Proceedings of the SAGE Working Group on Rubella Vaccines

1. Proceedings of the SAGE Working Group on Rubella Vaccines Susan E. Reef, MD Global Measles and Rubella Management Meeting March 15, 2011

2. Outline • Background • Terms of Reference • Opportunities to align with measles strategies • Recommendations from the WG • Phases of rubella control and CRS prevention (Goals) • Strategies • Paradoxical Effect • Minimum Coverage for Rubella Vaccine introduction • Recommendation from the WG on minimum threshold • Summary

3. Background • Current WHO rubella vaccine position paper was published in 2000 • Since the publication, there have been several areas that have changed • Additional countries using vaccine, • 2 regions with elimination goals and one with accelerated rubella control and CRS prevention • Additional information on vaccine safety (e.g., pregnant women) • Additional information duration of immunity • Additional formulations of vaccine

4. Terms of ReferenceSAGE Working Group on Rubella • Review and propose necessary updates to the WHO rubella vaccine position paper of 2000. • Identify the information gaps, guide the work required to address the information gaps, and prepare for a SAGE review of the updated vaccination strategies. • The specific questions to be addressed: • What are the possible goals for rubella/CRS prevention and rubella/CRS elimination (country, regional or global)? • With the goals mentioned in question 1, what are the most appropriate vaccination strategies to achieve these goals? • What is the minimum required routine immunization coverage that should be achieved and maintained to ensure that the introduction of rubella-containing vaccine does not increase the risk of CRS?

5. Opportunities • In 2000 PP • Countries undertaking measles elimination should consider taking the opportunity to eliminate rubella as well, through use of MR or MMR vaccine in their childhood immunization programmes, and also in measles campaigns • Several potential areas of integration of measles and rubella • Combined vaccine (MR, MMR, MMRV) • Combined surveillance • Measles/rubella surveillance • Vaccine coverage monitoring • Adverse events monitoring

6. TABLE of the phases

7. Strategies • For each phase of rubella control and CRS prevention • Vaccination strategies • Surveillance recommendations • Integrated measles/rubella surveillance • CRS surveillance • Monitoring vaccine coverage

8. Strategies

9. Strategies, con’t

10. Paradoxical Effect • Possibility that introduction of universal childhood vaccination with inadequate coverage may lead to an increase in CRS • Low coverage  reduced transmission, increase in average age of infection of remaining susceptible • Children miss natural disease and vaccination and may enter reproductive age susceptible to rubella • WHO policy (2000) – > 80% MCV1 coverage to the national routine (childhood) program

12. Minimum Coverage • WHO policy (2000) – > 80% MCV1 coverage to the national routine (childhood) program • Re-evaluate the 80% MCV1 cut-off in relationship to the accumulated experiences in countries and regions

16. Draft Recommendations for minimum coverage threshold • For countries that want to introduce • Must have a well functioning program that is committed to sustaining rubella vaccination program long term • Well functioning programs should achieve MCV1 coverage 80% using WHO/UNICEF estimates either through routine or campaign or, if program doesn’t have 80%, be committed to improve immunization program. • Point out it is OK to give at 9 months – same as the previous position paper

17. Summary • Since the 2000 PP, several changes have occurred prompting an updating of the PP. • WG was established in 2010 • Using the experiences from the regions and countries, several different phases (Goals) and corresponding strategies were developed • With the re-evaluation of the minimum coverage threshold, countries may introduce RCV into routine childhood program if they can achieve an 80% MCV1 threshold either through routine or SIA