Trans-boundary infections threaten measles elimination target

The country plans to eliminate measles by next year

Trans-boundary infections present serious challenges for the country to maintain its target to eliminate measles by the end of next year, say health officials.

Bhutan did not have any measles cases in 2013 and 2014. However, there was a measles outbreak in a school in Merak in Trashigang, last year.

Deputy chief programme officer with the vaccine preventable disease programme, Tshewang Tamang, said that in the case of the Merak outbreak, most of the infected were not vaccinated.

He pointed out that people did not come for vaccination because the health setting in the area was inadequate. Another reason attributed for the lack of vaccinations was that people moved around frequently while herding their animals which limited the effectiveness of their awareness campaigns.

“In response to the Merak outbreak, we did an awareness campaign in the area,” he said. “Measles vaccinations are available in all the health centres including Basic Health Units (BHUs) in the villages now.”

Measles is a highly contagious disease and the WHO South-East Asia Regional Office has set a measles elimination target by 2020. In line with that Bhutan has set up its own target to eliminate measles by 2018.

Of a total of 45 measles cases from Paro, Samtse, Sarpang, Thimphu, Trashigang and Wangdue last year, 33 were reported from Trashigang alone.

In 2015, some 11 measles cases were reported from Samtse, Paro, Sarpang, Phuentsholing and Thimphu.

The ministry investigated the measles cases in 2015 and 2016.

Tshewang Tamang said that based on the investigation and genotype of the measles, it is confirmed that the cases are imported. He said that WHO’s definition of elimination of measles means zero indigenous cases in a country.

“As of now, nothing can be said if Bhutan can achieve its target by next year.”

Meanwhile, some 16 measles cases were reported from Samtse, Phuentsholing and Thimphu till date this year.

Tshewang Tamang said that the investigation report on genotype of measles reported this year was sent to Bangkok in Thailand. The ministry is yet to get confirmation on whether the reported cases are imported or indigenous.

“It is likely to be importation because the outbreak started from Samtse and Phuentsholing, the dzongkhags that share a border with the neighbouring country,” he added.

The measles vaccination programme was first introduced in the country in 1979 where  toddlers were vaccinated at nine months. The second dose of measles vaccination for children at 24 months was started in 2006.

Tshewang Tamang also pointed out that some measles cases are seen in children below nine months. “If the vaccine is given to a child before he or she reaches nine months, the effect of the vaccine is only about 65 percent,” he said.

The efficacy of the first vaccine dose given to a child at nine months is 85 percent. Not all infants given the vaccine at nine months are guaranteed to be immunised from  measles.

Tshewang Tamang said that to protect the remaining 15 percent, the second dose of the measles vaccine is given at 24 months. The efficacy of the second dose is   95 percent.

In Bhutan, the measles vaccine is given in the form of the measles, mumps and rubella vaccine (MMR vaccine).

He said that it is mandatory for a child to get both the dosages. Unvaccinated young children are at a higher risk of getting measles and suffering complications. Any non-immune person who has not been vaccinated or was vaccinated but did not develop immunity can become infected.

Measles is easily spread by coughing, sneezing and close contact with those already infected. The symptoms of the disease are fever, cough, red eyes, muscle aches, runny nose, white spots inside the mouth and rash, for any age.

He pointed out that complications with measles are high with diarrhea and pneumonia at times leading to death.

Tshewang Tamang said that there is no specific treatment for measles. It is prevented by the measles vaccination given at nine and 24 month after birth.

“Anyone with fever and rash should visit nearest health centre,” he said. “Measles is confirmed only by a laboratory testing.”

In an effort to achieve its target to eliminate measles in the region by 2020, WHO recommended countries to carry out a nation wide awareness campaign on measles.

However, Tshewang Tamang said that it is expensive for the ministry to conduct a nationwide campaign. The ministry will be campaigning in high-risk areas where the terrain is challenging like Merak and the border areas to increase the immunity level of the population against measles.

“We will focus on labour camps and low immunisation coverage areas in the country identified by the dzongkhags.”

He said that the campaigns will target people up to the age of 40 years, assuming that they are exposed to the measles virus because measles cases were reported by people aged between 30 and 45 in 2016.

According to WHO, there were 134,200 deaths caused by measles globally in 2015, which means about 367 deaths daily or 15 deaths every hour. The vaccinations resulted in a 79 percent drop in deaths caused by measles between 2000 and 2015.

Dechen Tshomo

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