India: Mumbai races to halt measles outbreak

Measles has killed at least 16 children in the densely packed Indian city of Mumbai since the start of an outbreak in October. The disease is characterized by a high fever and a distinctive red rash. It can be contagious for days before the rash emerges and is often particularly dangerous for children under 5.

Experts have blamed a reduction in vaccination rates during the COVID-19 pandemic for the outbreaks, which have also been seen to a lesser degree in other cities across India.

"During the COVID-19 pandemic, many children missed a dose. And now they have grown into another age group," said Mangala Gomare, executive health officer at the Brihanmumbai Municipal Corporation (BMC), Mumbai's governing civic body.

The MMR (measles, mumps, rubella) vaccine is part of the national childhood immunization program, with two doses recommended for children between the ages of 9 months and 5 years.

Missing measles vaccine doses

Although measles is almost entirely preventable through vaccination, a 95% coverage rate is needed to create herd immunity and halt community spread. Once the number of unvaccinated children in an area reaches critical mass, the disease spreads, triggering an outbreak.

During the COVID pandemic, lockdowns and diverted resources caused disruption to routine childhood immunization programs, resulting in a significant drop in vaccination rates.

Data from the state's public health department shows that in the past year, only 41.2% of children eligible for the vaccine had received both doses up until October. This compares to 90% in 2019-2022.

Gomare noted that Mumbai, India's financial capital, also has a high population of migrant workers, many of whom returned to their home villages during the pandemic, causing their children to miss out on routine immunizations.

Last month, the World Health Organisation (WHO) warned that in 2021, a record high of nearly 40 million children globally missed a measles dose, leaving them "dangerously susceptible" to the virus.

"Getting immunization programs back on track is absolutely critical," said WHO Director-General Tedros Adhanom Ghebreyesus. Disruption to immunization programs has also led to a resurgence in other vaccine-preventable diseases around the world, such as polio.

Deadly fever

But affected communities in Mumbai have also blamed unsanitary living conditions in the densely packed megacity, claiming that substandard housing and a lack of clean drinking water regularly cause them to become sick.

Sehroon Khan lives in an informal settlement in Govandi, one of the areas most affected by the ongoing measles outbreak. The area is overcrowded and unclean, the 38-year-old said, claiming that her three sons regularly used to get sick due to the unsanitary conditions.

"There is stagnant water pooling outside in the street, and mosquitoes everywhere," she added.

In October, her 5-year-old son, Hasnain, was rushed to the hospital with a high fever and rash. Khan said that the doctors at the hospital did not take the boy's condition seriously, at first dismissing the illness as a common parasitic infection. By the evening, he was on a ventilator. "One second he was smiling, and the next second he stopped breathing," said Khan.

Hasnain's brother, 3-year-old Noorain, also started showing symptoms of the disease later that day. Within 24 hours, both boys had died.

Health officials in Mumbai have responded to the outbreak by ramping up routine surveillance measures, as well as through active case finding.

"We are visiting house-to-house, and we are trying to find out whether there are any cases with fever and rash," said Gomare. "If such cases are reported, then two doses of vitamin A are given, 24 hours apart."

The BMC is also attempting to rapidly increase vaccination coverage, running special camps in affected areas.

Fatal hesitation

According to government data, since November 1, at least 19,200 routine MMR doses have been administered, along with an additional 24,600 doses administered at special vaccination camps in targeted areas.

Local health care workers have reported high levels of vaccine hesitancy in some areas, however, with parents worried that the vaccinations may make their children sick.

"In some of the communities in particular, they are not coming forward for vaccination, they are not bringing their children for vaccination," said Gomare.

Khan said that both of her sons received the first dose of the measles vaccine but not the second, as they regularly fell ill due to the poor living conditions and Khan was afraid that the MMR vaccine would make things worse.

Door-to-door awareness campaigns — organized with the help of local health care workers — have been essential in educating people on the dangers of missed doses, said Gomare. The BMC has approached community and religious leaders to help them spread awareness and educate parents on when to bring their children for vaccination.

The BMC is now planning to provide an additional booster dose for all children between the ages of 9 months and 5 years, in accordance with government guidelines on disease outbreaks, Gomare said.

Edited by: Keith Walker