Measles and Rubella Serosusceptibity among Population Vaccinated with Different Schedule: The potential impact on Measles-Rubella elimination in Iran

Hana Saffar Department of antimicrobial and clinical Pathology, IKHC, Teheran University of Medical Sciences, Tehran Iran. Maryam Khalifeloo The University of Manchester Faculty of Biology Medicine and Health mohammed-Jafar Saffar (  saffar@softhome.net ) Mazandaran University of Medical Sciences https://orcid.org/0000-0002-9335-6262 Ali-Reza Abdollahi Department of antimicrobial and clinical Pathology, IKHC, Teheran University of Medical Sciences, Tehran Iran. Mohammad-Reza Parsaei Deputy of Health, Mazandaran University of Medical Sciences. Gholam-Reza Ghorbani Deputy of Health, Mazandaran University of Medical Sciences. Samaneh Salarvand Department of antimicrobial and clinical Pathology, IKHC, Teheran University of Medical Sciences. Mohsen Aarabi Deputy of Health, Mazandaran University of Medical Sciences.


Background
Measles, a highly contagious viral disease, recognized as a major public health concern worldwide (1) . In 2018, there were more than 140/000 measles-related death globally, mostly among children under the age of 5 years (2) . Age of vaccination is one of the key host-related determinants of vaccine e cacy (VE).
However, results of previous studies have revealed that measles vaccination at the age < 12 months is associated with the reduced immune response rate because the interference of maternal antibodies and immaturity of the immune system (3)(4)(5) . To prevent the measles virus transmission in a community, a population immunity rate of > 93-95% with > 95% vaccination coverage (with two-doses of vaccine) is required in all districts of the country (1,6) . In recent years, the number of measles cases and its outbreaks have started to increase, even in countries declaration disease elimination, also, some of these cases have been reported in fully vaccinated individuals (7)(8)(9)(10)(11)(12)(13)(14)(15)(16) . From January-to July 31 2019, a total of 364, 808 measles cases were reported to World Health Organization (WHO) by 182 countries, which surpasses the number of reported cases (129. 239) within the same period in 2018 (7) .
On the other hand, rubella a mild viral infection that affects unvaccinated children and adults. If a nonimmune women contracts rubella during pregnancy, especially in the rst trimester, serious consequences including miscarriage, fetal death, stillbirth and congenital rubella syndrome (CRS) may occur.
During the pre-vaccine era in Iran, measles and rubella were endemic and nearly 150,000-500,000 cases of measles with a high mortality rate were reported annually (18)(19) . However, more than three-fourth of adolescents and childbearing age women naturally acquired anti-rubella immunity (20)(21) , and the incidence of CRS was estimated to be two per 10,000 live birth (22) . Following the establishment of the WHO Expanded Program of Immunization (EPI) in Iran in 1984, the incidence of measles cases reduced markedly. However, in response to the increased number of measles cases particularly in older age groups, a nationwide measles-rubella (MR) immunization campaign targeting 5-25 year-old individuals was stablished in December 2003 to prevent CRS (23) .
Since March 2004, the mMV was replaced with two-doses of measles-mumps-rubella (MMR) vaccine, scheduled after the age of 12 months, with more than 95% coverage rate (23,30) . This shift in the program led to the accumulation of a birth cohort born between November 1998 to March 2004, who were vaccinated with two-doses of mMV at the age of nine and 15 months respectively. However, to provide protection against mumps and rubella, this particular groups was revaccinated with one dose of MMR vaccine at the time of school entrance (2 to 5 years after the last dose of mMV).
In 2019, WHO Region Veri cation Committee of the Eastern Mediterranean region declared the elimination of the measles and rubella in Iran (31) . However, in recent years, small outbreaks of measles have been reported in some parts of the country (12)(13)(14)(15)(16) Table 1. The measles virus causing these outbreaks was reported to originate from neighbor countries (16,32) .
There is little Information available regarding level of measles and rubella protection among children, adolescents and adults vaccinated with different schedules. Therefore, this study was designed to investigate the prevalence rates of measles and rubella immunity among various age groups that were vaccinated with different programs, and also to determine the relative role of secondary vaccine failure as a possible cause of serosusceptibility to viruses.

