Wednesday, 31 October 2007
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POST 01179E : ERADICATION EFFORTS Follow-up on Post 001174E 31 October 2007 _________________________________ This long contribution is sent by Robert Steinglass from IMMUNIZATIONbasics in the United States. _________________________________ "Stop the madness!" Dear Moderator, Thank you for posting Bob Davis' thoughtful piece. But at the very end, he asks: "Will rubella eradication move on to the global agenda in this century?" He provides us with an answer to his own question: "This can happen if, and only if African governments take congenital rubella syndrome and its elimination more seriously than they currently do." What may seem to him like a lack of seriousness should instead be interpreted as responsible public health practice. Perhaps it is we who should be taking African governments more seriously than we currently do… A recent thoughtful discussion on rubella in India will be of interest. Two meetings of the sub-group of the NTAGI were held on 3rd May and 15th May, 2007 under the chairmanship of Dr. Ambujam Nair Kapoor, DDG (SG), Indian Council on Medical Research to discuss the formulation of guidelines and strategies for introduction of Rubella/MMR/MR vaccine in the Indian National Immunization Program. I quote the conclusions verbatim from the minutes, which I consider to be a very prudent and responsible approach: (i) In view of current levels of immunization coverage, introduction of MMR/Rubella/ MR immunization at the national level in the Universal Immunization Programme is not recommended. (ii) Introduction of MMR could be considered in states which have the ability to achieve and sustain routine immunization coverage of >85% . (iii) The suggested strategy for immunization in these states is MMR at the time of DPT booster (16-24 months) assuming that the states will be able to achieve & maintain high immunization coverage at this age group, similar to that of measles vaccine coverage. This would also have the advantage of providing a second dose of measles vaccine in this age group. (iv) Simultaneously these states should undertake a one time immunization of adolescent girls (10-19 years) with rubella vaccine either as a campaign or as part of Adolescent Friendly Health Services initiatives under NRHM. (v) States introducing MMR should also establish surveillance for rubella and investigate all cases of fever with rash for measles and rubella as part of the measles surveillance undertaken by the NPSP/IDSP and also commence surveillance for cases of CRS by establishing sentinel surveillance units in the districts. At the Indian meetings, worrisome data were shown from Greece, which should be looked at closely by any country considering rubella vaccine introduction. The two following slides are sobering. Panagiotopoulos et al show that MMR was introduced in Greece in 1975 when coverage with measles was less than 50%. An epidemic of CRS occurred about 7 years later that was greater than the pre-introduction epidemic in the early 70's by a factor of two. Another epidemic in the early 90's was similar in size to the pre-vaccine introduction epidemic of the 70's, with a mean age of 17 years and 64% of cases older than 15 years of age. Vynnycky et al explain that persistently moderate coverage levels lead to reduced rubella virus circulation, leads to increased average age of infection, leads to risk of escaping from disease in early childhood when rubella is innocuous and, if low vaccination coverage, the accompanying risk of not receiving immunization, leads to increased rubella susceptibility among women of childbearing age, leads to increased risk of CRS. At a meeting on interruption of indigenous measles transmission in South Africa in October 2003, after a stirring presentation by one WHO staff member from Geneva about the dangers of rubella and the implication that African countries should begin introducing it as soon as possible, another WHO staff member from Geneva bravely challenged, saying that it would be "public health malpractice" for most African countries to introduce rubella vaccine at that time. Her concern was that a given high-performing country might succeed in reaching >80% measles coverage in a single year, but few were able to achieve that level of coverage for several years in a row. And most African countries are not yet performing at that high level even for a single year. In short, it should be obvious that African countries must focus on strengthening their ability to systematically immunize their kids with the primary first dose of measles vaccine (as well as to strengthen their systems to introduce new multiple-dose vaccines). Only if the system is strong enough to sustain high coverage over several consecutive years should a given country consider introduction of rubella vaccine. And the sudden increase of coverage to over 80% during a campaign should not be confused with the ability to provide the first primary dose year after year through the regular service delivery system. Countries should resist the implied pressure from agencies to move faster than is safely warranted. And for Bob to suggest not simply rubella vaccine introduction but its eventual eradication - - when we are still facing serious short- and long-term immunological, virological, epidemiological, operational and financial challenges in the "eradication" of polio (by which I do not mean the global interruption of circulating poliovirus a single time, but as many times as will be required due to re-emergence of "circulating" vaccine-derived polivirus (cVDPV) and "immunodeficient" vaccine derived polivirus (iVDPV) and the latest so-called "ambiguous" vaccine derived poliovirus (aVDPV, or should we be calling it "non-c, non-i VDPV" to leave room for others that may come along?) - - seems bizarre. Robert Steinglass IMMUNIZATIONbasics ______________________________________________________________________________ All members of the TechNet21 e-Forum are invited to send comments on any posting or to use the forum to raise a new discussion or request technical information in relation to immunization services. 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