Regional disparities in measles vaccination coverage and their associated factors: an ecological study in Japan.

BACKGROUND: The decline in measles vaccination coverage is a global concern. In Japan, coverage of the first-dose of measles vaccine, which had exceeded the target of 95.0% since fiscal year (FY) 2010, fell to 93.5% in FY 2021. Vaccination coverage increased to 95.4% in FY 2022 but varied by municipality. Few studies have focused on regional disparities in measles vaccination coverage. This study aimed to clarify the regional disparities in measles vaccination coverage by municipality in Japan and their associated factors. METHODS: In this ecological study, the measles vaccination coverage in FY 2022; population density; area deprivation index (ADI, an indicator of socioeconomic status); proportion of foreign nationals, single-father households, single-mother households, and mothers aged ≥30 years; and number of medical facilities, pediatricians, and non-pediatric medical doctors in 1,698 municipalities were extracted from Japanese government statistics. Negative binomial regression was performed with the number of children vaccinated against measles as the dependent variable, number of children eligible for measles vaccination as the offset term, and other factors as independent variables. RESULTS: Vaccination coverage was less than 95.0% in 54.3% of municipalities. Vaccination coverage was significantly positively associated with population density and negatively associated with the proportion of single-father households, mothers aged ≥30 years, and the ADI (incidence rate ratio [IRR]: 1.004, 0.976, 0.999, 0.970, respectively). CONCLUSION: This study showed regional disparities in measles vaccination coverage in Japan. Single-father households, age of mothers, and socioeconomic status may be key factors when municipalities consider strategies to improve vaccination coverage.

Immunogenicity and reactogenicity following MMR vaccination in 5-7-month-old infants: a double-blind placebo-controlled randomized clinical trial in 6540 Danish infants.

Background: Measles is a highly contagious viral disease. Vaccinated mothers transfer fewer antibodies during pregnancy, resulting in shortened infant immunity. Earlier primary vaccination might avert the gap in protection. Methods: Healthy 5-7-month-old Danish infants were assigned in a 1:1 ratio to M-M-RVaxPro or placebo (solvent) in a double-blind, randomized trial between April 15, 2019 and November 1, 2021 (ClinicalTrials.govNCT03780179, EudraCT 2016-001901-18). Eligibility criteria were birth weight >1000 g and gestational age ≥32 weeks.Immunogenicity was measured by plaque reduction neutralization test (PRNT) and IgG ELISA before intervention, four weeks after intervention and routine MMR. Reactogenicity data were collected for six weeks and measured by hazard ratios (HR). Findings: 647 and 6540 infants participated in the immunogenicity and reactogenicity study, respectively; 87% and 99% completed follow-up. After early MMR, seroprotection rates (SPRs) were 47% (13%) in measles PRNT; 28% (2%), 57% (8%) in mumps and rubella IgG (placebo). For measles PRNT, geometric mean ratio was 4.3 (95% CI: 3.4-5.3) between randomization groups after intervention and 1.5 (95% CI: 1.3-1.9) after routine MMR.Reactogenicity was independent of randomization (HR, 1.0; 95% CI: 0.9-1.1). Severe adverse events occurred in 25 infants (HR, 1.8; 95% CI: 0.8-4.0); none deemed vaccine related. Interpretation: Early MMR elicited low SPRs but did not negatively impact short-term responses to a subsequent MMR. MMR at 5-7 months was safe and not associated with higher rates of reactogenicity than placebo. Funding: Innovation Fund Denmark.

Achieving measles elimination and emerging modified measles: Longitudinal measles epidemiology from 1982 to 2021 in Osaka Prefecture, Japan.

BACKGROUND: Measles is a contagious viral disease causing infant mortality in developing countries without vaccination programs. In Japan, measles vaccination was launched in 1978, surveillance commenced in 1981, and elimination was achieved in 2015. This was due to improved, legally required surveillance methods and vaccine programs. METHODS: The data sets of sentinel (1982-2007) and notifiable (2008-2021) disease surveillance, as well as the vaccination coverage, detected genotypes, and seroepidemiology during the study period in Osaka Prefecture, were analyzed. Additionally, the trend under the current notifiable surveillance was compared before (2008-2014) and after (2015-2021) measles elimination. RESULTS: Under sentinel surveillance, 51,107 cases were reported, predominantly infants aged 1-4 years (63.6 %). Under notifiable disease surveillance, the 781 patients were predominantly in their 20s-30s (43.7 %). From 2000, the age of the major susceptible group increased due to the rise in vaccination coverage, which exceeded 95% for the first dose in 1998 and 90% for the second dose in 2009. Consistent with these data, seroprevalence exceeded 95% in 2011. However, the geometric mean of the antibody titer showed a decreasing trend with a falling number of patients. Compared with before and after measles elimination, the number of modified measles cases increased from 10.1% to 48.2%. During the study period, 398 strains comprising eight genotypes were identified, and the dominant type changed over time. After measles elimination, genotypes B3 and D8, derived from imported cases, became predominant. CONCLUSIONS: Improved vaccination coverage and surveillance reduced measles cases and increased herd immunity. However, the lack of a booster effect due to the low incidence of measles caused waning antibody titers despite high seroprevalence, which may contribute to the rising rate of vaccine failures causing modified measles. Careful monitoring of measles incidence and herd immunity are necessary for measles eradication.

