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Measles Vaccine: Pins and Needles

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How rumours, pseudoscience and the tricky issue of consent are derailing India’s measles vaccine programme

EARLIER THIS YEAR, Saeeda Khan sat in her office in Mumbai’s Kurla area, when a municipal official from the health department appeared unannounced.

In her late forties, Khan is a municipal corporator who dresses plainly, a white scarf always tied around her head. She possesses the air of someone who can never be surprised. Which perhaps serves her well. Her ward, No 168, lies in one of Mumbai’s most dense and chaotic neighbourhoods. Here, the houses are tiny and the streets narrow. And a profusion of hovels, tiny establishments, loud auto-rickshaws, human hands, dogs and wires (emerging from under the ground and from above in the air) make the space narrower. So when you move about in the neighbourhood, you are not so much as walking straight as sideways, fitting yourself into whatever little room appears. To the south, is the city’s large dumping yard, and to the immediate west, past a filthy river the size of a drain, the plush business district of the Bandra-Kurla Complex.

The municipal official, Khan recalls, looked incredibly frustrated. He flung his arms in the air and gestured emphatically, while Khan no doubt looked up from her table, her expression as ever nonplussed. “Madam, you have to do something,” she remembers him saying. “Your people (from the ward) are refusing to cooperate.”

The people from her ward were refusing to get their children inoculated with the MR (measles and rubella) vaccine. The MR vaccine—being delivered in phases nationwide under the country’s Universal Immunisation Programme (UIP) since February 2017—had started in Mumbai and the rest of Maharashtra in late November. It was to end in just a few more days then (by mid-January). But as the official explained, her ward was nowhere close to completing it.

“I was quite surprised to hear it, really. Because I couldn’t understand why, after being explained the importance of the vaccine, parents would hesitate,” she says.

So Khan had four schools in her ward organise parent- teacher meetings, which she would address. In every school she encountered the same response. “They said the vaccine would make their children impotent,” she says. “Whatever we said or did, no amount of persuasion by doctors or by me—and the locals all know me very well—nothing we said could make them budge from their stand.”

What Khan faced in her ward is an issue that has bedevilled the MR vaccine drive across the country. According to a particularly sinister rumour aimed at Muslims—spread especially through platforms like WhatsApp—the MR vaccine isn’t a vaccine at all but a ploy to render Muslim children impotent in the future and to curb their population.

“That rumour has been very bad for us in Muslim-dominated areas,” says Dr Chandrashekhar Chiplunkar, the assistant health officer in the Brihanmumbai Municipal Corp (BMC) who has been one of the key officials responsible for conducting the vaccination drive in Mumbai. “We have tried our level best [to assuage their fears], but people just refuse to believe us.”

To combat this, in Mumbai, officials have reached out to clerics and community leaders and roped in activists and sought the help of popular leaders. All this has helped to an extent. But not quite enough. The drive was to be over in the city by mid-January. The BMC hasn’t officially announced it, but Chiplunkar admits that the drive has now been extended indefinitely. “What can we do? We need to get as much [vaccination] coverage as possible for it to work [and for measles and rubella to be wiped out]. At least 95 per cent or more everywhere [in Mumbai].”

On January 16th, Khan had a function for schoolchildren from four schools organised in a playground. Parents were invited, under the ruse of showing what opportunities lay in front for their children, but the aim was really to dispel rumours about the vaccine. “If you would have told them it was part of the vaccination drive, [the parents] would never come,” she says. Here, she had a local municipal official, the assistant municipal commissioner Manish Valanju who has a 17-month-old daughter, get his child vaccinated on stage. “I believe there has been a big jump in parents getting their children vaccinated in my ward from that day onwards,” she says. “It’s still not all done. But it is much better.”

Rumours of the vaccine being an instrument to control the Muslim population isn’t the only impediment to the success of the campaign. Reluctance, Chiplunkar says, has come in from various other quarters too. “Some of the parents are affluent urban people who send their children to elite schools,” he says. While some, like the parents in Khan’s ward, have been victims of mischievous rumours, there are many others plagued with fears that the vaccine may have dangerous side effects. Various media reports of children falling ill after taking the vaccine shot haven’t helped. (Health authorities clarify that in almost all these incidents, the children fell ill from previous ailments unconnected to the vaccine.) The vaccine, according to health officials, is safe and effective. Yet, fuelled by misinformation and pseudoscience, an anti-vaccine sentiment has taken hold.

