Rubella is usually a mild rash illness in children and adults. However,
its seriousness and public health importance stem from the ability of
rubella virus to cross the placental barrier and infect fetal tissue,
which may result in congenital rubella syndrome (CRS). Recognising that
measles and rubella remain important causes of vaccine preventable morbidity
and mortality in Europe, the World Health Organization (WHO) Regional
Office for Europe has developed a Strategic Plan for Measles and Congenital
Rubella Infection. The overall objectives are to interrupt the indigenous
transmission of measles and reduce to very low levels the risk of congenital
rubella infection (<1 case of CRS per 100 000 live births annually)
by 2010. The strategy includes strengthening routine immunisation and
surveillance programs throughout the Region .
The Romanian ministry of health (MoH) currently has no national childhood
rubella vaccination program. However, rubella vaccine, in the form of
measles-rubella vaccine, was first offered to girls aged 15-18 years
(those born 1980-83) in 1998 as part of a measles vaccination campaign
following a nationwide measles outbreak. In 2002, in Bucharest only,
girls aged 14-18 years (born 1983-87) received rubella vaccine. In 2003,
nationwide, all girls in the 8th grade (born 1987-1988) received rubella
vaccine. In addition, in Bucharest only, 10% of girls in the 7th grade
also received the vaccine in 2003.
Before the 2003 outbreak reported here, the last widespread rubella
outbreak in Romania occurred in 1997, coincident with the measles outbreak,
and had an incidence of 192 reported cases per 100 000 population. The
average incidence in 1999-2001 was 26 reported cases per 100 000 population/year.
The following case definitions are used for surveillance:
- suspected rubella: any patient with fever and maculopapular rash and
one of the following: cervical, suboccipital, or post-auricular adenopathy
-suspected CRS: any infant less than one year of age born to a mother
with suspected or confirmed rubella during pregnancy or any infant less
than one year of age with one or more of the following: heart disease
(complex, patent ductus arteriosus, pulmonary artery stenosis, ventricular
septum defects), suspicion of deafness, or one or more of the following
eye signs: cataract, congenital glaucoma, microphthalmia, nystagmus,
Description of the surveillance systems
Rubella has been reported in Romania since 1949. Currently, rubella
cases are reported to MoH by family physicians, centers for diagnosis
and treatment, and hospitals, on a quarterly basis, aggregated by sex,
residence and in the following age groups: individual years of age 0-4
years, then in 5 year age groups from 5 to 24 years, in 10 year age
groups from 25 to 84 years, and =85 years.
As part of the measles surveillance system, since December 2002, clusters
with three or more cases of febrile rash illnesses are investigated
by district public health directorates (DPHD) and data are reported
to the regional institutes of public health. To confirm the clinical
diagnosis, it is recommended that a sample of 5 to 10 cases in each
cluster be investigated with serological testing for measles and, if
the results are negative, for rubella. If rubella transmission is confirmed,
pregnant women with suspected rubella or contacts of suspected rubella
cases are given priority for testing.
National surveillance for CRS was initiated in 2000. Suspected cases
are reported by the diagnosing physicians to DPHD, and from here, weekly,
to MoH. Suspected CRS cases are investigated for rubella-specific IgM
antibodies according to WHO methodology: a blood sample collected as
soon after birth as possible; for infants with negative results and
compelling clinical and/or epidemiological suspicion of CRS a second
blood specimen is requested .
We analysed data reported by these surveillance systems during the
2003 rubella outbreak.
During 2002-03, Romania experienced a large rubella outbreak with more
than 115 000 reported cases nationwide, for an incidence of 531 reported
cases per 100 000 population. More than 95% of the cases were reported
in the first six months of 2003. The outbreak started in the second
half of the last quarter of 2002, in the eastern part of the country,
and spread towards south, then west, involving the entire country by
June 2003. The incidence was highest among school-aged children (age-specific
incidence 2564 per 100 000 population aged 5-9 years and 2446 per 100
000 population aged 10-14 years). Of the total number of cases, 27 614
(23.8%) occurred in persons aged = 15 years. At the national level there
were no differences in incidences by sex; however, in Bucharest the
cohorts of girls vaccinated in 1998 and 2002 (age groups 20-24 and 15-19
years, respectively) had a significantly lower incidence (p<0.001)
compared with boys in the same age groups (208 per 100 000 versus 383
per 100 000 for ages 20-24 years and 640 per 100 000 versus 1569 per
100 000 for ages 15-19 years).
During 2003, more than 724 clusters of rubella cases were reported.
