepal's measles surveillance system, while improved over the years, still faces limitations in terms of reporting, investigation, and laboratory confirmation of cases. Strengthening the surveillance system is crucial for detecting outbreaks early and implementing effective control measures.

Moreover, the COVID-19 pandemic has posed additional challenges to measles immunization efforts in Nepal. The pandemic has disrupted routine immunization services, leading to a decline in vaccination coverage and an increased risk of measles outbreaks. Recovering from these disruptions and catching up on missed vaccinations is an important priority.

Progress Towards Measles Elimination

Despite the challenges, Nepal has made remarkable progress towards measles elimination. The country has achieved significant milestones, such as:

Reaching the WHO's regional measles elimination target of less than 1 case per million population in 2012.
Maintaining high measles vaccination coverage, with over 90% of children receiving the first dose of the measles vaccine in recent years.
Conducting successful measles vaccination campaigns to reach unvaccinated children and close immunity gaps.
Strengthening the measles surveillance system and improving outbreak response capacities.

These achievements have been made possible through the dedication of health workers, the commitment of the government, and the support of international partners. Nepal's Ministry of Health and Population has prioritized measles control in its national health strategies and has allocated resources for immunization services.

Role of Partnerships and Initiatives

International partnerships and local initiatives have played a crucial role in supporting Nepal's measles immunization efforts. Organizations such as UNICEF, WHO, and Gavi have provided technical assistance, financial support, and vaccine procurement to strengthen Nepal's immunization program.

In addition, local initiatives and community engagement have been key to improving measles immunization rates. Health workers, female community health volunteers (FCHVs), and community leaders have been instrumental in raising awareness about the importance of vaccination, dispelling misconceptions, and mobilizing communities to participate in immunization services.

Public-private partnerships have also contributed to measles control efforts in Nepal. For example, the partnership between the government and the Nepal Pediatric Society has helped to expand the reach of immunization services and improve the quality of care for children.

By continuing to address the challenges, building on the progress made, and leveraging partnerships and initiatives, Nepal can further advance towards the goal of measles elimination. Sustained commitment, investment, and collaboration at all levels - from the government to health workers to communities - will be essential to protect Nepal's population, particularly children, from the measles virus and its devastating consequences.

Public Health Initiatives and Awareness

Public health initiatives and awareness campaigns play a vital role in measles control efforts in Nepal. These initiatives aim to educate the public about the importance of the measles vaccine, dispel misconceptions, and promote vaccination as the primary means of preventing the disease.

Campaigns for Measles Vaccination

Nepal's Ministry of Health and Population, in collaboration with partners such as UNICEF and WHO, has implemented various public health campaigns to increase awareness about the measles vaccine, known as the "Dadura ko sui" or "Dadura ko vaccine" in Nepali.

These campaigns use a range of communication channels, including:

Mass media: Television and radio advertisements, public service announcements, and interviews with health experts are used to disseminate information about measles vaccination.
Print media: Posters, leaflets, and banners are displayed in health facilities, schools, and public places to raise awareness about the importance of the measles vaccine.
Community engagement: Health workers and female community health volunteers (FCHVs) conduct door-to-door visits, group meetings, and community events to educate families about measles vaccination and encourage them to vaccinate their children.
School-based programs: Awareness campaigns are conducted in schools to educate children and their parents about the measles vaccine and the vaccination schedule.

These campaigns emphasize the safety and effectiveness of the measles vaccine and highlight the risks associated with measles infection, particularly for young children. They also address common misconceptions and concerns about vaccination to build trust and confidence in the immunization program.

Emphasis on Prevention through Vaccination

Public health initiatives for measles control in Nepal prioritize prevention through vaccination rather than clinical treatment. While measles treatment options, such as supportive care and management of complications, are essential, the primary focus is on preventing the disease altogether through vaccination.

Awareness campaigns stress that the measles vaccine is the best way to protect children from the disease and its potential complications. They highlight the two-dose vaccination schedule and the importance of timely vaccination at 9 months and 15 months of age.

Moreover, these campaigns emphasize the role of vaccination in protecting not only individual children but also the community as a whole. By achieving high vaccination coverage, the risk of measles outbreaks can be significantly reduced, and the disease can be controlled and eventually eliminated.

Addressing Vaccine Hesitancy and Misconceptions

One of the challenges in measles control is addressing vaccine hesitancy and misconceptions about the safety and effectiveness of the measles vaccine. Public health initiatives in Nepal aim to tackle these issues through targeted communication and community engagement.

Health workers and community volunteers are trained to address common concerns and misconceptions about the measles vaccine, such as fears about side effects or beliefs that the vaccine is unnecessary or ineffective. They provide accurate information, share personal experiences, and emphasize the benefits of vaccination in protecting children's health.

Additionally, public health campaigns involve trusted community leaders, such as religious leaders and local influencers, to promote vaccination and build trust in the immunization program. By engaging with communities and addressing their concerns, these initiatives aim to increase vaccine acceptance and uptake.

Through sustained public health initiatives and awareness campaigns, Nepal continues to make progress in measles control and work towards the goal of measles elimination. By empowering communities with knowledge and promoting vaccination as the key to prevention, these efforts contribute to protecting children from this vaccine-preventable disease and ensuring a healthier future for all.