Methods And Participants
This descriptive-analytical cross-sectional study was conducted in the East of Mazandaran province, North of Iran, from 1-November 2017 to 30-June 2018.
This region is consists of three main districts with an approximate population of 460000. Depending on the population density of each district, some primary health care centers (PHCs) have been established. All basic health requirements including prenatal care and vaccination of children in the a liated families are met in these centers. Also, each family has a speci c le where all health related events of that family are recorded there.
To collect the data, the family les available in each PHC were thoroughly reviewed. Healthy subjects born during 1984-2011 with a documented history of measles vaccination were recruited in the study. The subjects required for this study were selected among eligible individuals, based on the population density of PHC by one to one selection method. Since the majority of selected cases were students (primary and high school students), their vaccination status was rechecked from a copy of their booklet record which was present in their school le. History of MR vaccination in some adults was based on their recall. Individuals with acute diseases, history of recent febrile exanthematous illnesses, chronic and metabolic illnesses, malignancies, immunode ciency, recipients of blood/ blood products within last year, recipient of an additional dose of measles containing vaccine after the recommended schedule (except those who received MR vaccine during nationwide measles-rubella campaign recipients of MMR vaccine at school entrance among birth cohort 1998-2003), and pregnant women were all excluded from the study.
Depending on age and vaccination status, the subjects were categorized as follows; Group A: the subjects were born 1984 to October 1998, (age range: 20-33 years). Most of them were vaccinated with 1-2 doses of measles vaccine at the ages of nine and 15 months and were also reimmunized with MR vaccine during the national MR Immunization campaign. Overall, they were vaccinated with three doses of measles and one dose of rubella vaccine. Group B: the subjects were born from November 1998 to March 2004 (age range: 15-19 years). This birth cohort was vaccinated with two doses of mMV at the ages of nine and 15 months, respectively. They were also reimmunized with additional dose of MMR vaccine of school entrance (age of 6 years); therefore, they received three doses for measles and one dose for rubella and mumps vaccine.  Table 2. After obtaining informed written consent from guardians/ individuals, 5 ml of venous blood of all enrolled subjects were collected. Sera were stored at-20°C to measure anti-measles and anti-rubella lgG antibodies qualitatively at the university laboratory by ELISA method using Vircell Microbiologic ELISA measles and rubella lgG/lgM kits (vircell, S. L. parquet Technologico dela salud. Avecina 8. 18016 Granada. Spain). Antibodies against measles and rubella were measured based on manufacture's guidelines. The results were interpreted as antibody indices. The samples antibody indices were calculated with positive and negative control (OD >0.9 and OD < 0.5) at a control cut-off range of >0.55 to -<1.5. Samples antibodies indexes were calculated as: (Sample OD/cut-off serum mean OD)×10. Samples with antibody index above 11 were considered as positive (having speci c measles IgG/IgM per procedure). Samples with antibody index less than 9 were considered as negative. Subjects with index between 9-11 were rechecked and if reported >11 were considered positive and if <11 as negative.
Similar categorization were applied for rubella. Nevertheless rubella ELISA IgG has been standardized against WHO rst international standard for antirubella IgG with a cut-off set at 10 UI/mL. Based on the manufacture srep or ts, whi ≤ comparedwithothercommercialELISAspec if ickits, thesensitivity and spec if icityofkitf or meas ≤ sIgGwere92 -100 % sera tested for measles and rubella speci c lgM and lgG. Subjects with both lgM and lgG seroconversion were considered as cases of primary vaccine failure [possibly never develop immune response to the initial vaccination: (PVF)]. Subjects with only lgG seroconversion were considered as secondary vaccine failure [loss of acquired speci c antibody with time (SVF)]. MCAs of seropositive individuals were calculated after boosting, and were compared with the previous level. The collected data were analyzed using SPSS version 16.0. Descriptive statistics were measured as percentile for seropositivity and response rate to revaccination. The chi-square and student t-test were used to determine differences between variables as appropriate. Results were considered to be statistically signi cant when the P value was less than 0.05.

Results
A total of 635 individuals participated in this study. The demographic characteristics and vaccination status of the participants are presented in Table 2.
