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 Table of Contents  
Year : 2022  |  Volume : 66  |  Issue : 3  |  Page : 251-256  

Measles surveillance in Kashmir: A mixed methods study

1 Senior Resident, Department of Community Medicine, GMC, Srinagar, India
2 Professor Department of Paediatrics, GMC, Srinagar, Jammu and Kashmir, India
3 Assistant Professor, Department of Community Medicine, GMC, Srinagar, India
4 Professor & Head, Department of Community Medicine, GMC, Srinagar, India

Date of Submission05-Jul-2021
Date of Decision07-May-2022
Date of Acceptance25-May-2022
Date of Web Publication22-Sep-2022

Correspondence Address:
Khalid Bashir
Botakadal Lalbazaar, Srinagar - 190 023, Jammu and Kashmir
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijph.ijph_1482_21

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Background: Measles surveillance serves as the means of monitoring program success. The quintessential purpose of measles surveillance is to identify gaps and garner effective public health responses to achieve measles elimination. Objectives: There were two key objectives: (i) to conduct an in-depth review of the existing measles surveillance system in Kashmir and highlight its strengths and weaknesses and (ii) to assess the pattern of measles-containing vaccine (MCV1) coverage and MCV2 coverage among under-5 years children and describe the health-seeking patterns of suspected cases of measles. Methods: The mixed methods study was conducted in the Kashmir valley from March 2018 to March 2019. An explorative qualitative design was followed using individual face-to-face interviews with thirty-two (n = 32) different stakeholders from the state, district, medical block, and primary health center (PHC) levels. To complement the qualitative study, a quantitative survey was done in two districts, Srinagar and Ganderbal, which consist of 5 and 4 medical blocks, respectively. Results: Among the suspected cases of measles, 52% had visited PHCs. Sixty-four suspected cases of measles (64) were immunized with two doses of MCV. None of the clinically suspected cases of measles were further investigated. In the qualitative analysis, five themes were generated viz, “measles surveillance description of Kashmir valley;” “factors affecting measles surveillance, perceptions, and experiences of stakeholders;” “barriers to measles surveillance;” “measles surveillance activities need to be intensified;” and “respondent recommendations for building an effective and sensitive measles surveillance system.” Conclusion: The current measles surveillance system in Kashmir was not effectively functioning; case-based measles surveillance is not being done as per the WHO guidelines. There is a lack of planning, advocacy, awareness, and communication of measles surveillance among the stakeholders. The visible barriers in measles surveillance included lack of training, logistics, incentives, and monitoring by internal and external agencies.

Keywords: Immunization, measles, surveillance

How to cite this article:
Bashir K, Wani KA, Qurieshi MA, Khan S M, Haq I. Measles surveillance in Kashmir: A mixed methods study. Indian J Public Health 2022;66:251-6

How to cite this URL:
Bashir K, Wani KA, Qurieshi MA, Khan S M, Haq I. Measles surveillance in Kashmir: A mixed methods study. Indian J Public Health [serial online] 2022 [cited 2023 Mar 26];66:251-6. Available from:

   Introduction Top

Measles is a widespread viral disease, having encumbered in some manner all countries around the world. Cases of measles are at their highest during dry conditions in the tropics and during late winter and early spring in regions having clement weather conditions, although cases can occur throughout the year.[1],[2] No antiviral treatment exists for measles. In 2013, around 0.14 million deaths were caused due to measles globally (nearly 16 deaths each hour), which necessitates efforts needed for measles elimination.[3],[4] The study findings have indicated that more than 50% of the global measles-associated deaths were reported in India alone.[5] Furthermore, the higher case fatality ratio was reported among under-5 children and children from the backward class.[6] Measles can be prevented through vaccination; the WHO's expanded program on immunization since 1981 approved a single dose of measles vaccine at the age of 9 months in countries where measles is preponderant in infants.[7] Nine months was chosen as an accommodating age between guaranteeing vaccine effectiveness and preventing early measles cases.[8] Vaccinating earlier than 9 months resulted in decreased vaccine efficacy owing to interference from the passively acquired maternal antibody. It was seen vaccinating later than 9 months was associated with good vaccine efficacy, but resulted in many measles cases among children before they reached the age of measles immunization. An interpretive appraisal of the current policies and their discharge in the field suggests that poor coverage of measles or high case fatality rates can be attributed to various existing shortcomings or barriers. These barriers include sociodemographic parameters, challenges faced by hard-to-reach areas; insufficient infrastructure, manpower, and communication; cold chains maintenance; faulty surveillance activities for measles outbreak reporting; and adverse events following immunization (AEFI) reporting.[9] Because some of the states and union territories had poor measles coverage, they required a catch-up immunization campaign, in contrast to the states with better coverage where there was a need to strengthen only routine immunization services.[10] In addition, in most regions of the country, the virologic surveillance data are often insufficient (B3, D4, D7 are noticeable strains in India).[11],[12] Measles surveillance serves as the means of monitoring progress towards elimination. There is a paucity of studies regarding measles surveillance in India and no such studies have been done in the Kashmir valley. The objective of this study was to conduct an in-depth review of the existing measles surveillance system in Kashmir and highlight its strengths and weaknesses.

