Factors Associated with High Prevalence of Multibacillary Leprosy in West Bengal: A Case-Control Study.

BACKGROUND: High proportion of multibacillary (MB) among newly diagnosed leprosy cases poses a public health challenge. OBJECTIVES: This study aimed to find out the factors associated with the high burden of MB leprosy in West Bengal. MATERIALS AND METHODS: This case-control study was conducted from August 2020 to December 2022 in three high-endemic districts (annual new case detection rate ≥10/lakh) of West Bengal. OBJECTIVES: MB cases registered under the National Leprosy Eradication Programme were considered as case and paucibacillary (PB) cases were considered as control. Weighted sample sizes for cases and controls in each of the three districts were selected using simple random sampling from the list of registered leprosy patients. Requisite data were collected through structured interview with a validated questionnaire in Bengali. R, version 4.1.1 (R Foundation for Statistical Computing, 2021, Vienna, Austria) was used for data analysis. A binary logistic regression model was prepared with the type of leprosy as a dependent variable. RESULTS: Three hundred and ninety-eight individuals, 204 MB and 194 PB, participated in this study with 1.97% nonresponse rate. Gender, marital status, and diagnostic delay (adjusted odds ratio = 2.75 [1.66,4.65]) were associated with developing MB. Not perceiving the symptoms seriously (90, 56% [PB], 97, 51% [MB]), lack of knowledge about the disease and its complications (47, 29% [PB], 53, 28% [MB]), delayed referral by the private practitioners (11, 7% [PB], 22, 12% [MB]) were the major reasons of delay. CONCLUSION: This study identified a vulnerable group - married and migrated males. Changing from annual screening to quarterly screening along with capacity building and awareness generation of the targeted population is the need of the hour for eradicating the disease.

The potential unintended consequences of Mental Health Act reforms in England and Wales on people with intellectual disability and/or autism.

The draft Mental Health Bill, which amends the Mental Health Act 1983 for England and Wales, proposes protections for people with intellectual disability and/or autism (ID/A) to prevent detention in hospital in the absence of mental illness. This editorial critically appraises the positive impact and unintended consequences of the proposed reforms for people with ID/A.

Assessment of knowledge about malaria and LLIN ownership and its use in Bankura, West Bengal, India.

BACKGROUND & OBJECTIVES: Community participation is one of the key factors for implementation and success of a public health programme which depends upon knowledge about that disease. Therefore, understanding the community knowledge about malaria is important for designing sustainable control programmes. This study was conducted to assess the knowledge about malaria, to evaluate long lasting insecticidal nets (LLINs) distribution and their use by LQAS method in endemic areas of Bankura district, West Bengal state, India Methods: It was a community based cross-sectional survey conducted in Bankura during December 2019-March 2020. Structured questionnaire under four categories: socio-demographic variables, knowledge of malaria, owner ship of LLINs and its use were used for the interview. Ownership of LLINs and its use were analysed by LQAS method. Data were analysed by binary logistic regression model and chi-squared test. RESULTS: Out of 456 respondents, 88.59% had good knowledge, 97.37% had good ownership of LLIN and 78.95% used LLINs properly. The knowledge about malaria was significantly associated with education level (p-value<0.0001). Out of 24 lots studied, 3, 2, 4 lots were underperforming with respect to knowledge, ownership of LLIN and its use, respectively. INTERPRETATION & CONCLUSION: The study population had a good knowledge about malaria. In spite of good coverage of LLIN distribution, the use of LLINs was not up to the mark. LQAS analysis showed underperformance in few lots about knowledge, ownership of LLIN and its use. The IEC and BCC activities about LLIN should be done to achieve the impact of this intervention at the community level.

Japanese Encephalitis Virus Infection among Wild Caught Vectors Mosquitoes and Domestic Pigs in Northern West Bengal, India.

