Elsevier

Vaccine

Volume 36, Issue 16, 12 April 2018, Pages 2079-2085
Vaccine

Epidemiological profile and progress toward rubella elimination in China. 10 years after nationwide introduction of rubella vaccine

https://doi.org/10.1016/j.vaccine.2018.03.013Get rights and content

Highlights

  • As a result of nationwide inclusion of rubella vaccine into EPI, in 10 years the incidence of rubella decreased from 91 per million population down to 1.2 per million.

  • Rubella epidemiology has shifted to far fewer cases, but with higher proportions of cases among adolescents and young adults.

  • Ensuring full vaccination of school children and identifying strategies to reach adults to hasten rubella elimination and prevent CRS outbreaks.

Abstract

Background

Rubella-containing vaccine (RCV) became available in China in 1993 and was introduced nationwide into the Expanded Immunization Program (EPI) in 2008. We evaluated implementation and impact of RCV from 2 years prior to nationwide introduction through the 10 years after nationwide introduction.

Methods

We analyzed RCV lot-release (doses distributed) data, 1- and 2-dose RCV coverage, and rubella data from China’s nationwide disease surveillance system to describe the current status and changes in rubella epidemiology between 2005 and 2017.

Results

While the vaccine was included into the routine immunization program in 2008, its full implementation required 4 years due to sporadic vaccine supply constraints. RCV1 and RCV2 coverage increased from 51.5% and 39.0% in 2008 to >95% during 2012 through 2016. From 2005 to 2017, the annual incidences (per million) of rubella ranged from 91.09 in 2008 down to 1.16 in 2017; reductions occurred in all age groups. The proportion of cases among individuals ≥20 years old increased from 0.97% in 2005 to 31.2% in 2017. In the better-developed eastern China, most cases were among adults; in central and western China, most cases were among children or adolescents.

Conclusions

The marked decrease rubella was a result of inclusion of RCVs into EPI targeting children less than 2 years of age and achieving high level of 2-dose coverage. Rubella was reduced in absolute terms, and its epidemiology was changed to older cases with substantial inter-province variation. Ensuring full vaccination of school children and identifying strategies to reach adults with measles and rubella combined vaccines will be important to hasten elimination of rubella and prevent CRS outbreaks.

Introduction

Though acquired rubella is usually a benign disease of children and young adults, rubella virus is a highly teratogenic pathogen, particularly when infection occurs during the first 16 weeks of pregnancy. In early-pregnancy infections, the developing organs of the fetus are often damaged, resulting in miscarriage, stillbirth, or an infant born with birth defects - congenital rubella syndrome (CRS). The goal of rubella vaccination programs is prevention of the intrauterine infection that causes CRS [1], and the only way to ensure that CRS does not occur is to eliminate the possibility of exposure to rubella virus. To this end, at the World Health Assembly (WHA) in May 2012, all 194 Member States endorsed the target of eliminating rubella in five of the six WHO Regions by 2020 as part of the Global Vaccine Action Plan (GVAP) of the Decade of Vaccines [2]. Feasibility has been shown by the elimination of endemic transmission of rubella virus in the WHO Region of the Americas, declared in 2009 [3]. In October 2017, the WHO Western Pacific Regional Committee passed unanimously a resolution that “urged that all Member States in the Region aim to eliminate rubella as soon as possible [4].”

China, with a mainland population of more than 1.38 billion and an area of 9.6 million km2, is the largest country in WHO’s Western Pacific Region. Rubella-containing vaccine (RCV) was licensed and made available in China in 1993 and was introduced nationwide into the Expanded Immunization Program (EPI) 10 years ago, in 2008. Given the interest in rubella elimination by WHO and ministries of health, we report a study in China about rubella vaccine use and coverage, the epidemiological profile of rubella, and progress and challenges of elimination of rubella from 2005 through 2017. We discuss implications of our findings and make recommendations to help hasten elimination of rubella and prevention of CRS outbreaks in China.

Section snippets

Study setting

The study is set in mainland of the People’s Republic of China, not including Hong Kong Special Administrative Region, Macao Special Administrative Region, and Taiwan.

Rubella vaccines in China

There are 3 types of rubella containing vaccine (RCV) available in China - standalone rubella vaccine (RV), measles-rubella combined vaccine (MR), and measles-mumps-rubella combined vaccine (MMR). China has used two rubella vaccine virus strains - an imported RA27 strain from international manufacturers and a domestic BRD-II

Rubella vaccine supply

From 2008 to 2016 in China, the annual number of doses of RCVs released to EPI and distributed increased from 40.0 million in 2008 to 62.6 million in 2016 with lowest number of doses occurring in 2009, at 20.8 million. In 2015 there was a decrease in vaccine production because of a GMP certification challenge. On average, more than 50 million doses of RCVs were released each year into China’s EPI system, which serves an annual birth cohort of 16 million live births (Fig. 1).

Rubella routine immunization coverage

Routine RCV1

Discussion

Incorporating rubella into the China EPI system in 2008 was an important step toward control and elimination of rubella and prevention of CRS. We have shown that the incidence of rubella has steadily decreased from 91.0 per million in 2008 down to 1.16 per million in 2017. Decreases occurred in all age groups, including the vaccine-targeted age groups of children 2 to 9 years and non-targeted age groups, showing direct and indirect protection from rubella. The impact on incidence was documented

Conflicts of interest

The authors declare that they have no conflict of interest.

Acknowledgements

The authors give special thanks to Dr. Lance E Rodewald (WHO China Representative Office) for his help in revising and polishing this manuscript and Dr. Walter Orenstein (Emory University) for his helpful comments on our manuscript.

Author Contributions

Chao Ma, Lixin Hao, Ning Wen conceived of the study, contributed to its design, analyzed and interpreted of data; Chunxiang Fan, Hong Yang contributed to study design, interpreted data, reviewed results, provided references to published ones; Huaqing Wang, Zundong Yin, Zijian Feng, Weizhong Yang contributed to study design, reviewed results, provided data and revised the article; Qiru Su conceived of the study, contributed to its design, analyzed and interpretation of data, and drafted the

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This study was funded in part by the World Health Organization Cooperation Project “Developing a mathematical model of measles and rubella elimination to refine the immunization strategies in China”.

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