Mongolia health situation: based on the Global Burden of Disease Study 2019.

BACKGROUND: Over the past few decades, economic, political, and social changes have directly and indirectly affected the health of the Mongolian population. To date, no comprehensive analysis has been conducted on the burden of diseases in this country. Thus, we aimed to describe the leading causes of death and disabling conditions and their trends between 1990 and 2019 in the Mongolian population. METHODS: We used the data from the Global Burden of Disease (GBD) 2019 study. In the current study, we examined life expectancy at birth, healthy life expectancy, the 20 leading causes of death, years of life lost (YLLs), years lived with disability (YLDs), disability-adjusted-life-years (DALYs), and the contribution of major risk factors to DALYs in Mongolia. FINDINGS: The life expectancy at birth in Mongolia has gradually increased since 1995 and reached 63.8 years for men and 72.7 for women in 2019. The highest increase in the age-standardised death rate between 1990 and 2019 occurred in alcohol use disorders (628.6%; 95% UI 10.0-1109.6) among men, and in liver cancer (129.1%; UI 65.3-222.4) among women. Ischaemic heart disease and stroke showed the highest rates of death, YLLs, and DALYs among both men and women. In 2019, the highest age-standardised rates of DALYs were attributable to high systolic blood pressure and dietary risks. INTERPRETATION: Although Mongolia saw substantial improvements across many communicable diseases, maternal and neonatal disorders, and under-5 mortality between 1990 and 2019, non-communicable diseases remained leading causes of mortality. The mortality from the most preventable causes such as injury, alcohol use, and dietary risks remain substantially high, suggesting that individual and social efforts are needed to tackle these diseases. Our analyses will support the development of policy priorities and action plans in multiple sectors to improve the overall health of the Mongolian population. FUNDING: Bill & Melinda Gates Foundation.

Measles and rubella IgG seroprevalence in persons 6 month-35 years of age, Mongolia, 2016.

BACKGROUND: In 2015-2016, Mongolia experienced an unexpected large measles outbreak affecting mostly young children and adults. After two nationwide vaccination campaigns, measles transmission declined. To determine if there were any remaining immunity gaps to measles or rubella in the population, a nationally representative serosurvey for measles and rubella antibodies was conducted after the outbreak was over. METHODS: A nationwide, cross-sectional, stratified, three-stage cluster serosurvey was conducted in November-December 2016. A priori, four regional strata (Ulaanbaatar, Western, Central, and Gobi-Eastern) and five age strata (6 months-23 months, 2-7 years, 8-17 years, 18-30 years, and 31-35 years) were created. Households were visited, members interviewed, and blood specimens were collected from age-appropriate members. Blood specimens were tested for measles immunoglobulin G (IgG) and rubella IgG (Enzygnost® Anti-measles Virus/IgG and Anti-rubella Virus/IgG, Siemens, Healthcare Diagnostics Products, GmbH Marburg, Germany). Factors associated with seropositivity were evaluated. RESULTS: Among 4598 persons aged 6 months to 35 years participating in the serosurvey, 94% were measles IgG positive and 95% were rubella IgG positive. Measles IgG seropositivity was associated with increasing age and higher education. Rubella IgG seropositivity was associated with increasing age, higher education, smaller household size, receipt of MMR in routine immunization, residence outside the Western Region, non-Muslim religious affiliation, and non-Kazakh ethnicity. Muslim Kazakhs living in Western Region had the lowest rubella seroprevalence of all survey participants. CONCLUSIONS: Nationally, high immunity to both measles and rubella has been achieved among persons 1-35 years of age, which should be sufficient to eliminate both measles and rubella if future birth cohorts have ≥ 95% two dose vaccination coverage. Catch-up vaccination is needed to close immunity gaps found among some subpopulations, particularly Muslim Kazakhs living in Western Region.

Use of a Diagonal Approach to Health System Strengthening and Measles Elimination after a Large Nationwide Outbreak in Mongolia.