Measles vaccination and reduced child mortality: Prevention of immune amnesia or beneficial non-specific effects of measles vaccine?

Measles vaccine (MV) has been observed to reduce all-cause mortality more than explained by prevention of measles infection. Recently, prevention of "measles-induced immune amnesia" (MIA) has been proposed as an explanation for this larger-than-anticipated beneficial effect of measles vaccine (MV). According to the "MIA hypothesis", immune amnesia leads to excess non-measles morbidity and mortality, that may last up to five years after measles infection, but may be prevented by MV. However, the benefits of MV-vaccinated children could also be due to beneficial non-specific effects (NSEs) of MV, reducing the risk of non-measles infections (The "NSE hypothesis"). The epidemiological studies do provide some support for MIA, as exposure to measles infection before 6 months of age causes long-term MIA, and over 6 months of age for 2-3 months. However, in children over 6 months of age, the MIA hypothesis is contradicted by several epidemiological patterns: First, in community studies that adjusted for MV status, children surviving acute measles infection had lower mortality than uninfected controls (44%(95%CI: 0-69%)). Second, in six randomised trials and six observational studies comparing MV-vaccinated and MV-unvaccinated children, the benefit of MV changed minimally from 54%(43-63%) to 49%(37-59%) when measles cases were censored in the survival analysis, making it unlikely that prevention of measles and its long-term consequences explained much of the reduced mortality. Third, several studies conducted in measles-free contexts still showed significantly lower mortality after MV (55%(40-67%)). Fourth, administration of MV in the presence of maternal measles antibody (MatAb) is associated with much stronger beneficial effect for child survival than administration of MV in the absence of MatAb (55%(35-68%) lower mortality). The MIA hypothesis alone cannot explain the strongly beneficial effects of MV on child survival. Conversely, the hypothesis that MV has beneficial non-specific immune training effects is compatible with all available data. Consideration should be given to continuing MV even when measles has been eradicated.

Second-dose measles vaccination and associated factors among under-five children in urban areas of North Shoa Zone, Central Ethiopia, 2022.

Introduction: Measles remain a leading cause of vaccine-preventable infant mortality. In Africa, about 13 million cases and 6,50,000 deaths occur annually, with Sub-Saharan Africa having the highest morbidity and mortality. Ethiopia launched second-dose measles vaccination into the routine immunization program in the second year of life in 2019. However, little has been known about the coverage of the second-dose measles vaccine. Therefore, the purpose of this study was to assess the level of second-dose measles vaccine uptake and associated factors in North Shoa Zone, Central Ethiopia. Objective: To assess second-dose measles vaccination and associated factors among under-five children and to identify reasons for not being vaccinated in urban areas of North Shoa Zone, Central Ethiopia, 2022. Method: A community-based cross-sectional study was conducted from 1 February to 15 March 2022. The sample size was 410, and it was allocated proportionally to each kebelle. The study units were selected consecutively. The data were collected using structured interviewer-administered questionnaires. Four nurses were used as data collectors. Data were coded manually and entered into Epi-data Version 4.4.2.1. Frequency and cross-tabs were used for data cleaning. Data were analyzed using SPSS Version 21 software. Multicollinearity and model goodness-of-fit tests were checked. A multivariable logistic regression model at 95% CI was used to identify factors associated with the dependent variable. Result: The response rate was 90.7%. The level of second-dose measles vaccination among children in urban areas of North Shoa Zone was 42.5% [95% CI (36.8, 47.3)]. Maternal age of ≤ 25 years [AOR = 9.12: 95% CI (1.97, 42.19)], 26-30 years [AOR = 9.49: 95% CI (2.33, 38.63)], 31-35 years [AOR = 7.87: 95% CI (1.78, 34.79)]; average time mothers had been waiting for vaccination at the health facility [AOR = 3.68: 95% CI (1.33, 10.23)]; awareness about vaccine-preventable diseases [AOR = 4.15: 95% CI (1.53, 11.26)]; and awareness on recommended measles doses [AOR = 17.81: 95% CI (3.91, 81.22)] were identified as factors associated with MCV2 vaccination. The major reason (48.1%) reported by mothers for not vaccinating second-dose measles vaccine was being unaware of the need to return for second-dose measles vaccination. Conclusion and recommendation: The level of second-dose measles vaccination (MCV2) among children in urban areas of the North Shoa Zone was low. Maternal age, average time mothers had been waiting for vaccination at the health facility, awareness about vaccine-preventable diseases, recommended age for the last vaccination, and recommended measles doses were identified as factors associated with MCV2 uptake. The major reason for not vaccinating MCV2 was a lack of information (unaware of the need to return for MCV2, unaware of the need to return for MCV2, and the place and/or time of immunization unknown). Hence, enhancing awareness about vaccine-preventable diseases, shortening the average time for vaccination at the health facility by half an hour, creating an alerting mechanism for MCV2 appointments, and future studies on the effect of healthcare provider-related factors on MCV2 uptake are recommended.

