Introduction of rubella-containing-vaccine to Madagascar: implications for roll-out and local elimination.
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.
Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, MA, USA Center for Communicable Disease Dynamics, Harvard T. H. Chan School of Public Health, Boston, MA, USA.
Amy
A
Wesolowski
Virology Unit and Measles and Rubella WHO National Reference Laboratory, Institut Pasteur de Madagascar, Antananarivo, Madagascar.
Keitly
K
Mensah
Department of Geography and Environment, University of Southampton, Southampton, UK.
Cara E
CE
Brook
Virology Unit and Measles and Rubella WHO National Reference Laboratory, Institut Pasteur de Madagascar, Antananarivo, Madagascar.
Miora
M
Andrianjafimasy
Fogarty International Center, National Institutes of Health, Bethesda, MD, USA.
Amy
A
Winter
Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, MA, USA Center for Communicable Disease Dynamics, Harvard T. H. Chan School of Public Health, Boston, MA, USA Office of Population Research, Woodrow Wilson School, Princeton University, Princeton, NJ, USA.
Caroline O
CO
Buckee
Virology Unit and Measles and Rubella WHO National Reference Laboratory, Institut Pasteur de Madagascar, Antananarivo, Madagascar.
Richter
R
Razafindratsimandresy
Department of Geography and Environment, University of Southampton, Southampton, UK Fogarty International Center, National Institutes of Health, Bethesda, MD, USA Flowminder Foundation, Stockholm, Sweden.
Andrew J
AJ
Tatem
Virology Unit and Measles and Rubella WHO National Reference Laboratory, Institut Pasteur de Madagascar, Antananarivo, Madagascar.
Jean-Michel
JM
Heraud
Department of Ecology and Evolutionary Biology, Princeton University, Princeton, NJ, USA Office of Population Research, Woodrow Wilson School, Princeton University, Princeton, NJ, USA cmetcalf@princeton.edu.
C Jessica E
CJ
Metcalf
D005260:Female; D006801:Humans; D008270:Madagascar / Q000453:epidemiology; D008297:Male; D032541:Mass Vaccination; D008954:Models, Biological; D009313:National Health Programs; D012410:Rubella Syndrome, Congenital / Q000453:epidemiology* / Q000517:prevention & control*; D012411:Rubella Vaccine / Q000008:administration & dosage*
D012411:Rubella Vaccine
Africa; Madagascar; congenital rubella syndrome; evaluation of vaccination programmes; rubella; vaccination