In July 2024, health authorities, both the provincial government and the federal government declared the entire Madhesh province fully immunised. But in less than 18 months, a measles outbreak occurred in Malangwa Municipality, Sarlahi District.

The outbreak was the first in more than two years, laying bare a vaccination gap and exposing the government’s shallow preparation to eliminate the deadly disease by 2026.

“Declaration of fully immunised local units and districts was based on the past year’s data on immunisation,” said Dr Abhiyan Gautam, chief of the Immunisation Section at the Family Welfare Division, under the Department of Health Services. “However, surveillance after the outbreak in Sarlahi shows that the outbreak resulted from gaps accumulated over the past 24 years.”

At least seven children tested positive for the measles virus in the first week of January, 16 others showed measles-like symptoms, which health officials called epi-confirmed (epidemiologically confirmed) cases of measles.

When health authorities declared the entire province fully immunised, child health experts had warned that the premature celebration could raise a sense of complacency in the public, which would ultimately backfire. They also questioned claims that all eligible children in Madhesh province had received routine vaccines.

Health officials at the time had claimed that all children under 15 months residing in the province had been administered all vaccines of the routine immunisation programme before declaring the province fully immunised.

Gautam admits that immunisation coverage in certain pockets of poor and marginalised communities was too low, and many children had missed vaccines during Covid lockdowns.

“The outbreak is the result of a longstanding gap in immunisation,” said Gautam. “We have intensified surveillance measures and have also planned to administer measles vaccines to all children under 15 years of age in the affected local units after the March 5 elections.”

Officials at the Health Ministry said that they have requested the Measles and Rubella Partnership, a global alliance of major international organisations working to eliminate measles and rubella, to provide vaccines for all vulnerable children in Malangawa Municipality.

Child health experts say that declarations of full immunisation and their celebration were the only focus of the relevant agencies, which did little to sustain achievements.

“Due to the continuous gap of unvaccinated children, a pool was created, and the outbreak occurred,” said Dr Shyam Raj Upreti, former director general at the Department of Health Services, who is also a child health and immunisation expert. “Outbreak could have been prevented had we intensively searched pockets where vaccine coverage is too low.”

Measles is a highly contagious viral disease transmitted through respiratory droplets from the nose, mouth, or throat of an infected person. It can be potentially deadly for unvaccinated people.

The disease can be prevented with a two-dose vaccine, administered to babies at 9 months and 15 months. The government provides measles vaccines free of charge from health facilities across the country.

Child health experts say a low vaccination coverage, floating population, lack of public awareness of the importance of vaccines and apathy of government agencies for plugging the loopholes are some reasons behind the regular outbreaks of measles in various parts of the country.

Health workers claimed that a recent measles outbreak in neighbouring India, which borders Nepal, triggered the outbreak in Nepal.

Nepal had aimed to eliminate measles by 2026, as there had been no outbreak since June 2023. However, the outbreak of the contagious virus in Malangwa hindered the country’s progress towards meeting the goal.

The country earlier missed the 2023 and 2019 deadlines. A massive measles outbreak occurred in 2022 and 2023.

To declare measles eliminated, the number of cases should be fewer than five per 1,000,000 people per year. The country must verify progress through foreign, independent verification. For independent verification, there should be no new outbreak for three consecutive years, officials say.

Doctors say people of all age groups are vulnerable to the deadly disease. Underage children, pregnant women, elderly people and those with weak immunity, such as HIV-infected people, are highly susceptible to measles.

Early symptoms, which usually appear 10-12 days after infection, include high fever, runny nose, bloodshot eyes and white, tiny spots inside the mouth. Several days later, rashes develop on the face, upper neck and other parts of the body.

Some people may suffer from severe complications, such as pneumonia and encephalitis, and these diseases may also lead to death.

Measles was endemic in Nepal, and an average of 90,000 cases were recorded every year from 1994 to 2004. Routine measles vaccination began in the country in 1979, starting with three districts. The campaign was made nationwide after 10 years.