   Materials and Methods Top

Study design

The mixed methods study was conducted in the Kashmir valley from March 2018 to March 2019. Kashmir Valley consists of ten districts, and many medical blocks (range 2-10) constitute a district. The qualitative study design was adopted for the key stakeholder in-depth interviews. Individual face-to-face interviews were conducted with the different stakeholders from the State, District, Medical block, and Primary health center (PHC) levels. [Table 1]. All the stakeholders (doctors) were selected purposively for the interview by adhering to the purposive sampling method. Pertinently, stakeholders included in the study had an essential role in measles surveillance in different capacities. A total of thirty-two (n = 32) stakeholders (doctors) were interviewed and data saturation was achieved. Moreover, among the interviewees, seven interviewees (doctors) were involved in private practice, out of which two (doctors) were pediatricians and five (doctors) were general practitioners. Moreover, block medical officer (BMO) was taken from one medical block nearer to the district headquarters and medical officer (MO) was selected from another far-off medical block of the district for better representation.
Table 1: Details of stakeholders

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Quantitative study settings

To complement the qualitative study and to enhance the validity and study rigor, triangulation of the qualitative study method was done by doing a quantitative survey in two districts, Srinagar and Ganderbal. Furthermore, quantitative survey had underpinnings for facilitation of a better understanding of the determinants and reasons embedded in the data abstracts of the respondent interviews. The two districts (Srinagar and Ganderbal) were chosen as per feasibility; also, they are reflective and representative of the predominantly urban and rural population, as the district Srinagar being capital of Kashmir Valley is having predominantly urban population of 98.60%, district Ganderbal having predominantly rural population of 84.19% as per 2011 census. The districts Srinagar and Ganderbal consist of five and four medical blocks, respectively. From each medical block of these districts, one subcenter area was chosen for study, twenty percent of the population of the subcenter area was surveyed for children under 5 years of age for measles surveillance, and information was gathered on the preformed questionnaire, which contained questions related to measles surveillance and vaccination of measles-containing vaccine (MCV). The questionnaire contained questions as per the case definition of a suspected case of measles, and only those children who had suffered the suspected measles as per case definition in the last year or during the survey period were labeled as suspected cases of measles. Only those households were considered for survey who had children under 5 years of age for the surveillance, and in case of nonavailability of children of this age group, next household was taken for the survey. The data were entered into a Microsoft Excel spreadsheet and descriptive analysis was done.

Data collection

In-depth interviews were conducted with stakeholders at all levels. Interviews were arranged by fixing prior appointments with the participant. An interview guide focusing on the specific areas of interest was developed beforehand to facilitate the interviews and was used to ensure participants' opinions were investigated fully during the interview, each interview started with some “background mapping questions,” interviews provided an opportunity to probe and gain deeper insights on the major issues of the topic being studied. In this study, in-depth interviews were held with 32 important stakeholders, interviews were audio-recorded after written informed consent was obtained from the respondents. The maximum duration of one interview was recorded 2 h, while a minimum of 45 min.


