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Published Date: 2013-05-23 23:48:08
Subject: PRO/EDR> Rubella - Poland: young male adults, CRS risk
Archive Number: 20130523.1733914

RUBELLA - POLAND: YOUNG MALE ADULTS, CRS RISK
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Date: Thu 23 May 2013
Source: Euro Surveill. 2013;18(21):pii=20485 [abridged, edited]
http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=20485

Ongoing outbreak of rubella among young male adults in Poland: increased risk of congenital rubella infections. (By Paradowska-Stankiewicz I, Czarkowski MP, Derrough T, Stefanoff P.)

Background
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From January to April 2013, Poland reported 21 283 rubella cases (55.2 per 100 000 inhabitants), the highest number since 2007. Some 81 percent of cases were among 15-29 year-old males. This outbreak reflects the history of immunisation policies, selective vaccination of adolescent girls since 1989, then universal 2-dose measles-mumps-rubella vaccination since 2004. The extent of virus circulation among adults increases the risk of congenital rubella infections and jeopardises the World Health Organization Regional Office for Europe's 2015 elimination goal.

Ongoing rubella outbreak
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From January to April 2013, physicians in Poland notified 21 283 rubella cases (55.2 per 100 000 inhabitants) [1], a near 10-fold increase compared with the 2224 cases (5.8 per 100 000 inhabitants) reported during the corresponding period of 2012.

Physicians use the European Union (EU) case definitions for rubella and congenital rubella syndrome (CRS) [2]. They report each rubella case to the local health department, providing demographic information, International Classification of Diseases (ICD)-10 code [3], case classification and vaccination status. Every 2 weeks, local health departments report the number of cases notified in their area to the provincial health departments that aggregate data, which they forward to the National Institute of Public Health - National Institute of Hygiene. Every month, local health departments prepare aggregated reports with more detailed data, including the number of cases by age group, sex, vaccination status and case classification.

Physicians report CRS cases to the local health departments. Local health departments investigate CRS cases and send individual reports to the National Institute of Public Health - National Institute of Hygiene. There is no routine active case finding search for CRS cases, nor has active CRS surveillance been implemented to date.

We describe here this country-wide rubella outbreak by person, place and time and propose implementation of preventive measures.

We calculated reported rates per 100 000 inhabitants, dividing the number of rubella reported cases by mid-year census estimates [4]. The reported rates of rubella varied substantially between provinces (median: 51.2 per 100 000 inhabitants; range: 7.4-151.1 per 100 000 inhabitants). The majority of cases were reported from 3 provinces in the southeast of the country (n=8.659; 41 percent), bordering Ukraine, Belarus and Slovakia, and 5 provinces in the northwest (n=7.997; 38 percent), 2 of which border Germany.

The male to female ratio was 10:1. The most affected groups were persons who were male aged 15-19 years (12 220 cases, reported rate: 1044.9 per 100 000 inhabitants; 57 percent of cases), 20-24 years (4000 cases, reported rate: 286.8 per 100000 inhabitants; 19 percent of cases) and 25-29 years (992 cases, reported rate: 61.1 per 100 000 inhabitants; 5 percent of cases). During 2003 to 2012 and the 1st 4 months of 2013, rubella reported rates suggested an increasing trend in 2006-2007 and then in 2012, and the 1st 1/3rd of 2013. The increases in 2006-2007 and from 2012 were both more pronounced among males 10 years of age and older, especially in the 1st 4 months of 2013.

Vaccination status was recorded for 15 237 (72 percent) reported cases. Of these, 1502 (10 percent) were vaccinated with one dose of rubella-containing vaccine, and 234 (2 percent) with 2 or more doses of rubella-containing vaccine. Of all reported cases, 29 (0.1 percent) were confirmed (based on a valid laboratory test); 57 (0.3 percent) were probable (based on an epidemiological link to a confirmed case), and 21 197 (99.6 percent) were possible (based on clinical symptoms).

From January to April 2013, 2 cases of (CRS) were reported, as compared with 4 cases reported during 2003 to 2012.

History of rubella immunisation in Poland
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In 1989, Poland started to administer monovalent rubella vaccine to 13-year-old girls. In 1992-2006, reported coverage ranged from 94 percent to 99 percent [5]. In 2004, measles-mumps-rubella (MMR) vaccine was administered to all children at the age of 13-15 months and 10 years [1]. In 2005-2012, 1st-dose coverage among 3-year-old children ranged from 91 percent to 98 percent [5].

