Progress Toward Regional Measles Elimination - Worldwide, 2000-2019

Second Dose Measles Vaccination Utilization and Associated Factors in Jabitehnan District, Northwest Ethiopia

Background

Herd immunity against measles is essential to interrupt measles transmission, and this can only be attained by reaching at least 95% coverage for each of the 2 doses of measles vaccine provided in infancy and early childhood age group. It is important to provide everyone with 2 doses of the measles vaccine in order to effectively safeguard the population. Despite this, little is known about the second dosage of the measles vaccine utilization status and the factors that affect it. Therefore, this study aimed to assess second dose of measles vaccination utilization and its associated factors among children aged 24-35 months in Jabitehnan district, 2020.

Methods

A community-based cross-sectional study design was conducted at Jabitehnan District, Northwest Ethiopia, from September 1st, 2020 to October 1st, 2020. Systematic random sampling technique was used to select 845 mothers/caregivers who had children aged 24-35 months. Both bi-variable and multivariable logistic regression was fitted to identify the determinant factors of second dose measles vaccination utilization. Finally, the statistical significant variables were declared by using 95% CI and P value less than .05 in the multivariable logistic regression analysis. The Hosmer and Lemeshow test was used to check the model's fit to the data, and the variance inflation factor was used to assess multi-collinearity.

Results

The overall second dose of measles vaccination utilization was 48.1%, (95% CI: 44.7-51.6). Mothers with primary school education (AOR = 1.91, 95% CI: 1.15-3.17), information about MCV2 (AOR = 6.53, 95% CI: 4.22-10.08), distance from vaccination site (AOR = 3.56, 95% CI: 2.46-5.14), knowledge about immunization (AOR = 1.935, 95% CI: 1.29-2.90), and favorable attitude about immunization (AOR = 5.19, 95% CI: 3.25-8.29) were significantly associated factors with second dose of measles vaccination utilization.

Conclusion

Second dose measles vaccination utilization in the district was lower than the national target. Maternal education, distances from vaccination site, information about MCV2, and knowledge about immunization were significantly associated variables with second dose measles vaccination utilization. Therefore, in order to increase the utilization of the second dose of the measles vaccine, improved health education and service expansion to difficult-to-reach areas are required.

Measles outbreak investigation in Kasoshekumer kebele, Sinana district, South-Eastern Oromia, Ethiopia: A case-control study

Objective

This study aimed at verifying the outbreak, preventing further transmission, and identifying the risk factors for the outbreak.

Method

A case-control study design was conducted from March 4, 2020 to April 30, 2020, in Kasoshekumer kebele of Sinana district. Thirty-seven carer-patient pairs and 74 controls were recruited in a 1:2 case-control ratio. Patients were selected using a national standard case definition of the Ministry of Health. Controls were selected from neighbors of patients and interviewed after the second incubation period from the last patient of the outbreak by a structured questionnaire similar to patients. All cases were included while controls were selected purposively for their exposure status. Vaccine efficacy, attack rate, and case fatality rate were conducted as a descriptive epidemiology. Multivariate analysis was used to identify associated factors.

Result

Out of 109 study participants, there were 37 cases and 72 controls. The mean age was 58.8 months with ±54 standard deviation. Thirty-one (83.8%) of the cases had a known contact history and 23 (62.2%) were unvaccinated. The age-specific attack rate was 36/1000 in <5 years and 53/100,000 in >15 years. The estimated vaccine efficacy was 73.7%. Having any type of socialization behavior (adjusted odds ratio = 6.8, confidence interval: 4.25, 11.4), maternal poor knowledge of measles prevention (adjusted odds ratio = 4.152, confidence interval: 1.226, 8.058), and being unvaccinated (adjusted odds ratio = 7.79, confidence interval: 2.281, 12.63) were associated factors for measles infection.

Conclusion

Poor knowledge of the parents on vaccination and the less effort taken to deliver good attitude toward vaccination are resulting in measles outbreak. However, herd immunity can prevent the outbreak; if not, the community will continue to suffer from mortality and morbidity. A resilient immunization program with sustainable and equitable supply, delivery, monitoring, and evaluation is a fundamental action in prevention of measles outbreak. Increased awareness of vaccination and other prevention measures are also crucial to end the outbreaks.

The Influence of Sex, Body Mass Index, and Age on Cellular and Humoral Immune Responses Against Measles After a Third Dose of Measles-Mumps-Rubella Vaccine

BACKGROUND

A third dose of measles-mumps-rubella vaccine (MMR3) is recommended in mumps outbreak scenarios, but the immune response and the need for widespread use of MMR3 remain uncertain. Herein, we characterized measles-specific immune responses to MMR3 in a cohort of 232 healthy subjects.

METHODS

Serum and peripheral blood mononuclear cells (PBMCs) were sampled at day 0 and day 28 after MMR3. Measles-specific binding and neutralizing antibodies were quantified in sera by enzyme-linked immunosorbent assay and a microneutralization assay, respectively. PBMCs were stimulated with inactivated measles virus, and the release of cytokines/chemokines was assessed by a multiplex assay. Demographic variables of subjects were examined for potential correlations with immune outcomes.

RESULTS

Of the study participants, 95.69% and 100% were seropositive at day 0 and day 28, respectively. Antibody avidity significantly increased from 38.08% at day 0 to 42.8% at day 28 (P = .00026). Neutralizing antibodies were significantly enhanced, from 928.7 at day 0 to 1289.64 mIU/mL at day 28 (P = .0001). Meanwhile, cytokine/chemokine responses remained largely unchanged. Body mass index was significantly correlated with the levels of inflammatory cytokines/chemokines.

CONCLUSIONS

Measles-specific humoral immune responses, but not cellular responses, were enhanced after MMR3 receipt, extending current understanding of immune responses to MMR3 and supporting MMR3 administration to seronegative or high-risk individuals.

Use of a rapid digital microfluidics-powered immunoassay for assessing measles and rubella infection and immunity in outbreak settings in the Democratic Republic of the Congo

The Democratic Republic of the Congo (DRC) has a high measles incidence despite elimination efforts and has yet to introduce rubella vaccine. We evaluated the performance of a prototype rapid digital microfluidics powered (DMF) enzyme-linked immunoassay (ELISA) assessing measles and rubella infection, by testing for immunoglobulin M (IgM), and immunity from natural infection or vaccine, by testing immunoglobulin G (IgG), in outbreak settings. Field evaluations were conducted during September 2017, in Kinshasa province, DRC. Blood specimens were collected during an outbreak investigation of suspected measles cases and tested for measles and rubella IgM and IgG using the DMF-ELISA in the field. Simultaneously, a household serosurvey for measles and rubella IgG was conducted in a recently confirmed measles outbreak area. DMF-ELISA results were compared with reference ELISA results tested at DRC's National Public Health Laboratory and the US Centers for Disease Control and Prevention. Of 157 suspected measles cases, rubella IgM was detected in 54% while measles IgM was detected in 13%. Measles IgG-positive cases were higher among vaccinated persons (87%) than unvaccinated persons (72%). In the recent measles outbreak area, measles IgG seroprevalence was 93% overall, while rubella seroprevalence was lower for children (77%) than women (98%). Compared with reference ELISA, DMF-ELISA sensitivity and specificity were 82% and 78% for measles IgG; 88% and 89% for measles IgM; 85% and 85% for rubella IgG; and 81% and 83% for rubella IgM, respectively. Rubella infection was detected in more than half of persons meeting the suspected measles case definition during a presumed measles outbreak, suggesting substantial unrecognized rubella incidence, and highlighting the need for rubella vaccine introduction into the national schedule. The performance of the DMF-ELISA suggested that this technology can be used to develop rapid diagnostic tests for measles and rubella.

Immunization programs to support primary health care and achieve universal health coverage

Gains in immunization coverage and delivery of primary health care service have stagnated in recent years. Remaining gaps in service coverage reflect multiple underlying reasons that may be amenable to improved health system design. Immunization systems and other primary health care services can be mutually supportive, for improved service delivery and for strengthening of Universal Health Coverage. Improvements require that dynamic and multi-faceted barriers and risks be addressed. These include workforce availability, quality data systems and use, leadership and management that is innovative, flexible, data driven and responsive to local needs. Concurrently, improvements in procurement, supply chain, logistics and delivery systems, and integrated monitoring of vaccine coverage and epidemiological disease surveillance with laboratory systems, and vaccine safety will be needed to support community engagement and drive prioritized actions and communication. Finally, political will and sustained resource commitment with transparent accountability mechanisms are required. The experience of the impact of COVID-19 pandemic on essential PHC services and the challenges of vaccine roll-out affords an opportunity to apply lessons learned in order to enhance vaccine services integrated with strong primary health care services and universal health coverage across the life course.