Of 635 studied subjects 78 (12.3%) and 117(18.4%) were serologically susceptible to measles and rubella respectively. The prevalence rates of measles and rubella susceptibility in different age groups varied signi cantly, as shown in table 3. The highest rates of susceptibility to measles and rubella were seen in the group B (15.3% and 25.0% respectively), followed by the group D (14.6% and 18.4%, respectively).the highest seroprotection rate (98% and 100%) were observed in oldest subjects, who were MR revaccinated. However, comparison of the prevalence rates of measles and rubella seroimmunity between the groups showed signi cant differences between gropupA and other groups: (P=0.000). Also, there were a signi cant differences in the measles MCA between groupA and groupB (P=0.006) and between groupA and groupC (P=0.001). Similarly signi cant differences were observed in rubella MCA bettwen groupA and groupD (P=0.013) and between groupC and groupD (P=0.031).
After revaccination of 171 susceptible cases (measles 78 and rubella 117), only 71 subjects (measles 50 and rubella 59) agreed to blood sample collection for reevaluation. As shown in table 3, 92% and 94.9% of revaccinated seronegative persons responded well to MMR vaccine boosting and became IgGseroconverted against measles and rubella, respectively. None of the boosted subjects showed evidence of antimeasles or antirubella IgM response; therefore, seronegativity was possibly caused by loss of acquired immunity over time and SVF. The MCA levels of seroimmune individuals for both measles and rubella were not statistically signi cant after revaccination as compared to MCA levels in the primary evaluation: for measles 18

Discussion
This study showed that more than 12% and 18% of the studied individuals were serologically susceptible to measles and rubella, respectively. The highest rates of susceptibility to measles and rubella (15.2% and 25% respectively) were observed among subjects in group B (15)(16)(17)(18)(19) year old) who were born within 5 years before national MR immunization program and were vaccinated initially with two doses of mMV at the ages nine and 15 months, respectively. Two to ve years later, they also received an additional dose of MMR vaccine right before entrance to school (age of 6 years). Moreover, the present results showed that 12.8% and 17.7% of subjects who were vaccinated with two doses of MMR vaccine after the age of 12 months (group C and group D), were serologically susceptible to measles and rubella, respectively. In this study the lowest rate of serosuseptibility to measles and rubella was detected among 20-33-year-old adults who were MR revaccinated. Based on our ndings, the main possible cause of susceptibility to measles and rubella in our vaccinated population was waning of acquired seroprotection with time (SVF), because of isolated lgG immunologic response to MMR revaccination in boosted susceptible individuals. Moreover, the results revealed that the levels of acquired MCA after revaccination of seroimmune subjects for both measles and rubella with MMR vaccine, did not improved speci c immunity to these viruses.
The present result showed that 98% and 100% of subjects in group A (age 20-33 years) who were covered by the national program of MR immunization were serologically immune to measles and rubella, respectively. The long-term high-rate of protection could be attributed to MR vaccination or natural boosting in recent years. Years before the MR campaign the measles seroprevalence rates in the Iranian population were much lower (33-37) (40.7% 33to 91.6% 37 ) than the rates reported in this study. However, studies performed years after revaccination in different age groups indicated much higher levels of seroprotection: (63.2 (29) % -to 91.7 (28) % for measles and 87.4 (28) %-to 99 (24) % for rubella) (24)(25)(26)(27)(28)(29) . The relevant data are presented in Table 4. In a recent nationwide study conducted 13-14 years after the national MR campaign on girls above 15 years, the seroprotection rates to measles and rubella were investigated. Nearly 1573 sera were included from ten different provinces. The seroimmunity rates to measles and rubella were 80.7% (range 73.1%-to 89.8%) and 90.6% (range; 81.2-95%) respectively (38) . However, these rates varied greatly between provinces. The relatively high rate of seroprotection observed in our study as well as the mentioned studies, which were conducted years after national campaign could be attributed to the positive impact of MR revaccination and/or natural boosting in the immunized population.
