Abstract
Few countries in Africa currently include rubella-containing vaccination (RCV) in their immunization schedule. The Global Alliance for Vaccines Initiative (GAVI) recently opened a funding window that has motivated more widespread roll-out of RCV. As countries plan RCV introductions, an understanding of the existing burden, spatial patterns of vaccine coverage, and the impact of patterns of local extinction and reintroduction for rubella will be critical to developing effective programmes. As one of the first countries proposing RCV introduction in part with GAVI funding, Madagascar provides a powerful and timely case study. We analyse serological data from measles surveillance systems to characterize the epidemiology of rubella in Madagascar. Combining these results with data on measles vaccination delivery, we develop an age-structured model to simulate rubella vaccination scenarios and evaluate the dynamics of rubella and the burden of congenital rubella syndrome (CRS) across Madagascar. We additionally evaluate the drivers of spatial heterogeneity in age of infection to identify focal locations where vaccine surveillance should be strengthened and where challenges to successful vaccination introduction are expected. Our analyses indicate that characteristics of rubella in Madagascar are in line with global observations, with an average age of infection near 7 years, and an impact of frequent local extinction with reintroductions causing localized epidemics. Modelling results indicate that introduction of RCV into the routine programme alone may initially decrease rubella incidence but then result in cumulative increases in the burden of CRS in some regions (and transient increases in this burden in many regions). Deployment of RCV with regular supplementary campaigns will mitigate these outcomes. Results suggest that introduction of RCV offers a potential for elimination of rubella in Madagascar, but also emphasize both that targeted vaccination is likely to be a lynchpin of this success, and the public health vigilance that this introduction will require.
Highlights
Rubella is a directly transmitted immunizing infection that usually occurs during childhood and is associated with low morbidity and mortality
The range of R0 values was determined by referencing existing estimates for rubella and choosing values consistent with the age range of rubella observed in the epidemiological data described above
With increased support from the Global Alliance of Vaccines, countries that have previously withheld rubella-containing vaccine (RCV) out of concerns for the potential paradoxical increase in the burden of rubella are considering introduction of the vaccine. This endeavour presents an opportunity to reduce the burden of a preventable disease (CRS), but may have additional public health benefits; in particular, that of strengthening existing measles vaccination programmes [32]
Summary
Rubella is a directly transmitted immunizing infection that usually occurs during childhood and is associated with low morbidity and mortality. A relatively inexpensive, high efficacy vaccine that provides lifelong immunity to rubella and can be combined as measles– rubella (MR), or measles –mumps – rubella (MMR) has been available for 50 years. Recent efforts for the control and elimination of measles have spurred renewed interest in the potential for rubella control, because the two vaccines are combined, and overall measles vaccination coverage levels have been climbing [4]. The Global Alliance for Vaccines Initiative (GAVI) has recently opened a funding window for rubella vaccination [5]. Madagascar is one of the countries that has successfully applied for this funding
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