A systematic literature review to clarify the concept of vaccine hesitancy

Vaccine hesitancy (VH) is considered a top-10 global health threat. The concept of VH has been described and applied inconsistently. This systematic review aims to clarify VH by analysing how it is operationalized. We searched PubMed, Embase and PsycINFO databases on 14 January 2022. We selected 422 studies containing operationalizations of VH for inclusion. One limitation is that studies of lower quality were not excluded. Our qualitative analysis reveals that VH is conceptualized as involving (1) cognitions or affect, (2) behaviour and (3) decision making. A wide variety of methods have been used to measure VH. Our findings indicate the varied and confusing use of the term VH, leading to an impracticable concept. We propose that VH should be defined as a state of indecisiveness regarding a vaccination decision.

Measles seroprevalence in persons over one year of age in Chandigarh, India

Measles continues to result in focal outbreaks in India, despite over three decades of universal infant vaccination. The aims of this study were to examine measles immunity in the population of Chandigarh, India, and to compare immunity by vaccination vs. natural infection. In a cross-sectional study of individuals 1-60 years selected from 30 communities within Chandigarh during 2017-2018, measles immunity was assessed using serological surveys. Seropositivity was compared across demographic groups, and by prior history of vaccination and natural history of infection. Among those 1-20 years old, measles seropositivity, and histories of measles vaccination or prior measles diagnosis were separately assessed as outcomes in logistic regression models, with demographic factors as independent variables. Among 1690 participants, 94% were seropositive, and 6% had borderline or negative antibody levels. Of those positive, 30% had prior vaccination, 16% had a history of natural infection, and 54% had an unknown history. Over 50% of individuals among those >20 years old, had unknown history of immunity. In the multivariable regression models, vaccination was more common in younger ages (P < .0001), and in males compared to females (P = .0220), and in those with more education (P < .0001). The majority of the population was seropositive, and seropositivity increased with age. Older age groups were more likely to be protected because of previous natural infection, whereas younger age groups were protected by vaccination. There was inequity in vaccination coverage by gender, and maternal education status.

Waning of maternal antibody against measles virus in Shufu, China

BACKGROUND

As measles vaccination coverage has increased, measles infection has shifted to the population of infants. We conducted a follow-up seroepidemiological study among mothers and their infants to evaluate measles seroprevalence and the persistence of maternal measles antibody in Shufu, Kashgar from 2018 to 2020.

METHODS

Maternal venous blood and cord blood was obtained among mothers and their infants at 0, 3, 5, 8, 9, and 12 months of age. An enzyme-linked immunosorbent assay was used for quantitative measurement of measles antibodies. We analyzed the correlation between maternal and neonatal measles antibodies, and antibodies persistence after infants were born.

RESULTS

The overall neonatal maternal ratio was 2.38 (95%CI: 2.05-2.71). The measles antibodies for mothers and newborns were 438.93 IU/mL (95%CI: 409.47-470.51 IU/mL) and 440.10 IU/mL (95%CI: 410.82-471.48 IU/mL), respectively. Neonatal measles antibodies were dropping after birth and then beginning to increase starting at 8 months of age.

CONCLUSIONS

Infant measles antibody levels progressively declined after birth regardless of maternal measles antibody levels. Efforts should be carried out to eliminate measles.

Measles Virus-Induced Host Immunity and Mechanisms of Viral Evasion

The immune system deploys a complex network of cells and signaling pathways to protect host integrity against exogenous threats, including measles virus (MeV). However, throughout its evolutionary path, MeV developed various mechanisms to disrupt and evade immune responses. Despite an available vaccine, MeV remains an important re-emerging pathogen with a continuous increase in prevalence worldwide during the last decade. Considerable knowledge has been accumulated regarding MeV interactions with the innate immune system through two antagonistic aspects: recognition of the virus by cellular sensors and viral ability to inhibit the induction of the interferon cascade. Indeed, while the host could use several innate adaptors to sense MeV infection, the virus is adapted to unsettle defenses by obstructing host cell signaling pathways. Recent works have highlighted a novel aspect of innate immune response directed against MeV unexpectedly involving DNA-related sensing through activation of the cGAS/STING axis, even in the absence of any viral DNA intermediate. In addition, while MeV infection most often causes a mild disease and triggers a lifelong immunity, its tropism for invariant T-cells and memory T and B-cells provokes the elimination of one primary shield and the pre-existing immunity against previously encountered pathogens, known as "immune amnesia".

Progress Toward Regional Measles Elimination - Worldwide, 2000-2021

All six World Health Organization (WHO) regions have committed to eliminating measles.* The Immunization Agenda 2021-2030 (IA2030)^† aims to achieve the regional targets as a core indicator of impact and positions measles as the tracer of a health system's ability to deliver essential childhood vaccines. IA2030 highlights the importance of ensuring rigorous measles surveillance systems to document immunity gaps and achieve 95% coverage with 2 timely doses of measles-containing vaccine (MCV) among children. This report describes progress toward measles elimination during 2000-2021 and updates a previous report (1). During 2000-2021, estimated global coverage with a first MCV dose (MCV1) increased from 72% to a peak of 86% in 2019, but decreased during the COVID-19 pandemic to 83% in 2020 and to 81% in 2021, the lowest MCV1 coverage recorded since 2008. All countries conducted measles surveillance, but only 47 (35%) of 135 countries reporting discarded cases^§ achieved the sensitivity indicator target of two or more discarded cases per 100,000 population in 2021, indicating surveillance system underperformance in certain countries. Annual reported measles incidence decreased 88% during 2000-2016, from 145 to 18 cases per 1 million population, then rebounded to 120 in 2019 during a global resurgence (2), before declining to 21 in 2020 and to 17 in 2021. Large and disruptive outbreaks were reported in 22 countries. During 2000-2021, the annual number of estimated measles deaths decreased 83%, from 761,000 to 128,000; an estimated 56 million measles deaths were averted by vaccination. To regain progress and achieve regional measles elimination targets during and after the COVID-19 pandemic, accelerating targeted efforts is necessary to reach all children with 2 MCV doses while implementing robust surveillance and identifying and closing immunity gaps to prevent cases and outbreaks.

Trends, barriers and enablers to measles immunisation coverage in Saskatchewan, Canada: A mixed methods study

Many social, cultural, and systemic challenges affect the uptake of measles immunisation services. Prior studies have looked at the caregivers' perspectives, but little is known about the perspectives of the health care providers on the barriers of measles immunisation services in Canada. This study examined measles immunisation coverage trends across the regional health authorities in Saskatchewan and explored the barriers and enablers to measles immunisation coverage from providers' perspectives. The study adopted an explanatory sequential mixed method. We utilized the entire population of 16,582 children under two years of age available in the Saskatchewan Immunisation Management System (SIMS) registry for 2002 and 2013 in aggregate format and interviewed 18 key informants in pre-determined two-stages in 2016 and 2017. The quantitative analysis was done with Joinpoint regression modelling, while the qualitative interview data was analyzed using hybrid inductive and deductive thematic approaches. There was a 16.89%-point increase in measles immunisation coverage in the province from 56.32% to 73.21% between 2002 and 2013. There was also a persistently higher coverage among the affluent (66.95% - 82.37%) than the most deprived individuals (45.79% - 62.60%) in the study period. The annual rate of coverage change was marginally higher among the most deprived (16.81%; and average annual percentage change (AAPC) 2.0, 95% CI 1.7-2.2) than among the affluent group (15.42% and AAPC 3.0; 95% CI 2.0-4.0). While access-related issues, caregivers' fears, hesitancy, anti-vaccination challenges, and resource limitations were barriers to immunisation, improving community engagement, service delivery flexibility, targeted social responses and increasing media role were found useful to address the uptake of measles and other vaccine-preventable diseases immunisation. There is low coverage and inequity in measles immunisation uptake in Saskatchewan from social and institutional barriers. Even though there is evidence of disparity reduction among the different groups, the barriers to increasing measles immunisation coverage have implications for the health of the socio-economically deprived groups, the healthcare system and other vaccination programs. There is a need to improve policy framework for community engagement, targeted programs, and public health discourse.

Seroprevalence of Varicella-Zoster Virus and Measles among Healthcare Workers in a Tertiary Medical Center in Korea

Measles and varicella still occur in the general population despite the widespread vaccination against them, and healthcare workers (HCWs) are still at risk of exposure to these diseases. Here, we evaluated the seroprevalence of measles and varicella-zoster virus (VZV) in HCWs and the trend of seroprevalence according to age, birth year, and occupational group. The serostatuses of measles and VZV of HCWs during new employee medical examinations between October 2015 and October 2021 were included. Thereafter, the trends of seroprevalence according to age, birth year, and occupational groups were evaluated. Overall, 2070 and 1827 HCWs were evaluated for VZV and measles serostatus, respectively. The seroprevalences of VZV and measles were 91% (1884/2070) and 70% (1284/1827), respectively. Younger HCWs had a significantly lower seroprevalence of measles (p = 0.02, age) and VZV (p = 0.003, birth year and p < 0.001, age). The seroprevalence of measles and VZV was significantly higher among doctors and nursing assistants than among nurses and other HCWs (p < 0.001 in both). In conclusion, the seroprevalence of measles and VZV significantly decreased in younger HCWs. Additionally, monitoring the serostatus of measles and VZV and the immunization of susceptible HCWs are required to prepare and control infectious diseases in healthcare facilities.

