Transcript Slide 1

Congenital rubella syndrome
surveillance
Dr Esteghamati, national EPI Manager
Pediatrician
Number of Vaccines in the Routine Childhood and
Adolescent Immunization Schedule
1985
1995
2006
Measles
Rubella
Mumps
Diphtheria
Tetanus
Pertussis
Polio
Measles
Rubella
Mumps
Diphtheria
Tetanus
Pertussis
Polio
Hib (infant)
HepB
Varicella
Measles
Rubella
Mumps
Diphtheria
Tetanus
Pertussis
Polio
Hib (infant)
Hep B
Varicella
Pneumococcal disease
Influenza
Meningococcal disease
Hep A
Rotavirus
HPV
7
10
16
Congenital Rubella Syndrome
• severe bilateral deafness
• severe bilateral visual defects
• cataract
• corneal opacity
WHO/UNICEF Global Strategic Plan for Measles
Mortality Reduction, 2001-2005
Each country should assess its rubella
situation
Countries undertaking measles elimination
may consider the opportunity to eliminate
rubella as well by using MR or MMR vaccine.
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Percentage of Member States, by WHO region,
with routine rubella vaccination nationwide, 1996 versus 2004
1996
2004
97%
100%
92%
90%
80%
71%
70%
61%
58%
60%
46%
50%
56%
43%
40%
32%
30%
18% 18%
20%
15%
7%
10%
0%
0%
Africa
Americas
E Med
Europe
Source: WHO/IVB database, August 2005
S-E Asia
W Pacific
Global
WHO Regions by Rubella/CRS
Control Target
Rubella Elimination/CRI Prevention - 2
CRS Elimination - 2010
Rubella
Elimination
2010
WHO/UNICEF Global Strategic Plan for Measles
Mortality Reduction, 2001-2005
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Each country should assess its rubella
situation
Countries undertaking measles elimination
should take the opportunity to eliminate
rubella as well by using MR or MMR vaccine
in their childhood immunization program and
also in measles campaigns.
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Rubella is a viral illness caused by a togavirus of the
genus Rubivirus and is characterized by a mild,
maculopapular rash.
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When rubella infection occurs during pregnancy,
especially during the first trimester, the risk of fetal
infection may be as high as 90%.
Rubella Complications
Arthralgia or arthritis
children
adult female
rare
up to 70%
Thrombocytopenic purpura
Encephalitis
Neuritis
Orchitis
1/3000 cases
1/6,000 cases
rare
rare
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Consequences of congenital rubella infection
include abortions, miscarriages, stillbirths, and a
constellation of severe birth defects known as
CRS.
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The most common congenital defects are
cataracts, heart defects, hearing impairment,
and developmental delay.
Congenital rubella syndrome (CRS)
a) infection of fetus during first trimester of pregnancy
b) at least 20% of infants have severe birth defects
i. neurosensory deafness
ii. blindness (total or partial; cataracts are especially common)
iii. congenital heart disease
iv. microcephaly with mental retardation
c) other symptoms associated with CRS
i. bone translucency and retarded growth
ii. hepatosplenomegaly
iii. Intrauterine growth retardation
d) 10 -20% of babies with CRS die within 1 year
e) 20 % will develop insulin dependent diabetes mellitus as young
adults
f) CRS babies continue to shed Rubella virus from their throats for
several months up to a year after birth and pose a serious risk to
pregnant women.
Congenital rubella syndrome (CRS)
Epidemic Rubella – United States, 1964-1965
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12.5 million rubella cases
2,000 encephalitis cases
11,250 abortions (surgical/spontaneous)
2,100 neonatal deaths
20,000 CRS cases
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Deaf - 11,600
Blind - 3,580
Mentally retarded - 1,800
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Rubella and CRS continue to be global burdens.
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With the increased use of rubella vaccine; however,
the burden of rubella infection should decrease in
the future.
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Despite routine rubella vaccination among
children, some rubella outbreaks continue in the
U.S.
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These outbreaks are primarily confined to groups
who traditionally refuse vaccinations and to adults
from countries without a history of rubella vaccine.
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Throughout the 1990s, the majority of infants with
CRS were infants of mothers who fall into these
categories.
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Worldwide, it is estimated that there are more than
100 000 infants born with congenital rubella
syndrome (CRS) each year.