In 2011, a mission of the World Health Organization (WHO) Regional Office for Europe reviewed the rubella situation in Poland, identified an immunity gap among adolescent males and young adults, and recommended supplementary immunisation of all adolescents and young adults, as the increased circulation of rubella among young adults increases the risk of congenital rubella syndrome (CRS) [6].

Discussion
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The 2013 outbreak of rubella in Poland reinforces the need for public health efforts to meet the WHO Regional Office for Europe target for the elimination of measles and rubella and prevention of CRS by 2015 [7]. From April 2012 to March 2013, rubella cases in Poland comprised 74 percent of those in the EU/European Economic Area (EEA) countries [8]. Despite the visible impact of the childhood immunisation programme in decreasing rubella activity among the vaccinated age groups, Poland will not achieve rubella elimination without targeted supplementary immunisation activities.

The outbreak reflects the historical immunisation activities in Poland: a combination of selective and universal vaccination led to a shift in the age of rubella infections to cohorts of young adults. This situation increases the risk for CRS, due to high circulation of the rubella virus among adolescents and young adult populations. Despite long-term vaccination of adolescent girls, about 10 percent of women of childbearing age may still be susceptible to rubella, as documented in a 2004 study [9]. From January to April 2013, 2 cases of CRS have already been reported, as compared with 4 cases during 2003 to 2012. Further cases are, unfortunately, expected and unavoidable, as observed during outbreaks in other EU/EEA countries in recent years.

The country most recently affected was Romania. In 2011-2012, Romania reported 20 772 rubella cases, 22 confirmed CRS cases, and 11 cases of congenital rubella infection [10,11]. A similar situation was observed in Greece in the 1990s: a large rubella outbreak was described in 1993, with 25 cases of CRS, and another epidemic occurred in 1999, mainly in young adults, with 4 cases of CRS [12].

These observations in Greece, Romania and now Poland are a consequence of immunisation practices that had been followed, leading to the build-up of susceptible cohorts. Sadly, rubella outbreaks in young adults unavoidably lead to children being born with CRS. This situation is likely to be repeated if women of childbearing age are left unprotected and become infected with rubella virus. All possible efforts should be undertaken to prevent any cases of CRS in Europe in the future. The availability of rubella-containing vaccines with a long-standing history of good safety and effectiveness profiles, and provision to all those who need it, would ensure that the potentially dramatic consequences of rubella infection in pregnancy would become a thing of the past.

Our report has one main limitation. The vast majority of cases were reported based on clinical symptoms and were not laboratory confirmed. Thus, the clinical cases could be potentially due to a concomitant outbreak of another illness causing a rash.

This outbreak empirically reflects the shift in the age of infections and the accumulation of susceptible cohorts 10 years after starting universal vaccination. The increased age of infected people leads to an increased risk of CRS. This situation requires immediate public health action to prevent further CRS cases.

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[Interested readers should consult the original text via the source URL to view the figures and references cited.

The eradication of rubella virus infection and elimination of the congenital syndrome are closely linked to vaccination policy as described above. Before the introduction of the MMR vaccine, some countries relied on comprehensive vaccination of female children with rubella vaccine, which achieved a reduction in the frequency of the congenital rubella syndrome (CRS) but could never achieve complete elimination. Recently in ProMED-mail, the consequences of a similar policy in Japan have been described in detail [see ProMED archives below].

Final eradication of congenital rubella syndrome (CRS) will require universal adoption of MR vaccination. Rubella is a contagious, generally mild viral infection that occurs most often in children and young adults. Rubella infection in pregnant women may cause fetal death or the congenital defects known as congenital rubella syndrome. According to the WHO, worldwide, an estimated 110 000 babies are born with CRS every year. When a woman is infected with rubella virus early in pregnancy, she has a 90 percent chance of passing the virus on to her fetus. This can cause miscarriage, stillbirth or the severe birth defects known as CRS. Children with CRS can suffer hearing impairments, eye and heart defects and other lifelong disabilities, including diabetes mellitus and thyroid dysfunction. Before the introduction of vaccine, up to 4 babies in every 1000 live births were born with CRS. - Mod.CP

A HealthMap/ProMED-mail map can be accessed at: http://healthmap.org/r/1JDJ.]

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