Measles second dose vaccine utilization and associated factors among children aged 24–35 months in Sub-Saharan Africa, a multi-level analysis from recent DHS surveys

Background

Although a safe and effective vaccine is available, measles remains an important cause of mortality and morbidity among young children in Sub-Saharan Africa (SSA). The WHO and UNICEF recommended measles-containing vaccine dose 2 (MCV2) in addition to measles-containing vaccine dose 1 (MCV1) through routine services strategies. Many factors could contribute to the routine dose of MCV2 coverage remaining far below targets in many countries of this region. This study aimed to assess the prevalence of MCV2 utilization among children aged 24–35 months and analyze factors associated with it by using recent nationally representative surveys of SSA countries.

Methods

Secondary data analysis was done based on recent Demographic and Health Surveys (DHS) data from eight Sub-Saharan African countries. In this region, only eight countries have a record of routine doses of measles-containing vaccine dose 2 in their DHS dataset. The multilevel binary logistic regression model was fitted to identify significantly associated factors. Variables were extracted from each of the eight country’s KR files. Adjusted Odds Ratios (AOR) with a 95% Confidence Interval (CI) and p-value ≤ 0.05 in the multivariable model were used to declare significant factors associated with measles-containing vaccine dose 2 utilization.

Result

The pooled prevalence of MCV2 utilization in SSA was 44.77% (95% CI: 27.10–62.43%). In the multilevel analysis, mothers aged 25–34 years [AOR = 1.15,95% CI (1.05–1.26), mothers aged 35 years and above [AOR = 1.26, 95% CI (1.14–1.41)], maternal secondary education and above [AOR = 1.27, 95% CI (1.13–1.43)], not big problem to access health facilities [AOR = 1.21, 95% CI (1.12–1.31)], four and above ANC visit [AOR = 2.75, 95% CI (2.35–3.24)], PNC visit [AOR = 1.13, 95% CI (1.04–1.23)], health facility delivery [AOR = 2.24, 95% CI (2.04–2.46)], were positively associated with MCV2 utilization. In contrast, multiple twin [AOR = 0.70, 95% CI (0.53–0.95)], rural residence [AOR = 0.69, 95% CI (0.57–0.82)] and high community poverty [AOR = 0.66, 95% CI (0.54–0.80)] were found to be negatively associated with MCV2 utilization.

Conclusions and recommendations

Measles-containing vaccine doses 2 utilization in Sub-Saharan Africa was relatively low. Individual-level factors and community-level factors were significantly associated with low measles-containing vaccine dose 2 utilization. The MCV2 utilization could be improved through public health intervention by targeting rural residents, children of uneducated mothers, economically poor women, and other significant factors this study revealed.

Increasing seroprevalence but waning herd immunity against measles after elimination: Longitudinal seroepidemiology of measles in Osaka Prefecture, Japan, 2003-2020

Japan is one of the countries conducting longitudinal serosurveillance of vaccine-preventable diseases. We conducted surveillance of the local measles-specific antibody titer, calculated the effective reproduction number (R_e), and compared data of four terms: term 1, 2003-2006 (before the introduction of the second shot of measles-containing vaccine); term 2, 2007-2010 (early term toward measles elimination); term 3, 2011-2014 (later term toward measles elimination); and term 4, 2015-2020 (after elimination of measles in Japan). Approximately 250 sera from volunteers aged 0 to ≥ 40 years were collected and examined for measles-specific IgG using the gelatin particle agglutination (PA) method annually from 2003 to 2020. Seroprevalence and the geometric mean of the PA antibody titer were examined by term. R_e was calculated using the age-dependent proportion immune and contact matrix for each term. Of the 4,716 sera, 886 in term 1, 1,217 in term 2, 1,069 in term 3, and 1,544 in term 4 were collected. The seroprevalence gradually increased from term 1 (88.3% CI 86.0-90.3) to term 4 (95.7% CI 94.6-96.7), and the seroprevalence of term 1 was significantly lower than those of other terms (Fisher's exact test, p < 0.001), with PA titer ≥ 16 as positive. By contrast, PA antibody titers significantly decreased from term 1 (median 1,024) to term 4 (median 256) (Mann-Whitney U test, p < 0.001). With the protection level (PA titer ≥ 128 and ≥ 256) as positive, R_e gradually increased from term 1 (1.8 and 2.3) to term 4 (2.5 and 4.8, respectively). Waning levels of measles antibodies potentially increase the measles susceptibility in Osaka, Japan. This trend might imply a limitation of vaccine-induced immunity in the absence of a natural booster for wild strains after measles elimination. This study provides a cue for maintaining continuous measles elimination status in the future.

Epidemiological features and risk factors for measles and rubella in Taiwan during 2011 to 2020

The risk of geographic transmission of infectious diseases due to air travel varies greatly. Our aim is to survey empirical data that provide a retrospective historical perspective on measles and rubella. This study used the open data website provided by the Taiwan Centers for Disease Control (TCDC) to extract the reported numbers of measles and rubella case between 2011 and 2020. There were 306 cases of measles and 135 cases of rubella. The incidence of measles and rubella per million population were 0 to 6.0 and 0 to 2.6, respectively. There was a gradual increase in the numbers of cases in those aged 20-39 years, and distinct duration patterns. It indicated that the risk of contracting rubella has significantly decreased in the last 5 years. Measles cases aged 20 to 39 years accounted for 72.5% of all cases. Rubella cases aged 20 to 39 years accounted for 59.3% of all cases. The male and residency in the Taipei metropolitan area or northern area were identified as potential risk factors for measles and rubella. Coverage with the first dose of the measles, mumps and rubella (MMR) vaccine in Taiwan increased from 97.31% to 98.86%, and the uptake rate of the second dose of the MMR vaccine increased from 95.73% to 98.39% between 2010 and 2020. Furthermore, the numbers of imported cases of measles (n = 0) and rubella (n = 0) reported during the coronavirus disease 2019 (COVID-19) pandemic were lower than those from 2011 to 2019. Measles and rubella cases were imported most frequently from Cambodia and Vietnam. This study represents the first report of confirmed cases of acquired measles and rubella from surveillance data of the TCDC between 2011 and 2020, also demonstrates that the numbers of cases of measles and rubella significantly decreased in Taiwan during the COVID-19 pandemic.

Nebulized fusion inhibitory peptide protects cynomolgus macaques from measles virus infection

Measles is the most contagious airborne viral infection and the leading cause of child death among vaccine-preventable diseases. We show here that aerosolized lipopeptide fusion inhibitor, derived from heptad-repeat regions of the measles virus (MeV) fusion protein, blocks respiratory MeV infection in a non-human primate model, the cynomolgus macaque. We use a custom-designed mesh nebulizer to ensure efficient aerosol delivery of peptide to the respiratory tract and demonstrate the absence of adverse effects and lung pathology in macaques. The nebulized peptide efficiently prevents MeV infection, resulting in the complete absence of MeV RNA, MeV-infected cells, and MeV-specific humoral responses in treated animals. This strategy provides an additional means to fight against respiratory infection in non-vaccinated people, that can be readily translated to human trials. It presents a proof-of-concept for the aerosol delivery of fusion inhibitory peptides to protect against measles and other airborne viruses, including SARS-CoV-2, in case of high-risk exposure.

Feasibility of measles and rubella vaccination programmes for disease elimination: a modelling study

Background

Marked reductions in the incidence of measles and rubella have been observed since the widespread use of the measles and rubella vaccines. Although no global goal for measles eradication has been established, all six WHO regions have set measles elimination targets. However, a gap remains between current control levels and elimination targets, as shown by large measles outbreaks between 2017 and 2019. We aimed to model the potential for measles and rubella elimination globally to inform a WHO report to the 73rd World Health Assembly on the feasibility of measles and rubella eradication.

Methods

In this study, we modelled the probability of measles and rubella elimination between 2020 and 2100 under different vaccination scenarios in 93 countries of interest. We evaluated measles and rubella burden and elimination across two national transmission models each (Dynamic Measles Immunisation Calculation Engine [DynaMICE], Pennsylvania State University [PSU], Johns Hopkins University, and Public Health England models), and one subnational measles transmission model (Institute for Disease Modeling model). The vaccination scenarios included a so-called business as usual approach, which continues present vaccination coverage, and an intensified investment approach, which increases coverage into the future. The annual numbers of infections projected by each model, country, and vaccination scenario were used to explore if, when, and for how long the infections would be below a threshold for elimination.