BACKGROUND: Japanese encephalitis (JE) is an emerging zoonotic disease caused by JE virus (JEV) and transmitted to humans from pigs or aquatic birds by vector mosquitoes in southeast Asian countries. In this study, JEV infection rate among vector mosquitoes and domestic pigs was determined by detecting viral RNA and anti-JEV antibody (immunoglobulin G), respectively. MATERIALS AND METHODS: A total of 146 pool mosquitoes of Culexvishnui subgroup and 278 pig blood samples were analyzed by reverse transcriptase polymerase chain reaction and enzyme-linked immunosorbent assay methods, respectively. E and premembrane (PrM) gene of JEV detected among vectors were sequenced and a phylogenetic tree was constructed. RESULTS: Five (5.81%) pools of Culextritaeniorhynchus were positive for JEV with pooled infection rate 1.70/1000 mosquitoes. A total of 108 (38.84%) blood samples were positive for anti-JEV antibody. Phylogenetic analysis revealed that our own E and PrM gene sequence of JEV belonging to Genotype III and showed 96.95% sequence similarities with the vaccine strain SA14-14-2. CONCLUSION: It was observed that domestic pigs of northern West Bengal were highly infected with JEV. Hence, the transmission should be blocked by pig vaccination. A pilot study may be undertaken for mass vaccination of the prevailing pig population to observe any reduced rate of JEV transmission from both pig to pig and pig to human.

Impact of COVID-19 on mental health research: is this the breaking point?

There are many structural problems facing the UK at present, from a weakened National Health Service to deeply ingrained inequality. These challenges extend through society to clinical practice and have an impact on current mental health research, which was in a perilous state even before the coronavirus pandemic hit. In this editorial, a group of psychiatric researchers who currently sit on the Academic Faculty of the Royal College of Psychiatrists and represent the breadth of research in mental health from across the UK discuss the challenges faced in academic mental health research. They reflect on the need for additional investment in the specialty and ask whether this is a turning point for the future of mental health research.

A formal model concerning policy strategies to build public acceptance of potable water reuse.

Water stress is an increasing burden in regions with arid climates, aquifer vulnerability, and erratic rainfall. Population growth and competing domestic, industrial, and agricultural uses are also stretching the capacity of water supply systems. Beyond groundwater extraction, surface water overuse, and inter-basin transfers, governments are exploring alternative sources amidst looming supply threats. These alternatives include desalination, greywater recycling, and reclaimed or recycled wastewater. The latter, also known as water reuse with varying levels of treatment, has been applied for irrigation, street cleaning, industrial processes, and groundwater recharge. However, reused water for potable purposes has seen limited uptake, due in part to lack of public acceptance. This article examines the dynamics of public acceptance for potable water reuse. The article's theoretical contribution is a formal mathematical model for understanding public acceptance of water reuse. The model conceptualizes how governments, water utilities and the public interact to facilitate or hinder acceptance of water supply sources, including potable reuse. The article concludes by applying the model to cases of water reuse in Windhoek, Namibia, and Singapore.

Clinical outcomes of staff training in positive behaviour support to reduce challenging behaviour in adults with intellectual disability: cluster randomised controlled trial.

BACKGROUND: Staff training in positive behaviour support (PBS) is a widespread treatment approach for challenging behaviour in adults with intellectual disability. Aims To evaluate whether such training is clinically effective in reducing challenging behaviour during routine care (trial registration: NCT01680276). METHOD: We carried out a multicentre, cluster randomised controlled trial involving 23 community intellectual disability services in England, randomly allocated to manual-assisted staff training in PBS (n = 11) or treatment as usual (TAU, n = 12). Data were collected from 246 adult participants. RESULTS: No treatment effects were found for the primary outcome (challenging behaviour over 12 months, adjusted mean difference = -2.14, 95% CI: -8.79, 4.51) or secondary outcomes. CONCLUSIONS: Staff training in PBS, as applied in this study, did not reduce challenging behaviour. Further research should tackle implementation issues and endeavour to identify other interventions that can reduce challenging behaviour. Declaration of interest None.

Taking stocks of antimalarial activities: A study on knowledge and skill of health personnel at primary care setting in the state of West Bengal, India.

BACKGROUND: Early diagnosis and effective treatment are the key areas in malaria control in India. OBJECTIVE: The present study was carried out to assess the knowledge and skill of health personnel at primary care level and the logistic support related to the program at subcenter (SC) level. METHODS: A cross-sectional, descriptive study was conducted among medical and paramedical personnel working at primary health-care institutions in two districts of West Bengal. Knowledge was assessed using a structured questionnaire while diagnostic skill and logistic support were assessed with structured checklists. Clinical skill was assessed with case vignettes. RESULTS: Requisite knowledge on diagnostic procedure was found in two-third to three-fourth of health personnel while only 26.7% and 12.4%, respectively, knew the correct treatment of Plasmodium vivax and Plasmodium falciparum malaria. Median standardized score for knowledge was 50.0 while the scores for skill of preparing blood slide and for rapid diagnostic test were 70.0 and 57.1, respectively. Education and work experience were related to diagnostic skill but had little effect on knowledge. In clinical skill, medical personnel scored 50% or more in investigation and treatment aspects only. In another case vignette, health workers excelled over medical officers and other staff in all axes other than history taking and clinical examination although their performance was also suboptimal. Formal training on malaria did not show any bearing on median knowledge and skill score. Supply of diagnostics and drugs was insufficient in majority of SCs. CONCLUSION: Renewed efforts are needed to create competent workforce and ensure adequate logistic supply.

