Progress Toward Measles and Rubella Elimination - India, 2005-2021

In 2019, India, along with other countries in the World Health Organization (WHO) South-East Asia Region,* adopted the goal of measles and rubella elimination by 2023,^† a revision of the previous goal of measles elimination and control of rubella and congenital rubella syndrome (CRS) by 2020^§ (1-3). During 2017-2021, India adopted a national strategic plan for measles and rubella elimination (4), introduced rubella-containing vaccine (RCV) into the routine immunization program, launched a nationwide measles-rubella supplementary immunization activity (SIA) catch-up campaign, transitioned from outbreak-based surveillance to case-based acute fever and rash surveillance, and more than doubled the number of laboratories in the measles-rubella network, from 13 to 27. Strategies included 1) achieving and maintaining high population immunity with at least 95% vaccination coverage by providing 2 doses of measles- and rubella-containing vaccines; 2) ensuring a sensitive and timely case-based measles, rubella and CRS surveillance system; 3) maintaining an accredited measles and rubella laboratory network; 4) ensuring adequate outbreak preparedness and rapid response to measles and rubella outbreaks; and 5) strengthening support and linkages to achieve these strategies, including planning and progress monitoring, advocacy, social mobilization and communication, identification and utilization of synergistic linkages of integrated program efforts, research, and development. This report describes India's progress toward the elimination of measles and rubella during 2005-2021, with a focus on the years 2017-2021.^¶ During 2005-2021, coverage with the first dose of a measles-containing vaccine (MCV) administered through routine immunization increased 31%, from 68% to 89%. During 2011-2021, coverage with a second MCV dose (MCV2) increased by 204%, from 27% to 82%. During 2017-2021, coverage with a first dose of RCV (RCV1) increased almost 14-fold, from 6% to 89%. More than 324 million children received a measles- and rubella-containing vaccine (MRCV) during measles-rubella SIAs completed in 34 (94%) of 36 states and union territories (states) during 2017-2019. During 2017-2021, annual measles incidence decreased 62%, from 10.4 to 4.0 cases per 1 million population, and rubella incidence decreased 48%, from 2.3 to 1.2 cases per 1 million population. India has made substantial progress toward measles and rubella elimination; however, urgent and intensified efforts are required to achieve measles and rubella elimination by 2023.

Expansion of the measles and rubella laboratory network, India

Objective

To expand the measles and rubella laboratory network of India by integrating new laboratories.

Methods

In collaboration with the World Health Organization (WHO), the Indian government developed a 10-step scheme to systematically expand the number of laboratories performing serological and molecular testing for measles and rubella. The Indian Council of Medical Research and WHO identified suitable laboratories based on their geographical location, willingness, preparedness, past performance and adherence to national quality control and quality assurance mechanisms. The 10-step scheme was initiated with training on measles and rubella diagnostic assays followed by testing of both measles and rubella serology and molecular unknown panels, cross-verification with reference laboratories and ended with WHO on-site accreditation.

Findings

After extensive training, technical support, funding and monitoring, all six selected laboratories attained passing scores of 90.0% or more in serological and molecular proficiency testing of measles and rubella. Since 2018, the laboratories are a part of the measles and rubella network of India. Within 12 months of initiation of independent reporting, the six laboratories have tested 2287 serum samples and 701 throat or nasopharyngeal swabs or urine samples.

Conclusion

The process led to strengthening and expansion of the network. This proficient laboratory network has helped India in scaling up serological and molecular testing of measles and rubella while ensuring high quality testing. The collaborative model developed by the Indian government with WHO can be implemented by other countries for expanding laboratory networks for surveillance of measles and rubella as well as other infectious diseases.