Findings

The intensified investment scenario led to large reductions in measles and rubella incidence and burden. Rubella elimination is likely to be achievable in all countries and measles elimination is likely in some countries, but not all. The PSU and DynaMICE national measles models estimated that by 2050, the probability of elimination would exceed 75% in 14 (16%) and 36 (39%) of 93 modelled countries, respectively. The subnational model of measles transmission highlighted inequity in routine coverage as a likely driver of the continuance of endemic measles transmission in a subset of countries.

Interpretation

To reach regional elimination goals, it will be necessary to innovate vaccination strategies and technologies that increase spatial equity of routine vaccination, in addition to investing in existing surveillance and outbreak response programmes.

Funding

WHO, Gavi, the Vaccine Alliance, US Centers for Disease Control and Prevention, and the Bill & Melinda Gates Foundation.

Communication lessons learned from the 2017 measles–rubella campaign in India: perspectives from vaccine decision-makers

In 2017, to reduce the burden of measles and rubella, a nation-wide measles–rubella campaign was launched in India. Despite detailed planning efforts that involved many stakeholders, vaccine refusal arose in several communities during the campaign. As strategic health communication and promotion is critical in any vaccine campaign, we sought to document lessons learned from the 2017 MR campaign from a strategic health communication and promotion perspective to capture lessons learned. To inform future campaigns, we conducted in-depth interviews through a perspective that is not usually captured, that of government and civil society stakeholders that had experience in vaccine campaign implementation (n = 21). We interviewed stakeholders at the national level and within three states that had diverse experiences with the campaign. Three key themes related to strategic health communication and promotion emerged: the importance of sensitizing communities at all levels through relevant and timely information about the vaccine and the vaccine campaign, leveraging key influencers to deliver tailored messaging about the importance of vaccines and mitigating vaccine misinformation rapidly. Our study findings have important implications for health communication and promotion research related to vaccine campaigns. The field must continue to enhance vaccine campaign efforts by identifying important health communication and promotion factors, including the importance of sensitization, trusted messengers that use tailored messaging and mitigating misinformation, as vaccine campaigns are crucial in improving vaccine acceptance.

Understanding Barriers and Facilitators to Maternal Immunization: A Systematic Narrative Synthesis of the Published Literature

Introduction

Vaccines are being developed against Group B Streptococcus and respiratory syncytial virus. These vaccines are designed to be given to pregnant women to protect infants; thus, their success depends on uptake in this population. Maternal immunization programs have struggled to achieve target coverage rates. This systematic narrative synthesis aims to define the most important barriers and facilitators for maternal immunization and to identify priority areas for future research.

Methods

A search strategy was developed in Medline and adapted according to the requirements of additional search engines. Two reviewers independently reviewed the studies, using pre-specified inclusion and exclusion criteria. Results sections of included studies were coded, and thematic analysis was used to identify prominent themes.

Results

321 studies were included in the final review. Most studies came from North America (37%), Europe (26%) or East Asia, Australia and New Zealand (22%). Low-and middle-income countries were under-represented. Five percent of studies came from Sub-Saharan Africa, and 2% came from South Asia. The prominent factors impacting maternal immunization were provider recommendation, perceived risks and benefits of maternal vaccines for the infant, race, birthplace, and access to healthcare. Few studies explored reasons behind racial and socioeconomic disparities in maternal immunization rates.

Discussion

A strong provider recommendation, equitable access to prenatal care and messaging that focuses on vaccine safety and infant benefits emerged as the key components for optimising vaccine uptake among pregnant women. Research among healthcare providers, minority groups and in low- and-middle-income countries was lacking. In anticipation of the expansion of maternal immunization programmes, focused research is needed to address these gaps and inform a successful public health strategy.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10995-022-03508-0.

Measles epidemic in Southern Vietnam: an age-stratified spatio-temporal model for infectious disease counts

Measles resurged in Vietnam between 2018 and 2020, especially in the Southern region. The proportion of children with measles infection showed quite some variation at the provincial level. We applied a spatio-temporal endemic-epidemic modelling framework for age-stratified infectious disease counts using measles surveillance data collected in Southern Vietnam between 1 January 2018 and 30 June 2020. We found that disease transmission within age groups was greatest in young children aged 0-4 years whereas a relatively high between-group transmission was observed in older age groups (5-14 years, 15-24 years and 25+ years groups). At the provincial level, spatial transmission followed an age-dependent distance decay with measles spread mainly depending on local and neighbouring transmission. Our study helped to clarify the measles transmission dynamics in a more detailed fashion with respect to age strata, time and space. Findings from this study may help determine proper strategies in measles outbreak control including promotion of age-targeted intervention programmes in specific areas.

Biological Profile and Clinical Features as Determinants for Prolonged Hospitalization in Adult Patients with Measles: A Monocentric Study in Western Romania

Measles is a highly infectious and sometimes deadly illness that is preventable with vaccination. The present research aims to analyze the most recent measles epidemic from Romania that occurred in a population with a falling desire to receive immunizations, by detailing the clinical picture and biological profile of hospitalized patients. A secondary goal of the present research is to identify characteristics that increase the likelihood of a longer hospitalization and the development of measles-related pneumonia. A retrospective cohort study was conducted to follow the course and effects of measles virus infection in adult hospitalized patients who were divided into two groups based on whether they had been in the hospital for more than 6 days or fewer than 6 days. A total of 114 adult patients with measles were eligible to participate in the trial if they had a positive measles-specific IgM antibody test resulting from the study. The average age in the short hospital stay group was 28.1 years, while the average age in the long hospital stay group was 31.9 years. There was a statistically significant difference in the number of Roma persons in the research groups, with 17.4 percent of them having a lengthy hospital stay compared to 5.9 percent in the group with a short hospital stay, according to the findings. It was observed that many patients had a long hospitalization associated with chronic lung disease (OR = 1.07), liver damage (OR = 1.66), Roma ethnicity (OR = 1.79), a long duration elapsed from the last MMR dose (OR = 2.02), elevated c-reactive protein (OR = 2.17), the presence of bilateral pulmonary condensations on X-ray (OR = 3.13), and elevated procalcitonin (OR = 3.49). The same significant independent risk factors were also associated with the development of pneumonia. It is of imperative need to address these risk factors in a patient with measles, moreover in association with an unknown status of vaccination. Vaccination awareness against measles must be pushed in Romania to determine a higher than 95% coverage. Significant efforts are still needed to ensure improved protection against measles epidemics within a specific region or population and, more importantly, in patients with significant risk factors for complications, as described in this study.

Performance of SARS-CoV-2 Antigens in a Multiplex Bead Assay for Integrated Serological Surveillance of Neglected Tropical and Other Diseases

Serosurveillance can provide estimates of population-level exposure to infectious pathogens and has been used extensively during the COVID-19 pandemic. Simultaneous, serological testing for multiple pathogens can be done using bead-based immunoassays to add value to disease-specific serosurveys. We conducted a validation of four SARS-CoV-2 antigens-full-length spike protein, two receptor binding domain proteins, and the nucleocapsid protein-on our existing multiplex bead assay (MBA) for enteric diseases, malaria, and vaccine preventable diseases. After determining the optimal conditions for coupling the antigens to microsphere beads, the sensitivity and specificity of the assay were determined on two instruments (Luminex-200 and MAGPIX) when testing singly (monoplex) versus combined (multiplex). Sensitivity was assessed using plasma from 87 real-time reverse transcription polymerase chain reaction (rRT-PCR) positive persons collected in March-May of 2020 and ranged from 94.3% to 96.6% for the different testing conditions. Specificity was assessed using 98 plasma specimens collected prior to December 2019 and plasma from 19 rRT-PCR negative persons and ranged from 97.4% to 100%. The positive percent agreement was 93.8% to 97.9% using 48 specimens collected > 21 days post-symptom onset, while the negative percent agreement was ≥ 99% for all antigens. Test performance was similar using monoplex or multiplex testing. Integrating SARS-CoV-2 serology with other diseases of public health interest could add significant value to public health programs that have suffered severe programmatic setbacks during the COVID-19 pandemic.

The impact of supplementary immunization activities on measles transmission dynamics and implications for measles elimination goals: a mathematical modelling study

BACKGROUND

Measles has re-emerged globally due to the accumulation of susceptible individuals and immunity gap, which causes challenges in eliminating measles. Routine vaccination and supplementary immunization activities (SIAs) have greatly improved measles control, but the impact of SIAs on the measles transmission dynamics remains unclear as the vaccine-induced immunity wanes.