A study on utilization of Janani Suraksha Yojana and its association with institutional delivery in the state of West Bengal, India.

BACKGROUND: India launched the Janani Suraksha Yojana (JSY) on the principles of conditional cash transfer providing monetary incentive to needy women to improve access to institutional childbirth. OBJECTIVES: This study was conducted among JSY-eligible women who delivered between April 2012 and June 2012 to assess the utilization of cash incentives toward institutional delivery, along with other associated factors influencing institutional delivery. METHODS: It was a cross-sectional, descriptive study conducted between July 2012 and May 2013 on 946 women selected through stratified random sampling of subcentres from better and worse performing districts of West Bengal. RESULTS: 74.7% of the study population was JSY-eligible. 90.2% of those who took three antenatal check-ups (ANCs) and 36.8% JSY-noneligible women received cash. Government institutions were preferred for childbirth among all groups irrespective of JSY eligibility, receipt of cash, and number of antenatal visits. Overall, 78.8% opted for institutional delivery if they had received cash, which was significantly more than those who did not (64.5%). JSY-eligible women were 1.5 times more likely to deliver in government institutions compared to JSY-noneligible women. With no incentive, the likelihood of institutional delivery was halved. The distance of a 24 Χ 7 delivery hub beyond 5 km (74.8% vs. 81.8%), the religion of Islam (62.7% vs. 83.2%), and multiparity (63.9% vs. 83.6%) were significant deterring factors. CONCLUSION: Despite some inclusion and exclusion errors, cash incentive under JSY was associated with increased institutional delivery, especially in government institutions though there were other factors influencing the decision as well.

Clinical and cost effectiveness of staff training in Positive Behaviour Support (PBS) for treating challenging behaviour in adults with intellectual disability: a cluster randomised controlled trial.

BACKGROUND: Many people with intellectual disability present with challenging behaviour which often has serious consequences such as the prescription of long term medication, in-patient admissions and disruption of normal daily activities. Small scale studies of Positive Behaviour Support (PBS) delivered by paid carers suggest that it reduces challenging behaviour and costs of care and improves quality of life. This study aims to investigate whether professionals training in the delivery of PBS as part of routine practice is clinically and cost effective compared to treatment as usual in community intellectual disability services. METHOD: The study is a multi-centre cluster randomised controlled trial involving community intellectual disability services in England and service users with mild to severe intellectual disability and challenging behaviour. The teams will be randomly allocated into one of two conditions, either training and support to deliver PBS or treatment as usual. We will carry out assessments of challenging behaviour, use of services, quality of life, mental health, and family and paid carer burden at six and 12 months. We will monitor treatment fidelity and we will interview a sample of paid and family carers, service users, staff and managers about what they think of the treatment and how best we can deliver it in routine care. The main outcome is reduction in challenging behaviour at one year after randomisation. We will also carry out a health economic evaluation to examine the costs and consequences of staff training in PBS. DISCUSSION: The study findings will have significant implications for the delivery of PBS in community based services with the potential for reducing inpatient admissions and out-of-area placements for adults with intellectual disability and challenging behaviour. TRIAL REGISTRATION: This trial is registered with Clinical Trials.gov (Ref NCT01680276 ). Clinical Trials Unit: PRIMENT https://www.ucl.ac.uk/priment/ .

Entomological investigations into an epidemic of Japanese encephalitis (JE) in northern districts of West Bengal, India (2011-2012).