Human papillomavirus (HPV) vaccine introduction in Sikkim state: Best practices from the first statewide multiple-age cohort HPV vaccine introduction in India-2018-2019

BACKGROUND

Cervical cancer is a leading cause of cancer-associated mortality among women in India, with 96,922 new cases and 60,078 deaths each year, almost one-fifth of the global burden. In 2018, Sikkim state in India introduced human papillomavirus (HPV) vaccine for 9-13-year-old girls, primarily through school-based vaccination, targeting approximately 25,000 girls. We documented the program's decision-making and implementation processes.

METHODS

We conducted a post-introduction evaluation in 2019, concurrent with the second dose campaign, by interviewing key stakeholders (state, district, and local level), reviewing planning documents, and observing cold chain sites in two purposefully-sampled community areas in each of the four districts of Sikkim. Using standard questionnaires, we interviewed health and education officials, school personnel, health workers, community leaders, and age-eligible girls on program decision-making, planning, training, vaccine delivery, logistics, and communication.

RESULTS

We conducted 279 interviews and 29 observations in eight community areas across four districts of Sikkim. Based on reported administrative data, Sikkim achieved >95% HPV vaccination coverage among targeted girls for both doses via two campaigns; no severe adverse events were reported. HPV vaccination was well accepted by all stakeholders; minimal refusal was reported. Factors identified for successful vaccine introduction included strong political commitment, statewide mandatory school enrollment, collaboration between health and education departments at all levels, and robust social mobilization strategies.

CONCLUSIONS

Sikkim successfully introduced the HPV vaccine to multiple-age cohorts of girls via school-based vaccination, demonstrating a model that could be replicated in other regions in India or similar low- and middle-income country settings.

New analytic approaches for analyzing and presenting polio surveillance data to supplement standard performance indicators

BACKGROUND

Sensitive surveillance for acute flaccid paralysis (AFP) allows for rapid detection of polio outbreaks and provides essential evidence to support certification of the eradication of polio. However, accurately assessing the sensitivity of surveillance systems can be difficult due to limitations in the reliability of available performance indicators, including the rate of detection of non-polio AFP and the proportion of adequate stool sample collection. Recent field reviews have found evidence of surveillance gaps despite indicators meeting expected targets.

METHODS

We propose two simple new approaches for AFP surveillance performance indicator analysis to supplement standard indicator analysis approaches commonly used by the Global Polio Eradication Initiative (GPEI): (1) using alternative groupings of low population districts in the country (spatial binning) and (2) flagging unusual patterns in surveillance data (surveillance flags analysis). Using GPEI data, we systematically compare AFP surveillance performance using standard indicator analysis and these new approaches.

RESULTS

Applying spatial binning highlights areas meeting surveillance indicator targets that do not when analyzing performance of low population districts. Applying the surveillance flags we find several countries with unusual data patterns, in particular age groups which are not well-covered by the surveillance system, and countries with implausible rates of adequate stool specimen collection.

CONCLUSIONS

Analyzing alternate groupings of administrative units is a simple method to find areas where traditional AFP surveillance indicator targets are not reliably met. For areas where AFP surveillance indicator targets are met, systematic assessment of unusual patterns ('flags') can be a useful prompt for further investigation and field review.

