Sri Lanka passed another milestone of progress in public health as the World Health Organisation (WHO) announced the country’s achievement of eliminating measles, interrupting transmission of the indigenous virus that causes the killer childhood disease.
“Sri Lanka’s achievement comes at a time when globally measles cases are increasing. The country’s success demonstrates its commitment, and the determination of its health workforce and parents to protect children against measles. Elimination of measles is a good indicator of the strength of immunization systems generally and by extension, of the quality and reach of the primary health care system,” said Dr Poonam Khetrapal Singh, Regional Director WHO South-East Asia, congratulating the country on Tuesday, July 9 at the South-East Asia Regional Immunisation Technical Advisory group meeting in New Delhi, India.
Sri Lanka is the fourth country in WHO South-East Asia Region, after Bhutan, Maldives and Timor-Leste, to eliminate measles and control rubella, a flagship priority program of WHO in the region, ahead of the 2020 regional target noted a media release from WHO.
According to Consultant Epidemiologist, Ministry of Health, and the focal point for the Measles Elimination Program (MEP) at the Ministry, Dr Deepa Gamage, the announcement comes consequent to a review by an independent expert committee of country specific measles data for the last five years. They have identified that the country does not have further circulation of the indigenous (country existed) viral type for the last 36 months.
The last country specific measles virus case was in May 2016. Though a few measles cases appeared in the country after May 2016, they had been identified as imported or import related cases. Other criteria the expert committee considered were the country capacity for early identification of measles and the capacity for rapid response and the ability to stop continuation of transmission of the virus. This also includes ongoing country specific activities on measles surveillance, laboratory confirmation capacities for early detection of measles cases, continuation of measles vaccination status and capacities for outbreak response. “ The independent review committee had been satisfied with the existing country capacities in these aspects,” said Dr. Gamage.
A highly contagious disease, one infected person could spread measles to about 16 to 18 others, if they are susceptible to disease. The virus living in the mucous of an infected person’s nose and throat is transmitted by direct contact or by airborne spread through breath, coughs or sneezes. While it causes fever followed by a skin rash of small reddish brown spots over the skin usually appearing on the face and neck spreading to the rest of the body, cough, red-eyes, runny nose and small grayish-white spots in the inner cheeks are the other recognizable basic symptoms.
However, complications exist. Infants, children under two years, pregnant women and those with compromised immune systems are recognized as high risk populations who could develop severe illness and complications. “Measles has fatal and serious complications especially among children. Some of these complications could occur even five to seven years later. These complications include pneumonia, diarrhea, bronchitis, meningitis, encephalitis, ear infections, and blindness. There are long term neurological brain complications which children can suffer due to measles. In fact, prevention of measles as early as possible is a requirement with a very effective and safe vaccine being available,” said Dr. Gamage.
Sri Lanka now runs a robust and mandatory vaccination program to prevent childhood measles. Delivered at two stages, at nine months and three years, the vaccination contains immunity for three diseases Mumps-Measles-Rubella (MMR).
It was in 1984, after the country saw measles cases in epidemic proportions that the measles vaccination was introduced at the age of nine months. Though the number of cases went down thereafter, a reappearance of the disease in 2000-2001, with nearly 20,000 cases and almost 180 deaths brought in the requirement of a second doze of the vaccination which was introduced at the age of three years, as the Measeles-Rubella (MR) combination through the National Immunization Program (NIP) in 2001.
The WHO recognizing the vaccination program notes that the country’s success in eliminating the indigenous measles viral strain, is due to its persistent efforts to ensure maximum coverage with two doses of measles and rubella vaccines being provided in the childhood immunisation program. “The vaccination coverage in the country has been consistently high – over 95% with both the first and second dose of measles and rubella vaccine provided to children under the routine immunization program. Additionally, mass vaccination campaigns with a measles-rubella vaccine have been held periodically to plug the immunization gaps, the last one in 2014.
The country has a strong surveillance system and all vaccine-preventable diseases are an integral part of the communicable disease surveillance system. Measles is a notifiable disease in the country.”
The success of measles elimination does not come easy. It was the result of many efforts by the Ministry of Health over more than four decades. While the Epidemiology Unit has been given the responsibility of closely monitoring and evaluating activities of the MEP on the areas of vaccination, surveillance, confirmation and rapid response to outbreaks, it was the hard work of the medical staff at all levels from the grass roots to those at the ministry, which had paved success, said Dr. Gamage.
“The field level staff, Medical Officers of Health, Public Health Nursing Sisters, Public Health Inspectors and Public Health Midwives have taken the major role in vaccination and surveillance in preventing community transmission. The hard work, contribution and cooperative activities of consultant paediatricians, physicians, dermatologists, virologists, epidemiologists, community physicians, district, provincial and hospital directors, other specialists, medical and supportive staff on early identification of suspected measles cases and responses should be appreciated,” she said.
However, being jubilant should not lull both the citizens and medical staff to complacency warns Dr. Gamage, the country has to be highly vigilant. Sri Lanka’s achievement comes at a time when measles cases had spiked four-fold globally.
In, May the WHO reported that there had been more than 112,000 confirmed cases of measles worldwide, the first quarter of the year, a 300% increase from the 28,124 cases of last year. Though no indigenous strain of the virus have been reported since 2016, a few cases of measles from imported strains had been reported thereafter.
“It is our challenge to prevent country level transmission from these imported cases,” Dr. Gamage points out. Sri Lanka being a favoured tourist destination and a lot of global travel happening throughout the year intensifies the challenge. “We should not forget that we also have to face the threat of importation and possibility of establishing further transmission of measles in the country.
In fact all parents are advised to vaccinate all children at nine months and three years and report all measles like fever and reddish rash cases to nearest doctor to inform to area MOH to take relevant outbreak responses on immunization.
This is essential and helps the country to ensure maintaining measles elimination status.” Yes, a collective effort from the citizens as well as those in the medical profession will sustain the measles elimination status of the country.