Measles surveillance in Kashmir: A mixed methods study

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.