METHODS

We developed a comprehensive measles transmission dynamics model by taking into account population demographics, age-specific contact patterns, seasonality, routine vaccination, SIAs, and the waning vaccine-induced immunity. The model was calibrated by the monthly age-specific cases data from 2005 to 2018 in Jiangsu Province, China, and validated by the dynamic sero-prevalence data. We aimed to investigate the short-term and long-term impact of three-time SIAs during 2009-2012 (9.68 million and 4.25 million children aged 8 months-14 years in March 2009 and September 2010, respectively, and 140,000 children aged 8 months-6 years in March 2012) on the measles disease burden and explored whether additional SIAs could accelerate the measles elimination.

RESULTS

We estimated that the cumulative numbers of measles cases from March 2009 to December 2012 (in the short run) and to December 2018 (in the long run) after three-time SIAs (base case) were 6,699 (95% confidence interval [CI]: 2,928-10,469), and 22,411 (15,146-29,675), which averted 45.0% (42.9%-47.0%) and 34.3% (30.7%-37.9%) of 12,226 (4,916-19,537) and 34,274 (21,350-47,199) cases without SIAs, respectively. The fraction of susceptibles for children aged 8-23 months and 2-14 years decreased from 8.3% and 10.8% in March 2009 to 5.8% and 5.8% in April 2012, respectively. However, the fraction of susceptibles aged 15-49 years and above 50 years increased gradually to about 15% in 2018 irrespective of SIAs due to the waning immunity. The measles elimination goal would be reached in 2028, and administrating additional one-off SIAs in September 2022 to children aged 8-23 months, or young adolescents aged 15-19 years could accelerate the elimination one year earlier.

CONCLUSIONS

SIAs have greatly reduced the measles incidence and the fraction of susceptibles, but the benefit may wane over time. Under the current interventions, Jiangsu province would reach the measles elimination goal in 2028. Additional SIAs may accelerate the measles elimination one year earlier.

Understanding the transmission dynamics of a large-scale measles outbreak in Southern Vietnam

OBJECTIVES

During 2018-2020, Southern Vietnam experienced a large measles outbreak of over 26,000 cases. We aimed to understand and quantify the measles spread in space-time dependence and the transmissibility during the outbreak.

METHODS

Measles surveillance reported cases between 1/2018 and 6/2020, vaccination coverage, and population data at provincial level were used. To illustrate the spatiotemporal pattern of disease spread, we employed the endemic-epidemic multivariate time series model decomposing measles risk additively into autoregressive, spatiotemporal, and endemic component. Likelihood-based estimation procedures were performed to determine the time-varying reproductive number R_e of measles.

RESULTS

Our analysis shows that measles incidence was associated with vaccination coverage heterogeneity and spatial interaction between provincial units. The risk of infections was dominated by between-province transmission (36.1% to 78.8%), followed by local endogenous transmission (4.1% to 61.5%) whereas the endemic behavior had a relatively small contribution (2.1% to 33.4%) across provinces. In the exponential phase of the epidemic, R_e was above the threshold with a maximum value of 2.34 (95%CI: 2.20-2.46).

CONCLUSION

Local vaccination coverage and human mobility are important factors contributing to the measles dynamics in Southern Vietnam and the high risk of inter-provincial transmission is of most concern. Strengthening disease surveillance is recommended, and further research is essential to understand the relative contribution of population immunity and control measures in measles epidemics.

Measles Experience, Practice, and Knowledge by Pediatricians in the Context of Resurgent US Outbreaks

OBJECTIVE

To assess measles experience, practice, and knowledge by pediatricians in the context of resurgent US outbreaks in 2018-2019.

STUDY DESIGN

A nationally representative network of pediatricians were surveyed by email and mail from January to April 2020.

RESULTS

The response rate was 67% (297 of 444). In the 3 years preceding the survey, 52% of the respondents reported awareness of measles cases in/near their community. Most thought that media reports about recent measles outbreaks had decreased delay/refusal of measles, mumps, and rubella (MMR) vaccine (6% "greatly decreased"; 66% "moderately decreased"). More than 60% of the pediatricians responded correctly for 6 of 9 true/false measles knowledge items. Less than 50% responded correctly for 3 true/false items, including statements about pretravel MMR recommendations for a preschooler and measles isolation precautions. The most common resources that the pediatricians would "sometimes" or "often/always" consult for measles information were those from the American Academy of Pediatrics (72%), a state or local public health department (70%), and the Centers for Disease Control and Prevention (63%). More than 90% of the pediatricians reported correct clinical practice for MMR vaccination of a 9-month-old before international travel. More than one-third of the respondents did not have a plan for measles exposures in their clinic. Pediatricians aware of measles cases in/near their community in the previous 3 years and those working in a hospital/clinic or Health Maintenance Organization setting were more likely to have a plan for measles exposures.

CONCLUSIONS

During this time of heightened risk for measles outbreaks, there are opportunities to strengthen the knowledge and implementation of measles pretravel vaccination and infection prevention and control recommendations among pediatricians.

Five-Year Trend of Measles and Its Associated Factors in Pahang, Malaysia: A Population-Based Study

Measles is a disease that has resurfaced as a public health concern in Malaysia. Malaysia has had a Measles Elimination Program in place since 2004, but the incidence of measles in Pahang has not improved significantly. The purpose of this study was to describe the incidence and trend of measles in Pahang, as well as to identify the risk factors. The five-year population-based surveillance data of the entire Pahang state was extracted and analyzed for the trend and incidence of measles from January 2016 to December 2020. Multiple logistic regression was used to examine the relationship between measles and available sociodemographic data. A total of 2844 reported measles cases were investigated. Out of the measles cases reported, 7.41 percent were confirmed. According to the five-year fluctuating trend, the incidence rate ranges from 13.51 to 50.97 per 1,000,000 population. Confirmed measles was significantly associated with an indigenous background (AdjOR = 4.90, 95% CI: 1.74, 13.78), history of contact with measles cases (AdjOR = 14.03, 95% CI: 8.23, 23.90), and incomplete vaccination (AdjOR = 3.38, 95% CI: 2.28, 5.01). In conclusion, the incidence of measles in Pahang remains sporadic, owing to sporadic outbreaks. Vaccination is an important preventive measure that must reach out to the isolated populations such as indigenous people.

[Vaccination Gaps of Employees in Institutions of Preschool Childcare before Introduction of the Measles Protection Act]

AIM OF THE STUDY

The measles protection act and the updated recommendations of the permanent commission of vaccination (STIKO) include the obligatory proof of a double vaccination against measles for employees (born after 1970) in childcare. In addition, the standard and professional recommendations for vaccinations should be respected. A retrolective evaluation of vaccination gaps of employees in institutions for preschool childcare was performed.

METHODS

The database of 2018 and 2019 of the B·A·D-Health center Erlangen have 1300 recorded cases of occupational medical consultations in preschool childcare. Double consultations and consultations with insufficient data were excluded. 1016 contacts were analyzed with regard to vaccination gaps of measles, mumps, rubella, varicella, pertussis, hepatitis A+B and early summer meningoencephalitis. The evaluation was primarily based on the employees' vaccination cards. Vaccination gaps were assumed in case of missing, commenced or incomplete vaccination protection.

RESULTS

In this cohort of 1016 employees, the vaccination gap for measles increased from 16.2% to 20.6%, when applying the updated STIKO recommendation and the resulting change of definition of complete vaccination protection from measles. Further gaps were 22.7% for mumps, 18.9% for rubella, 2.3% for varicella, 27.8% for pertussis, 61.1% for hepatitis A and 60.5% and tick-borne encephalitis. The age group <30 years showed less vaccination gaps than the age group ≥30 years.

CONCLUSION

The evaluation of the health center in Erlangen showed considerable age-dependent vaccination gaps in the cohort of employees of preschool childcare. The measles protection act that makes vaccination against measles mandatory contributes to closing this gap. There is room for counselling as well as for action regarding vaccine-preventable diseases in occupational medicine.

Sustainable Development Goals and childhood measles vaccination in Ekiti State, Nigeria: Results from spatial and interrupted time series analyses

Measles remains an important cause of childhood mortality in many resource-limited countries. With Sustainable Development Goals (SDG), there has been increasing emphasis on measles vaccination as a key strategy to remarkably improve child survival. While progress has been made towards measles vaccination coverage due to SDG in some settings, there has been no prior study evaluating its impact in Nigeria. To assess the effectiveness of SDG policy implementation on measles vaccination coverage, we examined the changes in first dose of measles vaccination coverage rates among children aged 9-15 months following the implementation of SDG, and changes in spatial patterns of measles vaccination from 2014 to 2019 in Ekiti State, Southwest Nigeria. Using state and local government area-level District Health Information data from January 2014 to December 2019, we conducted interrupted time series (ITS) and spatiotemporal analyses. The ITS evaluated the immediate and continuous effects of SDG policy implementation on the monthly childhood measles vaccination coverage by comparing longitudinal changes in rates between pre-intervention period (January 2014-December 2015) and during-intervention period (January 2016-December 2019). The low and high coverage clusters across the years were detected with spatial cluster analysis. The average state-level measles vaccination coverage rates from 2014 to 2019 was 70.67%. In 2019, coverage rate was 49%-a 35.53% decline from 76% in 2014 and a state-level gap of 46%. The geographical distribution of measles vaccination varied considerably across the local government areas from 2014 to 2019. There was an initial acceleration of vaccination rates (β^ = 24.07, p-value = 0.012), but a significant decrease in coverage rates after implementation of SDG policy in Ekiti State (β^ = -1.08, p-value < 0.001). No local government area had accelerated monthly coverage rates following SDG-implementation. Evidence suggests immediate acceleration in coverage rates which could not be sustained during SDG-era and calls for a rethink measles immunization coverage strategy in the state and other resource-limited jurisdictions to ensure vaccination scale-up.

