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COMMENTARY
Year : 2018  |  Volume : 62  |  Issue : 1  |  Page : 52-54  

Congenital rubella syndrome: A brief review of public health perspectives


1 Fellow, Department of Pediatrics, Division of Pediatric Infectious Disease, University of Texas Southwestern, Dallas, Texas, USA
2 Aditional Professor, Department of Paediatrics, Advanced Paediatric Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
3 Professor, Department of Pediatrics, Division of Neonatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India

Date of Web Publication6-Mar-2018

Correspondence Address:
Dr. Ashlesha Kaushik
Department of Pediatrics, Division of Pediatric Infectious Disease, University of Texas Southwestern, 5323, Harry Hines Blvd., Dallas 75390, Texas
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijph.IJPH_275_16

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   Abstract 


Congenital rubella syndrome (CRS) is one of the most devastating congenital infections and yet the only one which is vaccine preventable and is a public health challenge for clinicians and policymakers across the developing world including India. The clinical manifestations of CRS include growth retardation, cardiac defects, cataracts, and hearing impairment. The World Health Organization (WHO) estimates that worldwide over 100,000 babies are born with CRS every year despite the availability of safe and inexpensive vaccines, thus highlighting the need for broader vaccination coverage programs. This article briefly reviews the importance of CRS, the proposed strategies for prevention by the WHO, and the “Rubella initiative” that Government of India is launching in view of the recognition of CRS as a significant problem in India.

Keywords: Congenital rubella syndrome, public health, rubella initiative


How to cite this article:
Kaushik A, Verma S, Kumar P. Congenital rubella syndrome: A brief review of public health perspectives. Indian J Public Health 2018;62:52-4

How to cite this URL:
Kaushik A, Verma S, Kumar P. Congenital rubella syndrome: A brief review of public health perspectives. Indian J Public Health [serial online] 2018 [cited 2019 Dec 16];62:52-4. Available from: http://www.ijph.in/text.asp?2018/62/1/52/226616




   Introduction Top


Congenital rubella syndrome (CRS) is one of the most devastating viral congenital infections caused by rubella virus. Infection of nonimmune pregnant females can result in spontaneous abortion, stillbirth/fetal death, or birth of an infant with CRS.[1],[2],[3] First-trimester infections lead to CRS in up to 90% of liveborn infants.[1],[3] The characteristic features of CRS are eye anomalies (cataracts, pigmentary retinopathy, microphthalmia, and glaucoma), sensorineural hearing loss, and cardiac defects (most commonly patent ductus arteriosus and pulmonary stenosis). Other manifestations include intrauterine growth retardation, “blueberry muffin” spots, pneumonitis, bone defects, hepatosplenomegaly, developmental delay, encephalitis, autism, diabetes mellitus, and thyroid dysfunction.[1],[2] There is no specific treatment for rubella/CRS, and this can only be prevented by immunization.


   Prevention of Congenital Rubella Syndrome Top


The primary goal of rubella vaccination is prevention of CRS.[3] Rubella affects only humans; hence, vaccine prevention and disease elimination are considered possible. The current licensed rubella vaccines used globally are based on the live-attenuated RA 27/3 strain. Rubella vaccine can be administered at 9 or 12–15 months of age in combination with measles or mumps (measles–rubella [MR], measles–mumps–rubella [MMR], and MMR–varicella) or in monovalent form. One-dose schedule is considered sufficient for rubella. Being a live vaccine, it is contraindicated in immune deficiencies and during pregnancy. All pregnant women should be tested for rubella, and if found to be IgG negative, rubella vaccine should be given postpartum.[2]


   Global Burden of Congenital Rubella Syndrome Top


Before rubella vaccine was introduced, the incidence of CRS was 0.1–0.2/1000 live births during endemic periods and was approximately 0.8–4/1000 live births during rubella epidemics.[4] As per the 2008 World Health Organization (WHO) global estimates, the number of infants born with CRS exceeded 110,000, making rubella a leading cause of congenital anomalies.[4] The 2008 estimates suggest that the highest CRS burden is in the developing world, i.e., Southeast Asian region (approximately 48%) and African region (approximately 38%).[4],[5]

According to the WHO, still over 100,000 babies are born worldwide with CRS every year, i.e., globally nearly 300 children are born every day with the disabilities of CRS despite the availability of safe, effective, and inexpensive vaccines.[6],[7]


   World Health Organization Rubella and Congenital Rubella Syndrome Elimination Guidelines Top


In view of the significant public health impact of CRS, the WHO has recommended that developing countries should utilize the accelerated measles-control activities to introduce rubella-containing vaccines (RCVs).[4],[5] There are two approaches for the use of rubella vaccine: first is by focusing exclusively on reducing CRS by immunizing adolescent girls/women of childbearing age and second is by targeting viral transmission interruption, thereby eliminating rubella as well as CRS.[4]

