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Current Trends Elimination of Rubella and Congenital Rubella Syndrome -- United States

The administration of more than 123 million doses of rubella vaccine since 1969, the year of licensure, has successfully prevented epidemics of rubella and congenital rubella syndrome (CRS) from occurring in the United States (1,2). Reported cases of rubella and CRS are at all-time lows. The provisional 1984 totals for rubella cases and confirmed and compatible cases of CRS are 745 and two, respectively. Compared to prevaccine years, the number of reported rubella cases has decreased 98.7% overall, with 90% or higher declines recorded for all age groups (3-5). Similarly, the number of reported confirmed and compatible CRS cases has declined by 97.1% since 1970, the year the highest number of such cases was reported (4). Although there is believed to be underreporting of both rubella and CRS, these figures represent considerable progress.

Rubella vaccination has had a dramatic effect on the occurrence of rubella and CRS. Nonetheless, CRS cases continue to be reported at a low endemic level because the current 10%-20% susceptibility rate to rubella in the childbearing-aged population (6-8) has changed little from that noted in prevaccine years (9). The initial vaccination strategy adopted by the United States was aimed at controlling rubella in preschool-aged and young school-aged children, the known reservoirs for rubella transmission (9). The intent was to prevent exposure of susceptible pregnant women to rubella virus (10). Accordingly, the primary target group for vaccination was children of both sexes. Secondary emphasis was placed on vaccinating susceptible adolescents and young adults, especially women. While more than 95% of school enterers now provide evidence of immunization against rubella, comparable levels of rubella immunization have not been achieved in the postpubertal population. As a result, there is continuing endemic rubella activity among adolescents and young adults (3,11).

As the highly immune cohorts of young children enter the childbearing age, CRS can be expected to disappear from this country. However, since this process will take 10-30 years, potentially preventable cases of CRS will occur (2). It is estimated that each case incurs an average lifetime cost of over $200,000 (12). Furthermore, unnecessary instances of miscarriages, stillbirths, and induced abortions resulting from congenital infection will continue to occur.

Recent focus on the continued occurrence of rubella in childbearing-aged populations has led to increased efforts to effectively vaccinate this population and thus hasten the elimination of CRS (3-5,11). The number of doses of rubella vaccine administered in the public sector to postpubertal individuals doubled between 1978 and 1981 (3). The trend of increasing vaccination of this population is continuing. This has been accomplished in part by vaccinating susceptible students attending junior and senior high schools, clients of family planning clinics, hospital personnel, college and university students, women following premarital screening, and women immediately postpartum.

There still are, however, gaps in attempts to hasten CRS elimination. A number of states do not require proof of rubella immunity for postpubertal female elementary and secondary school students. The same is true of many colleges, universities, and health-profession institutions. When women are seen by internists or obstetricians/gynecologists, rubella immune status is not commonly considered. When women are screened for rubella immunity either premaritally or prenatally or in family planning clinics, only a low proportion of susceptibles so identified are subsequently vaccinated.

An initiative to hasten elimination of rubella has recently begun. As with measles elimination, efforts to eliminate CRS are aimed at (1) achieving and maintaining high immunization levels, (2) intensified surveillance of rubella and CRS, and (3) prompt outbreak control (2,11). Specific activities will focus on further increases in the delivery of rubella vaccine to women of childbearing age and enhancement of the lay and medical communities' awareness of the current rubella and CRS situation.

Vaccination of a nonschool-based population poses many logistical problems. A multifaceted approach that involves both the public and private sectors will be needed (2,13). Furthermore, information that may help identify select groups at increased risk of not being vaccinated will have to be sought to help focus vaccination efforts. However, considering the economic impact of CRS and the other outcomes of rubella infection during pregnancy, any effort that can hasten the elimination of CRS should be undertaken. Reported by Div of Immunization, Center for Prevention Svcs, CDC.

References

  1. Preblud SR, Serdula MK, Frank JA Jr, Brandling-Bennett AD, Hinman AR. Rubella vaccination in the United States: a ten-year review. Epidemiologic Reviews 1980;2:171-94.

  2. Orenstein WA, Bart KJ, Hinman AR, et al. The opportunity and obligation to eliminate rubella from the United States. JAMA 1984;251:1988-94.

  3. CDC. Rubella and congenital rubella--United States, 1980-1983. MMWR 1983;32:505-10.

  4. CDC. Rubella and congenital rubella--United States, 1983. MMWR 1984;33:237-42, 247.

  5. CDC. Rubella and congenital rubella syndrome--United States, 1983-1984. MMWR 1984;33:528-31.

  6. Preblud SR, Gross F, Halsey NA, Hinman AR, Herrmann KL, Koplan JP. Assessment of susceptibility to measles and rubella. JAMA 1982;247:1134-7.

  7. Dales LG, Chin J. Public health implications of rubella antibody levels in California. Am J Public Health 1982;72:167-72.

  8. Blouse LE, Lathrop GD, Dupuy HJ, Ball RJ. Rubella screening and vaccination program for U.S. Air Force trainees: an analysis of findings. Am J Public Health 1982;72:280-3.

  9. Witte JJ, Karchmer AW, Caes G, et al. Epidemiology of rubella. Am J Dis Child 1969;118:107-11.

  10. Hinman AR, Bart KJ, Orenstein WA, Preblud SR. Rational strategy for rubella vaccination. Lancet 1983;I:39-40.

  11. ACIP. Rubella prevention. MMWR 1984;33:301-10, 315-8.

  12. Koplan JP, White CC. An update on the benefits and costs of measles and rubella immunization. In: Proceedings of the symposium "Conquest of agents that endanger the brain." Baltimore, Maryland, October 28-29, 1982 (in press).

  13. Doster SW, Stetler HC, Orenstein WA, Bart KJ, Hinman AR. Measles and rubella: our remaining responsibilities ]editorial^. Am J Public Health 1983;73:490-2.



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