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Rubella virus is the most teratogenic virus known to science and is capable of causing large epidemics. The RA 27/3 rubella vaccine, usually combined with measles vaccine, has eliminated rubella and congenital rubella syndrome from much of the world, notably from the Western Hemisphere. Except in immunosuppressed individuals, it is remarkably safe. Together with rubella vaccine strains used in China and Japan, eradication of the rubella virus is possible, indeed more feasible than eradication of measles or mumps.

In the region of the Americas, goals for the elimination of endemic measles and rubella/congenital rubella syndrome (CRS) by the year 2000 and 2010, respectively were established. The successful implementation of measles elimination strategies in the region of the Americas resulted in the interruption of endemic measles transmission in 2002 and tremendous progress toward rubella and CRS elimination. In October 2007, the 27th Pan American Sanitary Conference adopted Resolution CSP27.R2 urging member states to begin documenting and verifying the interruption of endemic transmission of the measles and rubella viruses in the Americas. To ensure a standardized approach for the process of documentation and verification, the Pan American Health Organization/World Health Organization (PAHO/WHO) developed a regional plan of action to guide countries and their national commissions as they prepare and consolidate evidence of the interruption of endemic measles and rubella transmission. This article summarizes the plan of action including the essential criteria and components of the guidelines.

Background Rubella vaccination is contraindicated during pregnancy. During mass immunization of women of childbearing age against rubella, women unknowingly pregnant may be vaccinated. To evaluate the effects of rubella vaccination during pregnancy, the Brazilian state of Sao Paulo conducted a follow-up study of pregnant women vaccinated during a rubella campaign in 2001. Methods Women vaccinated during pregnancy were reported to a national surveillance system. In the state of Sao Paulo, follow-up of vaccinated women included household interviews. Serum samples from vaccinated women were tested for antirubella antibodies to classify susceptibility to rubella infection. Children born to susceptible mothers were tested for evidence of congenital rubella infection and evaluated for signs of congenital rubella syndrome. Results The Sao Paulo State Health Department received 6473 notifications of women vaccinated during pregnancy. Serology performed for 5580 women identified 811 (15%) that were previously susceptible. Incidence of spontaneous abortion or stillbirth among previously susceptible vaccinated women was similar to women with prior immunity. Twenty-seven (4.7%) of 580 newborns tested had evidence of congenital rubella infection; none had congenital rubella syndrome. Conclusions Mass rubella vaccination of women of childbearing age was not associated with adverse birth outcomes or congenital rubella syndrome among children born to women vaccinated during pregnancy.

Chile was the first country in the Americas to conduct surveillance for congenital rubella syndrome (CRS) as part of screening for common causes of congenital birth defects (referred to as TORCH pathogens). The surveillance system identified 15 CRS cases in 1999 and 2 cases in 2000, and it has identified no CRS cases since 2000. CRS surveillance in Chile meets recommended surveillance standards and may serve as a model for CRS surveillance in other countries.

BACKGROUND: A rubella mass vaccination campaign targeting 15-29-year-old women was performed in Brazil in 2001-2002. Rubella vaccination was contraindicated during pregnancy. A follow-up protocol was implemented for pregnant women who were vaccinated as well as their newborns. The risks of congenital rubella syndrome (CRS) and congenital rubella infection (CRI) after vaccination were assessed according to the pregnant womens immune status. METHODS: This was a prospective noncontrolled study of pregnancy outcomes in women vaccinated against rubella in the state of Rio de Janeiro including clinical and laboratory evaluations. RESULTS: Of 2292 reported pregnant women who were vaccinated 1636 had known outcomes: there were 1577 newborns (96.4%) 52 miscarriages (3.2%) and 7 stillbirths (0.4%). Gestational age at vaccination was

In 2003, the Pan American Health Organization (PAHO) adopted a resolution calling for rubella and congenital rubella syndrome (CRS) elimination in the Americas by the year 2010. To accomplish this goal, PAHO advanced a rubella and CRS elimination strategy including introduction of rubella-containing vaccines into routine vaccination programs accompanied by high immunization coverage, interruption of rubella transmission through mass vaccination of adolescents and adults, and strengthened surveillance for rubella and CRS. The rubella elimination strategies were aligned with the successful measles elimination strategies. By the end of 2009, all countries routinely vaccinated children against rubella, an estimated 450 million people had been vaccinated against measles and rubella in supplementary immunization activities, and rubella transmission had been interrupted. This article describes how the region eliminated rubella and CRS.