The thematic qualitative analysis approach was used; all interview recordings were transcribed verbatim; and the process of transcribing, reading, and rereading transcripts was continued till emerging key ideas, concepts, and themes were identified and made into a list. Voice recordings having Urdu or Kashmiri content were translated and transcribed verbatim into English. Transcripts were assigned in word files, and data analysis was started as a process of carefully scrutinizing data by placing it into inductively created code structures, categories, subthemes, and themes. The process of theme identification involved many stages: [13] (1) acquaintance with the data, (2) coding, (3) discerning themes, (4) analyzing themes, (5) delineating and naming themes, (6) write up.

   Results Top

Qualitative results: Five themes were generated and each of these themes included many subthemes as shown in [Table 2].
Table 2: Themes and subthemes generated from the qualitative data analysis

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Theme 1: Measles surveillance description of Kashmir valley

Nearly all the respondents described that the current measles surveillance system was not effectively functioning due to lack of advocacy of measles surveillance, lack of planning, and alignment between the stakeholders; case-based measles surveillance is not being done as per WHO guidelines. Ninenty-five 95% of respondent statements were amply clear in agreement and concurrence for building the scaffolding of this theme. Moreover, pivotal respondent statements elaborated the poignant abysmal picture of the current measles surveillance system.

“……measles surveillance is not satisfactory at the state level. We had 5 serologically confirmed outbreaks from the Jammu division (23 cases), we are not doing lab-based investigations since then. We don't send samples of suspected cases of measles to the designated laboratory.”(State level respondent).

“…….No one is after it; I mean we don't get any communication from our higher-ups for measles surveillance.”(PHC level respondent).

“…….unlike acute flaccid paralysis (AFP) Surveillance, we are not having planning in measles surveillance. As people think Integrated disease surveillance project (IDSP) is doing it, you know logistics for surveillance are with (National polio surveillance programme [NPSP]) office, they are not being utilized. At grassroots level health professionals are not in synergy, they think epidemiologist has a role in Surveillance, outbreak information is shared by chief medical officer to IDSP, district immunisation officer (DIO) doesn't get involved directly….”(State level respondent).

Theme 2: Factors affecting measles Surveillance, perceptions, and experiences of stakeholders

Nearly all respondents identified that lack of measles surveillance awareness, poor coordination, and lackadaisical measles surveillance system is responsible for the nonreporting of measles cases.

“……. I haven't heard of it (Measles surveillance). In the Yousmarg belt lot of cases came from the last 1-month, from areas Daariwan, Kanidajan. I saw 7 cases (suspected cases of measles) in the last 1-month, with cough coryza, maculopapular rash, and fever, they were typical measles cases, but I gave treatment to them, no reporting was done.….”(Pediatrician and primary health care level respondent).

“……. measles outbreak was flagged by (IDSP) in Pulwama and I had no information till it was over. They (IDSP) have a local lab. For (Ig M measles only), no testing for rubella, no genotyping, they didn't inform us (Department of health & family welfare).”(State level respondent).

Theme 3: Barriers to measles surveillance

The interviewees (84%) revealed various impediments in measles surveillance as lack of awareness, lack of monitoring from internal and external agencies, false beliefs, lack of logistics at district, block, and PHC level, no incentives, lack of training in measles surveillance, and case-based laboratory investigation.

“……. although we treat clinically suspected measles cases but don't report them as they may make us liable for the measles cases and subsequent outbreak. Also, many cases don't come to us, they go to faith healers, give Kahwa (local tea) to them, put in warm apparels, etc.” (Primary health care level respondent).

“……. I have not done reporting of suspected cases of measles till now; actually, we aren't aware of measles surveillance.” (Primary health care level respondent).

“……. In measles surveillance, we don't have any logistics, absolutely nothing, neither incentive, like in AFP Surveillance.” (District Level respondent).

“…….MOs don't have an idea of surveillance, they don't know guidelines, they feel their job is treatment part not reporting suspected cases of measles.” (District Level respondent).

“…………Internal and external agencies don't move to the field, they don't monitor at the grassroots level. I haven't seen any monitoring agency in my tenure as BMO for 9 years. Overall measles surveillance is confined to meetings only...” (Block level respondent).

