Factors precipitating outbreaks of measles in district Kangra of North India: A case-control study

Background: Globally, measles is the fi fth killer disease among children under fi ve years of age. Despite high immunization
coverage in Himachal, outbreaks are occurring. Upon two outbreaks in a hilly district in North India, a case control study
was conducted to identify factors contributing to outbreaks and to recommend remedial measures to prevent further
outbreaks. Materials and Methods: Factors were reviewed under three heads: program related, health care providers, and
benefi ciaries related. Cold chain maintenance was determined and responses were compared between workers from study
Shahpur and control Nagrota Bagwan blocks. All 69 mothers of age and sex matched children with measles were enrolled. A
pre-designed pre-tested data collection instrument was used. For statistical analysis, the odds ratio (OR) and adjusted odds
ratio with 95% confi dence interval (C.I.) among women of children exposed and unexposed to selected characteristics were
calculated. Results: Poor cold chain maintenance and gaps in knowledge of health workers supplemented with benefi ciaryrelated
issues precipitated outbreaks in case area. Univariate analysis yielded strong statistical signifi cance to 17 variables.
Important statistically signifi cant variables are educational status; OR 27.63 (C.I. 9.46-85.16); occupation; OR 0.35 (C.I. 0.16-
0.75); income; OR 5.49 (C.I. 2.36-13.00); mode of transport to health care facility; OR 8.74 (C.I. 2.90-28.23); spread of illness
from one person to another; OR 5.60 (95% C.I. 1.40-25.97); fi rst help for sick child OR 2.12 (C.I. 1.00-4.50), and place of
visit after recovery; OR 3.92 (C.I. 1.80-8.63). Multiple logistic regression yielded signifi cant association with educational status,
drinking water sources, and time taken to reach the nearest health facility. Conclusion: Measles outbreaks were confi rmed
in high immunization coverage areas. We recommend 2nd dose opportunity for measles (MR) between 5 and 17 years;
refresher trainings to workers; mobile access to health care facility, and Information Education Communication activities for
social behavioral change in affected areas.
Key words: Beliefs and barriers, immunization, measles, outbreaks

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