title: Factors precipitating outbreaks of measles in district Kangra of North India: A case-control study.
abstract: BACKGROUND
  Globally, measles is the fifth killer disease among children under five years of age. Despite high immunization coverage in Himachal, outbreaks are occurring. Upon two outbreaks in a hilly district in North India, a case control study was conducted to identify factors contributing to outbreaks and to recommend remedial measures to prevent further outbreaks.
  
  
  METHODS
  FACTORS WERE REVIEWED UNDER THREE HEADS: program related, health care providers, and beneficiaries related. Cold chain maintenance was determined and responses were compared between workers from study Shahpur and control Nagrota Bagwan blocks. All 69 mothers of age and sex matched children with measles were enrolled. A pre-designed pre-tested data collection instrument was used. For statistical analysis, the odds ratio (OR) and adjusted odds ratio with 95% confidence interval (C.I.) among women of children exposed and unexposed to selected characteristics were calculated.
  
  
  RESULTS
  Poor cold chain maintenance and gaps in knowledge of health workers supplemented with beneficiary-related issues precipitated outbreaks in case area. Univariate analysis yielded strong statistical significance to 17 variables. Important statistically significant variables are educational status; OR 27.63 (C.I. 9.46-85.16); occupation; OR 0.35 (C.I. 0.16-0.75); income; OR 5.49 (C.I. 2.36-13.00); mode of transport to health care facility; OR 8.74 (C.I. 2.90-28.23); spread of illness from one person to another; OR 5.60 (95% C.I. 1.40-25.97); first help for sick child OR 2.12 (C.I. 1.00-4.50), and place of visit after recovery; OR 3.92 (C.I. 1.80-8.63). Multiple logistic regression yielded significant association with educational status, drinking water sources, and time taken to reach the nearest health facility.
  
  
  CONCLUSIONS
  Measles outbreaks were confirmed in high immunization coverage areas. We recommend 2nd dose opportunity for measles (MR) between 5 and 17 years; refresher trainings to workers; mobile access to health care facility, and Information Education Communication activities for social behavioral change in affected areas.
authors.affiliation: MAE-FETP Graduate from National Institute of Epidemiology (NIE), Chennai; presently at Regional Health and Family Welfare Training Centre, Chheb, Kangra, Himachal Pradesh, India.
authors.forename: Surender Nikhil
authors.initials: SN
authors.lastname: Gupta
authors.forename: Ramachandran
authors.initials: R
authors.lastname: Vidya
authors.forename: Naveen
authors.initials: N
authors.lastname: Gupta
authors.forename: Mohan D
authors.initials: MD
authors.lastname: Gupte
keywords: Beliefs and barriers; immunization; measles; outbreaks