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
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.
Orenstein WA, Bart KJ, Hinman AR, et al. The opportunity and
obligation to eliminate rubella from the United States. JAMA
1984;251:1988-94.
CDC. Rubella and congenital rubella--United States, 1980-1983.
MMWR 1983;32:505-10.
CDC. Rubella and congenital rubella--United States, 1983.
MMWR
1984;33:237-42, 247.
CDC. Rubella and congenital rubella syndrome--United States,
1983-1984. MMWR 1984;33:528-31.
Preblud SR, Gross F, Halsey NA, Hinman AR, Herrmann KL, Koplan
JP. Assessment of susceptibility to measles and rubella. JAMA
1982;247:1134-7.
Dales LG, Chin J. Public health implications of rubella
antibody
levels in California. Am J Public Health 1982;72:167-72.
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.
Witte JJ, Karchmer AW, Caes G, et al. Epidemiology of rubella.
Am J Dis Child 1969;118:107-11.
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).
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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