BACKGROUND & OBJECTIVES: Japanese encephalitis (JE) is one of the most important arboviral diseases of human beings with outbreaks in many parts of Southeast Asia including India. We present the entomological findings of an outbreak occurred in northern part of West Bengal during 2011-2012 with special emphasis on the role of JE vectors in different seasons. METHODS: Adult mosquito collections were made with the help of mouth aspirators, aided by flash lights during day time resting inside human and animal habitations as indoor, and resting outside field grasses, bushes, underneath of culverts and bridges as outdoor, and in and around the pig enclosures and cattle sheds during dusk period in JE affected villages from Cooch Behar, Dakshin Dinajpur, Darjeeling and Jalpaiguri districts in North West Bengal. In all study villages, a long handled with enamel bowl dipper was used to obtain immature stages of mosquitoes from various breeding habitats. RESULTS: A total of 19 different types of mosquito breeding habitats were examined for vectors of JE. From these habitats, 23.7 per cent were positive for breeding during the study period. Overall, nine different species were recorded through emergence, but none was positive for JE virus when subjected for detection of virus. Adult mosquitoes of more than 50 per cent of the potential JE vector species obtained through dusk and the rest through indoor and outdoor collections in all seasons. Altogether, 27 different species were recorded. Most of these were JE vectors. INTERPRETATION & CONCLUSIONS: Our results showed that in addition to Cx. vishnui subgroup, detection of JE virus antigen in Cx. quinquefasciatus indicated the possible maintenance of JE virus in nature through poor vector mosquitoes throughout the year. Since, all potential vector species reported elsewhere in India were also found in this region and fluctuated in density in different seasons, a proper integrated vector control programme needs to be implemented to control JE transmission.

Goiter prevalence, urinary iodine, and salt iodization level in sub-Himalayan Darjeeling district of West Bengal, India.

National iodine deficiency disorders control program needs to be continuously monitored. Hence, a cross-sectional study was conducted during the period from April-May 2011 to assess the prevalence of goiter, status of urinary iodine excretion (UIE) level and to estimate iodine content of salts at the household level in Darjeeling district, West Bengal. Study subjects were 2400 school children, aged 8-10 years selected through "30 cluster" sampling methodology. Goiter was assessed by standard palpation technique, UIE was estimated by wet digestion method and salt samples were tested by spot iodine testing kit. Overall goiter prevalence rate was 8.7% (95% confidence intervals = 7.6-9.8) and goiter prevalence was significantly different with respect to gender. Median UIE level was 15.6 mcg/dL (normal range: 10-20 mcg/dL). About 92.6% of the salt samples tested had adequate iodine content of ≥15 ppm. Findings of the present study indicate that the district is in a transition phase from iodine-deficiency to iodine sufficiency.

In vivo therapeutic efficacy of chloroquine alone or in combination with primaquine against vivax malaria in Kolkata, West Bengal, India, and polymorphism in pvmdr1 and pvcrt-o genes.

Plasmodium vivax malaria, though benign, has now become a matter of concern due to recent reports of life-threatening severity and development of parasite resistance to different antimalarial drugs. The magnitude of the problem is still undetermined. The present study was undertaken to determine the in vivo efficacy of chloroquine (CQ) and chloroquine plus primaquine in P. vivax malaria in Kolkata and polymorphisms in the pvmdr1 and pvcrt-o genes. A total of 250 patients with P. vivax monoinfection were recruited and randomized into two groups, A and B; treated with chloroquine and chloroquine plus primaquine, respectively; and followed up for 42 days according to the WHO protocol of 2009. Data were analyzed using per-protocol analyses. We assessed polymorphisms of the pvmdr1 and pvcrt-o genes by a DNA-sequencing method. Out of the 250 patients recruited, 204 completed a 42-day follow-up period, 101 in group A and 103 in group B. In group A, the non-PCR-corrected efficacy of CQ was 99% (95% confidence interval [CI], 0.944 to 1.00), and in group B, all cases were classified as adequate clinical and parasitological response (ACPR). Day 3 positivity was observed in 11 (5.3%) cases. No specific mutation pattern was recorded in the pvcrt-o gene. Eight nonsynonymous mutations were found in the pvmdr1 gene, three of which were new. The Y976F mutation was not detected in any isolate. Chloroquine, either alone or in combination with primaquine, is still effective against P. vivax malaria in the study area. (The study protocol was registered in CTRI [Clinical Trial Registry-India] of the Indian council of Medical Research under registration no. CTRI/2011/09/002031.).

High prevalence of asymptomatic malaria in a tribal population in eastern India.