There were so many rumours, so much reservation. And there were all these messages about how the MR vaccination causes impotence going viral, says Dr Shimna Azeez, medical officer at Manjeri Medical College, Mallappuram

The issue has now come to a head in Delhi. A number of parents have approached the Delhi High Court claiming that their children do not want to inoculate themselves and such a vaccine campaign, which has an element of state force, is a violation of their fundamental rights. The campaign for the time being has been halted in Delhi.

THE AMERICAN PHYSICIAN Thomas Peebles, according to a popular story, is believed to have jabbed a needle into the arm of a sick 13-year-old boy in 1954 and told him, “Young man, you are standing on the frontiers of science.” Peebles was correct. He was able to use the blood sample to isolate the measles virus, which less than a decade later, a colleague (John Enders) used to create the measles vaccine. The vaccine has led to the near-complete elimination of the disease in the US and other developed countries.

But in countries like India, measles is still contracted in large numbers and is often fatal. According to the World Health Organisation (WHO), around 2.5 million children contract measles annually in India, killing more than 49,000 of them. India is believed to comprise one-third of all measles-related deaths in the world. Rubella, which can cause birth defects like irreversible deafness and blindness and sometimes even death, is also rampant, affecting an estimated 40,000 children every year.

For the prevention of outbreaks for diseases such as measles, according to experts, there should be at least around 90 per cent immunisation coverage rate in all areas. To stop transmission altogether, this should be at least 95 per cent. Achieving such vaccine coverage is important because it leads to what scientists refer as ‘herd immunity’, whereby a large vaccinated population forms a fence around even those few who are unvaccinated and susceptible. But in areas where there is a high anti- vaccine sentiment, the fence collapses.

According to the Indian Government, it is aspiring for 95 per cent immunisation coverage. That’s an incredibly ambitious programme, the largest such effort conducted anywhere in the world in recent times. The aim: to eliminate measles entirely and control rubella by 2020. The target: an estimated 405 million children (falling in the age group of and between nine months and 15 years) by 2019.

“We are treating it on a war footing. Like we did when we eliminated polio,” says Dr Pradeep Haldar, Deputy Commissioner, Immunisation, Ministry of Health and Family Welfare.

But there have been issues. Officially, the drive is currently supposed to be going on only in Madhya Pradesh and Bihar, with only West Bengal, Sikkim and Rajasthan left for the last phase. But extensions have had to be made in many places such as Mumbai and the rest of Maharashtra. “See, the way we are looking at it is that these are last-mile challenges. And we have to remember there were last-mile challenges even in [drives to eradicate] polio,” Dr Haldar says. He takes heart from the fact that in most places where the drive has been completed, they have managed almost 90 per cent vaccine coverage. “We have so far managed to vaccinate around 230 million children,” he says. That means there is still another 175 million children left.

The vaccine has always had a little bit of controversy around it. It started in the late 1990s when a British lecturer (Andrew Wakefield), published a paper suggesting a link between the vaccine and autism. The findings of the paper have since been discredited and several later studies have found no such link.

Measles cases have been dropping in India over the years, courtesy the earlier vaccine (which used to be delivered in two doses). But to eliminate it entirely, experts say, there was the need to introduce the new MR vaccine (which combines vaccines both for measles and rubella and is delivered only once) in an intense programme which ensures maximum coverage for all children.

The campaign has been designed in a way to reach as many children as possible, through health and Anganwadi centres and other special posts in rural and urban areas. But where can such large numbers of children be found?

“The school, of course,” says Chiplunkar. “That’s the best way to make the campaign successful.”

This has brought with it the somewhat tricky dimension of consent that has never quite been examined in this specific context. Vaccination is arguably a societal necessity since it concerns the health of both the individual and society at large. Yet an individual also has the choice to refuse treatment.

It is settled principle that the choice of an individual, even in cases where a person refuses life-saving medical treatment, is a part of his right to dignity, says Abinav Mukerji, advocate

So far, under routine immunisation programmes which takes place in healthcare centres or hospitals, the consent of parents has always been assumed. This is because it is invariably a parent or a family member who brings the child to the centre for vaccination.

