1. The Cape Verde experience with rubella outbreak & lessons from introducing rubella vaccines MoH Cape Verde ARCI meeting Dar es Salaam, Tanzania Dec 2012

2. Outline Country background information EPI Program Measles/rubella coverage and case reports Rubella outbreak 2008-09 CRS case reports 2009 - 2010 2013 measles/rubella campaign Way forward

3. Cape Verde: background Information 10 islands off the coast of West Africa Surface area: 4,030 Sq. KM Total population 2011 : 501,000 (UN Estimates) 61% urban Pop. <15 y: 155,000 Female 15-49: 135,000 GDP: 4123 US$

4. Overview of the EPI program – EPI program provides MCV1 at 9 months of age – Last case of polio in 2000 – Comprehensive measles elimination strategy implemented since 2002 – Reached and maintained high routine MCV1 coverage – Initiated rubella vaccination (MR) in routine EPI in 2010.

5. Routine Vaccine reported coverage, Cape Verde. 2000 - 2011 Reported MR vaccine admin coverage in 2011 = 99%

6. MCV1 coverage, measles and rubella cases reported in Cape Verde, 1980-2011 a total of 21,000 cases reported : 9648 cases in 2008 and 11329 cases in 2009

7. Rubella outbreak in Cape verde: Attack rate by region

8. 9 Meses – 15 Anos 9 Meses – 20 Anos

9. Documented rubella epidemic in Cape Verde. 2008 – 2009. [N=9468] 57% female 11% 57% 24% 4%

10. Congenital rubella syndrome. Cape Verde, 2008-2010 CRS cases reported in 2009 - 2010 – 46 CRS cases documented in 2009 (JRF report) – 16 CRS cases documented in 2010 (JRF report) Cumulative incidence of 2.8/1,000 LB ~ 20 cases of severe ocular manifestations: – Pigmentary Retinopathy: 25%-50% – Cataract: 15% – Glaucoma: 10%

11. WHO Rubella position paper, July 2011 SAGE recommends that countries should take the opportunity of the two dose measles vaccine strategy to use MR or MMR vaccine. The preferred approach is to begin with MR vaccine or MMR vaccine in a wide-age range campaign followed immediately with introduction of MR, or MMR vaccine in the routine program.

12. Does Cape verde need to do MR SIAs? Does Cape verde need to do MR SIAs? Cape Verde introduced a routine dose of rubella containing vaccine at 15 months in 2010 Cape Verde did not conduct a mass rubella campaign Answer: Yes – Large proportion of susceptible children and young adults despite the outbreak – Global policy recommends a wide age range catch-up campaign (from 9m to 15 years or older) depending on the epidemiology of the country as part of elimination strategy

13. Rubella susceptibility in Cape Verde. The distribution of rubella cases: – high susceptibility between 13 and 17 years of age. Most mothers of CRS cases were 17-18 years. – In 2013, this age group will be in the category 20 – 25 years.

15. Options for age groups to target in MR SIAs in 2013 Option 1: Vaccinate all children and young adults (9 months to 20 years). – This will leave an estimated immunity gap of 15 % for women and men older than 20 years. Option 2: Vaccinate all children 9 months– 18 years of age AND all women 19-25 years of age (most will be bringing their children to the health post). – This strategy will leave an estimated immunity gap of 24 % among men older than 18 years, but less than 5% among women above 25 years of age Option 2 will have the largest impact on reducing future risk of CRS among the Cape Verde population. Option 2 will have the largest impact on reducing future risk of CRS among the Cape Verde population.

16. Way forward Develop a long term strategy for the elimination of rubella and CRS: – Catch-up SIAs, follow up SIAs every 4 years, maintain high MR coverage in Routine immunisation Implement the MR catch-up SIAs in 2013; – target population 9 mo – 20 yrs Strengthen the sensitivity and specificity of the disease surveillance system – Build capacity of clinicians to improve reporting

17. Obrigado Thank you Merci