Trends and spatial distribution of MMR vaccine coverage in Brazil during 2007–2017

doi:10.1016/j.vaccine.2019.04.019

Vaccine

Volume 37, Issue 20, 6 May 2019, Pages 2651-2655

https://doi.org/10.1016/j.vaccine.2019.04.019 Get rights and content

Highlights

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The reintroduction of measles in Brazil is likely due to migration from Venezuela.
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The spread of measles in Brazil was made possible by the low levels of MMR coverage.
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Areas with low MMR coverage were concentrated in the North and Northeast regions.
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Increasing measles vaccine coverage is essential to block the ongoing outbreak.
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Vaccination strategies might target areas with a marked decrease in coverage.

Abstract

We analyzed the time trends and spatial distribution of MMR vaccine coverage in Brazil during 2007–2017. In early 2018, a measles outbreak started in the North region of Brazil, reaching 11 of the 27 federal units by January 24, 2019. In this period, 10,302 cases were confirmed. Although the reintroduction of measles in Brazil is likely due to migration from Venezuela, the spread of the virus was made possible by the low levels of MMR coverage, as a result of significant decreases during the study period. Areas with high concentration of municipalities with low coverage are more susceptible to the spread of the virus, especially in the North and Northeast regions. Increasing vaccination coverage is essential to block the ongoing outbreak in Brazil. Vaccination strategies might target priority areas, especially those with a marked decrease in coverage. Moreover, it is essential to extend actions to travelers, migrants and refugees.

Introduction

Measles is a highly contagious and vaccine-preventable viral disease that usually manifests with high fever, rash and cough or conjunctivitis or coryza, and can lead to complications such as blindness, encephalitis or death [1]. In 2016, the Region of the Americas was declared as free of the endemic transmission of the measles virus [2]. However, as the measles virus has been circulating worldwide, it is imperative that countries reach the target of 95% coverage of measles-containing vaccine [3].

In February 2018, the last outbreak of measles in Brazil began, where the last autochthonous cases had been registered in 2000. As of 24 January 2019, 10,302 cases of the disease were confirmed, of which 9,803 were registered in the state of Amazonas, 355 in Roraima, 62 in Pará, 46 in Rio Grande do Sul, 19 in Rio de Janeiro, 4 in Pernambuco, 4 in Sergipe, 3 in São Paulo, 3 Bahia, 2 in Rondônia and 1 in Distrito Federal [4]. In the states of Amazonas, which comprises 95% of the confirmed cases, the incidence was higher among children under 1 year of age (2,189.3 per 100.000 inhabitants), followed by the age groups 15–29 years (427.2 per 100.000 inhabitants) and 1–4 years (354.1 per 100.000 inhabitants). Most cases have been registered in the North region (99.2%) and the D8 genotype has been identified among the confirmed cases, which is identical to the one that has been circulating in Venezuela since the epidemiological week 26 of 2017 [5].

Section snippets

MMR coverage and measles outbreaks

We used MMR coverage data available through the Information System of the National Immunization Program (SI-PNI) of the Brazilian Ministry of Health (MoH), from 1 January 2007 to 31 December 2017. In Brazil, vaccination coverage is obtained through an administrative method, based on the number of doses and the target population [6]; therefore, coverage can be above 100% when the number of doses administered in the municipality is greater than the number of residents in a specific age group and

Time trends

We used linear multilevel regression models to calculate time trends at country, region and Federal Unit levels using the approach described by Victora et al. [8]. Aggregation at each level was done by pooling all municipalities with available data for the years under study, considering each years estimate as level one units, and regions or Federal Units as level two units. We also estimated the annual percentage change (APC) of MMR coverage using the Prais-Winsten regression [9].

The multilevel

Variations in spatial distribution

In 2009, 26 out 27 Federal Units reached the 95% target; the Federal District presented the lowest coverage. By 2013, most states maintained MMR coverage above the recommended target; however, the states of Amapá and Roraima, both located in the North region, presented decreases in coverage. The scenario worsened markedly in 2017, when two states in the North (Acre and Pará) and one in the Northeast region (Piauí) presented coverage below 80%. Only 11 out 27 Federal Units met the 95% target in

Discussion

The ongoing measles outbreak in Brazil seems to be related to the decrease in MMR coverage among infants, especially in the states of the North region. Areas with high concentration of municipalities with coverage below the 95% target were located mainly in the states of Pará, Maranhão, Piauí and Sergipe; these areas are more susceptible to the spread of the virus. Conversely, states such as Pernambuco and Ceará managed to keep MMR coverage above the target, even after the containment of the

Authors’ contributions

FCP and GVAF analysed the data, wrote the manuscript and coordinated the preparation of the manuscript. GAE supported data collection and reviewed the final manuscript. CMASD, CMO and DBG contributed to the outline of the manuscript and reviewed the final manuscript. All authors approved the manuscript.

Conflict of interest

None declared

Acknowledgement

DBG receives funding from the National Council for Scientific and Technological Development – CNPq and Research Productivity Grant 1-D (2016–2020).

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Short communicationTrends and spatial distribution of MMR vaccine coverage in Brazil during 2007–2017

Highlights

Abstract

Introduction

Section snippets

MMR coverage and measles outbreaks

Time trends

Variations in spatial distribution

Discussion

Authors’ contributions

Conflict of interest

Acknowledgement

The Lancet.

J Pediatr (Rio J)

Public health responses during measles outbreaks in elimination settings: Strategies and challenges

Hum Vaccin Immunother.

The contribution of poor and rural populations to national trends in reproductive, maternal, newborn, and child health coverage: analyses of cross-sectional surveys from 64 countries

The Lancet Global Health

Short communication
Trends and spatial distribution of MMR vaccine coverage in Brazil during 2007–2017