In a school, however, such an assumption does not hold. “You have to remember that the choice of an individual (in this case, parents representing their children) has to be respected,” says Abinav Mukerji, an advocate representing the parents of six children from Modern School who have filed a case against the vaccination drive in Delhi. “It is a settled principle that the choice of an individual, even in cases where a person refuses life-saving medical treatment, is a part of his right to dignity. And that has to be protected.”

Although he is representing the parents of six children, Mukerji claims there are several other parents from the school who also support their case. Parents from other schools have also filed petitions now. “The parents were initially told the vaccine won’t be given without consent. But later, the school circular was saying it would be,” he says.

The chief grouse appears to be that the children, whose parents filed the case, have already received the older measles vaccine. They see no reason why they have to take this new vaccine, according to Mukerji, which they are particularly suspicious about in terms of safety. “Also, why should it be conducted in a school? The teachers and school staff are not equipped to handle a drive,” he adds.

The Delhi High Court has so far rejected suggestions of an ‘opt out’ feature being deployed in the current campaign, where parents who don’t want their children inoculated can do so by raising individual concerns and opting out. Instead, petitioners have been asking for ‘express consent’ where the consent of every parent is taken before vaccination.

According to health officials off the record, acquiring express consent before vaccination from every parent will make the campaign’s aim of reaching over 95 percentage coverage in Delhi near impossible.

In Mumbai, according to Chiplunkar, around 44 schools are still refusing to allow their premises for the drive. “They don’t want to take the responsibility,” he says. “They are worried they will be held responsible if something untoward occurs.” Even in schools whose principals did come around, Chiplunkar says, parents invariably do not send their children on the day of the vaccination. “It’s so strange,” he says. “You see almost full attendance throughout the school on one day. And the next day [when vaccinations are due], each class is almost half-empty.”

One of the most severe resistances to the vaccine occurred early on in the first few months of the campaign in 2017 at Kerala’s Mallappuram district. The drive began in October and was to wrap up in a few weeks. But in Mallappuram, as also some other parts of the state, according to the then medical officer of the local Manjeri Medical College, Dr Shimna Azeez, it had to be carried on for almost four months, until the end of January 2018.

“There were so many rumours, so much reservation,” she says. “And there were all these messages about how it causes impotence going viral on WhatsApp.” Many healthcare workers vaccinating the children were threatened. At least in one case, Dr Azeez says, one such worker was also physically assaulted. “[Doctors] used to go to awareness meetings or vaccination centres with the police on call,” she says. The issue was made worse, she claims, with a lot of other people like naturopathy practitioners and anti-science groups jumping into the fray and calling the vaccine unsafe. A petition was also filed by a parent-teacher association insisting that consent has to be acquired from every parent before vaccination. But the Kerala High Court ruled that those parents who did not want their children could do so by raising individual objections at the school.

By early December, while many other parts of the state had gone on to register over 95 per cent vaccination coverage, and some even 98 per cent, Malappuram was languishing, she says, at around 62 per cent.

Dr Azeez began to go online on social media to combat the rumours. She is part of a popular Facebook page, Infoclinic, with almost 50,000 followers and run by a team of doctors to dispel myths about modern medicine. The forum now began to actively take on the MR vaccine resistance. Dr Azeez even live-streamed the vaccination of her two children (now a three-year-old girl, and an eight- year-old boy). Gradually, the numbers began to improve, she says.

Dr Azeez was a popular person whom the state authorities turned to. She was a local and a member of the Muslim community. But most importantly, she says, it was because she was a woman. “So there was less chance of me getting beaten,” she says.

One intimidating encounter turned out to be a visit to a school in the Kondotty area of Malappuram. Very few children had gotten inoculated in that school. And Dr Azeez could see why. The parents—some over 400 people—packed in the school hall, was a particularly hostile crowd. At one point, Dr Azeez mentioned that as a child she had taken the measles vaccine but had missed out on the rubella shot.

At a distance, an angry father rose and began to shout at her. “He was challenging me to take the vaccine,” she recalls. So even though the new MR vaccine was meant for children, Dr Azeez had the men leave the hall and the women gather around her, as she went on to inject herself. By the end of January, Malappuram managed about 85 per cent vaccine coverage. “It was a success because we couldn’t have managed more here,” she says.

In the school, after Dr Azeez held the demonstration, several parents queued up to have their children vaccinated. But many still stayed away. “They were saying, ‘Nothing happened to her. But she’s old. It might still happen to a child.’”

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