The first approach will provide direct protection to women of childbearing age; however, the impact of this strategy is limited by the coverage achieved.[4],[7] Since this strategy does not interrupt the virus circulation, there will be ongoing exposure of pregnant women and associated risk of CRS. In the presence of ongoing circulation of virus and less vaccination coverage initially, there could be an increase in the number of CRS cases because of increase in the age of primary infection. Therefore, the second approach, which targets elimination of rubella/CRS, is the preferred approach.[4] This begins with MR/MMR vaccine in a campaign targeting a wide range of ages, immediately followed by introduction of the vaccine in routine immunization schedules.[4],[7]

The WHO also recommends initiating rubella surveillance to estimate disease burden and to monitor the impact of rubella-control activities.[4] The following are the options for assessing the disease burden:[5]

  1. Establishing nationwide CRS surveillance
  2. Investigating rubella outbreaks to describe cases by time, place, and person, and
  3. Conducting seroprevalence surveys to document population immunity.


The CRS surveillance program focuses on identifying infants 0–11 months old attending health facilities with features of CRS (possible or confirmed, according to the WHO CRS case definitions[8]) and testing them for rubella infection.[8] The WHO also recommends establishing sentinel surveillance for CRS, to allow assessment of vaccination impact in the future.[3]

The WHO Strategic Plan for Measles Elimination and Rubella/CRS Control in the Southeast Asian region, 2014–2020, has laid out four strategic objectives to attain the goal of measles elimination and rubella/CRS control:

  1. To achieve and maintain at least 95% population immunity by providing high vaccination coverage with two doses of MR vaccines through routine and/or supplementary immunization activities, within each country in the region
  2. To develop and sustain a sensitive and timely integrated MR case-based surveillance system and CRS surveillance in each country in the region that fulfills the recommended surveillance performance indicators
  3. To develop and maintain an accredited MR laboratory network that supports every country/area in the region
  4. To maintain support systems and linkages to achieve the above three objectives.



   The Indian Scenario Top


Prevalence of congenital rubella syndrome

Exact estimates are not available; however, few studies have estimated the prevalence of CRS in children in India with clinically suspected intrauterine infection, ocular abnormalities, and congenital abnormalities.[9] A systematic review based on published studies in India indicated that 1%–15% of all infants suspected to have intrauterine infection had laboratory evidence of CRS.[9] CRS accounted for 10%–15% of all cases of pediatric cataract and as many as 10%–50% of all children with congenital anomalies were found to have laboratory evidence of CRS.[9]

A large community-based study in Tamil Nadu (from 2002 to 2004) included 51,548 children aged <5 years with ocular abnormalities and developmental delays. Nearly 2.1% (n = 1090) children had clinically suspected CRS (probable CRS), 0.58% (n = 299) had clinically confirmed CRS, and 0.0009% (n = 46) had laboratory-confirmed CRS.[10] In a study from Chandigarh from 1999 to 2006, 947 children with suspected intrauterine rubella infections were retrospectively evaluated. All children had clinically suspected or clinically confirmed CRS, and overall 2.8% were IgM positive for rubella infection.[11]


   Susceptible Target Population Top


In studies evaluating seroprevalence of rubella among the Indian population, 10%–30% of adolescent girls and 12%–30% of women in the reproductive age group were found to be susceptible to rubella infection.[9]


   Immunogenicity of Rubella-Containing Vaccines in India Top


RCVs have been shown to be highly immunogenic among adolescents and women in the Indian population. After RCV, good seroconversion rates (>92%) have been shown at 9 months that were maintained at 12 and 15 months.[12]


   Government of India and the Rubella Initiative Top


MMR vaccine is not a part of routine government national immunization program in India. However, it has been given to children as part of the state health policy in a few states such as Delhi, Goa, Puducherry, and Sikkim as a single dose at age 15–18 months. In Goa, rubella vaccine has also been administered to all adolescent girls since 2003 as a part of the state policy. All the other states and union territories in India have relied on private practitioners for rubella vaccination.

There are several challenges in India like other developing countries while targeting measles elimination and rubella/CRS control and in incorporating MR vaccination into national immunization program.[13] Highly infectious nature of these diseases, which require high population immunity to stop transmission, poses the biggest challenge in regions where factors facilitating virus transmission are prevalent, such as population growth, population density, and migration.[13] Technical challenges are related to the properties of the MR vaccine, including the need for an intact cold chain, two vaccine doses, sterile subcutaneous injection, and that the vaccine is not effective in early infancy.[13] Programmatic challenges include vaccination of children in difficult-to-reach areas (e.g., remote villages, border regions, and conflict areas) and the traditionally hard-to-reach populations (such as ethnic minorities, urban slum dwellers, and migrants).[13] However, India has successfully faced and addressed such challenges in eliminating polio.