Theme 4: Measles surveillance activities need to be intensified

To strengthen the surveillance activity respondents revealed the need for coordination between different arms of the health system is important, supervisory and logistic support from WHO (NPSP) is needed for active surveillance, strengthening of inextricable linkage of measles elimination with immunization, initiatives for collecting and analyzing surveillance data, and supporting integrated disease surveillance activities.

“.……We do it (measles surveillance) through IDSP, not through the Directorate of health and family welfare (DHFW) or WHO (NPSP). We are not involved in supervision or outbreak investigation, and there is no role from our side. We (DHFW) should be involved, IDSP is doing it through C. M. O (Chief MO)……….” (State level respondent).

“…………. We get information on vaccine preventable diseases (VPD) forms regarding AFP, measles, and AEFI from the field. Once these suspected cases of measles are getting reflected, BMO or DIO has to review these cases and reflect on the h002 form d002 form, then transmit the same information and forward it to us. As per guidelines when more than 5 cases are reported in a month, then the second step is preliminary cases search, detailed outbreak investigation is to be taken and samples from J&K should go to Chandigarh, which is not happening”.(State level respondent).

“…………Although routine immunization is going on well, I think measles supplementary immunization activities (SIAs) have a role besides routine immunization, this will strengthen herd immunity, some concerns remain regarding immunization, we need to address them, and we need to strengthen RI.”(State level respondent).

Theme 5: Respondent recommendations for building an effective and sensitive measles surveillance system

The data analysis of (64%) of respondents' echoed the need for enhancement of management, planning, political will for achieving effective case-based measles surveillance. There's a need for improved coordination and information sharing between different arms of the health system to build an organized measles surveillance system:

“………. Push has to be from the state level, they have to take charge with seriousness and political will is important, will in the system is important for measles surveillance. We need to build an organizational structure for measles surveillance. I do talk to the Director health & family welfare people and IDSP, we share problems with them, try to get a solution, we hope it comes into shape soon.”(External agency respondent).

“……Certain districts reflect cases in WHO surveillance formats. IDSP is very active in Kashmir, they get information on P-form, and the weekly report comes from institutions, but they don't share it with us DHFW. (State level respondent).

“... Measles surveillance is not visible here, it's not going on, we need to build it brick by brick, and we have to get the alignment of all arms of the health system. We need to sit together, evolve a joint mechanism for surveillance. We need laboratory-based measles surveillance; there is a need for regulation of measles surveillance from a higher level....”(State level respondent).

Quantitative results

A total of thirteen hundred and four (n=1304) families having children under 5 years of age were surveyed in a quantitative survey in two districts (Srinagar and Ganderbal). 689 (52.8%) families had two children in a family, 590 (45.2%) families had one child in a family, and 25 (1.9%) families had 3 children in a family. In the survey, 96 children were detected having suffered from suspected measles as per case definition in the last year or during the survey period and were labeled as suspected cases of measles. Of the suspected cases of measles who had visited PHC to seek health care were 50 (52%), followed by 16 (17.20%) had visited private practitioners [Table 3]. The maximum number of suspected cases of measles, 64 (68.8%), were immunized with two doses of MCV as per age, 25 (26%) had received one dose of MCV as per age, 7 (7.2%) did not remember the number of doses of MCV. None of the suspected cases of measles was investigated for measles. None out of the 96 cases had blood samples or throat swabs sent for measles investigation. In the survey, 1154 (88.5%) families reported that their under-5 children had received two doses of MCV as per age, 44 (3.3% families) reported their children had received one dose of MCV as per age immunization requirement, only 4 (0.3%) families had not immunized their under-5 years' children with MCV as per age immunization requirement.
Table 3: Details of the suspected measles cases survey of children (under 5 years of age)