One of the reasons the 1997 Technical Advisory Group on Vaccine-Preventable Diseases recommended acceleration of rubella and congenital rubella syndrome (CRS) prevention efforts was the fact that the enhanced measles surveillance system in the Americas found that 25% of reported measles cases were laboratory-confirmed rubella cases. Until 1997, the laboratory network primarily focused on measles diagnosis. Since 1999, due to the accelerated rubella control and CRS prevention strategy, laboratories have supported the regional measles, rubella, and CRS elimination goals. The measles-rubella laboratory network established in the Americas provides timely confirmation or rejection of suspected measles and rubella cases, and determination of the genotypic characteristics of circulating virus strains, critical information for the programs. A quality assurance process has ensured high-quality performance of procedures in the network. Challenges are occurring, but the measles-rubella laboratory network continues to adapt as the requirements of the program change, demonstrating the high quality of the laboratories in support of public health activities and elimination goals.

Rubella, usually a mild rash illness in children and adults, can cause serious consequences when a pregnant woman is infected, particularly in early pregnancy. These serious consequences include miscarriage, fetal death or an infant born with birth defects (i.e., congenital rubella syndrome (CRS)). The primary purpose for rubella vaccination is the prevention of congenital rubella infection including CRS. Since 1969, several rubella virus vaccines have been licensed for use; however, until the 1990s, use of rubella-containing vaccine (RCV) was limited primarily to developed countries. In 1996, it was estimated that 110,000 infants with CRS were born annually in developing countries. In 2000, the first World Health Organization rubella vaccine position paper was published to guide introduction of RCV in national childhood immunization schedules. From 1996 to 2009, the number of countries that introduced RCV into their national routine childhood immunization programs increased by 57% from 83 countries in 1996 to 130 countries in 2009. In addition, three of the six WHO regions established rubella control and CRS prevention goals: Region of the Americas and Europe rubella elimination by 2010 and 2015, respectively, and Western Pacific Region-accelerated rubella control and CRS prevention by 2015. Also, during this time period, the number of rubella cases reported decreased from 670,894 in 2000 to 121,344 in 2009. Rubella control and prevention of CRS can be accelerated by integrating with current global measles mortality reduction and regional elimination activities.

Background. The Government of Nepal is interested in preventing congenital rubella syndrome (CRS). Surveillance data were analyzed and studies conducted to assess the burden of rubella and CRS and aid in developing a rubella vaccination strategy. Methods. (1) Analysis of rubella cases reported through measles surveillance, 2004 - 2009; (2) in 2008, rubella seroprevalence among women 15 to 39 years of age was evaluated; and (3) in 2009, children attending a school for the deaf were examined for ocular defects associated with CRS. Results. From 2004-2009, there were 3,710 confirmed rubella cases and more than 95% of these cases were less than 15 years of age. Of 2,224 women of childbearing age (WCBA) tested for anti-rubella IgG, 2,020 (90.8%) were seropositive. Using a catalytic infection model, approximately 1,426 infants were born with CRS (192/100,000 live births) in 2008. Among 243 students attending a school for the deaf, 18 (7.4%) met the clinical criteria for CRS. Conclusions. Rubella and CRS were documented as significant public health problems in Nepal. A comprehensive approach is necessary, including introducing rubella vaccine in the routine program, assuring immunity among WCBA, strengthening routine immunization, integrating rubella surveillance with measles casebased surveillance, and establishing CRS surveillance.

Measles and rubella were common infectious diseases in Egypt during the prevaccine era. Monovalent measles vaccine was introduced in 1977, and measles vaccination coverage increased from50% to90% from 1980 to 1999; however, measles outbreaks continued to occur at 2- to 4-year intervals during this period. After the introduction of a second routine dose of measles vaccine as a combined measles-mumps-rubella (MMR) vaccine in 1999 and the implementation of measles immunization campaigns targeting 6- to 16-year-old children during 2000-2003, reported measles cases dramatically decreased by 2003. In 2002, Egypt established a goal to eliminate measles and rubella and to prevent congenital rubella syndrome (CRS) by 2010. Large-scale rubella and measles outbreaks in 2005-2007, however, led to a revision of the plan of action to achieve the 2010 goals. A nation-wide measles-rubella immunization campaign, targeting children, adolescents, and young adults 2-20 years old, was conducted in 2 phases during 2008-2009 and achieved coverage95%. With the decrease to record low levels of cases of measles and rubella in 2009 and 2010, Egypt should achieve measles and rubella elimination in the near future, but high coverage(95%) with 2 doses of measles-rubella vaccine needs to be maintained, measles-rubella surveillance strengthened, and CRS surveillance developed.