Global Routine Vaccination Coverage - 2017

Endorsed by the World Health Assembly in 2012, the Global Vaccine Action Plan 2011-2020 (GVAP) (1) calls on all countries to reach ≥90% national coverage with all vaccines in the country's national immunization schedule by 2020. This report updates previous reports (2,3) and presents global, regional, and national vaccination coverage estimates and trends as of 2017. It also describes the number of infants surviving to age 1 year (surviving infants) who did not receive the third dose of diphtheria and tetanus toxoids and pertussis-containing vaccine (DTP3), a key indicator of immunization program performance (4,5), with a focus on the countries with the highest number of children who did not receive DTP3 in 2017. Based on the World Health Organization (WHO) and United Nations Children's Fund (UNICEF) estimates, global DTP3 coverage increased from 79% in 2007 to 84% in 2010, and has remained stable from 2010 to 2017 (84% to 85%). In 2017, among the 19.9 million children who did not receive DTP3 in the first year of life, 62% (12.4 million) lived in 10 countries. From 2007 to 2017, the number of children who had not received DTP3 decreased in five of these 10 countries and remained stable or increased in the other five. Similar to DTP3 coverage, global coverage with the first measles-containing vaccine dose (MCV1) increased from 80% in 2007 to 84% in 2010, and has remained stable from 2010 to 2017 (84% to 85%). Coverage with the third dose of polio vaccine (Pol3) has remained stable at 84%-85% since 2010. From 2007 to 2017, estimated global coverage with the second MCV dose (MCV2) increased from 33% to 67%, as did coverage with the completed series of rotavirus (2% to 28%), pneumococcal conjugate (PCV) (4% to 44%), rubella (26% to 52%), Haemophilus influenzae type b (Hib) (25% to 72%) and hepatitis B (HepB) (birth dose: 24% to 43%; 3-dose series: 63% to 84%) vaccines. Targeted, context-specific strategies are needed to reach and sustain high vaccination coverage, particularly in countries with the highest number of unvaccinated children.

Women's agency and its relationship to current contraceptive use in lower- and middle-income countries: A systematic review of the literature

Research shows a positive relationship between women's empowerment and reproductive health. Yet we know little about the quantitative relationship between women's agency and contraceptive use. We conducted a systematic review of peer-reviewed literature assessing the link between women's decision-making and freedom of movement with their contraceptive use in lower- and middle-income countries. Of 102 articles that met the initial screening criteria, 12 met all inclusion and exclusion criteria. Of the 12 included studies, consistently positive associations with contraceptive use were found in those that measured decision-making and freedom of movement as separate constructs. Composite measures had a less clear relationship with contraceptive use. In conclusion, women's agency is associated with women's contraceptive use in lower- and middle-income countries. However, the relationship is sensitive to how agency and its components are measured. Our review suggests the need for consistent validation of scales for women's agency as well as more rigorous research using standardised and validated scales, when possible. Longitudinal and intervention studies in lower- and middle-income countries will be useful for understanding the causal impact of women's agency on contraceptive use, and will help to inform policies and programmes to increase contraceptive use in these settings.

Adverse Childhood Experiences and HIV Sexual Risk-Taking Behaviors Among Young Adults in Malawi

Adverse childhood experiences (ACEs) exhibit a dose-response association with poor health outcomes in adulthood, including HIV. In this analysis, we explored the relationship between ACEs and HIV sexual risk-taking behaviors among young adults in Malawi. We analyzed responses from sexually active 19- to 24-year-old males and females ( n = 610) participating in the Malawi Violence Against Children Survey. We tested the association between respondents' exposure to six ACEs (having experienced emotional, physical, or sexual violence; witnessing intimate partner violence or an attack in the community; one or both parents died) and infrequent condom use in the past year and multiple sexual partners in the past year. We used logistic regression to test the association between ACEs and these sexual risk-taking behaviors. A majority (82%) of respondents reported at least 1 ACE, and 29% reported 3+ ACEs. We found positive unadjusted associations between the number of ACEs (1-2 and 3+ vs. none) and both outcomes. In adjusted models, we found positive associations between the number of ACEs and infrequent condom use (adjusted odds ratio [aOR]: 2.7, 95% confidence interval [CI]: [1.0, 7.8]; aOR: 3.7, CI: [1.3, 11.1]). Among young adults in Malawi, exposure to ACEs is positively associated, in a dose-response fashion, with engaging in some sexual risk-taking behaviors. HIV prevention efforts in Malawi may benefit from prioritizing programs and policies aimed at preventing and responding to violence against children.

Why Do Women Justify Violence Against Wives More Often Than Do Men in Vietnam?

