Measles, mumps, rubella prevention: how can we do better?

INTRODUCTION: Measles, mumps, and rubella incidence decreased drastically following vaccination programs' implementation. However, measles and mumps' resurgence was recently reported, outbreaks still occur, and challenges remain to control these diseases. AREAS COVERED: This qualitative narrative review provides an objective appraisal of the literature regarding current challenges in controlling measles, mumps, rubella infections, and interventions to address them. EXPERT OPINION: While vaccines against measles, mumps, and rubella (including trivalent vaccines) are widely used and effective, challenges to control these diseases are mainly related to insufficient immunization coverage and changing vaccination needs owing to new global environment (e.g. traveling, migration, population density). By understanding disease transmission peculiarities by setting, initiatives are needed to optimize vaccination policies and increase vaccination coverage, which was further negatively impacted by COVID-19 pandemic. Also, awareness of the potential severity of infections and the role of vaccines should increase. Reminder systems, vaccination of disadvantaged, high-risk and difficult-to-reach populations, accessibility of vaccination, healthcare infrastructure, and vaccination services management should improve. Outbreak preparedness should be strengthened, including implementation of high-quality surveillance systems to monitor epidemiology. While the main focus should be on these public health initiatives to increase vaccination coverage, slightly more benefits could come from evolution of current vaccines.

PLAIN LANGUAGE SUMMARYWhat is the context?Measles, mumps, and rubella are highly contagious diseases associated with significant medical and societal burden. Effective vaccines against these diseases are available, and the implementation of vaccination programs drastically reduced disease incidence globally. However, reports of measles and mumps outbreaks in the last few years highlight remaining challenges to eliminate these diseases.What does the review highlight?We conducted a literature review to identify challenges associated with controlling measles, mumps, and rubella infections, and interventions needed to address them. We identified 11 challenges mainly related to low immunization coverage and vaccine characteristics. Societal challenges could be addressed by increasing awareness of disease severity and vaccines impact, targeting high-risk, unvaccinated, and under-vaccinated populations, improving vaccination access, setting up clear outbreak preparedness plans, and implementing country-specific vaccination policies. System weaknesses could be addressed through improving vaccination services and health infrastructure, implementing high-quality surveillance, patient invite, and reminder systems, ensuring vaccine implementation and long-term supply. Interventions related to vaccine characteristic challenges could include adaptation of vaccination schedules (shorter interval between doses, administration of a third dose) and development of vaccines against emerging strains.What is the take-home message?Policymakers should support the following strategies to increase vaccination coverage and reach elimination of measles, mumps, and rubella: strengthening health systems and vaccination access; raising awareness of disease severity and vaccination impact; limiting disease propagation owing to global changing environment and population dynamics (traveling, migration); improving surveillance systems to rapidly address the immunity gaps against disease resurgence.

The 'Dangerous Cocktail': an epidemiological survey on the attitude of a population of pregnant women towards some pregnancy risk factors.

Many investigations have shown the important role played by risk factors such as tobacco and alcohol and infectious agents (especially Rubella) in the development of congenital anomalies (CAs). Through the administration of a questionnaire, we evaluated the attitude of a population of pregnant women towards some risk factors in pregnancy (smoking and alcohol habit and risk of contracting one of TORCH agents). 14% of the women continued to smoke despite pregnancy; the majority of these were 34-35 years old, divorced, workers and with a high educational level. The 4.3% who identified as moderate drinkers; were mainly younger and married. Concerning the TORCH agents, it a high percentage were negative to the Rubella antibodies (62.8%). In order to improve the awareness of pregnant women on these risk factors, health education campaigns represent a public health cornerstone. Impact statementWhat is already known on this subject? Several investigations have shown an association between congenital anomalies (CAs) and various exogenous factors such as air pollutants, pesticides, metals, radiations and others present in the environmental matrices. Moreover, an important role is played by some risk factors linked to the lifestyles (i.e. tobacco and alcohol).What do the results of this study add? Our study shows that the awareness of the women about the importance of these risk factors is still rather poor, especially concerning the avoidable risks associated with smoke and alcohol and the preventable risk associated with rubella infection.What are the implications of these findings for clinical practice and/or further research? Our results highlight the importance of continuous health education both about the risk to smoke and drink during pregnancy and about the risk not to have had contract the rubella infection before the pregnancy. Particularly, about the latter issue, it appears necessary to increase the pre-conceptional diagnosis and, eventually, to vaccinate the women resulted negative in order to eliminate congenital rubella.

[The knowledge about measles, mumps and rubella among parents in the county of Roskilde]. / Viden om maeslinger, fåresyge og røde hunde hos foraeldre i Roskilde Amt.