Leveraging a national biorepository in Zambia to assess measles and rubella immunity gaps across age and space

High-quality, representative serological surveys allow direct estimates of immunity profiles to inform vaccination strategies but can be costly and logistically challenging. Leveraging residual serum samples is one way to increase their feasibility. We subsampled 9854 residual sera from a 2016 national HIV survey in Zambia and tested these specimens for anti-measles and anti-rubella virus IgG antibodies using indirect enzyme immunoassays. We demonstrate innovative methods for sampling residual sera and analyzing seroprevalence data, as well as the value of seroprevalence estimates to understand and control measles and rubella. National measles and rubella seroprevalence for individuals younger than 50 years was 82.8% (95% CI 81.6, 83.9%) and 74.9% (95% CI 73.7, 76.0%), respectively. Despite a successful childhood vaccination program, measles immunity gaps persisted across age groups and districts, indicating the need for additional activities to complement routine immunization. Prior to vaccine introduction, we estimated a rubella burden of 96 congenital rubella syndrome cases per 100,000 live births. Residual samples from large-scale surveys can reduce the cost and challenges of conducting serosurveys, and multiple pathogens can be tested. Procedures to access quality specimens, ensure ethical approvals, and link sociodemographic data can improve the timeliness and value of results.

Identifying immunity gaps for measles using Belgian serial serology data

Vaccine-preventable diseases, such as measles, have been re-emerging in countries with moderate to high vaccine uptake. It is increasingly important to identify and close immunity gaps and increase coverage of routine childhood vaccinations, including two doses of the measles-mumps-rubella vaccine (MMR). Here, we present a simple cohort model relying on a Bayesian approach to evaluate the evolution of measles seroprevalence in Belgium using the three most recent cross-sectional serological survey data collections (2002, 2006 and 2013) and information regarding vaccine properties. We find measles seroprevalence profiles to be similar for the different regions in Belgium. These profiles exhibit a drop in seroprevalence in birth cohorts that were offered vaccination at suboptimal coverages in the first years after routine vaccination has been started up. This immunity gap is observed across all cross-sectional survey years, although it is more pronounced in survey year 2013. At present, the COVID-19 pandemic could negatively impact the immunization coverage worldwide, thereby increasing the need for additional immunization programs in groups of children that are impacted by this. Therefore, it is now even more important to identify existing immunity gaps and to sustain and reach vaccine-derived measles immunity goals.

Nebulized fusion inhibitory peptide protects cynomolgus macaques from measles virus infection

Measles is the most contagious airborne viral infection and the leading cause of child death among vaccine-preventable diseases. We show here that aerosolized lipopeptide fusion inhibitors, derived from heptad-repeat regions of the measles virus (MeV) fusion protein, block respiratory MeV infection in a non-human primate model, the cynomolgus macaque. We used a custom-designed mesh nebulizer to ensure efficient aerosol delivery of peptides to the respiratory tract and demonstrated the absence of adverse effects and lung pathology in macaques. The nebulized peptide efficiently prevented MeV infection, resulting in the complete absence of MeV RNA, MeV-infected cells, and MeV-specific humoral responses in treated animals. This strategy provides an additional shield which complements vaccination to fight against respiratory infection, presenting a proof-of-concept for the aerosol delivery of fusion inhibitory peptides to protect against measles and other airborne viruses, including SARS-CoV-2, in case of high-risk exposure, that can be readily translated to human trials.

'Get your own house in order': Qualitative dialogue groups with nonvaccinating parents on how measles outbreaks in their community should be managed

Objective

Communities with high levels of vaccine rejection present unique challenges to vaccine‐preventable disease outbreak management. We sought perspectives of nonvaccinating parents to inform public health responses in such communities.

Methods

Nineteen purposively sampled nonvaccinating Australian parents participated in one of seven online dialogue groups. We asked what they thought parents, school principals and public health professionals should do in a hypothetical school measles outbreak and used a framework approach to data analysis.

Results

Parents' views were grounded in strong beliefs in parental responsibility and the belief that vaccines are not effective, thus unvaccinated children do not therefore pose a threat. They then reasoned that the forced exclusion of unvaccinated children from school in a measles outbreak was disproportionate to the risk they pose, and their child's right to education should not be overridden. Nonvaccinating parents judged that all parents should keep sick children at home regardless of disease or vaccination status; that school principals should communicate directly with parents and avoid using social media; that public health professionals should provide information to parents so they can decide for themselves about excluding their children from school; that public health responses should avoid accidental identification of unvaccinated children and that mainstream media should be avoided as a communication tool.

Conclusion

Nonvaccinating parents do not always agree with current Australian approaches to measles outbreak management. Their perspectives can inform approaches to outbreak responses in communities with high levels of vaccine rejection.

Patient or Public Contribution

We sought input from individuals who did and did not vaccinate on study design in its early phases. Individual conversations were used deliberately as we felt the group advisory situation may have felt less safe for nonvaccinating parents, given the divisive and often hostile nature of the topic.

Efficient Recovery of Attenuated Canine Distemper Virus from cDNA

To provide insights into the biology of the attenuated canine distemper virus (CDV) Onderstepoort (OP) strain (large plaque forming variant), design next-generation multivalent vaccines, or further investigate its promising potential as an oncolytic vector, we employed contemporary modifications to establish an efficient OP-CDV-based reverse genetics platform. Successful viral rescue was obtained however only upon recovery of a completely conserved charged residue (V13E) residing at the N-terminal region of the large protein (L). Although L-V13 and L-V13E did not display drastic differences in cellular localization and physical interaction with P, efficient polymerase complex (P+L) activity was recorded only with L-V13E. Interestingly, grafting mNeonGreen to the viral N protein via a P2A ribosomal skipping sequence (OP^neon) and its derivative V-protein-knockout variant (OP^neon-V^ko) exhibited delayed replication kinetics in cultured cells. Collectively, we established an efficient OP-CDV-based reverse genetics system that enables the design of various strategies potentially contributing to veterinary medicine and research.

Evaluation of catastrophic health expenditure risk due to measles in Nigeria

Measles can have a substantial negative impact not only on people’s health but also on their finances, especially in developing countries. This study evaluates the household risk of catastrophic health expenditure (CHE) due to measles, according to regions and wealth quintiles. The CHE risk due to measles was computed based on (1) the likelihood of health service utilization to treat measles, (2) out-of-pocket (OOP) expenditure and indirect costs associated with disease treatment, and (3) household consumption expenditures. I derived the CHE risk associated with measles, conditional on contracting the disease, across regions and wealth quintiles in Nigeria, using secondary data sources for health-care utilization, OOP expenditures, and consumption expenditures. There was a large variation in CHE risk according to regions and wealth quintiles. Among the poorest households, those in the northeast and northwest would have the highest risk of CHE, up to 17%, while those in the southwest would have the lowest risk of 5%. For all regions, as the wealth increases, the CHE risk would decrease. There would be zero or very little CHE risk among the richest households in any regions. Given the proven efficacy of measles vaccines, immunizations can prevent households, especially poorer households in northeast and northwest regions, from facing the CHE risk due to measles.

Accelerating the Development of Measles and Rubella Microarray Patches to Eliminate Measles and Rubella: Recent Progress, Remaining Challenges

Measles and rubella microarray patches (MR-MAPs) are critical in achieving measles and rubella eradication, a goal highly unlikely to meet with current vaccines presentations. With low commercial incentive to MAP developers, limited and uncertain funding, the need for investment in a novel manufacturing facility, and remaining questions about the source of antigen, product demand, and regulatory pathway, MR-MAPs are unlikely to be prequalified by WHO and ready for use before 2033. This article describes the current progress of MR-MAPs, highlights challenges and opportunities pertinent to MR-MAPs manufacturing, regulatory approval, creating demand, and timelines to licensure. It also describes activities that are being undertaken by multiple partners to incentivise investment in and accelerate the development of MR-MAPs.

