Supplementary immunization activities (SIAs) aim to interrupt measles transmission by reaching susceptible children, including children who have not received the recommended two routine doses of MCV before the SIA. However, both strategies may miss the same children if vaccine doses are highly correlated. How well SIAs reach children missed by routine immunization is a key metric in assessing the added value of SIAs.Children aged 9 months to younger than 5 years were enrolled in cross-sectional household serosurveys conducted in five districts in India following the 2017-2019 measles-rubella (MR) SIA. History of measles containing vaccine (MCV) through routine services or SIA was obtained from documents and verbal recall. Receipt of a first or second MCV dose during the SIA was categorized as "added value" of the SIA in reaching un- and under-vaccinated children.A total of 1,675 children were enrolled in these post-SIA surveys. The percentage of children receiving a 1st or 2nd dose through the SIA ranged from 12.8% in Thiruvananthapuram District to 48.6% in Dibrugarh District. Although the number of zero-dose children prior to the SIA was small in most sites, the proportion reached by the SIA ranged from 45.8% in Thiruvananthapuram District to 94.9% in Dibrugarh District. Fewer than 7% of children remained measles zero-dose after the MR SIA (range: 1.1-6.4%) compared to up to 28% before the SIA (range: 7.3-28.1%).We demonstrated the MR SIA provided considerable added value in terms of measles vaccination coverage, although there was variability across districts due to differences in routine and SIA coverage, and which children were reached by the SIA. Metrics evaluating the added value of an SIA can help to inform the design of vaccination strategies to better reach zero-dose or undervaccinated children.
Introduction: Supplementary immunization activities (SIAs) aim to interrupt measles transmission by reaching susceptible children, including children who have not received the recommended two routine doses of MCV before the SIA. However, both strategies may miss the same children if vaccine doses are highly correlated. How well SIAs reach children missed by routine immunization is a key metric in assessing the added value of SIAs.Methods: Children aged 9 months to younger than 5 years were enrolled in cross-sectional household serosurveys conducted in five districts in India following the 2017-2019 measles-rubella (MR) SIA. History of measles containing vaccine (MCV) through routine services or SIA was obtained from documents and verbal recall. Receipt of a first or second MCV dose during the SIA was categorized as 'added value' of the SIA in reaching un- and under-vaccinated children.Results: A total of 1,675 children were enrolled in these post-SIA surveys. The percentage of children receiving a 1st or 2nd dose through the SIA ranged from 13% in Thiruvananthapuram District to 49% in Dibrugarh District. Although the number of zero-dose children prior to the SIA was small in most sites, the proportion reached by the SIA ranged from 46% in Thiruvananthapuram District to 95% in Dibrugarh District. Fewer than 7% of children remained measles zero-dose after the MR SIA (range: 1% to 6%) compared to up to 28% before the SIA (range: 7% to 28%).Discussion: We demonstrated the MR SIA provided considerable added value in terms of measles vaccination coverage, although there was variability across districts due to differences in routine and SIA coverage, and which children were reached by the SIA. Metrics evaluating the added value of an SIA can help to inform the design of vaccination strategies to better reach zero-dose or undervaccinated children.
All World Health Organization regions have set measles elimination goals. We find that as countries progress toward these goals, they undergo predictable changes in the size and frequency of measles outbreaks. A country's position on this "canonical path" is driven by both measles control activities and demographic factors, which combine to change the effective size of the measles-susceptible population, thereby driving the country through theoretically established dynamic regimes. Further, position on the path to elimination provides critical information for guiding vaccination efforts, such as the age profile of susceptibility, that could only otherwise be obtained through costly field studies or sophisticated analysis. Equipped with this information, countries can gain insight into their current and future measles epidemiology and select appropriate strategies to more quickly achieve elimination goals.
Measles elimination depends on the successful deployment of measles containing vaccine. Vaccination programs often depend on a combination of routine and non-routine services, including supplementary immunization activities (SIAs) and vaccination weeks (VWs), that both aim to vaccinate all eligible children regardless of vaccination history or natural infection. Madagascar has used a combination of these activities to improve measles coverage. However, ongoing massive measles outbreak suggests that the country was in a "honeymoon" period and that coverage achieved needs to be re-evaluated. Although healthcare access is expected to vary seasonally in low resources settings, little evidence exists to quantify temporal fluctuations in routine vaccination, and interactions with other immunization activities.We used three data sources: national administrative data on measles vaccine delivery from 2013 to 2016, digitized vaccination cards from 49 health centers in 6 health districts, and a survey of health workers. Data were analyzed using linear regressions, analysis of variance, and t-tests.From 2013 to 2016, the footprint of SIAs and VWs is apparent, with more doses distributed during the relevant timeframes. Routine vaccination decreases in subsequent months, suggesting that additional activities may be interfering with routine services. The majority of missed vaccination opportunities occur during the rainy season. Health facility organization and shortage of vaccine contributed to vaccination gaps. Children born in June were the least likely to be vaccinated on time.Evidence that routine vaccination coverage varies over the year and is diminished by other activities suggests that maintaining routine vaccination during SIAs and VWs is a key direction for strengthening immunization programs, ensuring population immunity and avoiding future outbreaks.Wellcome Trust Fund, Burroughs Wellcome Fund, Gates Foundation, National Institutes of Health.