Measles is a highly transmissible infectious disease that causes serious illness and death worldwide. Efforts to eliminate measles through achieving high immunization coverage, well-performing surveillance systems, and rapid and effective outbreak response mechanisms while strategically engaging and strengthening health systems have been termed a diagonal approach. In March 2015, a large nationwide measles epidemic occurred in Mongolia, 1 year after verification of measles elimination in this country. A multidisciplinary team conducted an outbreak investigation that included a broad health system assessment, organized around the Global Health Security Agenda framework of Prevent-Detect-Respond, to provide recommendations for evidence-based interventions to interrupt the epidemic and strengthen the overall health system to prevent future outbreaks of measles and other epidemic-prone infectious threats. This investigation demonstrated the value of evaluating elements of the broader health system in investigating measles outbreaks and the need for using a diagonal approach to achieving sustainable measles elimination.

Risk Factors for Measles Virus Infection Among Adults During a Large Outbreak in Postelimination Era in Mongolia, 2015.

Background: In 2015, a large nationwide measles outbreak occurred in Mongolia, with very high incidence in the capital city of Ulaanbaatar and among young adults. Methods: We conducted an outbreak investigation including a matched case-control study of risk factors for laboratory-confirmed measles among young adults living in Ulaanbaatar. Young adults with laboratory-confirmed measles, living in the capital city of Ulaanbaatar, were matched with 2-3 neighborhood controls. Conditional logistic regression was used to estimate adjusted matched odds ratios (aMORs) for risk factors, with 95% confidence intervals. Results: During March 1-September 30, 2015, 20 077 suspected measles cases were reported; 14 010 cases were confirmed. Independent risk factors for measles included being unvaccinated (adjusted matched odds ratio [aMOR] 2.0, P < .01), being a high school graduate without college education (aMOR 2.6, P < .01), remaining in Ulaanbaatar during the outbreak (aMOR 2.5, P < .01), exposure to an inpatient healthcare facility (aMOR 4.5 P < .01), and being born outside of Ulaanbaatar (aMOR 1.8, P = .02). Conclusions: This large, nationwide outbreak shortly after verification of elimination had high incidence among young adults, particularly those born outside the national capital. In addition, findings indicated that nosocomial transmission within health facilities helped amplify the outbreak.

Cost-effectiveness of 13-valent pneumococcal conjugate vaccination in Mongolia.

OBJECTIVE: The Ministry of Health (MOH), Mongolia, is considering introducing 13-valent pneumococcal conjugate vaccine (PCV13) in its national immunization programme to prevent the burden of disease caused by Streptococcus pneumoniae. This study evaluates the cost-effectiveness and budget impact of introducing PCV13 compared to no PCV vaccination in Mongolia. METHODS: The incremental cost-effectiveness ratio (ICER) of introducing PCV13 compared to no PCV vaccination was assessed using an age-stratified static multiple cohort model. The risk of various clinical presentations of pneumococcal disease (meningitis, pneumonia, non-meningitis non-pneumonia invasive pneumococcal disease and acute otitis media) at all ages for thirty birth cohorts was assessed. The analysis considered both health system and societal perspectives. A 3+0 vaccine schedule and price of US$3.30 per dose was assumed for the baseline scenario based on Gavi, the Vaccine Alliance's advance market commitment tail price. RESULTS: The ICER of PCV13 introduction is estimated at US$52 per disability-adjusted life year (DALY) averted (health system perspective), and cost-saving (societal perspective). Although indirect effects of PCV have been well-documented, a conservative scenario that does not consider indirect effects estimated PCV13 introduction to cost US$79 per DALY averted (health system perspective), and US$19 per DALY averted (societal perspective). Vaccination with PCV13 is expected to cost around US$920,000 in 2016, and thereafter US$820,000 every year. The programme is likely to reduce direct disease-related costs to MOH by US$440,000 in the first year, increasing to US$510,000 by 2025. CONCLUSION: Introducing PCV13 as part of Mongolia's national programme appears to be highly cost-effective when compared to no vaccination and cost-saving from a societal perspective at vaccine purchase prices offered through Gavi. Notwithstanding uncertainties around some parameters, cost-effectiveness of PCV introduction for Mongolia remains robust over a range of conservative scenarios. Availability of high-quality national data would improve future economic analyses for vaccine introduction.