Globally, measles cases and deaths have been increasing in recent years, with over 6.9 million cases and 130,000 deaths reported in 2021 alone. Pakistan has experienced measles outbreaks as well, reporting over 3270 cases in the last 12 months, the 5th highest in the world. Complications from measles such as pneumonia and encephalitis are common, especially in children under 5, and cause significant illness and death. While vaccine coverage in Pakistan has improved over time, it remains below the 95% threshold needed to prevent outbreaks. A large nationwide vaccination campaign was launched in 2021 to try to control ongoing measles outbreaks exacerbated by the COVID-19 pandemic, though coverage varies significantly between provinces

1. Saddam Ali Khan and Amir Nazir
Prevalence of measles in Pakistan
and across the globe

2. What is the global impact of measles?
According to CDC (DHHS) USA :
 Worldwide, 36 cases of measles per 1 million persons are reported each year; about 134,200
die.
 Globally, in 2021, there were 6.9 million measles cases and 130,000 measles-related deaths.
 For every 1,000 children who get measles, one or two will die from it.
According to WHO and UNICEF:
 Almost 17 338 measles cases were reported worldwide in January and February 2022,
compared to 9665 during the first two months of 2021.
 As of April 2022, the agencies report 21 large and disruptive measles outbreaks around the
world in the last 12 months. Most of the measles cases were reported in Africa and the East
Mediterranean region.
 Countries with the largest measles outbreaks since the past year include Somalia, Yemen,
Nigeria, Afghanistan and Ethiopia. Insufficient measles vaccine coverage is the major reason
for outbreaks

3. Top 5 countries with reported measles cases in
the last 12 months, until April 2022 (WHO)
Country
Reported
Measles cases
Rate per
million cases
First dose
measles
coverage (%),
2019
First dose
measles
coverage (%),
2020
India 11055 554 46 46
Yemen 7914 119 67 68
Somalia 7397 91 64 66
Zimbabwe 4861 58 54 54
Pakistan 3270 26 60 58

4. Other complications because of
measles
According to CDC USA :
• About 30-40% of patients with measles develop one or more complications.
• One out of 20 children develops pneumonia which causes 56-86% of measles-related deaths.
• About one child out of every 1,000 who get measles will develop encephalitis (swelling of the
brain) that can lead to convulsions and can leave the child deaf or with an intellectual
disability.
• One in 12 children with measles develops diarrhea. Measles-associated diarrhea can result
from the measles virus itself or secondary bacterial and viral infection may add to the severity
and duration of the illness.
• Measles can cause or worsen malnutrition due to mouth ulcers, anorexia, and diarrhea, which
further worsens complications, risk of secondary infections, and mortality.
• Measles damages almost all body organs due to damage to mucous membranes and transient
and profound immunosuppression.
• Complications are high in children aged <5 years.

5. Prevalence in Pakistan
According to WHO:
o 3270 cases reported in Pakistan. Ranked 5th in the world.
o 1/3 deaths /1000.
o 12/1000 develop diarrhea
o 20/1000 develop pneumonia.
o Encephalitis in 10-15% and severe neurological damage 25%.
According to (Brekhna et al ., 2017) study was conducted at PIMS Islamabad:
o Of the 307 children admitted with complications of measles, 79(26%) were aged <9
months and were excluded as they were not old enough to receive the measles
vaccine.
o Of the remaining 228(74%) subjects, 138(60.5%) were males and 90(39.5) were
females.
o Overall, 109(47.8) subjects were non-vaccinated and 39(17%) children died within
15 days of admission.

6. Timeline in Pakistan
According to Muuhammad Musa Meer et al.,2020
o Overall, measles incidence averaged 24.6 cases per million population during 2000–2006.
o After implementing nationwide catch-up measles SIAs during 2007–2008, the number of
confirmed measles cases decreased from 7,641 in 2006 to 863 in 2009.
o Following extensive flooding and large-scale population movements in 2010, the number of
measles cases increased approximately eightfold, from 4,321 in 2010 to 40,923 in 2013,
corresponding to an incidence of 230.3 per million.
o In 2013–2014, the number of confirmed cases declined to 4,112 in 2015 but increased to
33,007 in 2018 (incidence = 153.6 per million); most of these cases occurred in October 2018.
o During 2017 and 2018, the rates of suspected cases discarded after investigation were 2.1 and
1.5 per 100,000 population, respectively.
o Survey reported more than 4902 cases of measles nationwide during 2019 and 1980 cases in
2020.
o 17,000 suspected measles and rubella cases were reported in Pakistan in 2021, this marks a
sharp increase in reported cases and has resulted in an increase in measles outbreaks; 70
districts in the country reported outbreaks and 51 children have died from complications from
the outbreaks so far. An increase in Congenital rubella syndrome cases was also recorded in
2020 and 2021 – 70% of children affected suffer from congenital heart disease, and 30% from
congenital cataract. One of the reason id Covid 19 pandemic and low vaccination coverage.

7. Vaccine coverage
o Estimated MCV1 coverage increased from 57% to 76% during 2000–2017, and second-dose coverage
increased from 30% to 45% during 2009–2017( second dose was first started in 2009).
o Despite these efforts, MCV coverage remained well below the recommended level of 95%, and measles
incidence increased during 2010–2018.
o Health Survey implemented nationwide during 2017–2018 estimated MCV1 and MCV2 coverage at 73%
and 67%, respectively.
o Geneva, 12 November 2021 ,Dr Faisal Sultan, Special Assistant to the Prime Minister on Health, launched
a nationwide campaign to vaccinate more than 90 million children against the deadly measles and rubella
viruses across Pakistan, in what is bound to become one of the biggest campaigns in the world, despite the
challenges of the COVID-19 pandemic.
According to survey conducted by Muhammad Musa Meer et al ., 2020 ,Among the provinces and federal areas,
survey estimates of MCV1 and MCV2 coverage were :
• highest in Punjab (85% and 82%, respectively),
• Islamabad (83%, 77%),
• Azad Jammu and Kashmir (83%, 75%),
• Gilgit-Baltistan (66%, 62%) ,
• Khyber Pakhtunkhwa (63%, 50%) ,
• Sindh (61%, 60%),
• lowest in the Federally Administered Tribal Areas (35%, 21%) ,
• Baluchistan (33%, 34%) .

8. The
emergence
of measles
during the
COVID-19
pandemic in
Pakistan
2021