In alignment with the Measles and Rubella (MR) Strategic Elimination plan, India conducted a mass measles and rubella vaccination campaign across the country between 2017 and 2020 to provide a dose of MR containing vaccine to all children aged 9 months to 15 years. We estimated campaign vaccination coverage in five districts in India and assessed campaign awareness and factors associated with vaccination during the campaign to better understand reasons for not receiving the dose.
Residual blood specimens collected at health facilities may be a source of samples for serosurveys of adults, a population often neglected in community-based serosurveys. Anonymized residual blood specimens were collected from individuals 15 - 49 years of age attending two sub-district hospitals in Palghar District, Maharashtra, from November 2018 to March 2019. Specimens also were collected from women 15 - 49 years of age enrolled in a cross-sectional, community-based serosurvey representative at the district level that was conducted 2 - 7 months after the residual specimen collection. Specimens were tested for IgG antibodies to measles and rubella viruses. Measles and rubella seroprevalence estimates using facility-based specimens were 99% and 92%, respectively, with men having significantly lower rubella seropositivity than women. Age-specific measles and rubella seroprevalence estimates were similar between the two specimen sources. Although measles seropositivity was slightly higher among adults attending the facilities, both facility and community measles seroprevalence estimates were 95% or higher. The similarity in measles and rubella seroprevalence estimates between the community-based and facility serosurveys highlights the potential value of residual specimens to approximate community seroprevalence.
Implications of the COVID-19 pandemic for both populations and healthcare systems are vast. In addition to morbidity and mortality from COVID-19, the pandemic also disrupted local health systems, including reductions or delays in routine vaccination services and catch-up vaccination campaigns. These disruptions could lead to outbreaks of other infectious diseases that result in an additional burden of disease and strain on the healthcare system. We evaluated the impact of the COVID-19 pandemic on Zambia's routine childhood immunization program in 2020 using multiple sources of data. We relied on administrative vaccination data and Zambia's 2018 Demographic and Health Survey to project national disruptions to district-specific routine childhood vaccination coverage within the pandemic year 2020. Next, we leveraged a 2016 population-based serological survey to predict age-specific measles seroprevalence and assessed the impact of changes in vaccination coverage on measles outbreak risk in each district. We found minor disruptions to routine administration of measles-rubella and pentavalent vaccines in 2020. This was in part due to Zambia's Child Health Week held in June of 2020 which helped to reach children missed during the first six months of the year. We estimated that the two-month delay in a measles-rubella vaccination campaign, originally planned for September of 2020 but conducted in November of 2020 as a result of the pandemic, had little impact on modeled district-specific measles outbreak risks. This study estimated minimal increases in the number of children missed by vaccination services in Zambia during 2020. However, the ongoing SARS-CoV-2 transmission since our analysis concluded means efforts to maintain routine immunization services and minimize the risk of measles outbreaks will continue to be critical. The methodological framework developed in this analysis relied on routinely collected data to estimate disruptions of the COVID-19 pandemic to national routine vaccination program performance and its impact on children missed at the subnational level can be deployed in other countries or for other vaccines.
7-11 November 2010, Tenth International Congress on Drug Therapy in HIV Infection, Glasgow, UK Despite increasing reports of successful pregnancies whilst using Efavirenz (EFZ), the drug remains Category C during pregnancy due to concerns around teratogenicity [1]. Additionally, EFZ can render many hormonal methods of contraception less effective. For these reasons, UK guidance suggests that HIV positive women should be informed of these effects before commencing treatment [2]. Following a case in this unit where a young HIV-positive woman had an unplanned pregnancy whilst using Implanon and taking EFZ/Truvada, we examined contraceptive use and advice given to women in our cohort using EFZ, and then instigated changes to improve practice in this area. Case-note review of all women taking EFZ in Jan 2008 and again in Feb 2010. Current contraception used, advice on teratogenicity, and advice on efficacy documentation was recorded. Women over 50, with documented menopause or hysterectomy were excluded. In 2008 we identified 31 females using EFZ in our cohort of 912 patients. Contraceptive choices are shown in Figure 1. 68% were using an 'effective' method of contraception (one not liable to reduced efficacy when using EFZ - condoms, IUS/IUD, sterilisation or recently documented no partner). 36% had documented advice regarding teratogenicity and 75% regarding reduced efficacy of hormonal methods. Following these results we introduced a section for contraception on our clinical review form (which is updated at each HIV clinic review) to act as a prompt for clinicians. After this change was made, we re-examining these data following this in 2010 (See Fig 1) and found 35 females using EFZ. 80% were using an 'effective' method of contraception, 50% had documented advice on teratogenicity and 100% regarding reduced efficacy of hormonal contraception (if appropriate). Simple changes such as adding contraception to a clinic proforma can help improve sexual and reproductive health outcomes in HIV positive women. However, there are still improvements to be made in documentation of advice given, particularly when using a Category C drug in women who may become pregnant. Additionally, women should be made aware of the potential interaction between antiretrovirals and hormonal contraceptives at the HIV clinic — particularly as some may not disclose their status to Family Planning or GP services and therefore we cannot assume that this advice is being given elsewhere.
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.
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