The number of cases per cluster ranged from 3 to 278. At the national
laboratory testing for rubella IgM antibodies was performed for 1252
specimens using Dade Behring kits. Of these, 626 (50%) were IgM positive.
One specimen tested positive for measles. A total of 272 pregnant women
with suspected rubella or contacts of rubella cases were tested; of
these 29 (10.7%) were rubella IgM positive and IgG negative, consistent
with an acute rubella infection in previously susceptible women.
Since surveillance for CRS was initiated in 2000, there have been 127
(2000), 123 (2001), and 124 (2002) suspected CRS cases reported, of
which 20 (15.4%), five (4.1%), and five (4.1%) respectively were laboratory
confirmed. In 2003, of 150 suspected CRS cases, seven (4.6%), were confirmed
by positive rubella IgM antibodies. These cases were diagnosed in June
(1), in September (1), in October (1), and in November (4). Of these,
five had ocular abnormalities (cataracts (4) and microphthalmia (1))
and six had cardiac abnormalities (ventricular septum defects (2), complex
congenital heart disease (2), atrial septum defects (1), patent ductus
arteriosus (1)). The age of the mothers ranged from 16 to 36 years;
four of them reported having a febrile rash illness during pregnancy
(three during the first trimester and one during the second trimester
of pregnancy). However, full assessment of CRS cases resulting from
this outbreak will be done at nine months following the end of the outbreak.
In 2004, preliminary results indicate that eight CRS cases were confirmed
by April 15.
In the absence of supply of rubella-containing vaccine for outbreak
control, MoH developed an outbreak response plan to improve the detection
of cases and to limit rubella virus transmission as much as possible.
The following activities were conducted:
1. Surveillance of pregnant women with suspected rubella or history
of exposure to rubella virus was implemented. A detailed set of guidelines
was prepared and distributed to DPHD to:
a. Detect, test and counsel pregnant women with suspected rubella or
history of exposure to rubella virus
b. Classify cases using WHO case classification
c. Follow up these women for pregnancy outcomes. A pregnancy outcome
registry was established at the district level
2. Surveillance for CRS was strengthened:
a. CRS case definitions and classification were harmonised with the
WHO regional case definitions
b. In May 2003, active surveillance was introduced in maternity wards
in the capital city, Bucharest. Public health directorate staff reviewed
medical charts of newborns on a weekly basis to identify children with
signs and symptoms consistent with CRS case definition
3. Existing general infection control guidelines to prevent disease
transmission within healthcare facilities were reinforced.
4. A communication plan was developed to:
a. Increase awareness among healthcare providers of the possibility
of rubella and CRS and of the appropriate follow-up for pregnant women
exposed to rubella virus
b. Respond to inquiries from district epidemiologists, clinicians, and
media regarding the rubella outbreak, detection, testing and counselling
of pregnant women, and enhanced CRS surveillance
Key elements to prevent rubella outbreaks and occurrence of congenital
rubella syndrome include ensuring high levels of rubella immunity through
an ongoing childhood immunisation program, vaccinating susceptible adolescents
and adults if necessary, and conducting rubella and CRS surveillance.
Without a rubella vaccination program, periodic rubella outbreaks and
subsequent CRS cases are expected. Two rubella immunisation strategies
are currently available: selective vaccination of adolescent girls and/or
women of childbearing age to protect those who have escaped natural
infection, and comprehensive vaccination of all young children, (e.g.,
routine childhood immunisation) combined with vaccination of susceptible
women of childbearing age (1, 3-6). However, these two approaches are
frequently combined. In Romania, the selective vaccination of only a
few cohorts of adolescent girls implemented in 1998 and 2002 resulted
in a significantly lower incidence among girls in the target age cohorts
in Bucharest, compared to that among the boys of the same age group.
In the light of the recent outbreak, the Romanian MoH is considering
making a long term commitment to finance routine vaccination against
rubella to prevent CRS. Beginning in May 2004, MoH will introduce combined
measles-mumps-rubella (MMR) vaccine for routine vaccination of children
aged 12 to 15 months and continue rubella vaccination of girls in the
8th grade (aged 13-14 years). Ongoing routine vaccination of all young
children appears to be feasible in view of consistently high routine
vaccination coverage with other antigens in Romania.
Our special thanks to health care providers, epidemiologists from DPHD
and institutes of public health who investigated and reported CRS and
rubella cases, Dr Nicoleta Teletin and other laboratory personnel from
NIRDM "Cantacuzino" where testing was performed, WHO European
Regional Office for providing technical and financial assistance to
NIRDM "Cantacuzino", Peter Strebel, MBChB, MPH, who provided
advice on methodological and scientific issues, and Mary McCauley, MS,
for editorial assistance.