Background. Rubella is usually a mild rash illness. However, when a woman contracts rubella early in pregnancy, serious consequences may occur, including birth defects known as congenital rubella syndrome (CRS). Information is limited on the epidemiology of rubella and CRS in Ethiopia.Method. Rubella cases reported through the measles case-based surveillance system during 2004–2009 were analyzed.Results. A total of 8212 samples were tested for rubella immunoglobulin (Ig) M, and 992 (12.1%) of these specimens had test results that were positive for rubella IgM. The age distribution of patients with rubella-positive cases ranged from 3 months to 44 years. The majority (94.7%) of the cases were in individuals

Rubella and congenital rubella syndrome (CRS) continue to be important health problems in many countries. In June 2004, the World Health Organization Steering Committee on Research Related to Measles and Rubella Vaccines and Vaccination met to evaluate data from research and operational activities and to identify critical scientific issues and gaps in knowledge that need to be addressed to improve the global control of rubella and CRS. Information about surveillance for rubella, natural and vaccine-induced immunity to rubella, laboratory diagnosis, the molecular epidemiological profile of rubella virus, and mathematical modeling to assess the burden of CRS and the impact of rubella vaccination was reviewed. This report summarizes the presentations and recommendations for future research.

In 2000, Albania resolved to eliminate measles by 2007 by use of a four-step program: by conducting a "catch-up" vaccination campaign for all children aged 1-14 years, achieving and sustaining high coverage (>/=95%) among children aged 1 year with the first dose of a measles-containing vaccine, by introducing a routine second dose of measles-containing vaccine for children at age 5 years, and by improving measles surveillance. This catch-up campaign took place in November 2000: 867,000 doses of measles-rubella vaccine were administered for an estimated coverage of 99%. In all, 231 campaign-related adverse events were reported: syncope, 206; allergic reactions, 10; fever, 8; encephalitis/encephalopathy, 2; and aseptic meningitis, seizures, Guillain-Barre syndrome, anaphylaxis, and arthralgia, 1 each. All resolved without sequelae. This report describes the status of measles and rubella/congenital rubella syndrome control in Albania before 2000 and reports on implementation of the catch-up campaign.

In 1999 the Ministry of Health of Kyrgyzstan adopted the goal of measles elimination. This opportunity was used to launch a rubella and congenital rubella syndrome prevention program. Between January and August 2001 a rubella outbreak occurred in Bishkek City and Chui Oblast. Rubella surveillance data were reviewed for Kyrgyzstan (1981–2000) and rubella case-patient and laboratory information from Bishkek City and Chui Oblast during the outbreak. The data suggest that rubella is endemic in Kyrgyzstan with periodic epidemics every 3–5 years. From January to August 2001 1936 rubella case-patients were reported from Bishkek City and Chui Oblast; 242 were tested and 176 (73%) were laboratory confirmed. Most case-patients were 3–14 years old. However the incidence rate per 100000 among persons aged 15–35 years increased >/= 40-fold from 1 in 2000 to 41 in 2001. These findings highlight the importance of introducing rubella-containing vaccine in conjunction with measles elimination activities. (authors)

In 2000, Costa Rica set a goal for accelerated rubella control and congenital rubella syndrome (CRS) prevention in conjunction with its established measles eradication goal. To achieve this goal, a National Plan of Action for the integration of a measles-rubella (MR) vaccination strategy was implemented. The components of the national plan included conducting a national vaccination campaign with a single dose of MR vaccine for men and women aged 15-39 years, establishing routine postpartum MR vaccination of all previously unvaccinated women, maintaining high coverage among children with two doses of measles-mumps-rubella vaccine, strengthening the integrated measles and rubella surveillance system, and developing a CRS surveillance system. This report summarizes the results of a successful adult campaign. Targeting MR vaccination appropriately and using the opportunity to strengthen surveillance for rash illness has benefits beyond accelerated rubella control and CRS prevention, including strengthening of the measles eradication program.