In Elimination Settings, Measles Antibodies Wane After Vaccination but Not After Infection: A Systematic Review and Meta-Analysis.

BACKGROUND: We conducted a systematic review to assess whether measles humoral immunity wanes in previously infected or vaccinated populations in measles elimination settings. METHODS: After screening 16 822 citations, we identified 9 articles from populations exposed to wild-type measles and 16 articles from vaccinated populations that met our inclusion criteria. RESULTS: Using linear regression, we found that geometric mean titers (GMTs) decreased significantly in individuals who received 2 doses of measles-containing vaccine (MCV) by 121.8 mIU/mL (95% confidence interval [CI], -212.4 to -31.1) per year since vaccination over 1 to 5 years, 53.7 mIU/mL (95% CI, -95.3 to -12.2) 5 to 10 years, 33.2 mIU/mL (95% CI, -62.6 to -3.9), 10 to 15 years, and 24.1 mIU/mL (95% CI, -51.5 to 3.3) 15 to 20 years since vaccination. Decreases in GMT over time were not significant after 1 dose of MCV or after infection. Decreases in the proportion of seropositive individuals over time were not significant after 1 or 2 doses of MCV or after infection. CONCLUSIONS: Measles antibody waning in vaccinated populations should be considered in planning for measles elimination.

Measles Vaccination Elicits a Polyfunctional Antibody Response, Which Decays More Rapidly in Early Vaccinated Children.

BACKGROUND: Measles outbreaks are reported worldwide and pose a serious threat, especially to young unvaccinated infants. Early measles vaccination given to infants under 12 months of age can induce protective antibody levels, but the long-term antibody functionalities are unknown. METHODS: Measles-specific antibody functionality was tested using a systems serology approach for children who received an early measles vaccination at 6-8 or 9-12 months, followed by a regular dose at 14 months of age, and children who only received the vaccination at 14 months. Antibody functionalities comprised complement deposition, cellular cytotoxicity, and neutrophil and cellular phagocytosis. We used Pearson's r correlations between all effector functions to investigate the coordination of the response. RESULTS: Children receiving early measles vaccination at 6-8 or 9-12 months of age show polyfunctional antibody responses. Despite significant lower levels of antibodies in these early-vaccinated children, Fc effector functions were comparable with regular-timed vaccinees at 14 months. However, 3-year follow-up revealed significant decreased polyfunctionality in children who received a first vaccination at 6-8 months of age, but not in children who received the early vaccination at 9-12 months. CONCLUSIONS: Antibodies elicited in early-vaccinated children are equally polyfunctional to those elicited from children who received vaccination at 14 months. However, these antibody functionalities decay more rapidly than those induced later in life, which may lead to suboptimal, long-term protection.

Nigeria experience on the use of polio assets for the 2017/18 measles vaccination campaign follow-up.

BACKGROUND: The global polio eradication initiative has made giant stride by achieving a 99% reduction in Wild poliovirus (WPV) cases, with Nigeria on the verge of being declared polio-free following over 36 months without a WPV. The initiative has provided multiple resources, assets and lessons learnt that could be transitioned to other public health challenges, including improving the quality and vaccination coverage of measles campaigns in order to reduce the incidences of measles in Nigeria. We documented the polio legacy and assets used to support the national measles campaign in 2017/2018. METHODS: We documented the integration of the measles campaign coordination with the Polio Emergency Operation Centre (EOC) at national and state levels for planning and implementing the measles SIA. Specific polio strategies and assets, such as the EOC incident command framework and facilities, human resource surge capacity, polio GIS resource These strategies were adapted and adopted for the MVC implementation overcome challenges and improve vaccination coverage. We evaluated the performance through a set process and outcome indicators. RESULTS: All the 36 states and Federal Capital Territory used the structure and resources in Nigeria and provided counterpart financing for the MVC 2017/ 2018. The 11 polio high-risk states deployed the use of GIS for microplanning process, while daily call-in data were tracked in 99.7% of the LGAs and 70,846 reports were submitted real-time by supervisors using Open data kit (ODK). The national coverage achieved was 87.5% by the post-campaign survey with 65% of states reporting higher coverage in 2018 compared to 2015. CONCLUSION: Polio eradication assets and lessons learned can be applied to measles elimination efforts as the eradication and elimination efforts have similar strategies and programme implementation infrastructure needs. Leveraging these strategies and resources to support MVC planning and implementation resulted in more realistic planning, improved accountability and availability of human and fiscal resources. This approach may have resulted in better MVC outcomes and contributed to Nigeria's efforts in measles control and elimination.

