Elsevier

Vaccine

Volume 31, Issue 17, 19 April 2013, Pages 2145-2151
Vaccine

A systematic review of rubella vaccination strategies implemented in the Americas: impact on the incidence and seroprevalence rates of rubella and congenital rubella syndrome

https://doi.org/10.1016/j.vaccine.2013.02.047Get rights and content

Abstract

Objective

To evaluate the impact of rubella vaccination strategies on the rates of acquired rubella and congenital rubella syndrome in the Americas.

Methods

We conducted a systematic review of the literature (MEDLINE, PubMed, EMBASE, Cochrane Library, Artemisa Database, LILACS Database, Evidence Portal, VHL-PAHO Portal, Scielo, and Grey-Literature sources) that was published from 1969–2010. We included studies on rubella incidence and seroprevalence rates that were associated with rubella vaccination. The quality of the studies was evaluated according to international guidelines.

Results

A total of 14 studies were identified: 2 clinical trials, 2 cohort studies, 3 transversal studies, 5 ecological studies, and 2 mathematical models. Childhood vaccination reduced the incidence of rubella by 23.6% to 99.6%, increased the occurrence of epidemic cycles in Argentina and in the United States, and shifted the illness to susceptible adults. Vaccination strategies that focused on women and children in Brazil were associated with a 5.5-fold greater incidence of rubella in men leading to new outbreaks and CRS. A combined vaccination strategy with a universal approach that included routine vaccination for boys, girls, women, and men in Mexico and in Costa Rica reduced the incidence of rubella by more than 98% and led to absence of CRS since 2008. A medium and a low risk of bias were found in 3 and 4 articles, respectively.

Conclusion

The results of this review demonstrate that the combined vaccination strategy with a universal approach was the most effective strategy as evidenced by a drastic reduction in the number of cases and the interruption of endemic transmission of rubella in the Americas.

Highlights

► A combined universal vaccination strategy was the most effective measure. ► This strategy would help achieve the goal of global rubella eradication in the near future. ► Other strategies shifted the disease to susceptible groups continuing transmission.

Introduction

The worldwide distribution of rubella is heterogeneous, and the Americas are a pioneer in the eradication of this disease [1]. This achievement was the result of the collaboration between countries and international agencies and the introduction of the rubella vaccine in 1969. More than 90% of the countries in the Americas were administering the vaccine by 2003. In 2010, the rubella vaccine was administered in all of the countries in the Americas, with a coverage rate greater than 92% and a 99.9% reduction in cases [2], [3]. The last endemic case occurred in Argentina in 2009 [4].

Two previous analyses demonstrated that vaccination strategies for children and combined vaccination strategies with a risk approach for adults, which are the two strategies that were implemented during the control phase, lengthened epidemic cycles and increased the occurrence of adult outbreaks [5], [6]. These strategies were used exclusively for more than 20 years with no interruption of the viral circulation of rubella.

Because of the commitment to eliminate rubella in the Americas, a comparison between the combined vaccination strategies that were used in the elimination phase, which incorporated a universal approach, and the strategies that were used in the control phase is needed. Therefore, we conducted a systematic literature review of the rubella vaccination strategies that were implemented in the Americas to document their impact on the incidence and seroprevalence rates of acquired rubella (AR) and congenital rubella syndrome (CRS).

Section snippets

Systematic review

We conducted a systematic review of all of the literature that was published from 1969–2011. We selected original studies that analyzed rubella incidence and seroprevalence in the Americas. The article search was performed from January 11, 2011, to March 16, 2011.

The descriptors that were used in the search are shown in the Supplemental Table. We conducted an electronic review of virtual libraries, search systems, databases, grey literature, and bibliographical reference lists for articles and

Results

We identified 3390 and 2397 article titles through electronic and manual searches, respectively (Supplemental Figure). A total of 14 studies met the selection criteria, of which 10 measured the incidence of AR, 4 measured CRS, and 7 measured the seroprevalence of rubella antibodies. The study design, year of publication, country, study population, vaccination strategy, number of doses, duration of follow-up, and outcomes (either seroprevalence or incidence) in each study are shown in Table 1.

Seroprevalence results

Vaccination strategy for children. The vaccination strategy for children that incorporated a universal approach with 2 anti-rubella vaccine doses (at 1 and 5 years of age) achieved a higher level of seroprevalence (90%) [26] compared with single-dose regimens (84.72%) [29] (Table 4).

Eight years after the implementation of single-dose vaccination among infants in Sao Jose do Rio Preto, Brazil, a seroprevalence survey documented reduction in antibody levels to below those required for protection

Discussion

The results of our systematic literature review demonstrate that the combined vaccination strategy with a universal approach, 2 doses in children 1–6 years of age and 1 dose in susceptible adult (both men and women) populations through a speed-up campaign, contributed to the elimination of rubella in the Americas, as observed in Costa Rica and in Mexico [10], [32]. The results of this vaccination strategy were observed in less than 5 years according to reports that described trends in the AR

Conclusions and public health implications

The combined vaccination strategy with a universal approach led to the interruption of wild rubella virus circulation, the elimination of active disease, and the prevention of CRS in the Americas in a period of time that was shorter than estimated compared with vaccination strategies for children or combined vaccination strategies with a risk approach for adult populations.

Because the rubella virus is easily transmitted and is present in other regions of the world, the Americas should continue

Conflicts of interest

The authors declare no conflicts of interest.

Funding

NMR received a scholarship from the Instituto Carlos Slim de la Salud.

The funding agency did not participate in the study design or in the decision to submit the paper for publication.

Acknowledgments

We would like to thank BA Natalia López and her personnel for their support in the literature search.

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