POLICY BRIEF: Introduce Measles Mumps Rubella (MMR) vaccine into Uganda’s Routine Immunization Schedule

Summary

Uganda gives one dose of measles vaccination to children at 9 months or at first contact after that age with a monovalent measles vaccine. There is no vaccination against Rubella and Mumps in the routine immunization schedule. Introduction of MMR will therefore offer a new opportunity for an integrated approach to enable comprehensive measles, mumps and rubella prevention.

Background

Vaccination against specific diseases reduces the incidence of the disease, and its overall burden on the population. High immunization coverage can lead to a complete blockage of transmission for Vaccine Preventable Diseases (VPD). For measles in particular, Uganda gives one dose of vaccination to children at 9 months or at first contact after 9 months with a monovalent measles vaccine.

Measles has been targeted for elimination due to its high public health impact on morbidity and mortality and its control has been implemented through routine vaccination, periodic measles supplemental immunization activities (SIAs) and monitoring through case-based surveillance. Unfortunately, there is no vaccination against Rubella and Mumps in the routine immunization schedule yet outcomes due to these infections are detrimental. Out comes such as permanent deafness, Congenital Rubella syndrome may result due to infection with these diseases.

Descriptive data analysis of a five-year period (2012 2016), indicates that the proportion of rubella positivity in the measles case- based surveillance system was three times that of measles, indicating the high circulation of rubella. Rubella positivity increased by 12% from 2012 to 2016. Rubella disease caused by rubella virus is a preventable public health problem which presents as mild in both children and adults.

When it occurs during the first trimester of pregnancy, infection with rubella virus is associated with development of Congenital Rubella Syndrome (CRS) in the unborn babies (1); This may include congenital heart disease, loss of hearing or eyesight and intellectual disabilities. The risk of CRS may go as high as 90% in rubella infected persons (2). In 2016, over 75% of the reported rash like febrile illness diagnosed as measles suspected cases turned out to be rubella, this laboratory evidence of rubella infection indicates that there is high circulation of rubella in Uganda.

Context and Importance of the Problem

Measles, mumps and rubella outbreaks continue to occur globally. In a study conducted in the United Kingdom between 2000 and 2006, complications of mumps included permanent deafness, and orchitis in over 6% of mumps cases. Other complications include pancreatitis and meningitis (3). In Uganda, a cluster of mumps was investigated in a children’s home in Wakiso District where 19 cases were registered in June 2017. Other sporadic mumps cases still occur among children and usually go uninvestigated. Orchitis among males who have reached puberty may lead to fertility problems.

Encephalitis, which is the inflammation of the tissue covering the brain and spinal cord (meningitis) may also result from complications of mumps. In women, it may result in inflammation of the ovaries (oophoritis) and/or breast tissue (mastitis). Uganda registered measles outbreaks in districts of Kayunga, Lyantonde, Kampala, Wakiso, Lwengo, Kibuku in 2017. Additional districts that have confirmed measles outbreaks since the beginning of 2018 include; Nakaseke, Luwero, Mityana, Butambala, Iganga, Kamuli, Butambala, Hoima, Namutumba, Mbale, Lwengo, Kasese, Luwero, Kamwenge, Jinja.

In most of these outbreaks, children < 5 years of age were the most affected, with highest incidence among children less than 1 year of age. Critique of Policy Options World Health Organization (WHO) recommends introduction of rubella vaccine in countries that have achieved high coverge (>80%) of the first-dose measles-containing vaccine. In Uganda, National  Supplementary Immunization Activities (SIAs) which were conducted in 2009, 2012 and 2015 achieved an administrative coverage of 104%, 100% and 95%, respectively. Additionally, according to Uganda EPI administrative data (2016), measles vaccination coverage was 90%, which surpassed the WHO target of 80%. This gives Uganda an option to adopt the combined MMR vaccine rather than the currently administered monovalent measles vaccine.

Availability of a combined vaccine that protects the body against the three infections is an opportunity which should be embraced by Uganda National Immunization Technical Advisory Group (UNITAG) for consideration and forwarded to Uganda National Expanded Program on Immunization for implementation. Combined MMR vaccine induces immunity less painfully than three separate injections at the same time and more efficiently than three injections given on three different dates. Administering combined vaccines reduces the chances of drop-out as compared to spreading out single vaccines. In addition, when single vaccines are administered, children keep vulnerable for longer while waiting for other separate jabs. With MMR, children have protection against mumps, measles and rubella from the first jab onwards.

With single vaccines, they remain open to infection for weeks or months, giving the diseases more opportunity to take root among their age group. In 2012, the Cochrane Library published a systematic review of scientific studies and concluded that, “Existing evidence on the safety and effectiveness of MMR vaccine supports current policies of mass immunization aimed at global measles eradication and in order to reduce morbidity and mortality associated with mumps and rubella.” In a UK study during 2000-2006, the risk of mumps reduced by over.70% when a patient received one dose of the MMR vaccine. The risk of mumps orchitis was reduced by 28%(3).

Policy recommendations

In order to close the immunity gap that is propelling the constant outbreaks of Measles, Mumps and Rubella, introduction of a combined MMR vaccine will offer a new opportunity to enhance comprehensive measles, mumps and rubella prevention and control as observed in countries where
MMR has been introduced.