Effect of early measles vaccination on long-term protection: A systematic review.

BACKGROUND: In North America, the first dose of a measles-containing vaccine (MCV1) is administered at ≥12 months of age. However, MCV1 may be given to infants <12 months living in highly endemic areas or traveling to these areas. Although an early dose of MCV1 leads to immediate protection, it remains unclear how this impacts long-term immunity. METHODS: This systematic review and meta-analysis evaluates the impact of MCV1 given at <12 months vs. ≥12 months of age on long-term immunogenicity and vaccine effectiveness, with long-term defined as at least one-year post-vaccination. PubMed, EMBASE, Global Health, Web of Science and Scopus were searched on October 31st, 2019. Studies were included if they included a cohort of infants vaccinated <12 months of age and evaluated long-term immunogenicity, vaccine efficacy, or effectiveness. RESULTS: A total of 51 texts were identified: 23 reported outcomes related to vaccine effectiveness and 30 to immunogenicity. Infants vaccinated with MCV1 < 12 months of age showed an overall higher risk of measles compared to ≥12 months of age (RR = 3.16, 95% CI: 2.00, 5.01; OR = 2.46, 95% CI: 1.40, 4.32). Risk of measles decreased with increasing age at first vaccination, with those vaccinated with one dose ≥15 months at a lesser risk compared to 12-14 months or <12 months. Measles seroconversion and seropositivity was not affected by age at first vaccination, but antibody levels were significantly lower in the MCV1 < 12-month group (MD = -0.40, 95% CI: -0.71, -0.09). CONCLUSION: Long-term measles seroconversion and seropositivity did not appear to be affected by age at MCV1, while vaccine effectiveness decreased with younger age. There was not enough evidence to look at the effect of age at MCV1 on immune blunting.

Factors associated with measles vaccination status in children under the age of three years in a post-soviet context: a cross-sectional study using the DHS VII in Armenia.

BACKGROUND: The resurgence of measles globally and the increasing number of unvaccinated clusters call for studies exploring factors that influence measles vaccination uptake. Armenia is a middle-income post-Soviet country with an officially high vaccination coverage. However, concerns about vaccine safety are common. The purpose of this study was to measure the prevalence of measles vaccination coverage in children under three years of age and to identify factors that are associated with measles vaccination in Armenia by using nationally representative data. METHODS: Cross-sectional analysis using self-report data from the most recent Armenian Demographic Health Survey (ADHS VII 2015/16) was conducted. Among 588 eligible women with a last-born child aged 12-35 months, 63 women were excluded due to unknown status of measles vaccination, resulting in 525 women included in the final analyses. We used logistic regression models in order to identify factors associated with vaccination status in the final sample. Complex sample analyses were used to account for the study design. RESULTS: In the studied population 79.6% of the children were vaccinated against measles. After adjusting for potential confounders, regression models showed that the increasing age of the child (AOR 1.07, 95% CI: 1.03-1.12), secondary education of the mothers (AOR 3.38, 95% CI: 1.17-9.76) and attendance at postnatal check-up within two months after birth (AOR 2.71, 95% CI: 1.17-6.30) were significantly associated with the vaccination status of the child. CONCLUSIONS: The measles vaccination coverage among the children was lower than the recommended percentage. The study confirmed the importance of maternal education and attending postnatal care visits. However, the study also showed that there might be potential risks for future measles outbreaks because of delayed vaccinations and a large group of children with an unknown vaccination status.

Measles outbreak among children ≤15 years old, Jaintia Hills District, Meghalaya, India, 2017.

BACKGROUND: Of 1115 measles outbreaks during 2015 in India, 61,255 suspected measles cases were reported. In 2016, a measles outbreak was reported at East and West Jaintia Hills districts in Meghalaya State, India. OBJECTIVES: The outbreak was investigated to describe the epidemiology, estimate vaccination coverage and vaccine effectiveness (VE), determine risk factors for the disease, and recommend control and prevention measures. METHODS: A measles case was defined as new-onset fever with maculopapular rash occurring between May 1, 2016, and January 21, 2017, in a resident of East and West Jaintia Hills. Cases were identified by active and passive surveillance. Serum and urine samples were collected from cases with laboratory diagnosis for confirmation. A retrospective cohort study was conducted to estimate vaccination coverage, VE, and risk factors for the disease. RESULTS: We identified 382 cases (51% female). The attack rate was 24% with three deaths. The case fatality rate was <1%. The median age was 4 years (range: 3 months-12 years). Among children 12-60 months, 128 (56%) received measles-containing-vaccine first-dose (MCV1), 85 (37%) received measles-containing-vaccine second-dose (MCV2), and 80 (35%) received Vitamin A. VE for MCV1 was 78% and for MCV2 94%. Being unvaccinated for MCV1 (relative risk [RR] = 9.7, 95% confidence interval [CI] = 4.6-20.5) and MCV2 (RR = 17.4, 95% CI = 4.3-69.4) were both strongly associated with illness. CONCLUSIONS: Poor vaccination coverage led to the measles outbreak in East and West Jaintia Hills districts of Meghalaya. Strengthening the routine immunization systems and improving Vitamin A uptake is essential to prevent further outbreaks.

