A group of parents in Bengaluru are wary about a mass immunisation drive with a measles-rubella vaccine that the central government has planned across five states including Karnataka. Public health officials in Karnataka announced a three-week drive in February, in which they plan to immunize 1.64 crore children with the MR vaccine at both government and private schools across the state.

What has most of these parents, like most of those from middle and higher income backgrounds who get their children immunised by private doctors, worried is the lack of information and the seeming indifference for parental consent on the part of the government.

“Are they going to have trained paramedics?” asked businessman and parent Saurabh Kalra, who has put up an online petition against the drive, which so far has got more than 250 signatures. “Are they going to follow standard safety procedures?”

“I don’t like the feeling I get that this vaccination is being imposed on us,” said another parent Shweta Sharan, “I would like to decide how and when I want to vaccinate my child.” Sharan feels parents should take their children to designated vaccination centres rather than have them vaccinated at immunisation drives in schools.

Other questions that the petitions raises are about data and information about whether children actually need this MR vaccination and about whether it is safe.

Measles is a contagious respiratory disease that causes a rash and fever, and may cause death among vulnerable people, including malnourished children. According to the results of a worldwide study conducted in 2008, and later published in the medical journal Lancet, 80,0000 children die of measles in India every year. For vaccinations by private doctors, the Indian Academy of Pediatrics recommends that the first measles, mumps and rubella or MMR vaccine be given at 9 months, the second at 15 months and the third between 4 and 6 years.

Most middle-class parents in urban areas follow this immunisation schedule of three shots of the MMR vaccine guided by paediatricians in private hospitals. However, this is a small percentage of the population. As per the government’s vaccine coverage survey of 2009, only 8.7% of vaccination in India is through the private sector, while 89.8% of vaccination is provided through the public sector. A measles vaccine is provided through the public sector, under the country’s Universal Immunisation Program and consists of two doses.

Rubella is also a contagious disease but with mild symptoms that include rash and fever. It is harmless in children but when contracted by women during early pregnancy, their babies may be born with serious congenital defects in a condition known as Congenital Rubella Syndrome.

Infant with skin lesions from congenital rubella. (Photo: CDC/Wikimedia Commons)

Infants and children are given the rubella vaccine to contain the disease and prevent its spread to pregnant women or other vulnerable people. According to the World Health Organisation, there were 83 outbreaks and over 4,000 cases of rubella in just the first eight months of 2014.

Public immunisation upgrade

The government included the rubella vaccine in the Universal Immunisation Programme only in 2014 along with other vaccines like one for rotavirus . Till then, only private hospitals and clinics offered immunisation to rubella through the MMR vaccine. The government is now introducing the MR vaccine against measles and rubella, which will replace the measles vaccine that only protects against measles, in a phased manner across several states.

According to Dr Saroja P, project director for the Reproductive and Child Health Programme of Karnataka’s Department of Health and Family Welfare, children between the ages of five and fifteen will be vaccinated through the campaign, to be conducted between February 7 and February 28. Anganwadi workers and Accredited Social Health Activists or ASHAs will be deployed to spread awareness and auxiliary nurses will deliver the vaccine through injections.

“Even if children are vaccinated, this drive will offer an additional dose,” said Saroja.

The WHO recommends the inclusion of “catch up” vaccinations – offering additional doses of vaccines against contagious diseases to a broader age-group of children – to public immunisation campaigns, said Dr. Sheffali Gulati, consulting paediatrician and faculty at the All India Institute of Medical Sciences in New Delhi.

“Mass immunisation campaigns, such as the proposed MR drive, add to routine immunisation and interrupt and reduce the magnitude of potential outbreaks,” said Gulati.

However, some parents question the need for extra vaccine shots. “My child has already been vaccinated and so have many other children and booster shots are included in the immunisation schedule that we follow,” said Charmaine, who has a 5-year-old child. “I am worried about the effect of all these additional doses.”

“The third dose may act as a booster dose in those who’ve been vaccinated earlier. Also, in children who have missed the second dose or who have not received even a single dose, catch-up is recommended,” said Gulati.

The WHO recommends two doses of the measles vaccine. Between 10% and 15% of infants who are given the first dose of the vaccine fail to seroconvert, that is, they fail to generate antibodies and develop immunity to the disease. The seroconversion rate after a second dose is 99%. The measles vaccine offers long-term immunity that lasts between 26 and 33 years.

Many children get rubella and recover, said Dr Jacob Puliyel, consultant paediatrician at St Stephen’s Hospital in Delhi. Typically, those who have recovered from rubella, acquire immunity to the disease naturally but not everybody gets rubella and naturally acquired immunity offers incomplete coverage.

The rubella vaccine is highly effective with 95% or more children developing long-term immunity after a single dose. The vaccine is administered two to three times when following a standard immunisation schedule, because it is part of the MR or MMR vaccine.

Puliyel, who is also an expert member of the National Technical Advisory Group on Immunisation for the Indian government, recommends that the rubella vaccine be given around 13 years of age in order to complement naturally acquired immunity, protect a larger percentage of the population, and thus reduce the incidence of congenital rubella.

The United Kingdom attempted partial vaccination for rubella with only adolescent girls given the vaccine. However, the country revised its immunisation strategy to combine universal immunisation of infants and targeted immunisation of adolescent girls as girls who refused to be vaccinated were exposed to the rubella virus through men and children.

Plugging gaps

To prevent epidemics of measles and rubella, the WHO says that between 93% and 95% of children in the general population need to be immunised. Only such extensive immunisation coverage builds “herd immunity” and so spread of disease is contained because majority of the people within a region are immune. However, measles vaccination coverage varies across India, with the average in 2013 being 89% for the first dose and only 47% for the second dose.

Immunisation drives are normally held to make up for unequal vaccination coverage and make sure that a population has developed herd immunity. But the opacity of the MMR immunisation drive in February has many parents in Bengaluru worried and wondering if it is mandatory.

“According to the government of India, in a mass immunisation drive, we have to vaccinate children, even if they’ve been vaccinated before,” said Saroja. “It is very difficult to get the immunity status of a child, and for the safety of the community, we would request parents to cooperate with us.”