Future Directions in Measles Control and Elimination

As Nepal continues to make progress in measles control, it is crucial to look towards the future and consider the steps needed to sustain the gains made and ultimately achieve the goal of measles elimination. This involves maintaining and increasing vaccination coverage, staying abreast of advancements in vaccine research, and demonstrating an ongoing commitment to measles elimination as a public health priority.

Maintaining and Increasing Vaccination Coverage

One of the key priorities for Nepal in the future is to maintain and further increase measles vaccination coverage. While Nepal has achieved high coverage rates in recent years, it is essential to ensure that these rates are sustained and even improved to prevent measles outbreaks.

This requires continued efforts to strengthen routine immunization services, particularly in hard-to-reach and underserved areas. Strategies such as expanding outreach services, improving vaccine supply and cold chain management, and enhancing the capacity of health workers will be crucial in ensuring that all children have access to the measles vaccine.

Additionally, conducting periodic catch-up vaccination campaigns can help to close immunity gaps and reach children who may have missed their routine vaccinations. These campaigns should be targeted based on epidemiological data and focus on high-risk areas or populations.

Advancements in Measles Virus Vaccine Research and Development

While the current measles vaccines are highly effective, ongoing research and development efforts aim to further improve the vaccines and address the remaining challenges. Some potential advancements in measles virus vaccine research include:

Developing thermostable vaccines: Researchers are working on developing measles vaccines that can remain stable at higher temperatures, reducing the need for strict cold chain requirements and facilitating vaccine delivery in remote areas.
Exploring new vaccine delivery methods: Investigations are underway to assess alternative vaccine delivery methods, such as microneedle patches or oral vaccines, which could make vaccination more accessible and acceptable.
Combining measles vaccine with other antigens: Studies are exploring the possibility of combining the measles vaccine with other antigens, such as rubella and varicella, to protect against multiple diseases with a single vaccine.

Nepal should stay informed about these advancements and consider their potential application in the national immunization program to further strengthen measles control efforts.

Commitment to Measles Elimination as a Global Health Goal

Nepal has demonstrated its commitment to measles elimination by setting national targets and aligning its efforts with regional and global goals. In the future, Nepal needs to maintain this commitment and continue to prioritize measles elimination as a public health imperative.

This involves allocating sufficient resources for immunization services, strengthening surveillance systems, and responding promptly to measles outbreaks. It also requires collaboration with international partners, such as WHO and UNICEF, to share best practices, access technical support, and contribute to regional and global measles elimination initiatives.

Moreover, Nepal should actively participate in global discussions and decision-making processes related to measles elimination, ensuring that the perspectives and needs of developing countries are adequately represented.

By maintaining high vaccination coverage, staying at the forefront of vaccine research advancements, and demonstrating an unwavering commitment to measles elimination, Nepal can continue to make significant strides in protecting its population from this vaccine-preventable disease. With sustained efforts and collaboration at all levels, Nepal can contribute to the global vision of a world free from measles and ensure a healthier future for generations to come.

Conclusion

In conclusion, measles immunization plays a critical role in protecting public health in Nepal. The measles vaccine, known as the "Dadura ko sui" or "Dadura ko vaccine," has been a vital component of Nepal's national immunization program, leading to significant reductions in measles incidence and mortality.

Through the implementation of a two-dose vaccination schedule, high vaccination coverage, and successful measles vaccination campaigns, Nepal has made remarkable progress toward measles control. The country has achieved milestones such as reaching the WHO's regional measles elimination target and maintaining low incidence rates in recent years.

However, challenges remain in ensuring equitable access to the measles vaccine, particularly in remote and underserved areas. Strengthening routine immunization services, addressing vaccine hesitancy, and improving surveillance systems are ongoing priorities to prevent measles outbreaks and protect vulnerable populations.

Public health initiatives and awareness campaigns have been instrumental in educating communities about the importance of the measles vaccine and promoting vaccination as the primary means of prevention. These efforts emphasize the safety and effectiveness of the vaccine and address misconceptions to build trust and confidence in the immunization program.

Looking to the future, Nepal must maintain its commitment to measles elimination and continue to prioritize immunization efforts. This involves sustaining high vaccination coverage, staying informed about advancements in vaccine research, and collaborating with international partners to contribute to regional and global measles elimination goals.

Continued vigilance, vaccination, and public awareness are essential to control and eventually eliminate measles in Nepal. By investing in immunization services, engaging communities, and demonstrating political will, Nepal can build on its progress and ensure that future generations are protected from this vaccine-preventable disease.

Measles elimination is not only a public health imperative but also a moral obligation to safeguard the health and well-being of every child in Nepal. With sustained efforts and collaboration at all levels - from health workers to policymakers to communities - Nepal can move closer to the vision of a measles-free future and contribute to the global fight against this devastating disease.

In the words of the famous Nepali proverb, "सानो प्रयासले पनि ठूलो परिवर्तन गर्न सकिन्छ" (Sano prayasle pani thulo parivartan garna sakincha), which means "Even small efforts can bring about big changes." By continuing to prioritize measles immunization and working together, Nepal can make a significant impact in controlling and eliminating measles, protecting the health of its population, and building a brighter future for all.