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   Discussion Top

This was the first in-depth exploration of the measles surveillance system in Kashmir to the best of our knowledge. The study explored that the measles surveillance system was in disarray and off track and blinking in attaining its objectives. There was a lack of coordination between different arms of the health system(Directorate of Health Services, IDSP, Department of Family Welfare and Immunization, and WHO NPSP). The study conspicuously unraveled the lack of planning and advocacy for measles surveillance at different levels. Moreover, there was a lack of communication and information sharing among various stakeholders. The overlap of responsibilities, lack of clarity of roles, and lack of ownership have led to measles surveillance “falling between the cracks.” This study explored the number of barriers to measles surveillance, which showed that the measles surveillance guidelines were not practically known to health professionals. Although six different barriers were found to hamper measles surveillance, lack of awareness of measles surveillance and lack of training among respondents were felt to hamper implementation of the measles surveillance mostly. Furthermore, a clear and explicit understanding of measles surveillance guidelines was lacking due to a lack of knowledge and training. Pertinently, lack of logistics and incentives and lack of reporting by MOs were other barriers hampering measles surveillance. The respondents in our study expressed the need for intensification of activities of measles surveillance, the need for laboratory confirmation of suspected cases of measles, training, and strengthening of the inextricable linkage between achieving measles elimination and immunization system. The intensification factors on measles surveillance suggested by respondents in our study go in line with findings on the reinforcing factors reported in another study, which revealed that Cuba, another developing country, adopted the above measures and has interrupted the transmission of measles since the late 80s, while Haiti, Venezuela, and Colombia achieved similar success by 2002.[14] The respondents suggested the necessity of building an organized surveillance system and strengthening health professionals at the grassroots with improved coordination and information sharing, which can shape a measles control strategy and will help in measles elimination. There is a need for supervision to improve the quality of services and program management. Supportive supervision is a process in which experienced technical staff designated and trained as supervisors assess other staff members' job performance, give feedback, and work cooperatively with the staff to improve weaker performance areas.

The study reported ninety six (n=96) suspected cases of measles from the door-to-door survey and they had sought health care from health professionals at different places. Nevertheless, none of these suspected cases of measles were evaluated for measles and no blood samples or throat swabs were sent for measles investigation. The study findings showed that although the coverage of MCV was excellent in the surveyed areas, laboratory-based case investigation of suspected measles cases was poor. This stresses the need for improved case-based measles surveillance in line with surveillance guidelines. The presence of a sensitive measles surveillance system is important to achieve the goal of measles elimination. The recognition of early warning signals, timely investigation of suspected cases of measles, and application of specific control measures can contain the measles outbreaks as shown by the study conducted by Hashmi et al.[15] They conducted door to door search of six measles-affected villages in Dwarahat block of district Almora, covering a population of 2408 to identify the cases of measles. A total of ten blood samples were randomly collected for detecting immunoglobulin M (IgM) antibodies against measles. For all cases, information on personal details, place of residence, time of onset, and status of immunization were obtained. Statistically significant higher attack rate (AR),16.26%, was seen for the age group of 0–5 years. Of the 10 samples, nine were positive for measles IgM antibodies by enzyme-linked immunosorbent assay in the study. This shows that recognition of early warning signals, timely investigation, and application of specific control measures are elementally critical and essential in containing the emergence of an outbreak. The unvaccinated or partially protected human beings serve as the reservoir of the measles virus. To have good herd immunity, there is a need for improved and effective immunization coverage along with SIAs.

There is a palpable need for surveillance advocacy, logistics, communication/training on measles surveillance, better utilization of human and financial resources, and stewardship to invigorate the surveillance system. Planning will enable the efficient use of resources, viz, human, financial, and material. The commitment and involvement from the top to bottom in the hierarchy can bring focus on measles surveillance. The respondents in our study reflected insufficient training and the attitude of health professionals responsible for non-reporting cases apart from other highlighted gaps in measles surveillance; poor coordination and inadequate information sharing are affecting measles surveillance. Clarity of roles, coordination and information sharing between different arms of the health system needs to be ensured. The systems fail when they work in isolation, no matter how well individually they fair and work. Therefore, augmentation of coordination between the Directorate of Health Services Department, IDSP, and Department of Family Welfare and Immunization will be fundamentally essential to streamline the surveillance process in Kashmir. Pertinently, coordination is pivotal to the successful elimination of measles.

   Conclusion Top

The current measles surveillance system in Kashmir was not effectively functioning; case-based measles surveillance is not being done as per the WHO guidelines. The visible barriers in measles surveillance included lack of training, logistics, incentives, and monitoring by internal and external agencies. Planning, advocacy, awareness, and communication of measles surveillance among the stakeholders need considerable strengthening.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

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