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In 2001, 123 countries/territories reported a total of
836 356 rubella cases.
In the future more countries are expected to report on rubella as a global
measles/rubella laboratory network is further developed under the coordination
of the WHO.
Rubella vaccine use varies by stage of economic development:
100% for industrialized countries, 71% for countries
with economies in transition, and 48% for developing
countries.
Cost-effectiveness estimates for the
English-speaking Caribbean, 1996-2010
• No rubella vaccine
• Rubella vaccination
• 1500 CRS cases with
treatment &
rehabilitation
• Target of CRS
elimination
• US$ 60 million
• US$ 5 million
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Congenital rubella syndrome
(CRS) can lead to deafness,
heart disease, and cataracts,
and a variety of other
permanent manifestations.
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Hearing loss occurs in 70-90% of CRS cases
and in 50% is the only sign of CRS, although
it is often not detected initially.
Evidence for underestimation.
In developing countries, the burden of
CRS can be assessed by:
surveillance of CRS;
surveillance of acquired rubella;
age-stratified serosurveys;
serosurveys documenting the rubella susceptibility of women of childbearing age.
Rates of CRS per 1000 live births
Jamaica
1.7
Israel
1.7
Oman
0.7
Panama
2.2
Singapore
1.5
Sri Lanka
0.9
Trinidad and Tobago
0.6
*These rates are similar to those reported from industrialized countries during the pre-vaccine era.
Importance of rapid case identification
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As infants with CRS may shed virus for
prolonged periods, they should be identified as
early in life as possible in order to prevent further
spread of the virus.
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Infants with CRS may shed virus up to 1 year of
age or longer and should be considered
infectious until they are at least 1 year old or until
two cultures of clinical specimens obtained 1
month apart are negative for rubella virus after
age 3 months.
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Early diagnosis of CRS facilitates early
intervention for specific disabilities.
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Significant enhancement of speech and
language development, and eventual
success in school, for children with hearing
impairment if they are identified early and
intervention begins immediately.
Importance of surveillance
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The goal of rubella vaccination is to prevent
congenital rubella infection.
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Surveillance data are used to identify groups
of persons or areas in which disease control
efforts can reduce disease incidence
To evaluate the effectiveness of disease
prevention programs and policies.
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Promoting awareness that rubella and CRS
still exist.
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Efforts should continue to promote physicians’
awareness of the possibility of rubella and
CRS, especially when evaluating patients with
suspected measles who have negative
serologic tests for acute measles infection
(negative serum measles IgM).
Patient with fever and rash
Sampling
Test for M.IgM
Negative
Positive
Check for Rubella
Confirmed Measles case
Positive
Negative
Confirmed Rubella
Check for parvo V.B19
Promoting awareness of high-risks groups for rubella
infection and CRS births
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Rubella vaccine is not administered
routinely in many countries, Hence
Health-care providers should have a
heightened index of suspicion of rubella
and CRS births in individuals from
countries without a history of routine
rubella vaccination programs.
Conducting active surveillance
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Surveillance for CRS should be implemented when
confirmed or probable rubella cases are documented
in a setting where pregnant women might have been
exposed.
Women who contract rubella while pregnant should be
monitored for birth outcome, and a rubella-specific IgM
antibody test should be performed on the infant after
birth.
Health-care providers should be advised to evaluate
infants born with conditions consistent with CRS and
to perform a rubella-specific IgM antibody test on
infants suspected of having CRS.
In order to identify CRS cases in infants, it is important to
investigate rash illness in pregnant women.
will be most practical in countries where women attend
antenatal clinics during the first 16 weeks of pregnancy,
as the risk of CRS is low in women infected after the
first trimester.
Searching laboratory records
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laboratory records may provide reliable evidence of
previously unreported serologically confirmed or
culture-confirmed cases of congenital rubella
syndrome.
Infants with CRS have been identified by including
the serological results for toxoplasmosis, rubella,
cytomegalovirus, and herpes (TORCH) agents in
laboratory records.
This may be particularly useful in hospitals.
Comparing other data sets
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Birth defects registries may reveal unreported CRS
cases.
In addition, children with CRS whose cases were
never reported may be enrolled in schools for the
deaf or blind.