Asymptomatic infection by Plasmodium falciparum is an important obstacle to eliminating malaria. Asymptomatic carriers do not seek treatment for infection, and therefore they become a reservoir for the parasite. For this reason, these carriers pose a real public health risk. The systematic identification and treatment of asymptomatic infections should reduce the parasite reservoir. A large reduction in this pool will lower the chance of transmission of the disease. In this study, we screened a tribal population of 1,040 individuals in the Purulia district of West Bengal by using a dual-antigen rapid diagnostic kit (RDK), microscopy, and species-specific PCR. All positive individuals were treated with artemisinin-based combination therapy (ACT) (artesunate plus sulfadoxine-pyrimethamine) and followed for 42 days. Polymorphisms in candidate genes were screened by DNA sequencing. A significant proportion (8.4%) of the study population was infected with P. falciparum but showed no clinical manifestations. The PCR method was more sensitive in detecting infection than the RDK or microscopy. The efficacy of the ACT was 97%. In the pfcrt gene, the mutation K76T (the mutated amino acid is indicated by bold type) was found in 100% of the cases. In the pfmdr1 gene, the mutations N86Y and Y184F were noted in 55.5% and 11% of the cases, respectively. Six different haplotypes were identified in the pfdhfr-pfdhps genes. Most importantly, the quintuple mutant A(16)I(51)R(59)N(108)I(164)-S(436)G(437)E(540)A(581)A(613) was found in 10% of the isolates, which is potentially important for the development of sulfadoxine-pyrimethamine resistance. A significant proportion of the study population harboring P. falciparum does not seek treatment and therefore serves as a reservoir for the parasite, maintaining the natural cycle. If the National Vector Borne Disease Control Programme (NVBDCP) of India is to eliminate malaria, then this hidden parasite burden needs to be addressed properly. Similar study in other parts of the country could help to determine the magnitude of the problem.

Status of birth preparedness and complication readiness in Uttar Dinajpur District, West Bengal.

CONTEXT: Birth Preparedness and Complication Readiness (BPCR) is crucial in averting maternal morbidity and mortality. OBJECTIVES: To find out awareness and practices regarding BPCR among pregnant and recently delivered women in Uttar Dinajpur, West Bengal. MATERIALS AND METHODS: This is a cross-sectional, community-based, mixed methods study. Two-stage, 40 cluster sampling technique was used to select three pregnant and six recently delivered women separately. Information on socio-demographic variables as well as awareness and practices regarding BPCR were collected through semi-structured interview. In-depth interviews with one respondent per cluster were also conducted. For statistical analysis Z test was used. RESULTS: Around 50% of the respondents planned for first antenatal check-up (ANC) within 12 weeks, four or more ANCs and institutional delivery. Proportion of women aware of at least one key danger sign each of pregnancy, labor, postpartum, and newborn ranged from 12.1% to 37.2%, whereas 58.3% knew at least one key component of essential newborn care. Around two-thirds and one-third of women, respectively, especially those from backward and below poverty line (BPL) families knew about cash incentive and referral transport schemes. Proportions of women with first ANC within 12 weeks, four or more ANCs, institutional delivery, saving money, identifying transport, and blood donor were 50.4%, 33.6%, 46.2%, 40.8%, 27.3%, and 9.6%, respectively. Hindu religion, backward castes, BPL status, and education ≥ 5 years influenced the practices except for two regarding ANC. Overall BPCR index of the study population was 34.5. CONCLUSION: Preparedness in health system, ensuring competence, and motivation of workers are needed for promoting BPCR among the study population.

Comparative efficacies of artemisinin combination therapies in Plasmodium falciparum malaria and polymorphism of pfATPase6, pfcrt, pfdhfr, and pfdhps genes in tea gardens of Jalpaiguri District, India.