Intimate partner violence (IPV) harms the health of women and their children. In Vietnam, 31% of women report lifetime exposure to physical IPV, and surprisingly, women justify physical IPV against wives more often than do men. We compare men's and women's rates of finding good reason for wife hitting and assess whether differences in childhood experiences and resources and constraints in adulthood account for observed differences. Probability samples of married men ( n = 522) and women ( n = 533) were surveyed in Vietnam. Ordered logit models assessed the proportional odds for women versus men of finding more "good reasons" to hit a wife (never, 1-3 situations, 4-6 situations). In all situations, women found good reason to hit a wife more often than did men. The unadjusted odds for women versus men of reporting more good reasons to hit a wife were 6.55 (95% confidence interval [CI] = [4.82, 8.91]). This gap disappeared in adjusted models that included significant interactions of gender with age, number of children ever born, and experience of physical IPV as an adult. Having children was associated with justifying wife hitting among women but not men. Exposure to IPV in adulthood was associated with justifying wife hitting among men, but was negatively associated with justification of IPV among women. Further study of the gendered effects of resources and constraints in adulthood on attitudes about IPV against women will clarify women's more frequent reporting than men's that IPV against women is justified.

Violent experiences in childhood are associated with men's perpetration of intimate partner violence as a young adult: a multistage cluster survey in Malawi

PURPOSE

To examine the association between exposures to violence in childhood, including exposure to multiple forms of violence, with young men's perpetration of intimate partner violence (IPV) in Malawi.

METHODS

We analyzed data from 450 ever-partnered 18- to 24-year-old men interviewed in the Malawi Violence Against Children and Young Woman Survey, a nationally representative, multistage cluster survey conducted in 2013. We estimated the weighted prevalence for perpetration of physical and/or sexual IPV and retrospective reporting of experiences of violence in childhood and examined the associations between childhood experiences of violence and perpetration of IPV using logistic regression.

RESULTS

Among young men in Malawi, lifetime prevalence for perpetration of sexual IPV (24%) was higher than for perpetration of physical IPV (9%). In logistic regression analyses, the adjusted odds ratios for perpetration of sexual IPV increased in a statistically significant gradient fashion, from 1.2 to 1.4 to 3.7 to 4.3 for young men with exposures to one, two, three, and four or more forms of violence in childhood, respectively.

CONCLUSIONS

Among young men in Malawi, exposure to violence in childhood is associated with an increased odds of perpetrating IPV, highlighting the need for programs and policies aimed at interrupting the intergenerational transmission of violence.

Women's age at first marriage and postmarital agency in Egypt

Early - or child - marriage (before age 18) may diminish women's ability to exercise agency, or their capacity to act upon their goals. Using a propensity score adjustment approach, we analyzed data from 2394 married women ages 35-49 years who participated in the 2006 Egypt Labor Market Panel Survey (ELMPS). We examined whether women's first marriage at age 18 or older was associated with their post-marital agency, measured in terms of their influence in family decisions, freedom of movement in public spaces, and unfavorable views about intimate partner violence against wives. In bivariate analyses, women's age at first marriage was positively associated with their decision-making and more equitable gender attitudes. However, once we controlled for selection into age-at-first-marriage groups, there were no significant differences between the two age-at-first-marriage groups in any dimension of women's agency. We examined the sensitivity of the non-significant age-at-first-marriage effects to possible violations of the strong ignorability assumption and the results did not alter our conclusions. The assumption that women's age at first marriage is a proxy for their post-marital agency, as defined here, warrants further study.

Initiation of a ring approach to infection prevention and control at non-Ebola health care facilities - Liberia, January-February 2015

