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COMMENTARY |
a Division of Pediatric Infectious Disease, New England Medical Center, Tufts University School of Medicine, Boston, Massachusetts
b National Immunization Program, Centers for Disease Control and Prevention, Atlanta, Georgia
Abbreviations: CRS—congenital rubella syndrome
Routine rubella vaccination was begun in the United States in 1969 with the goal of preventing congenital rubella infection. In October 2004, 35 years after initiation of the program, an independent panel of international experts was convened by the Centers for Disease Control and Prevention to assess progress toward elimination of rubella and congenital rubella syndrome (CRS). Based on available data, panel members concluded unanimously that rubella is no longer endemic in the United States. The national objective of elimination of rubella and CRS by 2010 from the United States has been attained.1
Rubella was first described as a mild exanthematous illness of childhood early in the 19th century by German physicians, resulting in the name German measles. In 1941, Sir Norman Gregg, an Australian ophthalmologist, recognized that a number of children developed cataracts after an epidemic of rubella and proposed an association between maternal rubella infection and the development of cataracts, deafness, heart disease, and mental retardation in the infant.2 In addition, Gregg is credited with introducing the concept of an intrauterine viral infection as having teratogenic potential. In 1962, rubella virus was isolated in cell culture.3,4 This was the same year as the start of a worldwide pandemic that spread to the United States in 1964-1965 and resulted in >12 million cases of rubella. This was the last rubella epidemic to occur in the United States, but it resulted in thousands of infections in pregnant women, causing 11250 fetal deaths and 20000 infants to be born with the congenital rubella syndrome. The financial cost of the epidemic was estimated at $1.5 billion.1 After the disastrous consequences of this epidemic, several attenuated rubella vaccines were developed, and in 1969, a national rubella vaccination program was begun.
Rubella is caused by an enveloped RNA-containing virus classified as a togavirus. Although rubella virus is closely related to the arthropod-borne viruses that cause Eastern and Western equine encephalitis, humans are the only known natural host for rubella virus.5 No condition is associated with chronic shedding of rubella virus, although infants with congenital rubella syndrome may excrete virus for months. Postnatally acquired rubella infection is asymptomatic in up to 50% of people. In those who develop symptoms, illness is generally mild, consisting of a rash that usually begins on the face, lymphadenopathy involving postauricular, posterior cervical, or suboccipital nodes, low-grade fever, and arthralgia. Rare complications include thrombocytopenia and encephalitis. The major impetus for implementation of the immunization program was prevention of the devastating consequences in women who are infected during the first 24 weeks of gestation, particularly the first trimester, which results in abortions, stillbirths, miscarriages, and fetal malformations.
Unborn children constituted the group most likely to benefit from widespread use of the rubella vaccine. Initially, vaccination of susceptible women of childbearing age was not acceptable because data were not available on the potential risk of adverse effects of the vaccine strain on the fetus. An alternative approach was to focus the vaccination campaign on young children, because they represented the group most likely to spread the virus. Subsequently, additional efforts were directed at identification and immunization of susceptible postpubertal women as well as other groups of susceptible individuals including military recruits and hospital personnel.6,7 In contrast, the United Kingdom initiated a policy of vaccinating 10- to 14-year-old schoolgirls as well as susceptible women of childbearing age.8,9 This policy resulted in a reduction in cases of congenital rubella syndrome in the United Kingdom, although rubella virus continued to circulate among adult males and unvaccinated children. After a rubella epidemic in 1986, the vaccination program was modified to vaccinate all children, similar to the practice in the United States.10–12
In the United States, the incidence of reported cases of rubella fell sharply after the initiation of rubella immunization of young children in 1969 (Fig 1). From the estimated 2 million cases per year in the prevaccine era, <1000 cases were reported in 1983. The incidence of rubella continued to fall during the 1980s and 1990s, although clusters of disease occurred among groups of susceptible individuals, including people with religious or philosophic exemption to immunization. Although rubella had been a disease of childhood, the proportion of remaining cases among people 
20 years of age increased to 79% in 1998.11 Sustained implementation of the rubella vaccination program resulted in a marked decrease in incidence among all age groups. Since the mid-1990s, most reported cases of rubella occurred among foreign-born young adults (particularly from Latin America) who were born in countries without routine rubella immunization programs.13,14 As shown in Fig 1, outbreaks of rubella usually are followed by an increase in newborns with congenital rubella syndrome. Each year from 1992 through 1999, an average of <6 cases per year of congenital rubella syndrome have been reported.14
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The absence of endemic rubella is not equivalent to the absence of rubella cases. Travelers and immigrants from areas of the world in which rubella is endemic continue to introduce virus into this country. If immunization practices are relaxed, pockets of susceptible persons will accumulate, and the risk of rubella transmission will increase. In 2003, member countries of the Pan American Health Organization established a goal of eliminating rubella and CRS from the Western hemisphere by 2010. As of 2004, 43 of the 44 countries and territories in the Western hemisphere had initiated routine rubella vaccination programs that target young children combined with catch-up mass-vaccination campaigns to reach older children, adolescents, and adults; the only remaining country should do so in 2005.17
Although rubella remains endemic on other continents, more than half of the member countries of the World Health Organization include routine rubella immunization, which raises the exciting possibility of global eradication of rubella at a future date.18 Until this time is reached, efforts must include continued surveillance for rubella and CRS, rapid response to outbreaks, and increased international efforts to support improved global rubella control. The challenge for pediatricians and others who administer vaccines is to ensure continued compliance with recommended rubella immunization guidelines, including vaccination of susceptible women of childbearing age, especially women born outside the United States.
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FOOTNOTES |
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Address correspondence to H. Cody Meissner, MD, Division of Pediatric Infectious Disease, Tufts-New England Medical Center, 750 Washington St, Boston, MA 02111. E-mail: cmeissner{at}tufts-nemc.org
The authors have indicated they have no financial relationships relevant to this article to disclose.
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REFERENCES |
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  C. T. D'Angio, P. A. Boohene, A. Mowrer, S. Audet, M. A. Menegus, D. S. Schmid, and J. A. Beeler Measles-Mumps-Rubella and Varicella Vaccine Responses in Extremely Preterm Infants Pediatrics, March 1, 2007; 119(3): e574 - e579. [Abstract] [Full Text] [PDF]
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