In India, chloroquine has been replaced by a combination of artesunate and sulfadoxine-pyrimethamine (AS-SP) for uncomplicated P. falciparum malaria. Other available combinations, artemether-lumefantrine (AM-LF) and artesunate-mefloquine (AS-MQ), not included in the national program, are widely used by private practitioners. Little is known about the therapeutic efficacy of these artemisinin combinations and the prevalence of molecular markers associated with antimalarial drug resistance. A total of 157 patients with P. falciparum monoinfection were recruited and randomized into three study groups (AS-SP, AM-LF, and AS-MQ). All patients were followed up for 42 days to study the clinical and parasitological responses according to the WHO protocol (2009). We assessed the polymorphism of the pfATPase6, pfcrt, pfdhfr, and pfdhps genes by the DNA-sequencing method. The PCR-corrected therapeutic efficacies of AS-SP, AM-LF, and AS-MQ were 90.6% (95% confidence interval [CI], 0.793 to 0.969), 95.9% (95% CI, 0.860 to 0.995), and 100% (95% CI, 0.927 to 1.00), respectively. No specific mutational pattern was observed in the pfATPase6 gene. All isolates had a K76T mutation in the pfcrt gene. In the pfdhfr-pfdhps genotype, quadruple mutation was frequent, and quintuple mutation was documented in 6.3% of P. falciparum isolates. The significant failure rate of AS-SP (9.5%), although within the limit (10%) for drug policy change, was due to SP failure because of prevailing mutations in pfdhfr, I(51)R(59)N(108), with pfdhps, G(437) and/or E(540). The efficacy of this ACT needs periodic monitoring. Artemether-lumefantrine and artesunate-mefloquine are effective alternatives to the artesunate-sulfadoxine-pyrimethamine combination.

Measles in rural West Bengal, India, 2005-6: low recourse to the public sector limits the use of vitamin A and the sensitivity of surveillance.

BACKGROUND: Measles is often underreported. We evaluated the sensitivity of the measles surveillance in 2 districts of West Bengal in 2005-2006. METHODS: We sampled households with children aged <5 years in village clusters selected with probability proportional to size. We searched households door to door to identify World Health Organization-defined suspected measles cases that had occurred during 12 months in 2004-2005 in Howrah and in 2006 in Purulia. We interviewed mothers about use of health care services during episodes and calculated the proportion of patients seen in the public sector. We reviewed surveillance records at all levels to estimate the proportion of cases seen in public health care facilities that had been reported to the district. We calculated the overall sensitivity of measles surveillance by multiplying these 2 proportions. RESULTS: In Howrah, we identified 240 cases of measles. Of these, 8 (3.3% [95% confidence interval {CI}, 1.5%-6.5%]) had been seen in public facilities and recorded. Of 980 cases identified in 448 public facilities in the periphery, 962 (98%) had been transmitted to the district (overall sensitivity of surveillance, 3.2%). In Purulia, we identified 167 measles cases. Of these, 39 (23.4% [95% CI, = 17.2%-30.5%]) had been seen in public facilities and recorded. Of 418 cases identified in public facilities in the periphery, 414 (99%) had been transmitted to the district (overall sensitivity of surveillance, 23.1%). CONCLUSIONS: Measles surveillance captured a minority of measles cases, but cases captured were transmitted well to the district. Surveillance must engage the private sector. Health education focusing on vitamin A treatment for measles might provide an incentive to seek care, which could increase the sensitivity of surveillance.

The heterogeneity of measles epidemiology in India: implications for improving control measures.

BACKGROUND: Measles vaccination coverage varies in India. Trainees of the Field Epidemiology Training Programme (FETP) investigated 8 outbreaks from 2004 through 2006 in Himachal Pradesh, Uttaranchal, Tamil Nadu, and West Bengal. We reviewed these outbreaks to contribute to the description of the epidemiology of measles and propose recommendations for control. METHODS: FETP trainees searched for measles cases through stimulated passive surveillance or door-to-door case search; estimated attack rates, case fatality, and the median age of case patients; interviewed mothers about vaccination status of their children; and collected serum samples for immunoglobulin M serological testing whenever possible. For 3 outbreaks, the trainees estimated the vaccine efficacy for children >12 months of age through cohort studies. RESULTS: Six of the 8 outbreaks were serologically confirmed. Compared with outbreaks in other states, outbreaks in states with vaccination coverage of >90% had a higher median age among case patients and a lower median attack rate. Six deaths (case fatality rate, 1.5%) occurred during the 5 outbreaks for which vitamin A was not used. The vaccine efficacy was 84% (95% confidence interval [CI], 74%-91%) in Himachal Pradesh. In West Bengal, it was 66% (95% CI, 44%-80%) in 2005 and 81% (95% CI, 67%-89%) in 2006. CONCLUSIONS: In states with higher coverage, attack rates were lower and case patients were older. Although states with coverage of <90% should increase 1-dose coverage and address coverage in pockets that are poorly reached, a second opportunity for measles vaccination could be considered in states such as Himachal Pradesh and Tamil Nadu. Use of vitamin A for case management needs to be generalized.