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Original
Article
Seroprevalence of
Measles, Mumps, and Rubella antibodies among Southwestern Libyan students.
Shahlol
Aisha1*, Al Mahde Gena1, Shahlol Elham2, Elzahaf
Raga3,4.
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1: Department
of Medical Laboratory Technology Faculty of Engineering and Technology Sabha University, Brack,
Libya 2: Department
of pediatrics, Sabha Hospital,Libya 3: Public
Health Department, College of Medical Technology, Derna,
Libya 4: MENA Research Group * Corresponding author Correspondence to: Publication data: Submitted: March 2, 2020 Accepted:
May 28, 2020 Online: June 30, 2020 This article was subject to
full peer-review. This is an open access article distributed under the terms of the
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Abstract: |
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Background Measles,
Mumps, and Rubella (MMR) are vaccine preventable viral diseases. They cause
significant mortality and morbidity worldwide. The seroprevalence
data on MMR in Libya is limited. The aim of our study was to assess the
immune status and infection susceptibility of primary school children and
university students for measles, mumps, and rubella in Libya through a seroprevalence survey. Methods A
cross-sectional serosurvey of MMR was conducted in Brack city, Libya among students of at Al-Shoroug Primary School (ASP) and the Faculty of
Engineering and Technology, Sabha University
(FETS). Results A
total of 76 participants were surveyed.
The age range was 7-20 years old with a mean of 13.6 years. The
overall mumps IgG seropositivity
rate was 43.4%. Measles and Mumps IgG levels among
children are significantly higher than University students. A high rubella IgG seroprevalence was
noticed in female university students. Conclusion The
measles and Mumps IgG sharply decreased with time
compared to rubella IGg. According to the Libyan
program the first and second dose of the MMR vaccine is given at the age
of 12and 18 months, respectively. That
may not be protective in adult age. A
third regular dose could be recommended in the national vaccine program to
prevent outbreaks in young adults. Clinical relevance These
results can inform the development of future screening programs and
contribute to the management of viral infections in schools and universities. Key words Measles, Mumps, Rubella, seroprevalence, seroprotection,
immunoglobulin G, Libya |
Introduction
Measles, mumps, and rubella (MMR) are frequent viral infection that causes considerable morbidity and mortality despite the availability of the vaccine. Mumps may cause deafness ,aseptic meningitis, and encephalitis in childhood. Rubella infection can be responsible for congenital rubella syndrome and complicated pregnancies.
MMR vaccination is recommended in Libya. A two-dose schedule is assigned at 12 and18 months of age [1].
According
to some international studies, levels of antibody against MMR decreased more
rapidly after childhood immunization compared to other vaccines. Despite the
high vaccination coverage, the incidence of the disease increased in older
individuals [2].
Several neighboring countries implemented a mass nationwide vaccination campaign to prevent MMR outbreak and to reduce the infection sequels. Libyan data about MMR is limited. Increasing MMR incidence, the unclear background on adult MMR serological status, and the lack of the studies about immunization success are the most remarkable epidemiological aspects of MMR in Libya.
The
aim of our serosurvey was to assess the immune status
and the susceptibility to MMR among students from different age groups in
southern Libya.
Patients and Methods
Study population
This
cross-sectional serosurvey of MMR included 76
participants. The survey was conducted in the southwestern Libyan Brack
city at Al-Shoroug Primary School (ASP) and the
Faculty of Engineering and Technology, Sabha
University (FETS). The ethical approval to conduct the study was granted from
the Research Ethics Committees of Sabha University.
All the participants had previously received only two doses of MMR vaccine. Eligible participants were
asked to complete a questionnaire including name, age, gender, MMR dose taken,
place of vaccination, and the past medical history. Parental consents were
obtained for school children participants.
Samples collection
A
blood specimen was collected from each study participant. Blood samples plain
tubes (4ml) were obtained from the vaccinated participants and centrifuged
serum was kept at- 20°C. Enzyme-linked immunosorbent
assay (ELISA) dedicated kits was used for MMR IGg detection and dosage (NeoBiotech,
France, BioCheck Inc, USA).
IgG Titers
analysis
IgG titers for Measles, Mumps, and
Rubella were assessed for each participant. The correlation of MMR IgG
titers with age subgroups, gender and
place of collection was noted. The evolution of the seroprotection
was assessed via the correlation with the overall MMR IgG
rates as marker of vaccine dose.
A
positivity for mumps and measles was detected for IgG titer
> 11NTU/ml. However, the required titer for Rubella was 15 IU/ml.
Statistical analysis
Statistical
analysis was performed by using a Minitab 16.1program (Microsoft Office 2010,
USA) for descriptive data. The statistical analysis was performed by ANOVA
two-way; Chi-Square and Pearson tests were used to rule out correlations. P
value <0.05 indicated significant correlation and was used to calculate the
confidence interval 95%.
Results
A
total of 76 participants from ASP School and FETS were surveyed. The mean participant
age was 3.69±5.04 years (7-20). There were 30 (39.5%) males and 46 (60.5%)
females.
The
age of school participants ranged between 7 and 12 years (M/F 29/9) and the age
of university students ranged between 17 and 20 years ( M/F
1/37).
The
triple vaccination coverage was higher among school participants.