In this study, the highest rate of measles and rubella susceptibility was observed in subjects of group B (age range: 15-19 years), who were vaccinated not only with two-doses of mMV at the ages of nine and 15 months, but also received an additional dose of MMR vaccine upon school entrance (three doses of measles and one dose of rubella vaccine). These seronegativity to MR viruses in this age group detected nearly 13-15 years after the last dose of MMR vaccine, are unusual and raise some concern. Since, there is no information about immune responses to the primary measles immunization in this age group, the actual reasons for this rate of susceptibility and vaccine failure is unclear. However, waning of acquired seroimmunity over time may be in uential, as the majority of boosted susceptible subjects in this group only showed IgG response to MMR revaccination.
The quality and durability of measles vaccine-induced immunity are dependent on a number of factors including the host and the vaccine status. The most important and well-studied host-related determinant is the age when the rst dose of vaccine is administered (3)(4)(5)39) . Studies on the immunogenicity and VE of MV administered before the age of 12 months, showed lower rates as compared to older ages (3)(4)(5)39) . In this regard, a prospective randomized trial by Redd et al (3) , investigated the immunogenicity of measles component of MMR vaccine administered at the ages 9,12, and 15-18 months. They found a 98% seroconversion rate among 15 month-old vaccinees as compared to 95% in those vaccinated at the age of 12 months and 81% in those vaccinated at the age nine months (3) . Moreover, a study by perez et al (4) revealed that measles vaccination at the age of < 12 months was associated with a higher risk of PVF. This negative effect persisted after vaccination with the second dose (4) . These results were con rmed supported by a recent systematic reviews and metaanalysis (5,39) . Moreover, to determine the effects of age on the immunogenicity of measles vaccine a systematic review was recently performed. This study showed that earlier age of vaccination decreased the measles vaccine immunogenicity and protection after the rst dose, and could in uence VE after administering two-doses measles vaccine (39) . However, in another review by Uzicanin et al (5) estimating the measles VE, they found that two-dose measles vaccine provide excellent protection. Nevertheless, in three out of eighth studies, VE was estimated at <90% relative to no vaccination (5).
On the other hand, some evidence suggests that antibody concentrations decline to low or undetectable levels over time (40)(41)(42)(43)(44) . In this regard a study was conducted on different age groups of Iranian children who were vaccinated against measles at the age of nine and 15 months. The seroimmunity rates were 52.9% and 89.2% at ve and three months after administering the rst and second doses of MV, respectively. These rates decreased to 68% by the age six years and 40.5% by the age ten years. However, the seroimmunity rates increased to 96.8% at nine months after boosting with one dose of MV at the age of 14 years (40) . Moreover, in a longitudinal study by Kremer et al (41) , on the kinetic of measles and rubella antibodies, both antibodies waned over time, also, the rate of waning immunity was relatively faster for measles (41) . Considering, the relatively high rates of measles and rubella susceptibility in group B in our study, this seronegativity could be attributed to both primary and secondary vaccine failure. To determine whether the seronegativity is related to PFV or SVF, there are two methods of assessment. These methods include IgG avidity test and IgM response to revaccination. In this study we used the IgM method, and found nobody positive response. These negative results are probably due to SVF. Possible delay in blood sampling for IgM detection and the lower sensitivity of the assay may be also in uential. Nevertheless, this nding is most probably associated with SVF, due to isolated IgG seroconversion in boosted seronegative subjects.
The results of most study from developed countries have shown that approximately 90-95% of children vaccinated at the age of ³12 months produce su cient speci c antibodies against measles and rubella. The protection rates will increase up to 95-98% after the second dose vaccination and persist for decades (1,(3)(4)(5)(6) , although some studies have shown that the achieved seroprotection rate may decline over time or years after the initial immunization (42)(43)(44) . In this study, nearly 12.8% and 17.7% of 7-15-year-old subjects in group C and D (vaccinated with two doses of MMR vaccine administered after the age of 12 months) were serologically susceptible to measles and rubella, respectively, however, the exact cause of this lower unexpected rate is unknown. After revaccination, nearly all boosted serosusceptible subjects develop isolated IgG antibody response without IgM, and showed evidence of secondary immune response, besides waning of acquired immunity over time. Nevertheless, the present study waning of measles and rubella seroprotection rates after the primary vaccination occurred relatively earlier than expected time (1,5,6,39) . Loss of acquired immunity after vaccination, particularly within a shorter period than expected time, is of concern (45,46) . Therefore, vaccine-related factors such as lack of adequate potency of vaccine because of using more thermolabile strains, inadequate control of cold chain shipment/storage/ and use, and other probable factors may be responsible (45)(46)(47) . Our assumption regarding the inadequate potency of vaccine is based on the results of studies that were designed to investigate the immunogenicity of MMR vaccine currently in used in Iran (48)(49)(50)(51)(52)(53) . The majority of these studies showed lower rates of seroconversion following the rst and/or the second doses of MMR vaccine after the age of 12 months ( Table  5).