Therefore, as per the WHO recommendations, the National Technical Advisory Group on Immunization (NTAGI) in India recommended the inclusion of rubella vaccination in universal immunization program, in February 2014. In accordance with the NTAGI recommendations, the Government of India has decided to introduce a rubella initiative as a part of the nationwide MR campaign in two stages – the first stage would be targeted to cover a wide age range of children and adolescents aged 9 months to 15 years with the MR vaccine. This would be followed by the second stage that would entail inclusion of MR vaccine in the routine immunization programs in a two-dose schedule at 9–12 months and at 16–24 months of age. These campaigns, by vaccinating all young people between 9 months and 15 years, would rapidly interrupt the spread of rubella virus. As part of this initiative, mass vaccination campaigns for children and adolescents aged 9 months–15 years with MR vaccine were planned in the country in a phased manner, similar to the Pulse Polio immunization campaign, in four phases from July 2015 to March 2017. In 2016, under the initiative, approximately 224,488,808 children in India were targeted to be vaccinated as per the WHO estimates.[3] MR vaccine was chosen over MMR, given the comparatively lower cost of the vaccine and a less significant mumps disease burden in the country.

In view of the proposed introduction of rubella vaccine in the country, the Ministry of Health and Family Welfare with the help of Indian Council of Medical Research is establishing sentinel sites, all over the country for CRS surveillance, which will provide a baseline estimate of disease burden and monitor the impact and progress made by rubella vaccination.


   Concluding Remarks Top


CRS is the only vaccine-preventable congenital infection and is an important public health concern both globally and in India. Hopefully, with the implementation of the rubella initiative to prevent CRS, India will be able to set an example of elimination of another dreadful disease, after the historic victories over poliomyelitis and small pox.



 
   References Top

1.
Reef SE, Plotkin SA. Rubella. In: Remington JS, Klein JO, Wilson CB, Nizet V, Maldonado YA, eds. Infectious Diseases of the Fetus and Newborn Infant. 8th ed. Philadelphia: Elsevier; 2015. p. 894-932.  Back to cited text no. 1
    
2.
Kimberlin DW, Brady MT, Jackson MA, Long SS, Eds. Rubella. In: American Academy of Pediatrics Red Book: 2015 Report of the Committee on Infectious Diseases. 30th ed. Elk Grove Village: IL; 2015. p. 688-95.  Back to cited text no. 2
    
3.
WHO Vaccines and Diseases: Rubella; 2015. Available from: http://www.who.int/immunization/diseases/rubella/en/. [Last accessed on 2016 Jul 29].  Back to cited text no. 3
    
4.
Rubella vaccines: WHO position paper. Wkly Epidemiol Rec 2011;86:301-16.  Back to cited text no. 4
    
5.
Centers for Disease Control and Prevention (CDC). Rubella and congenital rubella syndrome control and elimination – Global progress, 2000-2012. MMWR Morb Mortal Wkly Rep 2013;62:983-6.  Back to cited text no. 5
    
6.
WHO Rubella Fact Sheet. Available from: http://www.who.int/mediacentre/factsheets/fs367/en/. [Last accessed on 2017 Jul 01; Last updated on 2017 Mar 01].  Back to cited text no. 6
    
7.
WHO. Global Measles and Rubella Strategic Plan 2012-2020. Geneva: WHO; 2012.  Back to cited text no. 7
    
8.
WHO. Surveillance Guidelines for Measles, Rubella and Congenital Rubella Syndrome in WHO European Region. Geneva: WHO; 2012.  Back to cited text no. 8
    
9.
Dewan P, Gupta P. Burden of Congenital Rubella Syndrome (CRS) in India: A systematic review. Indian Pediatr 2012;49:377-99.  Back to cited text no. 9
    
10.
Vijayalakshmi P, Rajasundari TA, Prasad NM, Prakash SK, Narendran K, Ravindran M, et al. Prevalence of eye signs in congenital rubella syndrome in South India: A role for population screening. Br J Ophthalmol 2007;91:1467-70.  Back to cited text no. 10
    
11.
Singh MP, Arora S, Das A, Mishra B, Ratho RK. Congenital rubella and cytomegalovirus infections in and around Chandigarh. Indian J Pathol Microbiol 2009;52:46-8.  Back to cited text no. 11
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12.
Singh R, John TJ, Cherian T, Raghupathy P. Immune response to measles, mumps and rubella vaccine at 9, 12 & 15 months of age. Indian J Med Res 1994;100:155-9.  Back to cited text no. 12
    
13.
World Health Organization Regional office for South-East Asia. Measles Elimination and Rubella/CRS Control: Report of a Regional Consultation; 2013. Available from: http://www.apps.searo.who.int/PDS_DOCS/B4993.pdf. [Last accessed on 2017 Jul 24].  Back to cited text no. 13
    




 

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  In this article
    Abstract
   Introduction
    Prevention of Co...
    Global Burden of...
    World Health Org...
    Susceptible Targ...
    Immunogenicity o...
    Government of In...
   Concluding Remarks
   The Indian Scenario
    References

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