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Rubella in Colleges -- United States, 1983-1984

In 1983 and 1984, six rubella outbreaks in universities and colleges in four states were reported to CDC's Division of Immunization, Center for Prevention Services (Table 2). A total of 125 rubella cases were reported, 124 among students and one in a faculty member. Attack rates varied from 0.2 per 1,000 to 5.4/1,000 among students. Ninety-three (74.4%) of those persons had inadequate evidence of immunity (1).* No pregnant students or other pregnant contacts were identified. No uniform case definition was used to identify suspected cases in any of these outbreaks. However, most illnesses were characterized by one or more of the following: maculopapular rash, lymphadenopathy (cervical, postauricular, or occipital), low-grade fever, coryza, conjunctivitis, sore throat, and/or arthralgia. Fifty-two (41.6%) cases were serologically confirmed as rubella by a positive rubella-specific IgM titer or a fourfold or greater rise in hemagglutination-inhibition (HI) antibody titer. Although three of the colleges had rubella immunization requirements for school entry, there was little or no enforcement of these requirements (Table 2).

In one college, the index patient was a student from South America who was incubating disease on arrival to this country. Since all foreign students attended special English language courses, subsequent cases were clustered among other international students. Cases in the other colleges clustered among particular dormitories, fraternities, and sororities where frequent contact occurred.

As part of outbreak control measures, all the colleges issued notifications to students, faculty, and other employees urging that they provide proof of rubella immunity or be vaccinated with a rubella-containing vaccine. In some schools, outbreak-control measures also included: (1) reviewing student health records for immunization status; (2) providing free rubella vaccine at student health or special vaccination centers for susceptible persons and persons of unknown immune status; and (3) requesting pregnant women of susceptible or unknown immune status to avoid the campus and to contact a physician in the event of rash illness or exposure. Mandatory immunization programs or exclusion from the campus of susceptible or infected persons were not attempted in any of these outbreaks. Free vaccine, either measles-mumps-rubella (MMR) or measles-rubella (MR) vaccine, was provided by student health and local health department personnel at the student health service clinics in five schools. Acceptance of vaccination was poor, ranging from less than 50 students in one school (enrollment 37,000) to 1,100 students in another (enrollment 17,020) (Table 2). Overall, the 1,922 students vaccinated represented 2.5% of the total enrollment. If it were assumed that 7,546 (10.0%) of the 75,468 enrolled at these schools were susceptible (2-4) and that all 1,922 persons receiving vaccination were actually susceptible (Table 2), then the campus vaccination control programs would have reached 1,922 (25.5%) of 7,546 of those considered to be at risk for acquiring rubella. In most instances, the true number of students with records of either rubella immunization or serologic evidence of rubella immunity was unknown.

In two colleges--both of which had rubella immunity requirements--selective reviews of student health records were undertaken in an effort to estimate the number of potentially susceptible students. In one, 719 (71.3%) of 1,008 "day" students lacked acceptable evidence of immunity; in the other, 400 (15.1%) of 2,648 students lacked acceptable evidence of immunity. Of the 1,119 students considered susceptible in the two schools, 372 (33.2%) received MR or MMR vaccine as part of control efforts. The remainder were notified that they would not be registered in the next semester unless they produced records proving rubella immunity. Officials in the other schools had to base control measures on students' and parents' recollections of vaccine status. Reported by A Ley, MD, Student Health Svcs, Student Health Svcs staff, Cornell University, Ithaca, WC Schmidt, MD, Tompkins County Dept of Health, M Miller, MD, Student Health Svcs, Colgate University, Hamilton, K Cardina, Regional Immunization Program, J Grabau, PhD, Bureau of Communicable Disease Control, New York State Dept of Health; RR Albanese, J Bicknell, NJ Fiumara, MD, State Epidemiologist, Massachusetts Dept of Public Health; C Butler, R Gens, State Epidemiologist, Pennsylvania State Dept of Health; J Chin, MD, State Epidemiologist, California Dept of Health Svcs; Div of Immunization, Center for Prevention Svcs, CDC.

Editorial Note

Editorial Note: The 1984 provisional total of 746 reported rubella cases in the United States is a new record low for rubella and represents a 23.1% decline from the 1983 total of 970 cases. In addition, based on the National Congenital Rubella Syndrome Register (NCRSR), only two infants with confirmed and compatible cases of congenital rubella syndrome (CRS) were reported to have been born in 1984, compared with six in 1983. Although these CRS statistics are provisional, they reflect the expected continuous decline in reported rubella and CRS cases that has occurred as the result of rubella vaccination. Although both rubella and CRS cases are underreported, these observed declines probably represent accurate trends in disease incidence, since the degree of underreporting is not expected to have changed appreciably over time.

Rubella outbreaks in the university setting illustrate the potential for outbreaks wherever large numbers of young adults congregate, since 5%-20% of adolescents and young adults remain susceptible to rubella and/or measles (2-5). Colleges and universities have become a primary focus for rubella and measles activity (6-9), with disease being introduced both from domestic sources and by foreign importation (7,8). For example, in 1983, 38.1% of all reported measles cases were college-associated; 19.8% occurred on college campuses. No comparable statistics for rubella in colleges are available. Undoubtedly, many college outbreaks went unrecognized and unreported because many cases of rubella are mild or subclinical. For the same reason, the number of rubella cases in the six reported outbreaks was also probably underestimated. Unless there is a sustained awareness among college health personnel that college-aged populations represent a significant pool of susceptibles to both rubella and measles, early recognition and rapid investigation of reported suspected cases may be seriously delayed. Most schools lack the immunization records to accurately identify susceptibles if an outbreak were to occur. Furthermore, reviewing records and implementing control programs during an outbreak are costly, disruptive, and not often effective. Voluntary programs, like those used in these outbreaks, have generally resulted in poor participation rates and vaccination of many individuals probably already immune. Mandatory control programs will increase compliance but have been rarely instituted to date.

Besides being costly and disruptive to campus life, outbreaks of rubella and measles pose special health risks to this childbearing-aged population, which would likely have higher morbidity rates from these diseases than children (1,8). No infected pregnant women were identified in these outbreaks. Pregnant women were involved in rubella outbreaks on university campuses in Washington and California in 1981; some of these women elected to terminate their pregnancies (9). The anxiety and disruption of classes associated with the warnings to and exclusion of pregnant women would have been unnecessary if these women had previously had adequate documentation of immunity with rubella vaccine. In spite of this recognized threat, most colleges lack immunization requirements. A 1984 survey assessed measles and rubella requirements among institutions of higher education in the United States. Preliminary findings suggested that as few as 16% of an estimated 1,861 colleges assessed have requirements for measles and/or rubella immunity as a condition of attendance. No information on actual enforcement of these requirements was obtained.

While many serious health issues--ranging from alcohol and drug abuse to sexually transmitted venereal diseases and suicide--face college health officials, outbreaks of rubella and measles are problems with an available solution. The only way to prevent introduction of rubella on the campus is to have immune students, faculty, and employees. To support this goal, the American College Health Association and the Immunization Practices Advisory Committee strongly urge educational institutions to consider requiring proof of immunity against these diseases as a condition of registration or employment (1). Both male and female students and staff should be included in any such requirement. Such a requirement minimizes the likelihood of rubella or measles being introduced onto the campus and places the principal responsibility for assuring adequate vaccination status on the student.

Rhode Island and the District of Columbia have had longstanding college entrance requirements. Rhode Island has required rubella immunization for college women since 1980 and measles and rubella

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