Congenital Rubella Syndrome: Progress and Future Challenges
Congenital Rubella Syndrome: Progress and Future Challenges
Since 1941, when Gregg first described the triad of deafness, cataracts and cardiac disease as the classical clinical manifestations of congenital rubella syndrome (CRS), strong efforts have been implemented around the world to achieve effective preventive strategies. In Costa Rica, vaccination against rubella started in 1972 and in 1986, the combined measles, mumps and rubella vaccine was introduced in the national schedule among 1-year-old children. This vaccination strategy shifted the susceptibility to other groups at child-bearing age. To protect this age group, in 2001 Costa Rica implemented a successful national immunization campaign targeting both men and women aged 15-39 years, followed by postpartum vaccination of women who were pregnant when the campaign was implemented. The epidemiological surveillance system of rubella and CRS cases was strengthened and it was integrated with the investigation and notification system of febrile eruptive diseases. We describe the Costa Rican experience, which has led to similar actions in other countries in Latin America. Challenges and strategies in the elimination of rubella and CRS are also discussed.
Infection by the rubella virus during pregnancy produces severe clinical manifestations that can be transient, permanent or of late-onset appearance. The severe defects observed in children with congenital rubella syndrome (CRS) include deafness, cardiac disease and mental retardation, which are associated, not only with increased patient morbidity and a negative impact on the family environment and dynamics, but also with high economic healthcare costs for systems and society in general, especially in developing countries, such as Costa Rica and other Latin American countries.
After the first isolation of rubella virus in 1962, considering the devastating effects of fetal infection by rubella virus, efforts were directed toward the production of an effective and safe vaccine to prevent rubella. Therefore, the availability of this vaccine, after it was licensed in 1969 at an affordable economic cost and with high and long-term efficacy rates, aroused important challenges for public-health systems around the world, as the possibility of eliminating rubella and CRS was seen as a great success in public health.
Costa Rica was one of the first countries in the world to initiate vaccination against the rubella virus, initially in 1972, only to specific target groups and with very low coverage rates. Several decades went by before reaching universal vaccination for young children, when the combined triple viral measles, mumps and rubella (MMR) vaccine was introduced in 1986 in the official immunization schedule. However, a combined strategy targeting both adolescents and child-bearing-age mothers was not planned initially. Over the years, a shift of susceptible age groups was seen toward the adolescent and adult groups in the country. Therefore, owing to these changes and the endemic circulation of the virus in the Costa Rican population, vaccination strategies were re-addressed and focused on men and women of child-bearing age.
At the end of 2000, a national action plan was implemented to advance toward the elimination of CRS, which also strengthened actions toward measles elimination. This plan was also successful in improving surveillance systems of febrile eruptive diseases and CRS. This led to a change in national vaccination strategies, when a postpartum vaccination strategy was introduced and, in May 2001, when a national catch-up immunization campaign in adults was initiated.
This campaign highlighted important challenges for the nation because this meant that vaccination was required for certain groups (i.e., men, adolescents and adults), who traditionally were not target groups in previous vaccination programs. Furthermore, the vaccine was not indicated in pregnant women and a massive strategy would have increased the possibility that women who were unknown to be pregnant might have been exposed to the vaccine. Therefore, the campaign led to a close follow-up of safe vaccination practices during pregnancy for these women.
This article describes the Costa Rican experience on the elimination of rubella and CRS starting in the 1970s, continuing during the current decade and looking at the global vaccination strategies and tasks for the future.
Abstract and Introduction
Abstract
Since 1941, when Gregg first described the triad of deafness, cataracts and cardiac disease as the classical clinical manifestations of congenital rubella syndrome (CRS), strong efforts have been implemented around the world to achieve effective preventive strategies. In Costa Rica, vaccination against rubella started in 1972 and in 1986, the combined measles, mumps and rubella vaccine was introduced in the national schedule among 1-year-old children. This vaccination strategy shifted the susceptibility to other groups at child-bearing age. To protect this age group, in 2001 Costa Rica implemented a successful national immunization campaign targeting both men and women aged 15-39 years, followed by postpartum vaccination of women who were pregnant when the campaign was implemented. The epidemiological surveillance system of rubella and CRS cases was strengthened and it was integrated with the investigation and notification system of febrile eruptive diseases. We describe the Costa Rican experience, which has led to similar actions in other countries in Latin America. Challenges and strategies in the elimination of rubella and CRS are also discussed.
Introduction
Infection by the rubella virus during pregnancy produces severe clinical manifestations that can be transient, permanent or of late-onset appearance. The severe defects observed in children with congenital rubella syndrome (CRS) include deafness, cardiac disease and mental retardation, which are associated, not only with increased patient morbidity and a negative impact on the family environment and dynamics, but also with high economic healthcare costs for systems and society in general, especially in developing countries, such as Costa Rica and other Latin American countries.
After the first isolation of rubella virus in 1962, considering the devastating effects of fetal infection by rubella virus, efforts were directed toward the production of an effective and safe vaccine to prevent rubella. Therefore, the availability of this vaccine, after it was licensed in 1969 at an affordable economic cost and with high and long-term efficacy rates, aroused important challenges for public-health systems around the world, as the possibility of eliminating rubella and CRS was seen as a great success in public health.
Costa Rica was one of the first countries in the world to initiate vaccination against the rubella virus, initially in 1972, only to specific target groups and with very low coverage rates. Several decades went by before reaching universal vaccination for young children, when the combined triple viral measles, mumps and rubella (MMR) vaccine was introduced in 1986 in the official immunization schedule. However, a combined strategy targeting both adolescents and child-bearing-age mothers was not planned initially. Over the years, a shift of susceptible age groups was seen toward the adolescent and adult groups in the country. Therefore, owing to these changes and the endemic circulation of the virus in the Costa Rican population, vaccination strategies were re-addressed and focused on men and women of child-bearing age.
At the end of 2000, a national action plan was implemented to advance toward the elimination of CRS, which also strengthened actions toward measles elimination. This plan was also successful in improving surveillance systems of febrile eruptive diseases and CRS. This led to a change in national vaccination strategies, when a postpartum vaccination strategy was introduced and, in May 2001, when a national catch-up immunization campaign in adults was initiated.
This campaign highlighted important challenges for the nation because this meant that vaccination was required for certain groups (i.e., men, adolescents and adults), who traditionally were not target groups in previous vaccination programs. Furthermore, the vaccine was not indicated in pregnant women and a massive strategy would have increased the possibility that women who were unknown to be pregnant might have been exposed to the vaccine. Therefore, the campaign led to a close follow-up of safe vaccination practices during pregnancy for these women.
This article describes the Costa Rican experience on the elimination of rubella and CRS starting in the 1970s, continuing during the current decade and looking at the global vaccination strategies and tasks for the future.