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Rubella infection in pregnancy and congenital rubella in United Kingdom, 2003 to 2016

Bukasa, A; Campbell, H; Brown, K; Bedford, H; Ramsay, M; Amirthalingam, G; Tookey, P; (2018) Rubella infection in pregnancy and congenital rubella in United Kingdom, 2003 to 2016. Eurosurveillance , 23 (19) pp. 2-9. 10.2807/1560-7917.ES.2018.23.19.17-00381. Green open access

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Abstract

Although rubella is usually a mild, sometimes asymptomatic illness in childhood, the consequences of rubella infection in pregnancy can be devastating. In 2010, the Pan American Health Organisation announced that the Region of the Americas had eliminated rubella and congenital rubella syndrome (CRS) [1,2]. In the same year all 53 Member States of the World Health Organization (WHO) European Region committed to the goal of eliminating endemic transmission of measles and rubella, initially by 2015 and later revised to 2020. For the elimination of rubella and congenital rubella, high coverage of a two-dose childhood vaccination programme of a rubella-containing vaccine must be sustained [3]. Rubella can be easily mistaken for a number of other viral infections, and in order to monitor progress towards elimination it is essential that countries across Europe have robust surveillance systems in place to identify all suspected cases and reliably confirm or exclude rubella and congenital rubella infection (CRI) using appropriate laboratory methods [4]. Surveillance systems and laboratory confirmation of rubella and congenital rubella cases vary across Europe. Despite the elimination goals set for the WHO European Region, three of 28 European Union (EU) countries do not have national surveillance systems for all rubella cases [5,6]. In 2016, only 5% of all cases reported to the European Centre for Disease Prevention and Control (ECDC) were laboratory-confirmed. The United Kingdom (UK) vaccination strategy and programme surveillance is very similar to other western European countries and is based on laboratory-confirmed cases. It is, however, the only country to perform routine IgM confirmatory testing of oral fluid of notified cases (since 1994), which has strengthened surveillance and improved ascertainment [7-9]. The consequences of rubella infection in the first 20 weeks of pregnancy, and the relationship between gestational week of exposure and likelihood of fetal loss or features of congenital rubella syndrome, have been well documented [10,11]. With the introduction of effective vaccination strategies in the UK, the incidence of rubella has decreased dramatically and the last large outbreak of rubella occurred in 1995–96. Most clinicians who have qualified in this country in the past 20 years will never have seen a case of rubella, rubella infection in pregnancy or congenital rubella. Before routine vaccination was introduced, rubella was a common childhood disease in the UK with 80% of adults having evidence of prior infection [12]. Rubella vaccination was introduced for susceptible women and girls aged 11–14 years in 1970 with the aim of allowing most girls to acquire natural immunity in earlier childhood [13,14]. Non-immune women of child-bearing age were also targeted following the introduction of antenatal screening for rubella susceptibility based on rubella IgG testing throughout the UK in the early 1970s. The main programme aim was to ensure women of childbearing age were immune to rubella and thus prevent primary infection in pregnancy. This strategy successfully increased the proportion of women with antibodies to rubella from 85–90% in 1970 to 97–98% in 1987 [15]. Surveillance of CRS and CRI infections was established in the UK in 1971 to monitor the effectiveness of the vaccination programme [16]. While programmes to directly protect women of childbearing age against rubella successfully reduced cases of congenital rubella and terminations following rubella infection in pregnancy [16,17], the disease continued to circulate among young children, who were a potential source of infection to any women who remained susceptible. In 1988, a combined measles-mumps-rubella (MMR) vaccination was introduced into the routine childhood schedule at 12–15 months of age. The rubella component of MMR vaccine is highly effective and a single dose of a rubella-containing vaccine confers around 95–100% protection; the measles and mumps components require two doses to reach high levels of effectiveness [10,18]. A successful mass school-based measles-rubella immunisation campaign targeting all children aged 5–16 years was conducted in 1994 to prevent a predicted measles epidemic and to address continuing high levels of rubella susceptibility in school-aged children, particularly among boys [15]. To ensure continued high population protection, a routine second dose of MMR for 3–4-year-olds was introduced from 1996, when selective immunisation of schoolgirls ended. Uptake of the two-dose schedule by fifth birthday in the UK reached 75% by June 2005 [19] and was 88.5% in October to December 2016 [20]. MMR first-dose coverage by fifth birthday reached the 95% WHO elimination target for the first time in 2016. Determination of rubella susceptibility is not straightforward. The widespread use of an ELISA cut-off value of 10IU/ml, generally accepted as evidence of immunity, is based on levels following vaccination [21]. Vaccine-induced rubella antibody levels, while protective, appear to be lower at a population level than those resulting from naturally acquired infection. With an increasing proportion of UK-born women acquiring immunity through vaccination rather than natural infection and the absence of circulating rubella in the UK, reported antenatal susceptibility rates have increased in recent years based on this cut-off value [9]. In 2013, 27% of all births in England were to women born outside the UK, with geographical variation peaking in London at 58% [22]. Many of these women are likely to have come from rubella-endemic countries, with no or disrupted routine immunisation against rubella. A higher proportion of non-UK-born mothers, particularly those from sub-Saharan Africa and south-east Asia were more likely to be seronegative than UK-born women or white British women [23], [24] and analysis of antenatal rubella susceptibility data from London suggested that between 16% and 65% of non-UK-born women were susceptible in 2007 [25]. This paper summarises cases of laboratory-confirmed rubella infection in pregnancy (IIP), CRI and CRS reported to Public Health England (PHE) and other national surveillance programmes in the UK between 2003 and 2016.

Type: Article
Title: Rubella infection in pregnancy and congenital rubella in United Kingdom, 2003 to 2016
Open access status: An open access version is available from UCL Discovery
DOI: 10.2807/1560-7917.ES.2018.23.19.17-00381
Publisher version: http://doi.org/10.2807/1560-7917.ES.2018.23.19.17-...
Language: English
Additional information: License and copyright: This is an open-access article distributed under the terms of the Creative Commons Attribution (CC BY 4.0) Licence. You may share and adapt the material, but must give appropriate credit to the source, provide a link to the licence, and indicate if changes were made. This article is copyright of the authors, 2018.
UCL classification: UCL
UCL > Provost and Vice Provost Offices
UCL > Provost and Vice Provost Offices > School of Life and Medical Sciences
UCL > Provost and Vice Provost Offices > School of Life and Medical Sciences > Faculty of Population Health Sciences
UCL > Provost and Vice Provost Offices > School of Life and Medical Sciences > Faculty of Population Health Sciences > UCL GOS Institute of Child Health
UCL > Provost and Vice Provost Offices > School of Life and Medical Sciences > Faculty of Population Health Sciences > UCL GOS Institute of Child Health > Population, Policy and Practice Dept
URI: https://discovery.ucl.ac.uk/id/eprint/10050471
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