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WHO REVISED RECOMMENDATIONS ON RUBELLA VACCINATION

Sunday, 31st of July 2011 Print

WHO REVISED RECOMMENDATIONS ON RUBELLA VACCINATION

 

‘WHO recommends that countries take the opportunity offered by accelerated

measles control and elimination activities to introduce RCVs.’

 

Full text, with figures, is at http://www.who.int/wer/2011/wer8629.pdf

 

Since 1996, when only 83 WHO Member States used RCVs in their national immunization schedules, there has been a steady increase in the number of countries introducing vaccination against rubella, which is delivered in most countries as MMR during the second year of life. The level of introduction varies by WHO region, however: as of December 2009, a total of 130 of 193 Member States used RCVs in national immunization

schedules, including 2 (4%) of 46 Member States in the African Region, 35 (100%) in Region of the Americas, 15 (71%) of 21 in the Eastern Mediterranean Region,

53 (100%) in the European Region, 4 (36%) of 11 in the South-East Asia Region, and 21 (78%) of 27 in the Western Pacific Region.51 Of the remaining 63 countries that

have not yet introduced the vaccine, all are providing 2 doses of measles vaccine through a combination of routine immunization and supplementary immunization activities (SIAs) as part of accelerated efforts to reduce measles mortality or regional elimination efforts.

 

The Region of the Americas and the European Region have established goals to eliminate rubella by 2010 and 2015, respectively; the Western Pacific Region has established

an accelerated rubella and CRS prevention goal (<1 case per 100 000 live births); the Eastern Mediterranean Region has established a goal of CRS prevention without a target date for countries that have introduced national rubella vaccination programmes; the African Region and the South-East Asia Region have not established goals for rubella control or elimination. The African and South-East Asia regions have the highest estimated number of CRS cases and are also the regions with the lowest uptake of vaccine. However, in some countries within these regions high birth rates or high rubella transmission rates, or both, will result in a lower average age of infection that will likely result in a lower

incidence of CRS.10

WHO position on rubella vaccines

 

In light of the remaining global burden of CRS and proven efficacy and safety of RCVs, WHO recommends that countries take the opportunity offered by accelerated

measles control and elimination activities to introduce RCVs. These measles vaccine delivery strategies provide an opportunity for synergy and a platform for advancing rubella and CRS elimination.

 

All countries that have not yet introduced rubella vaccine, and are providing 2 doses of measles vaccine using routine immunization or SIAs, or both, should consider including RCVs in their immunization programme.

 

There are 2 general approaches to the use of rubella vaccine. One approach focuses exclusively on reducing CRS by immunizing adolescent girls or women of childbearing

age, or both, to provide individual protection.

The second approach is more comprehensive, focusing on interrupting rubella virus transmission and thereby eliminating rubella as well as CRS. To ensure the success

of this approach, rubella vaccination should be integrated with measles-vaccine delivery strategies through the use of MR or MMR vaccines.

 

Countries planning to introduce RCVs should review the epidemiology of rubella, including the susceptibility profile of the population; assess the burden of CRS; and

establish rubella and CRS prevention as a public health priority. Cost–benefit studies are not needed in every country before rubella vaccination is implemented; results from studies in countries with similar sociodemographic circumstances can be informative. Depending

on the burden of CRS and available resources, countries should define their goal and the time frame for achieving it (Table 1).

 

Introducing rubella vaccine into childhood immunization programmes implies a long-term commitment to achieving and maintaining sufficient immunization coverage to ensure a sustained reduction in the incidence of CRS and ultimately the elimination of rubella and

CRS. Strong political commitment to the elimination of rubella and CRS, and sustainable financing for vaccination and surveillance activities, should be in place before introducing rubella vaccination into the childhood immunization programme.

 

For countries undertaking the strategy of CRS reduction alone, adolescent and adult females should be vaccinated through either routine services or SIAs. This option will provide direct protection to women of childbearing age; however, the impact of this strategy is limited by the coverage achieved and the age groups targeted. In the absence of a programme that vaccinates infants and young children, rubella will continue to circulate,

resulting in ongoing exposure of pregnant women and the associated risk of CRS.

 

For countries undertaking the elimination of rubella and CRS, the preferred approach is to begin with MR vaccine or MMR vaccine in a campaign targeting a wide range of ages that is followed immediately by the introduction of MR or MMR vaccine into the routine programme. The first dose of an RCV can be delivered at 9 months or 12 months, depending on the level of measles virus transmission.23 All subsequent follow-up campaigns should use MR vaccine or MMR vaccine. In addition, countries should make efforts to reach women of childbearing age by immunizing adolescent girls or women of childbearing age, or both, either through routine services or mass campaigns.

 

Sustained low coverage of rubella immunization in infants and young children (for example, when rubella vaccine is used only in the private sector) can result in an increase in susceptibility among women of childbearing age that may increase the risk of CRS above

levels prior to the vaccine being introduced (known as a paradoxical effect). However, if vaccination coverage is sufficiently high, rubella transmission will be markedly reduced or interrupted, thereby removing the risk of rubella exposure for pregnant women.

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