The main objectives of our article were to describe the strategies adopted by Govt. of India to introduce a second dose of measles vaccine in the country and the rationale behind those strategies [1]. The correspondent here has not questioned the basic rationale behind the introduction of second dose of measles vaccine per se, but has raised an issue of choice between measles vaccine and combined mumps-measles-rubella (MMR) vaccine and has recommended that MMR vaccine be used straightaway in childhood immunization in the National Immunization program in India.

For private sector clinicians and their clients, the choice of which vaccine to provide is often governed by the clinician’s judgment of the expected benefit-risk ratio of the vaccine and the client’s ability to pay for the goods and services offered. The key context is benefit to the individual client and not the community at large. Conversely, selecting a vaccine for a national immunization program in which the Government bears the burden of entire costs and has to consider individual as well as community benefit, is quite different. Public health policy making is often choosing one practically feasible option among many which are ideally possible.

The Universal Immunization Program (UIP) in India is one of the largest immunization programs in the world and targets an annual cohort of approximately 26 million children. Choosing MMR over single antigen measles vaccine (MV) in the national immunization program would have definite cost implications as MMR is considerably more expensive than single antigen MV.

In 2008, the National Technical Advisory Group on Immunization (NTAGI), Govt. of India had deliberated on this issue and recommended that the available data did not justify including the mumps component with measles vaccine as the benefits would not be commensurate with the additional costs incurred [2]. In 2009 and 2010, successive NTAGI sessions once again determined that available epidemiologic evidence did not warrant the additional cost of mumps antigen with the second dose of measles containing vaccine (MCV).

Measles continues to cause significant morbidity and mortality in young children where vaccination coverage remains low. Rubella and mumps infection do cause significant complications in adolescent and older age groups but once again, the actual burden is not well documented. Introducing mumps and rubella vaccines into childhood vaccination programmes that do not achieve high coverage (≥80%) increases the median age at infection and has the potential risk of paradoxically increasing the public health consequences of the very diseases that vaccination is attempting to control. WHO position papers on both mumps and rubella vaccines have stated the risks of such "paradoxical effects" in quite unambiguous terms [3,4]. The evidence for the danger of paradoxical increase of Congenital Rubella Syndrome (CRS) owing to private sector usage of rubella vaccine achieving low coverage overall, comes from observational and modeling studies [3,4].

These are well known facts regarding mumps and rubella vaccine introduction in children. In fact, in its April 2011 meeting, the Strategic Advisory Group of Experts (SAGE) has cautioned against the possibility of paradoxical increase of CRS owing to widespread use of rubella containing vaccines by private sector service that ultimately achieves low overall coverage (<80%) [5].

The question posed in the end is actually a non-starter from the perspective of the national immunization programme. At present, Govt. of India policy is to give the first dose of measles vaccine between 9 and 12 months to all children in the country. The second dose of measles vaccine will be given through routine immunization between 16 and 24 months of age in 21 states and through mass vaccination campaigns for 9 months to 10 year old children in 14 states. Thus, in any particular state, a child will get the second dose of measles vaccine through either routine immunization or mass campaigns, not both.

1. Gupta SK, Sosler S, Haldar P, Hombergh HVN, Bose AS. Introduction strategy of a second dose measles containing vaccine in India. Indian Pediatr. 2011;48:379-82.

2. Minutes and Recommendations of National Technical Advisory Group on Immunization (NTAGI), 16th June 2008, Ministry of Health and Family Welfare, Government of India. Available at http://mohfw.nic.in/WriteReadData/l892s/6664716297file23.pdf. Accessed on June 13, 2011

3. Mumps virus vaccines. WHO position paper. Weekly Epidemiological Record. 2007; 82:51-60.

4. Rubella vaccines. WHO position paper. Weekly Epidemiological Record. 2000;75:161-9.

5. Panagiotopoulos T, Antoniadou I, Valassi­Adam E. Increase in congenital rubella occurrence after immunisation in Greece: retrospective survey and systematic review. BMJ. 1999;319:1462-7.