Internal displacement; an impediment to the successful implementation of planned measles supplemental activities in Nigeria, a case study of Benue State.

BACKGROUND: Measles is a highly infectious disease with great burden and implication on a displaced population with low immunity status. The disease can cause up to 140,000 deaths annually. Internal displacement during supplemental immunization activities often affects optimal reach and coverage of the campaign as people move and implementation and logistic plans are usually disrupted with attendant missed children. This study documented the process of extension of the measles vaccination campaign (MVC) 2018 for five internally displaced persons (IDPs) camps in Benue state, not previously in the microplan, to increase population herd immunity. METHODS: We obtained population figures and disease surveillance data for five IDPs camps and used it to conduct detailed microplanning to determine the requirement for the conduct of additional days of measles vaccination. Vaccination teams used fixed posts in the camps and temporary posts strategy in designated locations in the host communities. RESULTS: The estimated total population of the IDPs was 170,000 with MVC target population of 9374 which was not earlier planned for. There was reported measles outbreaks in IDP camps in both Guma and Makurdi Local Government areas (LGAs) during period of displacement. Microplans requirement determined 10,421 bundled measles vaccine, 30 health workers, 5 vehicles and 15 motorcycles. A total of 7679 out of 9374 (81.9%) of the eligible children aged 9-59 months were vaccinated during the 3 days of the campaign. CONCLUSION: Non-inclusion of plans on internally displaced population in supplemental immunization activities (SIAs) microplans have a potential risk of vaccine preventable diseases (VPDs) outbreak. Future Measles Vaccination campaigns should take cognizance of internal displacement due to insecurity and other humanitarian emergencies.

Potential impact of COVID-19 pandemic on vaccination coverage in children: A case study of measles-containing vaccine administration in the United States (US).

BACKGROUND: The COVID-19 pandemic and stay-at-home orders have caused an unprecedented decrease in the administration of routinely recommended vaccines. However, the impact of this decrease on overall vaccination coverage in a specific birth cohort is not known. METHODS: We projected measles vaccination coverage for the cohort of children becoming one year old in 2020 in the United States, for different durations of stay-at-home orders, along with varying catch-up vaccination efforts. RESULTS: A 15% sustained catch-up rate outside stay-at-home orders (compared to what would be expected via natality information) may be necessary to achieve projected vaccination coverage similar to previous years. Permanent decreases in vaccine administration could lead to projected vaccination coverage levels below 80%. CONCLUSION: Modeling measles vaccination coverage under a range of scenarios provides useful information about the potential magnitude and impact of under-immunization. Sustained catch-up efforts are needed to assure that measles vaccination coverage remains high.

Limited Impact of Human Cytomegalovirus Infection in African Infants on Vaccine-Specific Responses Following Diphtheria-Tetanus-Pertussis and Measles Vaccination.

Human cytomegalovirus (HCMV) infection has a profound effect on the human immune system, causing massive clonal expansion of CD8, and to a lesser extend CD4 T cells. The few human trials that have explored the effect of HCMV infection on responses to vaccination are conflicting, with some studies suggesting no effect whilst others suggest decreased or increased immune responses. Recent studies indicate substantial differences in overall immune system reactivity to vaccines based on age and sex, particularly cellular immunity. 225 nine-month old Gambian infants were immunized with diphtheria-tetanus-whole cell pertussis and/or measles vaccines. HCMV infection status was determined by the presence of CMV DNA by PCR of urine samples prior to vaccination. The effect of HCMV infection on either protective antibody immunity or vaccine-specific and overall cellular immune responses 4 weeks post-vaccination was determined, further stratified by sex. Tetanus toxoid-specific antibody responses were significantly lower in HCMV+ infants compared to their HCMV- counterparts, while pertussis, diphtheria and measles antibody responses were generally comparable between the groups. Responses to general T cell stimulation with anti-CD3/anti-CD28 as well as antigen-specific cytokine responses to purified protein derivative (PPD) were broadly suppressed in infants infected with HCMV but, perhaps surprisingly, there was only a minimal impact on antigen-specific cellular responses to vaccine antigens. There was evidence for subtle sex differences in the effects of HCMV infection, in keeping with the emerging evidence suggesting sex differences in homeostatic immunity and in responses to vaccines. This study reassuringly suggests that the high rates of HCMV infection in low income settings have little clinically significant impact on antibody and cellular responses to early life vaccines, while confirming the importance of sex stratification in such studies.