INTRODUCTION: The aim was to determine how much knowledge parents have of MMR diseases and the side effects of the vaccine, and what influence this has on acceptance of the vaccination programme. MATERIALS AND METHODS: Sampling three districts of Roskilde County was done by the distribution of 1867 questionnaires to the parents of children aged 0-15 years in 22 institutions and schools (1 January to 28 February 2000). RESULTS: Of the 878 (47%) replies, 825 (94%) had followed the vaccination programme. There was no difference between those who had followed the programme and those who had not with respect to reports of complications to the diseases, but the latter group reported more complications to the vaccine. In the vaccinated group, there were significantly more who stated that the doctor's opinion of the vaccine was positive, and acceptance of the remaining vaccination programme was also greater in this group. More children in the non-vaccinated group were involved in the decision about vaccination. DISCUSSION: Though knowledge of the diseases does not seem to influence the decision about vaccination, the responses raise the question of how information is to reach the general public. An open debate is needed on vaccination complications, as it is these or uncertainty about them that seem to influence the parents' choice. For 70% of parents, the doctor is their source of information, and it is therefore important for acceptance of the MMR vaccine that doctors have a positive view and are able to communicate this view to the parents.

Psychological variables as predictors of rubella antibody titers and fatigue--a prospective, double blind study.

When exposed to infectious pathogens, human beings manifest variability in the incidence and severity of infection. This variability may partly depend on psychological variables, which have long been thought to contribute to the predisposition, onset, and course of various physical illnesses, including infectious diseases. The objective of the study was to investigate the predictive value of several personality and other psychological variables on antibody titers and fatigue following a specific viral infection. Subjects were divided into a seronegative group (not immune prior to vaccination) (N = 60) and a seropositive group (immune prior to vaccination) (N = 180), based on antibody titers to rubella before and 10.5 weeks after vaccination with live-attenuated rubella virus. Questionnaires assessing externalizing, internalizing, self-esteem, neuroticism, and fatigue-related symptoms were administered to the subjects before vaccination. Fatigue-related symptoms were re-evaluated 10 weeks post vaccination. In the seronegative group, low titers of rubella antibodies, 10.5 post-vaccination, were predicted by high internalizing or neuroticism scores, and by low self-esteem, measured at baseline. Higher externalizing scores indirectly predicted lower titers of antibodies, via fatigue-related symptoms, measured 10 weeks post vaccination. In contrast, in the seropositive group no association was found between any of the psychological variables and antibody titers. Personality and other psychological variables can predict antibody titers to rubella vaccination, in infected individuals. The associations between the psychological variables and antibody titers are complex, and involve both direct and indirect associations. Specific psychological variables can also be used to predict levels of post-vaccination fatigue.

Influence of socioeconomic status on behavioral, emotional and cognitive effects of rubella vaccination: a prospective, double blind study.

A double-blind prospective design was used to investigate the immediate and prolonged psychological effects of a specific viral infection, and the role of immune activation in mediating these effects. Subjects were 240 female teenager girls who were vaccinated with rubella vaccine. Based on analysis of levels of antibodies to rubella, subjects were divided into two groups. An experimental group (n = 60), which included subjects who were initially seronegative and were infected following vaccination, and a control group (n = 180), which included subjects who were already immune to rubella before vaccination. Compared with the control group and to their own baseline, low socioeconomic status (SES) subjects within the experimental group showed a significant increase in the severity of depressed mood, social and attention problems, and delinquent behavior. Ten weeks post-vaccination there were no differences between the experimental and control groups in serum levels of interleukin-1 beta, interferon-gamma, soluble interleukin-2 receptors (sIL-2r), and cortisol. However, a significant negative correlation was found between fatigue-related symptoms and sIL-2r levels in the experimental (r = -0.325), but not the control group (r = -0.046). These findings suggest that viral infection can produce prolonged behavioral, emotional and cognitive problems mainly in subjects belonging to the low SES.

A search for congenital rubella in psychiatric day treatment, language and learning centres.

A search for previously undiagnosed congenital rubella (CR) was made on 672 children who had attended psychiatric day treatment, learning, and speech and language centres. This was done by observing the seroresponse of seronegative children to rubella vaccine, since 90% of patients with known CR who are seronegative fail to seroconvert to the vaccine. Of the 225 seronegative children 23 did not seroconvert after a single vaccination. Five of these failed to respond on revaccination. These five children had a high frequency of severe language and learning disability as well as frequent diagnoses of major CNS disorders. It is likely that a far greater number of children in the population studied had CR, since our methods identify only about 20% of those affected. Clinically, a specific diagnosis of CR is helpful in facilitating genetic counselling and in allowing the clinician to offer a more hopeful prognosis.

Behavioral treatment of high-rate aggression in a rubella child.

In the present study, a 12-yr-old rubella child exhibiting high rates of aggression was treated through a combination of differential reinforcement and time-out procedures in a residential school program. Following a baseline phase in which differential reinforcement for non-aggression was in effect, the reinforcement method was combined sequentially with three types of response-contingent time-out which varied in the degree of social isolation provided. While acts of aggression decreased from an average of 7 occurrences per day during baseline to 3 per day under the first two treatment conditions, the behavior was rapidly eliminated following application of isolation time-out with effects maintained 7 months post-treatment.