Measles-Rubella Positivity Rate and Associated Factors in Pre-Mass and Post-Mass Vaccination Periods: Analysis of Uganda Routine Surveillance Laboratory Data

Toward 2019, Uganda experienced an extensive outbreak of measles and rubella. The Uganda National Expanded Programme on Immunization implemented a mass measles-rubella vaccination campaign aimed at halting the ongoing transmission. This study determined the changes in the disease burden thereafter. We conducted a retrospective cross-sectional study on measles-rubella positivity and its associated factors in Uganda using 1697 case-based surveillance data for 2019 and 2020 stratified into two dispensations: prevaccination and postvaccination campaigns. Statistical tests employed in STATA 15 included chi-square, Fisher’s exact, and binomial tests. Measles positivity rates in the period before and after the mass immunization campaign were 41.88% (95% CI: 39.30–44.51) and 37.96% (95% CI: 32.81–43.40), respectively. For rubella, the positivity rate in the precampaign season was 21.73% (95% CI: 19.61–23.99) and in the postvaccination season was 6.65% (95% CI: 4.36–10.00). Binomial tests indicated that postcampaign positivity rates were significantly lower than the precampaign rate for measles ( $p=0.003$ ) and rubella ( $p<0.001$ ). Generally, age (χ2 = 58.94, $p=0.001$ /χ2 = 51.91, $p<0.001$ ) and vaccination status (χ2 = 60.48, $p=0.001$ /χ2 = 16.90, $p=0.001$ ) were associated with the measles positivity rate in both pre/postcampaign periods. Rubella positivity rate was associated with vaccination status (χ2 = 32.97, $p<0.001$ / $p=0.001$ ) in both periods and age in the precampaign season ( $p<0.001$ ). The measles-rubella mass campaign lessened rubella burden remarkably, but barely adequate change was observed in the extent of spread of measles. Children aged less than 9 months are at higher chances of testing positive amidst low vaccination levels among the eligible. The immunization programme must attain and maintain routine immunization coverage at 95% or more and roll out a second-dose measles-rubella vaccination to sustain the reduced disease burden.

Seroprotection against measles in previously vaccinated children with difficult-to-treat nephrotic syndrome

BACKGROUND

Children with nephrotic syndrome (NS) are vulnerable to infections. Measles infection is an important cause of morbidity and mortality in immunosuppressed children. A suboptimal seroprotection against measles has been shown in immunocompromised children. There is limited published literature on measles immunity in children with difficult-to-treat nephrotic syndrome (DTNS). We compared the proportions of children with DTNS and healthy controls who were seroprotected against measles.

METHODS

This was a cross-sectional study. Measles-specific IgG antibodies of 108 children with DTNS (3 to 10 years of age) and an equal number of age-matched healthy controls were measured. All children had received two doses of measles-containing vaccine at 9-12 and 16-24 months of age under routine immunisation programme. Serum measles IgG antibody titres were measured by indirect ELISA. The assay results were interpreted as (1) > 11 NTU (NovaTec Units), positive/seroprotective titres; (2) 9-11, equivocal; and (3) < 9 NTU, negative. Inter- and intra-group comparisons were made to identify the disease characteristics related to seroprotection status.

RESULTS

The proportion of children with protective anti-measles antibodies (n = 70, 65%) was significantly lower in DTNS as compared to controls (n = 88, 81.48%) (p = 0.005). Their median [IQR] antibody titres were also significantly lower than those in controls (14.1 [14] NTU vs. 18.3 [15.2] NTU (p = 0.001). The age, gender, clinical subtype, duration of disease, and type of immunosuppressive therapy were not significantly different between seroprotected and non-seroprotected children with DTNS.

CONCLUSION

A significantly lower percentage of fully vaccinated children with DTNS were seroprotected against measles compared to healthy controls. A higher resolution version of the Graphical abstract is available as Supplementary information.

Subacute Sclerosing Panencephalitis in Children: The Archetype of Non-Vaccination

Subacute sclerosing panencephalitis (SSPE) is a late complication of measles virus infection that occurs in previously healthy children. This disease has no specific cure and is associated with a high degree of disability and mortality. In recent years, there has been an increase in its incidence in relation to a reduction in vaccination adherence, accentuated by the COVID-19 pandemic. In this article, we take stock of the current evidence on SSPE and report our personal clinical experience. We emphasise that, to date, the only effective protection strategy against this disease is vaccination against the measles virus.

Feasibility of identifying plasma donors with high measles neutralizing antibody concentrations for the use of producing a measles hyperimmune globulin for postexposure prophylaxis

Immune globulin (IG) is administered as measles postexposure prophylaxis (PEP) in people with primary immunodeficiency disorders or individuals not eligible for live virus vaccination. However, measles virus (MeV) neutralizing antibody (nAb) levels in plasma for fractionation and IG products fractionated thereof have declined. Here, the feasibility of producing a measles hyperimmune globulin (HIG) for PEP of high-risk individuals was investigated. Plasma samples (n = 384) were selected based on donor self-identification for previous MeV infection or vaccination, to determine the MeV-nAb content and compare it to the potency of plasma pools (n = 13) from the current IG manufacture. Convalescent donors have higher mean MeV-nAb concentrations (3.9 IU/mL) than vaccinated donors (2.5 IU/mL), as previously reported. However, their selection would only result in a 1.4-fold elevated nAb concentration compared to current plasma pools, which is not sufficient for HIG production. Interestingly, thirty-two donors (8%) had a MeV-nAb concentration of ≥ 8 IU/mL. The selective use of these plasma donations would result in sixfold higher plasma pool concentrations, which should permit the manufacture of the measles HIG. Further, the longitudinal analysis of a subset of individuals who repeatedly donated plasma at a high frequency revealed only a minor decline (~ 30%) of MeV-nAb levels. Repeat donations of such high-potency donors would thus facilitate the production of the measles HIG. Due to its markedly raised MeV-nAb concentration compared to standard IG, such preparation could significantly shorten infusion time and thus improve the treatment experience for both physicians and patients, especially infants.

Molecular identification and characterization of Measles virus genotypes circulating in Afghanistan, 2008-2018

The measles virus remains a leading cause of morbidity and mortality in children under five years of age. Molecular identification of circulating wild-type measles virus (MV) strains is a vital component of the measles elimination program. We received 159 oral swab samples from Afghanistan during 2008-2018. Viral RNA was extracted, followed by one-step RT-PCR and positive amplicons were subject to sequencing for genotype identification. Out of 159 total samples, 52% (83/159) were detected positive by RT-PCR. Genotype D4 was identified from 2.4% (2/83), genotype H1, 4.8% (4/83) and genotype B3, 92.7% (77/83) cases respectively. This article is protected by copyright. All rights reserved.

Innovations in vaccine delivery: increasing access, coverage, and equity and lessons learnt from measles and rubella elimination

Disease eradication and elimination programs drive innovations based on progress toward measurable objectives, evaluations of new strategies and methods, programmatic experiences, and lessons learned from the field. Following progress toward global measles elimination, reducing measles mortality, and increasing introductions of measles and rubella vaccines to national programs, the measles and rubella immunization program has faced setbacks in recent years. Currently available vaccine delivery methods have complicated logistics and drawbacks that create barriers to vaccination; innovations for easier, more efficient, and safer vaccine delivery are needed. Progress can be accelerated by new technologies like microarray patches (MAPs) that are now widely recognized as a potential new tool for enhancing global immunizations efforts. Clinical trials of measles-rubella vaccine MAPs have begun, and several other vaccine MAPs are in the pre-clinical development pathway. MAPs could significantly contribute to Immunization Agenda 2030 priorities, including reaching zero-dose children; increasing vaccine access, demand, coverage, and equity; and achieving measles and rubella elimination. With strong partnerships between public health agencies and biotechnology companies, translational novel vaccine delivery systems can be developed to help solve public health problems and achieve global health priorities.

Measles susceptibility in maternal-infant dyads-Bamako, Mali

Measles is endemic in Africa; measles mortality is highest among infants. Infant measles antibody titer at birth is related to maternal immune status. Older mothers are likelier to have had measles infection, which provides higher antibody titers than vaccine-induced immunity. We investigated the relationship between maternal age and measles susceptibility in mother-infant pairs in Mali through six months of infancy. We measured serum measles antibodies in 340 mother-infant pairs by plaque reduction neutralization test (PRNT) and calculated the proportion of mothers with protective titers (>120 mIU/mL) at delivery and the proportion of infants with protective titers at birth, and at three and six months of age. We explored associations between maternal age and measles antibodies in mothers and infants at the timepoints noted. Ten percent of Malian newborns were susceptible to measles; by six months nearly all were. Maternal and infant antibody titers were highly correlated. At delivery, 11% of mothers and 10% of newborns were susceptible to measles. By three and six months, infant susceptibility increased to 72% and 98%, respectively. Infants born to younger mothers were most susceptible at birth and three months. Time to susceptibility was 6.6 weeks in infants born to mothers with measles titer >120-<430 mIU/mL versus 15.4 weeks when mothers had titers ≥430 mIU/mL. Maternal and newborn seroprotective status were positively correlated. Improved strategies are needed to protect susceptible infants from measles infection and death. Increasing measles immunization coverage in vaccine eligible populations, including nonimmune reproductive-aged women and older children should be considered.