The reduced levels of measles-rubella antibodies in the post-vaccinated period may result in the accumulation of potentially susceptible individuals to measles and/or rubella in the community. Several reports have described signi cant rates of SVF in population with a sustained high rates of vaccination coverage and long absence of measles virus transmission (40)(41)(42)(43)(44) . In this regard, a prospective multicenter study performed by Smetana et al (43) , evaluated the measles lgG antibody concentrations among vaccinated subjects ³ 18 years. Of 1911 sera, 83.3% were seropositive. When different age groups were compared, the seroprevalence rate decreased overtime: (18-29 years: 81.1%, and 30-39 years: 61.5%). The results of a similar study in Korea, also indicated a progressive decline in antibodies as well as the avidity of antibodies over time in 2-to 30-year-old vaccinated persons (44) . Investigation of the measles outbreaks indicated the vaccine failure in 11-49% of measles cases in several large outbreaks (11,(54)(55)(56)(57) . Also, in an epidemic (56) , up to 14%of cases had received at least two-doses of measles vaccine. These ndings suggest SVF as the main cause of susceptibility which was mentioned earlier in group C and D of our study population. However, since the development of SVF was faster in these groups as compared to other studies, further investigations are recommended to evaluate the immunogenicity and long-term protection of measles vaccine in the Iranian population.
The WHO Regional Veri cation Commission of the Eastern Mediterranean region for measles and rubella elimination declared elimination of measles and rubella in Iran (31) . In the present study among 7-to 33 year-old individuals, who were vaccinated at least with two-doses of measles vaccine with different schedules, nearly 87% and 81% were seroprotected to measles and rubella respectively. Considering a 95% coverage rate with two-doses of vaccine, immunity rates of 83% and 77.6% were estimated in the population respectively. This level of immunity is less than what is necessary to prevent measles and rubella virus transmission in the community and achieve disease elimination (93%-95% and 88-90% for measles and rubella respectively) (1,6) . Also, phylogenetic analysis of the isolated measles viruses in the outbreaks of Iran showed major similarity with the measles viruses detected in neighbor countries. In some of these countries measles is still endemic (16,32) , which can be an alarming sign for Iran. Therefore further long-term prospective studies are recommended to evaluate the immunogenicity of MMR vaccine and investigate the persistence of seroimmunity. If the present study are con rmed in further studies, additional dose of MMR vaccine is required as a national/regional supplementary immunization activity program for the age group of 10-25 year old individuals to sustain measles-rubella elimination in Iran (38) .
One of the limitations of this study is the lack of information about the seroimmunity status after the primary vaccination which can differentiate between PVF and SVF. Also, the method used for the assessment of IgM response to revaccination may not be sensitive enough. Another limitation of this study is that it was not designed as a population based study, it was carried out in East of Mazandaran province, North of Iran with a modest number of participants which made the results less generalizable. Finally, there may be recall bias in group A regarding MR vaccination.

Conclusion
Based on the ndings, nearly 12.3% and 18.4% of fully vaccinated individuals aged 7-33 years were seronegative to measles and rubella. The main causes of negativity to measles and rubella was SVF. The levels of seroprotection detected in this study was lower than what is required to achieve/maintain the elimination goals. To sustain measles and rubella elimination in Iran, further studies are recommended to assess the immunogenicity of the current MMR vaccine and strictly monitor the vaccine cold chain in all stages until use. Finally, periodic serosurveillance studies must be designed for different age groups in different provinces of Iran to detect gaps in the population immunity. They were assured about con dentially and that their contribution would be on a voluntary bases as well as that they had full rights to withdraw from the study at any time.

Consent for Publication: Not applicable
Availability of data and materials: obtained for this study will be available from the corresponding author at a reasonable request.
Competing interests: The authors declare that they have no competing interest