From mid-January to mid-February 2015, all confirmed Ebola virus disease (Ebola) cases that occurred in Liberia were epidemiologically linked to a single index patient from the St. Paul Bridge area of Montserrado County. Of the 22 confirmed patients in this cluster, eight (36%) sought and received care from at least one of 10 non-Ebola health care facilities (HCFs), including clinics and hospitals in Montserrado and Margibi counties, before admission to an Ebola treatment unit. After recognition that three patients in this emerging cluster had received care from a non-Ebola treatment unit, and in response to the risk for Ebola transmission in non-Ebola treatment unit health care settings, a focused infection prevention and control (IPC) rapid response effort for the immediate area was developed to target facilities at increased risk for exposure to a person with Ebola (Ring IPC). The Ring IPC approach, which provided rapid, intensive, and short-term IPC support to HCFs in areas of active Ebola transmission, was an addition to Liberia's proposed longer term national IPC strategy, which focused on providing a comprehensive package of IPC training and support to all HCFs in the country. This report describes possible health care worker exposures to the cluster's eight patients who sought care from an HCF and implementation of the Ring IPC approach. On May 9, 2015, the World Health Organization (WHO) declared the end of the Ebola outbreak in Liberia.

Effect of face-to-face interview versus computer-assisted self-interview on disclosure of intimate partner violence among African American women in WIC clinics

African American women in the United States report intimate partner violence (IPV) more often than the general population of women. Overall, women underreport IPV because of shame, embarrassment, fear of retribution, or low expectation of legal support. African American women may be especially unlikely to report IPV because of poverty, low social support, and past experiences of discrimination. The purpose of this article is to determine the context in which low-income African American women disclose IPV. Consenting African American women receiving Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) services in WIC clinics were randomized to complete an IPV screening (Revised Conflict Tactics Scales-Short Form) via computer-assisted self-interview (CASI) or face-to-face interview (FTFI). Women (n = 368) reported high rates of lifetime and prior-year verbal (48%, 34%), physical (12%, 7%), sexual (10%, 7%), and any (49%, 36%) IPV, as well as IPV-related injury (13%, 7%). Mode of screening, but not interviewer race, affected disclosure. Women screened via FTFI reported significantly more lifetime and prior-year negotiation (adjusted odds ratio [aOR] = 10.54, 3.97) and more prior-year verbal (aOR = 2.10), sexual (aOR = 4.31), and any (aOR = 2.02) IPV than CASI-screened women. African American women in a WIC setting disclosed IPV more often in face-to-face than computer screening, and race-matching of client and interviewer did not affect disclosure. Findings highlight the potential value of face-to-face screening to identify women at risk of IPV. Programs should weigh the costs and benefits of training staff versus using computer-based technologies to screen for IPV in WIC settings.

Community-level correlates of physical violence against unmarried female adolescents in Bangladesh

BACKGROUND

While the majority of research in Bangladesh has focused on intimate partner violence (IPV) against women, less is known about the correlates of physical violence against unmarried female adolescents, particularly community-level characteristics that may increase their risk of experiencing violence.

METHODS

We used multilevel logistic regression analysis to assess the variability in physical violence against unmarried female adolescents at the community level and to explore the role of community-level characteristics in explaining this variability. The data for this analysis were taken from a 2005 nationally representative survey of 20,000 adolescents aged 10 to 24 living in Bangladesh. Data from 4,370 unmarried female adolescents were included in the final model.

RESULTS

Communities in Bangladesh have, on average, high levels of physical violence against unmarried female adolescents, and these levels vary widely across communities. Community-level acceptance of physical punishment against adolescents was related to unmarried female adolescents' risk of experiencing physical violence.

CONCLUSIONS

It is important to find and target communities in which unmarried adolescent girls are at higher risk of experiencing physical violence. Programs and policies must focus specifically on changing attitudes regarding treatment of women and girls. As these attitudes accepting of physical violence are found in adolescents aged 10 to 19, school and community-based programs should particularly target this age group.