Measles

Measles is a highly contagious, potentially fatal, but vaccine-preventable disease caused by measles virus. Symptoms include fever, maculopapular rash, and at least one of cough, coryza, or conjunctivitis, although vaccinated individuals can have milder or even no symptoms. Laboratory diagnosis relies largely on the detection of specific IgM antibodies in serum, dried blood spots, or oral fluid, or the detection of viral RNA in throat or nasopharyngeal swabs, urine, or oral fluid. Complications can affect many organs and often include otitis media, laryngotracheobronchitis, pneumonia, stomatitis, and diarrhoea. Neurological complications are uncommon but serious, and can occur during or soon after the acute disease (eg, acute disseminated encephalomyelitis) or months or even years later (eg, measles inclusion body encephalitis and subacute sclerosing panencephalitis). Patient management mainly involves supportive therapy, such as vitamin A supplementation, monitoring for and treatment of secondary bacterial infections with antibiotics, and rehydration in the case of severe diarrhoea. There is no specific antiviral therapy for the treatment of measles, and disease control largely depends on prevention. However, despite the availability of a safe and effective vaccine, measles is still endemic in many countries and causes considerable morbidity and mortality, especially among children in resource-poor settings. The low case numbers reported in 2020, after a worldwide resurgence of measles between 2017 and 2019, have to be interpreted cautiously, owing to the effect of the COVID-19 pandemic on disease surveillance. Disrupted vaccination activities during the pandemic increase the potential for another resurgence of measles in the near future, and effective, timely catch-up vaccination campaigns, strong commitment and leadership, and sufficient resources will be required to mitigate this threat.

Spatial distribution and associated factors of measles vaccination among children aged 12-23 months in Ethiopia. A spatial and multilevel analysis

INTRODUCTION

In Ethiopia, measles continues to be the cause of a significant number of vaccine-preventable infant morbidity and mortality due to the low vaccination rate. However, understanding the geographical distribution of the measles-containing vaccine first dose (MCV1) and identifying associated factors is crucial to setting up appropriate interventions. This study aimed to explore the spatial distribution and associated factors of MCV1 coverage among children aged 12-23 months in Ethiopia using national representative data.

METHODS

A cross-sectional study design using a two-stage stratified sampling technique was used. The analysis was performed using STATA 14.2, ArcGIS 10.8, and SaTScan version 9.6 software. To find significant related factors with measles vaccination, researchers used multilevel logistic regression.

RESULTS

The prevalence of MCV1 in Ethiopia was 58.5%. A spatial variation of MCV1 coverage was observed across the study area. The most likely significant primary clusters with low MCV1 coverage were observed in Liben, Afder, Shebelle, Korahe, and Nogob zones of the Somali region; Bale and Guji zones of the Oromia region, and Gedeo and Sidama zones of the SNNPR. Rural areas, maternal primary education, secondary and above school education, Orthodox religion, Muslim religion, health facility delivery, and Afar region were significantly associated with MCV1 vaccination.

CONCLUSION

The overall MCV1 coverage in Ethiopia was low. Aside from the inadequate coverage, there was a geographical variation across the country. Low MCV1 coverage areas should be prioritized to improve vaccination efforts to control measles across the country.

Polio health economics: assessing the benefits and costs of polio, non-polio, and integrated activities of the Global Polio Eradication Initiative

Background: Investments made by countries and donors to support polio eradication and the Global Polio Eradication Initiative (GPEI) over the past 35 years provided financial support for significant health interventions beyond the prevention of polio. Prior economic analyses that sought to quantify the economic benefits of some interventions encountered insufficient data and evidence associated with non-polio-specific activities. The 2022-2026 GPEI Strategic Plan explicitly identified integration and gender equity as funded mandates that must move forward in parallel with polio eradication, but these goals remain vaguely defined from a health economic perspective. Methods: To ensure unambiguous and full accounting for all financial investments in the GPEI, polio eradication, and other desirable objectives, we identify the health economic analysis methods and inputs needed to ensure transparent financial accountability and cost-effective use of funds. Results: Sufficient inputs and methods exist to characterize the health and economic benefits of polio-specific activities, but we identified the need for additional information and method development for some non-polio-specific and cost-sharing activities. Donors who seek to support non-polio-specific objectives as part of the GPEI may want to provide dedicated support financing for which it may be difficult to apply typical health economic criteria and to expect net health and/or net economic benefits. Conclusions: Given the mixture of funding sources provided to the GPEI, which includes support by governments and private donors, we recommend that the GPEI separately account for financial needs that represent necessities for polio eradication from those used for other stated objectives. An added layer of specificity that identifies all funds according to each activity, the accountable party and/or parties, and the associated measurable health or other outcome(s), will enable improved health economic analyses and reporting to donors who seek to track returns on their investments.

Nepal Measles outbreak response immunization during COVID-19: a risk-based intervention strategy

In 2020, National Immunization Programme (NIP) of Nepal implemented a measles outbreak response immunization (ORI) campaign, which was additional to an ongoing preventive measles-rubella SIA campaign. Both campaigns were implemented during ongoing COVID-19 transmission. By April, 220 measles cases and two deaths were confirmed from eight districts of Nepal. The NIP triangulated information from surveillance (measles and COVID-19), measles immunization performance and immunity profile, programme capacities and community engagement and applied a logical decision-making framework to the collated data to inform ‘Go/No-Go’ decisions for ORI interventions. This was reviewed by the National Immunization Advisory Committee (NIAC) for endorsement. Outbreak response with non-selective immunization (ORI), vitamin-A administration and case management were implemented in affected municipalities of four districts, while in the remaining districts outbreak response without ORI were undertaken. The structure and iterative application of this logical framework has been described. ORI was implemented without interrupting the ongoing measles-rubella vaccination campaign which had targeted children from 9 to 59 months of age. The age group for ORI was same as SIA in one sub-district area, while for the other three sub-district areas it was from 6 months to 15 years of age. More than 32,000 persons (97% coverage) were vaccinated in ORI response. Overall measles incidence decreased by 98% after ORI. The daily incidence rate of measles was 94 times higher (95% confidence interval: 36.11 – 347.62) before the ORI compared to two weeks after ORI until year end. Close attention to surveillance and other data to inform actions and seamless collaboration between NIP and core immunization partners (WHO, UNICEF), with guidance from NIAC were key elements in successful implementation. This was an example of feasible application of the global framework for implementation of a mass vaccination campaign during COVID-19 through application of a simple decision-making logical framework.

Trends of the Global, Regional, and National Incidence of Measles, Vaccine Coverage, and Risk Factors in 204 Countries From 1990 to 2019

Background

Measles is a highly contagious disease that has caused global morbidity and mortality. Though great progress has been made in measles elimination, the resurgence of measles has been observed in recent years. As extant literature were mainly confined to data of local area, we conducted a systematic analysis to explore the trends of the incidence of measles, coverage rate, and the risk factors from 1990 to 2019 on global, regional, and national levels.

Methods

Data on cases of incidence, age standardized rate (ASR), vaccine coverage, and risk factors of measles were retrieved from the Global Burden of Disease (GBD) Study 2019 database. Estimated averaged percentage change (EAPC) of ASR was calculated to quantify the trends of measles incidence. Pearson correlation was applied to assess the association of EAPC and measles-containing vaccine coverage rate with socio-demographic index (SDI) in 2019, and the correlation between ASR and measles-containing vaccine coverage rate.

Results

Globally, there was a significant decrease in the number (84.18%) and ASR (6.13%, 95% CI: 5.41–6.84%) of measles incidence from 1990 to 2019. More than 80% of incidence cases were attributed to children under 5 and the proportion was highest in low SDI region. Countries and territories with low ASRs are mostly clustered in North America, Southern Latin America, and Western Europe, whereas those with high ASRs are mainly clustered in Africa, East Asia, and South Asia. Lower SDI was associated with higher ASR and lower vaccine coverage rate. The more the SDI value was further away from 0.6, the smaller the absolute value did EAPC have. Child wasting accounted for the most measles-related death cases, followed by child underweight, child stunting, and vitamin A deficiency.

Conclusions

Measles eradication is feasible, but urgently demands political commitment, financial support, and public engagement. In the context of COVID-19 pandemic and the global resurgence of measles, surveillance systems and routine immunization programs should be improved, while vaccine hesitancy needs to be addressed.