India's Measles-Rubella Campaign: Readiness Checks Before Vaccinating, 2017–2018

In 2013, the 11 countries of the World Health Organization's South-East Asia Region set goals to eliminate measles and control rubella and congenital rubella syndrome by 2020. India launched a phased, nationwide measles-rubella vaccination campaign (a supplementary immunization activity, or SIA) in 2017, aimed at about 410 million children aged 9 months to 14 years. Campaigns on that scale need careful preparation, so India's Ministry of Health and Family Welfare checked readiness with a tool adapted from a WHO field guide.

How readiness was checked

• Where: 24 of the 58 districts in Andhra Pradesh (7), Kerala (5) and Telangana (12), plus 74 of Telangana's 103 blocks — chosen for low routine vaccination, hard-to-reach or largely urban populations, or high polio risk.
• Who: teams coordinated by the WHO India Country Office, with members from the health ministry, the National Institute of Health and Family Welfare, officers from other states, UNICEF, the UN Development Program, and nongovernmental groups such as John Snow Inc., Global Health Strategies and the CORE Group Polio Project.
• What: yes/no checklists on planning and coordination, advocacy, accountability, handling of adverse events, vaccine logistics, funding and communication.
• Scoring: on track (80% or more "yes"), needs work (60–79%) or not ready (under 60%).
• When: 4–6 weeks and again 1–2 weeks before the campaign. After the second check, areas on track got a "go", those not ready a "delayed go" — a term chosen over "no go" to encourage staff who needed more time — and those needing work were judged case by case.

What the checks found

• First assessment: no state and no district was on track. The most common gaps: missing logistics and training materials, and schools not yet engaged. Feedback went straight to state program managers, who ordered fixes in every district.
• Second assessment: Kerala and Telangana were on track. Andhra Pradesh still needed work and delayed its start by a week. Most districts were on track; one was not ready and had a delayed go.

During the campaign

Rapid convenience monitoring, which finds children missed during the campaign and asks why, found 9,912 of 143,894 targeted children (6.9%) unvaccinated:

Why children were missed, by caregivers' accounts:

• the child was sick — 3,715 (37%);
• the family didn't know about the campaign — 1,566 (16%);
• in Kerala, refusal accounted for about a quarter;
• operational failures — closed sites, absent or late vaccinators, vaccine shortages — were the rarest reason, 209 (2%), a sign of good preparation.

Reported administrative coverage reached 95% or more in two states and 17 districts.

Reasons children were missed, from rapid convenience monitoring. Image from the Centers for Disease Control and Prevention

Lessons

• Readiness checks work: immediate feedback helped leaders plan, direct resources and fix problems in time — and statewide orders may have improved preparation well beyond the assessed districts.
• Communication is the weak spot: most missed children reflected gaps in information, education and communication and parents' misperceptions, lack of awareness or availability — so WHO's checklist section on communication may need expanding.
• More checks, more places: WHO recommends four to six assessments before a campaign; India did two per area, at no extra cost, within existing WHO, UNICEF and partner support. Covering more districts, blocks and health centers could make quality more even.

Limitations: areas were chosen deliberately, with no comparison group, and the effect on reaching 95% coverage was not measured by post-campaign surveys.

The region aims to vaccinate more than 500 million children with measles-rubella vaccine through campaigns by 2019; India's experience can help others prepare.

Sources

Based on "Measles-Rubella Supplementary Immunization Activity Readiness Assessment — India, 2017–2018," by Vandana Gurnani, Pradeep Haldar, Sudhir Khanal and colleagues, Morbidity and Mortality Weekly Report 67(26), Centers for Disease Control and Prevention; a work of the United States government in the public domain. The source gives the number of districts on track at the second assessment as both 21 (88%) and 19 (79%), so neither is given.