Updated 2011 WHO Rubella Vaccine
Position Paper and Implications for
Regions and Countries
10th Measles Initiative Meeting
September 13-14, 2011,
Washington DC
Susan. E. Reef, CDC/GID/DEEB
Peter M. Strebel, WHO/HQ/IVB/EPI
Outline
• Global and regional status
– CRS burden
– Vaccine uptake and regional goals
• 2011 WHO Rubella Vaccine Position paper
– Vaccine Strategy Recommendations
– Modeling Examples
• GAVI update
• Summary
Updated Estimates of the Burden of
CRS, globally*† in 1996 and 2008
*unpublished, Adams E, Vynnycky E
†All member states
Rubella Vaccine Use by WHO Region,
1996 vs. 2010
Region
1996
No. of countries (%)
2010
No. of countries (%)
AFR
2 (4%)
3 (7%)
AMR
21 (60%)
35 (100%)
EMR
9 (43%)
15 (71%)
EUR
39 (74%)
53 (100%)
SEAR
2 (20%)
4 (36%)
WPR
10 (37%)
21 (78%)
Global
83 (43%)
131 (68%)
WHO Regions by Rubella/CRS Control Target
(2011) EUR-Rubella
Elimination 2015
WPRAccelerated
Rubella
Control
and CRS
Prevention
2015
AMRRubella
Elimination
2010
EMR-National
CRS Prevention
2011 WHO Rubella Vaccine
Position Paper
Purpose and Approaches
• The primary purpose is to prevent the occurrence of
congenital rubella infection including CRS
• Two general approaches to using rubella vaccine:
– CRS reduction only through immunization of adolescent
girls and/or women of childbearing age (WCBA)
– Interruption of rubella virus transmission, thereby
eliminating rubella as well as CRS.
• Introduction of RCV in the routine childhood
immunization schedule combined with vaccination of
older age groups who are susceptible to rubella.
Countries planning to introduce RCV
• Should review the epidemiology of rubella and assess the
burden CRS
• Establish rubella/CRS prevention as a public health priority
• Depending on the burden of CRS and available resources,
countries should determine their goal and time frame for
achieving it
• Introduction of RCV implies a long-term commitment to
achieving and maintaining sufficient immunization coverage
to ensure sustained reduction in CRS incidence.
• Strong political commitment to the elimination of rubella and
CRS, and sustainable financing for vaccination and
surveillance activities must be in place before initiating
rubella vaccination.
Field and laboratory surveillance
• Should be fully integrated with measles in a single surveillance
system
• Need to document the impact of rubella vaccination:
– laboratory-supported surveillance for rubella and CRS
surveillance
– molecular epidemiology
– monitoring of vaccine coverage
– monitoring population immunity using seroprevalence
surveys where appropriate.
Rubella/CRS Elimination
• SAGE recommends that countries should take the opportunity
of the two dose measles vaccine strategy to use MR or MMR
vaccine.
• The preferred approach is to begin with MR vaccine or MMR
vaccine in a wide-age range campaign followed immediately
with introduction of MR, or MMR vaccine in the routine
program.
• The first dose of MR vaccine can be delivered at 9 months or
12 months of age depending on the level of measles virus
transmission[1].
– Only one dose of RCV is needed to achieve rubella and CRS
elimination
• All subsequent follow-up campaigns should use MR vaccine or
MMR vaccine.
[1] See Wkly Epid Rec No. 35, 2009, pp. 349-360.
Paradoxical Effect
• Sustained low rubella immunization coverage in infants
and young children (for example, when rubella vaccine is
used in the private sector alone) will result in an increase
in susceptibility among WCBA that may increase the risk
of CRS (i.e., a paradoxical effect).
• However, if vaccination coverage is sufficiently high,
rubella transmission will be markedly reduced or
interrupted, thereby removing the risk of rubella
exposure for pregnant women.
Minimum coverage required
• SAGE recommends that countries introducing
RCV should achieve and maintain
immunization coverage of 80% or greater
with RCV delivered through routine services
and/or regular SIAs.
Predictions of the effect of combining 80% routine RCV coverage
among 1 yr olds from 2010 in Ethiopia (Addis Ababa) with a starting
mass campaign (1-15 yr olds) with + without subsequent SIAs (1-4 yr
olds), with 80% coverage
Mass campaign
+ routine
CRS incidence/100,000 livebirths
Routine only
Mass campaign + routine
+ 4 yearly SIAs
100
100
100
80
80
80
60
60
60
40
40
40
20
20
20
0
0
0
Years since the start of vaccination
CRS Reduction Alone
•
•
•
•
Vaccination of adolescent and adult females only
Through either routine services or SIAs
Provides direct protection to WCBA
Impact is limited by the coverage achieved and the
age groups targeted
• In the absence of vaccination of infants and young
children, rubella continues to circulate resulting in
ongoing exposure of pregnant women and the
associated risk of CRS.
GAVI
• Timeline for support
– 2008 –Selected HPV, JE, typhoid and rubella vaccines
to support but due to the financial crisis, did not make
any financial commitment.
– 2011 – GAVI Accelerated Vaccine Introduction (AVI)
worked with subteams to develop Vaccine
Introduction Strategy (VIS) for HPV, JE, typhoid and
rubella vaccines
• September - PPC Program and Policy Committee will review
proposed strategies
• November – GAVI board will the recommended strategies
from the PPC
Summary
• Burden of CRS greatest in regions that most of the countries
are not using rubella vaccine and have no regional control
goal
• Risk of CRS is greater than the risk of a paradoxical effect
• SAGE is recommending countries use the measles vaccine
delivery strategy to introduce rubella vaccine
– "every dose of single antigen measles vaccine is a missed
opportunity for prevention of CRS"
• Requirements are political and financial commitment to
achieve and maintain coverage at >80%
• GAVI is considering supporting rubella vaccine introduction
Thank You