To describe clinical presentation and epidemiology of US infants with congenital rubella syndrome (CRS) and to identify missed opportunities for maternal vaccination, data from CRS cases reported to the National Congenital Rubella Syndrome Registry (NCRSR) from 1985 through 1996 were analyzed. Missed opportunities for maternal vaccination were defined as missed postpartum, premarital, and occupational opportunities, that is, times when rubella vaccination is recommended but was not given. From 1985 through 1996, 122 CRS cases were reported to the NCRSR. The most frequent CRS-related defect was congenital heart disease. Of the reported infants with CRS, 44% were Hispanic. Of 121 known missed opportunities for rubella vaccination among 94 mothers of infants with indigenous CRS, 98 (81%) were missed postpartum opportunities. CRS continues to occur in the United States. Hispanic infants have an increased risk of CRS. Missed opportunities for postpartum rubella vaccination were identified for 52% of indigenous CRS cases.

In most developing countries, rubella vaccine has not been included in the Expanded Programme on Immunization because of lack of information on the burden of disease caused by rubella virus, increased cost associated with adding rubella vaccine, and the concern that if high vaccine coverage cannot be achieved and maintained, the risk of congenital rubella syndrome (CRS) may increase. Data for 2009 reported by countries to the World Health Organization (WHO) and United Nations Children's Fund through the annual Joint Reporting Form were used to indicate patterns in the worldwide use of rubella vaccines, describe the number of reported rubella and CRS cases by WHO Region, and explore factors associated with decisions by countries to introduce rubella vaccine in their national childhood immunization programs. The number of WHO Member States using rubella-containing vaccine (RCV) in their national childhood immunization schedule increased from 83 (43%) in 1996 to 130 (67%) in 2009. Although scheduled ages for rubella vaccination vary across countries and regions, most countries have a 2-dose schedule using a combined measles-mumps-rubella vaccine. Among 130 countries using RCV in 2009, median coverage with the first dose of measles-containing vaccine (MCV1) was 95% (interquartile range [IQR], 90%-98%), compared with a median MCV1 coverage of 76% (IQR, 64%-88%) in countries not using RCV. The median per capita gross national income among 130 countries using RCV was US $6300 (IQR, $3227-$20 916), compared with $635 (IQR, $337-$1027) for 63 countries not using RCV. In 2009, 121 344 rubella cases from 167 countries were reported to WHO. However, only 165 CRS cases were reported globally, of which 67 were in the Eastern Mediterranean Region. Further improvements in surveillance are needed to better document the burden of CRS, and new financing mechanisms will be required to catalyze the introduction of rubella vaccine in developing countries that currently meet the coverage criteria for introduction of rubella vaccine.

BACKGROUND A national campaign was conducted in Haiti in 2007-2008 to vaccinate all children and adolescents aged 1-19 years with measles-rubella vaccine in support of achieving the Region of the Americas' 2010 goal of eliminating rubella and congenital rubella syndrome (CRS). Measles-rubella vaccine was introduced into the country's routine childhood immunization schedule after the campaign. METHODS A nationwide, stratified, multistage cluster sample survey of 20859 children was conducted to assess coverage using house-to-house interviews. RESULTS Estimated national coverage with measles-rubella vaccine was 79.2% (95% confidence interval, 77.6%-80.7%), ranging from 90.2% in Nord-Ouest Department to 70.0% in Cite Soleil Metropolitan Area. National coverage was lower for children aged 1-5 years (76.7%) than for those aged 6-19 years (80.3%) (P< .001) but similar in rural departments (79.4%) and metropolitan areas (78.6%; P = .61). The reasons most frequently cited for nonparticipation in the campaign were that the child was ill or unavailable (18.6%), did not know vaccinations were important (13.8%), did not know when to go or forgot to go (13.3%), and did not have enough time (12.3%). CONCLUSIONS The measles-rubella vaccination campaign was critical for raising rubella immunity levels in children and adolescents in Haiti. To remain free of rubella transmission and CRS, Haiti must also achieve and sustain high routine measles-rubella vaccination coverage and maintain high-quality integrated measles-rubella and CRS surveillance, including laboratory-based confirmation for reported rash illnesses. If routine measles-rubella vaccination coverage is suboptimal or if gaps in coverage are identified, additional mass campaigns with measles-rubella vaccine will be necessary.