Pediatric specialty clinics caring for children with
mental retardation, congenital heart defects,
congenital deafness and hearing impairment,
congenital cataracts, and growth retardation may be
a source of unreported CRS patients.
These activities should be undertaken following
rubella outbreaks as part of enhancing surveillance
for CRS.
Reviewing hospital discharge data and linkages with
newborn hearing screening programs
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Reviewing hospital discharge data in high-risk areas
has proven useful in identifying undiagnosed cases of
CRS.
Infants with discharge codes consistent with CRS may
then be categorized according to the CRS case
definition, allowing for greater insight into the rates of
CRS in high-risk populations.
Furthermore, if newborn hearing screening is routinely
performed, infants identified through screening with
hearing deficiencies or progressive hearing loss may
also be tested for CRS, as hearing impairment is the
most common single defect associated with CRS.
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Cases of indigenous rubella have occurred among
susceptible persons providing care for infants with
CRS.
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Persons having contact with infants with CRS should
be immune to rubella.
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Infants with CRS should be placed in contact isolation.
Comparison of 20th Century Annual Morbidity and Current Morbidity:
Vaccine-Preventable Diseases
20th Century
Annual Morbidity†
Disease
2006 (final)††
Percent
Decrease
Smallpox
48,164
0
100%
Diphtheria
175,885
0
100%
Measles
503,282
55
> 99%
Mumps
152,209
6,584
96%
Pertussis
147,271
15,632
89%
Polio (paralytic)
16,316
0
100%
Rubella
47,745
11
> 99%
Congenital Rubella Syndrome
823
1
> 99%
Tetanus
1,314
41
97%
Haemophilus influenzae
20,000
208*
99%
Surveillance of congenital rubella syndrome (CRS) requires a comprehensive
system to detect suspected CRS cases in infants who present to a range
of different health services.
Most industrialized countries have established surveillance of CRS with
national disease notification programs and/or birth defects monitoring
programs
in developing countries CRS cases are likely to be underreported in areas
and among populations where a high proportion of births occur at home and
Where neonatal and childhood deaths are often unreported
The following sites and specialists should be
provided with written guidelines and training:
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Sites that routinely participate in surveillance for EPI diseases
Neonatal wards and neonatal intensive care units,
Obstetrics services, including obstetricians and midwives,
General hospitals, including the pediatric ward,
Referral hospitals,
Ophthalmologists, optometrists
Otologists and audiologists,
Cardiologists and cardiac surgeons.
Surveillance of rubella is
likely to be most practical
when countries have reached
the stage of measles/rubella
elimination,
case-based rubella surveillance
is only recommended in countries
that have established a rubella
elimination goal
Routine CRS surveillance focuses on identifying infants 0-11
months of age with CRS, although some defects associated with
CRS may not be detectable until older ages
In children older than one year it is very difficult to confirm
rubella as the specific etiology of congenital malformations or
birth defects.
CRS case definitions (1)
Suspected CRS: A child <1 year with
maternal history of rubella in pregnancy
and/or
heart disease
eye signs
Cataract
Diminished vision
Pendular eye movement (nystagmus)
Squint
Smaller eye ball (micropthalmos)
Larger eye ball (congenital glaucoma)
deafness
CRS case definitions (2)
Clinically confirmed CRS: A child <1 year
with two complications in group (a) or
one from (a) and one from (b)
(a): cataract, congenital glaucoma, congenital heart disease,
loss of hearing, pigmentary retinopathy
(b): purpura, splenomegaly, microcephaly, mental
retardation, meningoencephalitis, radiolucent bone
disease, jaundice with onset within 24 hours after birth.
CRS case definitions (3)
Laboratory-confirmed CRS:
An infant with a positive blood test for rubellaspecific IgM and clinically-confirmed CRS.
Congenital rubella infection (CRI):
An infant with a positive blood test for rubellaspecific IgM who does not have clinicallyconfirmed CRS.
Suspected CRS
Refer suspected CRS case to qualified physician
Blood sample not obtained
Examination by qualified physician
Blood sample(1 ml ) obtained
Rubella IgM
negative
Rubella IgM
positive
+
Discard
Clinically-confirmed
CRS
Discard
Not
clinically- confirmed
Congenital Rubella Infection
(CRI)
Clinically-confirmed
CRS
Laboratory-confirmed
CRS