Descriptive study of measles vaccination second dose reporting and barriers to improving coverage in six districts in Malawi.

INTRODUCTION: Malawi's National Immunization Program introduced a second routine dose of measles containing vaccine (MCV2) in 2015 but found coverage lagging. We assessed data quality and gaps in service delivery. METHODS: Investigators used a modified data quality audit in 6 low performing districts accompanied by questionnaires for health facilities (HF) and households with children with >1 vaccination. RESULTS: MCV2 doses administered according to source were: 733 in registers, 2364 in reports, 1655 in district reports, 2761 in the electronic database. There was 77% agreement regarding status for MCV2 between the register and the home-based record (HBR). Drop-out differences were found between HF according to the practice of waiting for a minimum number of children to open an MCV vial, canceling sessions due to stock-out and requesting payment for a home-based record. Eighty one percent (81%) of children whose caregivers knew 2 doses were needed had received MCV2 vs fifty eight (58%) of children whose caregivers didn't know. Sixty two (62%) of children who were charged for HBR received MCV2 vs 78% reporting no charge. CONCLUSION: The drop-out between the first and second doses of MCV was high and inconsistent with elimination goals. The quality of administrative data in these 6 districts was found to be poor. This investigation found that session cancelation, charging for HBR and lack of caregiver knowledge affected completion of the vaccination series. The authors recommend program improvements in these areas to increase uptake of MCV2 and improved reporting practices at all levels of the system.

Are the Objectives Proposed by the WHO for Routine Measles Vaccination Coverage and Population Measles Immunity Sufficient to Achieve Measles Elimination from Europe?

Background: The World Health Organization (WHO) proposed two-dose measles vaccination coverage of at least 95% of the population and percentages of measles immunity in the population of 85%-95% in order to achieve measles elimination in Europe. The objectives of this study were: (1) to determine the measles vaccination coverage required to establish herd immunity against measles viruses with basic reproduction numbers (Ro) ranging from 6 to 60, and (2) to assess whether the objectives proposed by the WHO are sufficient to establish herd immunity against measles viruses. Methods: The herd immunity effects of the recommended objectives were assessed by considering the prevalence of protected individuals required to establish herd immunity against measles viruses with Ro values ranging from 6 to 60. Results: The study found that percentages of two-dose measles vaccination coverage from 88% to 100% could establish herd immunity against measles viruses with Ro from 6 to 19, assuming 95% measles vaccination effectiveness. The study found that the objective of 95% for two-dose measles vaccination coverage proposed by the WHO would not be sufficient to establish herd immunity against measles viruses with Ro ≥ 10, assuming 95% measles vaccination effectiveness. By contrast, a 97% measles vaccination coverage objective was sufficient to establish herd immunity against measles viruses, with Ro values from 6 to 13. Measles immunity levels recommended in individuals aged 1-4 years (≥85%) and 5-9 years (≥90%) might not be sufficient to establish herd immunity against most measles viruses, while those recommended in individuals aged 10 or more years (≥95%) could be sufficient to establish herd immunity against measles viruses with Ro values from 6 to 20. Conclusion: To meet the goal of measles elimination in Europe, it is necessary to achieve percentages of two-dose measles vaccination coverage of at least 97%, and measles immunity levels in children aged 1-9 years of at least 95%.

Field challenges to measles elimination in the Democratic Republic of the Congo.

BACKGROUND: During a measles epidemic, the Ministry of Public Health (MOH) of the Democratic Republic of the Congo conducted supplementary immunization activities (2016-SIA) from August 28-September 3, 2016 throughout Maniema Province. From October 29-November 4, 2016, Médecins Sans Frontières and the MOH conducted a reactive measles vaccination campaign (2016-RVC) targeting children six months to 14 years old in seven health areas with heavy ongoing transmission despite inclusion in the 2016-SIA, and a post-vaccination survey. We report the measles vaccine coverage (VC) and effectiveness (VE) of the 2016-SIA and VC of the 2016-RVC. METHODS: A cross-sectional VC cluster survey stratified by semi-urban/rural health area and age was conducted. A retrospective cohort analysis of measles reported by the parent/guardian allowed calculation of the cumulative measles incidence according to vaccination status after the 2016-SIA for an estimation of crude and adjusted VE. RESULTS: In November 2016, 1145 children (6-59 months old) in the semi-urban and 1158 in the rural areas were surveyed. Post-2016-SIA VC (documentation/declaration) was 81.6% (95%CI: 76.5-85.7) in the semi-urban and 91.0% (95%CI: 84.9-94.7) in the rural areas. The reported measles incidence in October among children less than 5 years old was 5.0% for 2016-SIA-vaccinated and 11.2% for 2016-SIA-non-vaccinated in the semi-urban area, and 0.7% for 2016-SIA-vaccinated and 4.0% for 2016-SIA-non-vaccinated in the rural area. Post-2016-SIA VE (adjusted for age, sex) was 53.9% (95%CI: 2.9-78.8) in the semi-urban and 78.7% (95%CI: 0-97.1) in the rural areas. Post 2016-RVC VC (documentation/declaration) was 99.1% (95%CI: 98.2-99.6) in the semi-urban and 98.8% (95%CI: 96.5-99.6) in the rural areas. CONCLUSIONS: Although our VE estimates could be underestimated due to misclassification of measles status, the VC and VE point estimates of the 2016-SIA in the semi-urban area appear suboptimal, and in combination, could not limit the epidemic. Further research is needed on vaccination strategies adapted to urban contexts.