The
overall positivity for Measles, Mumps, and Rubella IgGs were
71%, 53% and 93.4% respectively. However at least one vaccine IgG was negative for 56.5 % of the participants (28 from
FETS and 15 from
ASP School).
The
overall vaccine IgG positivity was higher in male
school students. Rubella IgG was significantly higher
among university than school females (47.3%) (X2=82.086, P=0.001) “Table1”.
A
higher level of MMR IgG was seen at the age subgroup of 7-8
years. The seroprevalence for Measles, Mumps, and
Rubella in this subgroup were 23.6%, 19.7% and 22.3%, respectively.
There was a significant difference between age
group and MMR IgG, Two-way ANOVA (82.95%, P=0.009).
The inverse correlation of age and measles = -0.414(P <0.0001), age and
mumps = -0.213(P = 0.0065) and age and rubella = -0.089 (P = 0.443) (figure 1).
The
overall concentration of MMR IgG antibodies was
variable. The titers above 50-65 NTU for Measles, Mumps, and Rubella were 1.3
%, 1.3 % and 3.9% respectively. Adult participant had significantly a lowest
concentration of Measles, Mumps IGg (p=0.000). The
Rubella
IgG record showed the same findings with no
significance (p=0.056) “Figure 2”.
The
statistical analysis of MMR IgG in different age subgroups showed a significant
trend of the decrease in the titer and concentration of Measles, Mumps vaccine
antibodies with age.
Table 1: MMR IgG
vaccine positivity among school and university
participants.
|
|
Measles
IgG |
Mumps
IgG |
Rubella
IgG |
|||
|
|
M(
n /%) |
F
(n/%) |
M
(n/%) |
F
(n/%) |
M(n/%) |
F
(n/%) |
|
ASP School |
25(32.8) |
7(9.2) |
22(28.9) |
5 (6.5) |
26(34.2) |
8(10.5) |
|
FETS |
0(0) |
22(28.9) |
0(0) |
14(18.4) |
1(1.3) |
36(47.3) |
|
Pvalue |
<0.0001 |
|
<0.0001 |
|
0.003 |
0.0001 |
|
Figure
1: IgG positivity distribution according to age
subgroups
|
Figure
1: IgG titer distribution among school and
university participants
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Discussion
This
is the first study that assesses the immune response to MMR vaccine in the south west of
Libya. The estimated seroprevalence was 43%. It is
lower but still comparable to the findings of other studies. This could be due
to the older age of volunteers serum collection [3].
According
to the Libyan vaccination program, two doses of MMR vaccine are assigned at 15 and 18
months [4]. That could partially explain the higher MMR IgG
level for the school students compared to the university students. The Belgium
vaccination program recommend a second dose of MMR vaccine at the age 5 years. A Belgian
study estimated seroprevalence for measles IgG at 86.8% [5]. The same findings were noticed in other seroprevalence studies that confirmed the local variation of the IgG antibodies titers as well its decrease over the time [6,7].
Our
study showed more persistent IgG protective titers
for Measle in males
participants. This could be explained partially by the male predominance in our
series. This was not concordant with the conclusions of some other studies [4,7,8]. The
Mumps IgG titer decrease with age as per most of the seroprevalence studies. A protective titer could be
detected 5 years after the first vaccine dose [9]. Our study showed significant
titer for Measles and Mumps 12 years after the vaccine dose. This Could advocate a longer life for these IgG
and an objective protection in teenagers only. The Rubella IgG
titers were significantly higher in adult females. Recent Indian study recorded
88% IgG Rubella seropositivity
in university students [10]. This could be explained by the complexity of the
immune reaction against Rubella and some independence of the immunoglobulin
production after the first vaccine stimulation. The tardive immune system
reaction to MMR vaccine is not yet totally clear especially in adults [11-14].
The
immune reaction is variable and may depend on many hormonal ,
cytogenetic and familial factors. This diversity is noted mostly for the
Rubella immunization while the mechanisms of the immune response variability
are still unclear for Measles and Mumps [15,16]. Findings of concordant
studies noted that the long interval between the first and second vaccine dose
improves the avidity of IgG [17].
It
is evident that the immunization by a vaccine dose is efficient in the
prevention of viral infection outbreak. MMR vaccine is responsible for considerable direct
and indirect immunity. This vaccine is safe and practical in large public scale
[18]. Most of the seroprevalence studies confirmed
the gradual decrease of IgG titers and avidities in
adult patients [19,20].
We
recommend the maintenance of protective IgG titers by
giving a “reminder third dose” in the beginning of school education. That may
contribute to the MMR immunity in young adults.
These
results and our recommendations should be confirmed on larger trials with
specific assessment of MMR IgG avidity behavior in
this exposed scholar population.
Conclusion
This
study tried to assess the level of MMR immunity related to the vaccination
program implemented in Libya.
Three
of the MMR IgGs are unstable and show a variable
avidity in adults. South western Libya has a poruos
borders with adjacent African countries due to high flow of migration. That
could be an exposing factor for viral diseases outbreak. A revision of the MMR
national vaccine program is advisable to ensure maximum protection of this
population.
Conflict of interest
The
authors declare that there is no conflict of interest.
Acknowledgement
We
would like to thank all volunteering participant and Al-Shoroug
school manager who contributed to the samples collection.
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