Nepal’s Hard-fought Victory Against Rubella
Rubella virus can infect susceptible women in pregnancy causing miscarriage and significant lifelong disability in the offspring. Infection of the mother during pregnancy can damage the unborn child’s heart, eyes, and ears leading to lifelong disability from congenital rubella syndrome (CRS). Studies in Nepal had estimated that in the pre-vaccination era, more than a 1000 infants were born with CRS every year in Nepal (annual incidence rate ~192/100,000 live births), inflicting a significant burden of life long disability for a developing country.
The Verification Commission for WHO South East Asia Region (SEAR), an independent body of experts, met in Delhi from 31 July to 2 August 2018 for its annual review and validation of measles elimination and rubella and CRS control for WHO SEAR countries.
Based on an in-depth review of the data and reports provided by independent country national verification committees, the Commission certified on 3 August 2018 that Nepal has successfully controlled rubella and congenital rubella syndrome. Nepal has achieved 97% reduction of rubella cases (against a target of 95%) compared to 2008. Nepal has achieved this goal two years ahead of the regional target year of 2020 and one year ahead of the national target of 2019.
This is indeed a proud moment for Nepal and is another milestone in its list of successes against vaccine preventable disease (VPD) like polio, measles, and Japanese encephalitis. At this moment, we pause and look back, asking ourselves what did Nepal do to reach here?
The strategy and execution
Strong immunization delivery systems guided by sensitive and actionable surveillance data are the main strategies to control any VPD including rubella.
The National Immunization Programme (NIP) of Nepal had been delivering one dose of measles vaccine to all infants since 1989. The NIP introduced Rubella vaccine in 2013 as measles-rubella (MR) vaccine. Since 2015, NIP delivers two doses of MR vaccine to all children in Nepal at 9 and 15 months of age. All vaccines included in NIP are given free of cost.
As per WHO and UNICEF estimates of national immunization coverage for 2017, Nepal has a high coverage of MR first dose at 90%, while coverage of MR second dose is 59%. NIP is trying to reach at least 95% with both doses of MR vaccine to sustain rubella control and to achieve measles elimination.
Further, Nepal has conducted mass immunization campaigns with measles vaccine in 2004 and 2008, and with measles-rubella vaccine in 2012 and in 2015-2016 after the massive earthquake. Another MR vaccination campaign has been planned in the last quarter of 2019.
While high coverage with two doses of MR vaccine through routine immunization remains the key to maintaining high population immunity for both measles and rubella, these supplementary immunization campaigns help to quickly enhance population immunity to reduce or interrupt transmission.
To validate that a control or elimination target has been achieved, and to identify geographic areas and target age groups for immunization activities, national programmes need to be guided by timely and reliable surveillance data. This is a critical piece of information which needs sustained engagement with health care providers to encourage reporting of suspected cases, clinical and field investigations, and laboratory testing to confirm rubella infection in suspected cases of fever and rash.
In Nepal, the Immunization Preventable Disease (IPD) unit of WHO Nepal provides technical support to the Family Welfare Division of Ministry of Health and Population in all areas of VPD surveillance and control. It was surveillance data from this system that was used by the Regional Verification Commission to validate that indeed Nepal has achieved rubella control by reducing rubella incidence by 97%.
As surveillance data shows, measles incidence has also been reduced by 98%. However, the target for measles is elimination (zero incidence) which is what Nepal must strive for now, trying to increase coverage with two doses of MR vaccine to at least 95% supported by sensitive surveillance.
WHO Nepal would like to congratulate Government of Nepal, Ministry of Health & Population, all health workers, partners, and stakeholders on achieving this historic milestone in rubella control. WHO Nepal also renews its commitment to support sustaining rubella control and strive for measles elimination in the country. WHO will continue providing robust technical assistance to intensify efforts to raise population immunity to above 95% with a sensitive surveillance system to achieve measles elimination.
. Upreti S R, et al. Developing rubella vaccination policy in Nepal—results from rubella surveillance and sero- prevalence and congenital rubella syndrome studies. The Journal of Infectious Diseases 2011;204: S433–S438
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