Reported measles cases, measles-related deaths and measles vaccination coverage in Myanmar from 2014 to 2018.

BACKGROUND: There is a global resurgence of measles, consequent upon worldwide stagnating measles vaccination coverage. The study aim was to document trends and characteristics of reported cases of measles, measles-related deaths, and measles vaccination coverage (MCV1-first dose of measles-containing vaccine and MCV2-second dose of measles-containing vaccine) at national and sub-national level in Myanmar over a five year period between 2014 and 2018. METHODS: This was a descriptive study using routine data collected and submitted to the Expanded Programme on Immunization. RESULTS: Between 2014 and 2018, there were 2673 measles cases of which 2272 (85%) occurred in 2017 and 2018. Five adjacent regions in lower Myanmar were the most affected: in 2017 and 2018, these regions reported 1647 (73%) of the 2272 measles cases in the country. Overall, 73% of measles cases were laboratory confirmed, 21% were epidemiologically linked, and 6% were clinically compatible (clinical diagnosis only), with more laboratory confirmed cases in recent years. Annual measles-related deaths were either zero or one except in 2016 when there were 21 deaths, all occurring in one remote village. In the recent years, the most commonly affected age groups were 0-8 months, 9 months to 4 years, and ≥ 15 years. Among 1907 measles cases with known vaccination status, only 22% had been vaccinated and 70% of those had only received one dose of vaccine. Annual MCV1 coverage nationally varied from 83 to 93% while annual MCV2 coverage nationally varied from 78 to 87%, with no clear trends over the years. Between 2014 and 2018, a high proportion of the 330 townships had MCV coverage < 95%. Over 80% of measles cases were reported from townships that had MCV coverage < 95%. CONCLUSION: There have been a large number of measles cases in recent years associated with sub-optimal measles vaccine coverage. Myanmar has already conducted supplemental immunization activities in October and November, 2019. Myanmar also needs to improve routine immunization services and targeted responses to measles outbreaks.

Mídia e saúde: a cobertura da epidemia de sarampo de 2019 no Brasil / Media and health: the coverage of 2019 measles epidemic in Brazil / Medios y salud: la cobertura de la epidemia de sarampión de 2019 en Brasil

Introdução: A mídia é um importante elemento na construção de significados sobre os acontecimentos de saúde, influenciando nas crenças e na formação da opinião popular, tendo especial papel nos processos epidêmicos. No atual cenário epidemiológico do Brasil, que está vivenciando o recrudescimento do sarampo, reintroduzido no país em 2018, os profissionais da Atenção Primária à Saúde (APS) devem estar instrumentalizados sobre os sentidos que estão sendo construídos pelos veículos de comunicação. Objetivo: Avaliar o conteúdo midiático que está sendo produzido acerca do atual cenário epidemiológico do sarampo no Brasil, observando que sentidos estão sendo construídos e analisando-os criticamente, traçando um paralelo com o papel que a APS ocupa neste cenário, principalmente no que diz respeito à educação em saúde. Métodos: Trata-se de pesquisa qualitativa, exploratória, na qual realizou-se duas buscas através da ferramenta de busca online Google Notícias. Buscou-se pelo termo 'sarampo' e pelos termos 'sarampo' e 'autismo'. Foram catalogados os 50 primeiros resultados, sendo o critério de inclusão que fossem notícias. Utilizou-se a análise de conteúdo, inicialmente, para categorização e inferência, porém foi necessário utilizar instrumentos da análise de discurso para aprofundar algumas subjetividades encontradas. Resultados: A busca retornou resultados das cinco regiões do país, todos com postura pró-vacina. A APS foi citada em praticamente todos os resultados encontrados, que frisavam a disponibilidade da vacina gratuitamente neste nível de atenção. As três áreas temáticas encontradas a partir da análise do material foram: "gravidade, sequelas e morte: a produção do sentido do medo"; "vacinação, medidas e ações; e "justificativas para a queda da cobertura vacinal, responsabilização do indivíduo e atribuição do cenário ao movimento antivacina". Conclusão: Conclui-se que o atual cenário epidemiológico do sarampo tem sido encarado como unicausal, o que precisa ser revisto para que as campanhas governamentais e as ações das Equipes de Saúde da Família tornem-se mais efetivas. A estratégia do convencimento pelo medo ou pela obediência mostra-se ineficaz. Pouco ou nada se discute sobre as recentes políticas de desmonte do Sistema Único de Saúde, que têm impacto direto na cobertura da Estratégia de Saúde da Família. Também pouco foi discutido sobre questões de acesso. A compreensão deste cenário sob uma ótica multifacetada e contextualizada ao momento sociocultural e histórico é o ponto central para o sucesso do desfecho.