Measuring attitudes about intimate partner violence against women: the ATT-IPV scale

In lower-income settings, women more often than men justify intimate partner violence (IPV). Yet, the role of measurement invariance across gender is unstudied. We developed the ATT-IPV scale to measure attitudes about physical violence against wives in 1,055 married men and women ages 18-50 in My Hao district, Vietnam. Across 10 items about transgressions of the wife, women more often than men agreed that a man had good reason to hit his wife (3 % to 92 %; 0 % to 67 %). In random split-half samples, one-factor exploratory factor analysis (EFA) (N 1 = 527) and confirmatory factor analysis (CFA) (N 2 = 528) models for nine items with sufficient variability had significant loadings (0.575-0.883; 0.502-0.897) and good fit (RMSEA = 0.068, 0.048; CFI = 0.951, 0.978, TLI = 0.935, 0.970). Three items had significant uniform differential item functioning (DIF) by gender, and adjustment for DIF revealed that measurement noninvariance was partially masking men's lower propensity than women to justify IPV. A CFA model for the six items without DIF had excellent fit (RMSEA = 0.019, CFI = 0.994, TLI = 0.991) and an attitudinal gender gap similar to the DIF-adjusted nine-item model, suggesting that the six-item scale reliably measures attitudes about IPV across gender. Researchers should validate the scale in urban Vietnam and elsewhere and decompose DIF-adjusted gender attitudinal gaps.

Measuring attitudes about women's recourse after exposure to intimate partner violence: the ATT-RECOURSE scale

Attitudes about intimate partner violence (IPV) against women are widely surveyed, but attitudes about women's recourse after exposure to IPV are understudied, despite their importance for intervention. Designed through qualitative research and administered in a probability sample of 1,054 married men and women 18 to 50 years in My Hao District, Vietnam, the ATT-RECOURSE scale measures men's and women's attitudes about a wife's recourse after exposure to physical IPV. Data were initially collected for nine items. Exploratory factor analysis (EFA) with one random split-half sample (N 1 = 526) revealed a one-factor model with significant loadings (0.316-0.686) for six items capturing a wife's silence, informal recourse, and formal recourse. A confirmatory factor analysis (CFA) with the other random split-half sample (N 2 = 528) showed adequate fit for the six-item model and significant factor loadings of similar magnitude to the EFA results (0.412-0.669). For the six items retained, men consistently favored recourse more often than did women (52.4%-66.0% of men vs. 41.9%-55.2% of women). Tests for uniform differential item functioning (DIF) by gender revealed one item with significant uniform DIF, and adjusting for this revealed an even larger gap in men's and women's attitudes, with men favoring recourse, on average, more than women. The six-item ATT-RECOURSE scale is reliable across independent samples and exhibits little uniform DIF by gender, supporting its use in surveys of men and women. Further methodological research is discussed. Research is needed in Vietnam about why women report less favorable attitudes than men regarding women's recourse after physical IPV.

Violence in childhood, attitudes about partner violence, and partner violence perpetration among men in Vietnam

PURPOSE

We assess the association of men's exposure to violence in childhood-witnessing physical violence against one's mother and being hit or beaten by a parent or adult relative-with their attitudes about intimate partner violence (IPV) against women. We explore whether men's perpetration of IPV mediates this relationship and whether men's attitudes about IPV mediate any relationship of exposure to violence in childhood with perpetration of IPV.

METHODS

Five hundred twenty-two married men 18-51 years in Vietnam were interviewed. Multivariate regressions for ordinal and binary responses were estimated to assess these relationships.

RESULTS

Compared with men experiencing neither form of violence in childhood, men experiencing either or both had higher adjusted odds of reporting more reasons to hit a wife (aOR, 1.43; 95% CI, 1.03-2.00 and aOR, 1.66; 95% CI, 1.05-2.64, respectively). Men's lifetime perpetration of IPV accounted fully for these associations. Compared with men experiencing neither form of violence in childhood, men experiencing either or both had higher adjusted odds of ever perpetrating IPV (aOR, 3.28; 95% CI, 2.15-4.99 and aOR, 4.56; 95% CI, 2.90-7.17, respectively). Attitudes about IPV modestly attenuated these associations.

CONCLUSIONS

Addressing violence in childhood is needed to change men's risk of perpetrating IPV and greater subsequent justification of it.