Introduction: The media is an important element in the construction of meanings about health events, influencing beliefs and popular opinion formation, having a special role in epidemic processes. In the current epidemiological scenario in Brazil, which is experiencing measles recrudescence, reintroduced in 2018, Primary Health Care (PHC) professionals must be instrumentalised in the meanings that are being constructed by communication vehicles. Objective: To evaluate the media content that is being produced about the current epidemiological scenario of measles in Brazil, observing which senses are being constructed and critically analyzing them, drawing a parallel with the role that PHC plays in this scenario, especially with regard to Health education. Methods: This is a qualitative, exploratory research, in which two searches were performed through the Google News online search tool. We searched for the term 'measles' and the terms 'measles' and 'autism'. The first 50 results were cataloged, and the inclusion criteria were news. Content analysis was initially used for categorization and inference, but it was necessary to use discourse analysis instruments to deepen some subjectivities found. Results: The search returned results from the five regions of the country, all with a pro-vaccine stance. Primary Health Care was cited in virtually all results found, which emphasized the availability of the vaccine free of charge at this level of attention. The three thematic areas found from the analysis of the material were: "gravity, sequelae and death: the production of the sense of fear"; "Vaccination, measures and actions"; and "justifications for the drop in immunization coverage, individual accountability and setting of the scenario for the anti-vaccine movement". Conclusion: It is concluded that the current epidemiological scenario of measles has been viewed as unicausal, which needs to be reviewed for government campaigns and Family Health Team actions to become more effective. The strategy of convincing by fear or obedience is ineffective. Little or nothing is discussed about the recent dismantling policies of the Unified Health System, which have a direct impact on the coverage of the Family Health Strategy. Also little has been discussed about access issues. Understanding this scenario from a multifaceted perspective and contextualized to the socio-cultural and historical moment is the central point for the success of the outcome.

Introducción: Los medios de comunicación son un elemento importante en la construcción de significados sobre los eventos de salud, influyen en las creencias y en la formación de la opinión popular, y tienen un papel especial en los procesos epidémicos. En el escenario epidemiológico actual en Brasil, que está experimentando el recrudecimiento del sarampión, reintroducido en el país en 2018, los profesionales de Atención Primaria de Salud (APS) deben instrumentalizarse en los significados que están construyendo los vehículos de comunicación. Objetivo: Evaluar el contenido de los medios que se está produciendo sobre el escenario epidemiológico actual del sarampión en Brasil, observando qué sentidos se están construyendo y analizándolos críticamente, trazando un paralelismo con el papel que desempeña la APS en este escenario, especialmente con respecto a Educación en salud. Método: Esta es una investigación cualitativa, exploratoria, en la que se realizaron dos búsquedas a través de la herramienta de búsqueda en línea Google News. Buscamos el término 'sarampión' y los términos 'sarampión' y 'autismo'. Los primeros 50 resultados fueron catalogados, y los criterios de inclusión fueron novedades. El análisis de contenido se utilizó inicialmente para la categorización y la inferencia, pero fue necesario utilizar instrumentos de análisis del discurso para profundizar algunas subjetividades encontradas. Resultados: La búsqueda arrojó resultados de las cinco regiones del país, todos con una postura pro-vacuna. La APS se citó en prácticamente todos los resultados encontrados, lo que enfatizó la disponibilidad de la vacuna sin cargo en este nivel de atención. Las tres áreas temáticas encontradas en el análisis del material fueron: "gravedad, secuelas y muerte: la producción de la sensación de miedo"; "Vacunación, medidas y acciones; y "justificaciones para la caída de la cobertura de inmunización, la responsabilidad individual y el establecimiento del escenario para el movimiento antivacunas". Conclusión: Se concluye que el escenario epidemiológico actual del sarampión se ha visto como unicausal, que debe revisarse para que las campañas gubernamentales y las acciones del Equipo de Salud de la Familia sean más efectivas. La estrategia de convencer por miedo u obediencia es ineficaz. Poco o nada se discute sobre las recientes políticas de desmantelamiento del Sistema Único de Salud, que tienen un impacto directo en la cobertura de la Estrategia de Salud Familiar. También se ha discutido poco sobre problemas de acceso. Comprender este escenario desde una perspectiva multifacética y contextualizado en el momento sociocultural e histórico es el punto central para el éxito del resultado.