As part of regional commitments in the Americas aimed at elimination of rubella and congenital rubella syndrome, and consolidation of measles elimination, Colombia conducted mass vaccination of males and females aged 14-39 years in 2005-2006. The target population included 18,238< 443 persons (44% of the entire population). Vaccination activities were extended because of limited participation and public concerns about vaccine safety. Over a 10-month peroid, 17,697,717 doses of measles-rubella vaccine were administered, reaching 97% of the target population, including 96.4% of females and 97.6% of males. Estimated coverage exceeded 95% in 33 of 36 departments and districts, and in 3 others, it ranged from 92% to 95%. In rapid monitoring conducted in 504 (45%) of 1119 municipalities, 95% of persons in the target population were vaccinated. The Colombian experience underscores the importance of social mobilization at the local level, political commitment, and microplanning and offers lessons for future mass vaccination campaigns.

On 29 October 2004, an expert panel was convened to review the status of elimination of rubella and congenital rubella syndrome (CRS) in the United States. Primarily based on 5 types of information presented--epidemiology of reported cases, molecular epidemiology, seroprevalence, vaccine coverage, and adequacy of surveillance--the panel unanimously agreed that rubella virus is no longer endemic in the United States. Since 2004, new data continue to support the conclusion that elimination has been achieved and maintained. In documenting elimination in the United States, each of the 5 types of data provided evidence for elimination and collectively provided much stronger evidence than any one type could individually. As countries document the elimination of rubella and CRS, many sources and types of data will likely be necessary. Rigorous data evaluation must be conducted to look for inconsistencies among the available data. To maintain elimination, countries should maintain high vaccine coverage, adequate surveillance, and rapid response to outbreaks.

Background Strategies for accelerated control of rubella and congenital rubella syndrome (CRS) in Chile included mass vaccination of women of childbearing age in 1999 but did not include vaccination of adult men. Methods We reviewed data from Chile's integrated surveillance system for measles, rubella, and CRS from 2004 through 2009 and describe the epidemiology of rubella outbreaks and implementation of control measures in 2005 and 2007 following mass vaccination of women. Population estimates from census data were used to calculate rubella incidence rates. The age distribution of rubella cases during 2007 was compared with rubella vaccination opportunities by birth cohort to orient mass vaccination of adult men. Results In 2005, an institutional outbreak of rubella occurred among male naval recruits 18-22 years of age, with 46 confirmed cases over a 5-month period. Beginning in March 2007, rubella outbreaks among young adults in the capital of Santiago spread throughout Chile, resulting in >4000 confirmed rubella cases. Delayed control measures and rapid dissemination among young adults led to widespread transmission. From 2007 through 2009, rubella incidence was highest among adult men not included in previous vaccination strategies. Mass vaccination of men 19-29 years of age was conducted in November 2007 to interrupt rubella transmission. Conclusions Chile's experience suggests that vaccination strategies for rubella and CRS elimination need to include both men and women.

Costa Rica introduced the measles-mumps-rubella (MMR) vaccine in 1986. The Ministry of Health adopted the goal of eliminating endemic measles in 1991 by achieving and maintaining high vaccine coverage through routine delivery, mass campaigns and outreach activities, and the strengthening of expanded program on immunization (EPI) surveillance. Measles and rubella immunization strategies shifted susceptibility to older age groups, leading to the introduction of MMR2 in 1992, administered at age 7 years. In 2000, the goal of accelerated rubella control and congenital rubella syndrome prevention was established, and a nationwide vaccination campaign targeting men and women aged 15-39 was implemented to immunize the population of reproductive age. The last endemic case of measles was confirmed in 1999, and at the end of 2001 Costa Rica reported the last endemic cases of rubella and congenital rubella syndrome. Imported cases of measles and rubella were detected in 2003 and 2005, with no secondary cases detected. In 2008, Costa Rica established a National Committee of Experts, supported by technical teams, to collect the evidence required to verify the interruption of endemic transmission of the measles and rubella viruses. The evidence includes information on trends and epidemiologic analysis, molecular epidemiology, population immunity, the quality of surveillance, and the sustainability of the EPI program.

INTRODUCTION Congenital rubella syndrome (CRS) surveillance was established in Honduras to determine the scope of the problem and assess the impact of vaccination. METHODS Implementation of the surveillance system required the drafting of national CRS epidemiological surveillance guidelines, the development of a laboratory diagnostic method, and training of physicians, nurses, and microbiologists in the Honduran hospital network and social security system on CRS surveillance guidelines. RESULTS Honduras' experience with the surveillance of other vaccine-preventable diseases facilitated the implementation of hospital-based CRS surveillance. The surveillance system operates in 23 of the 25 public hospitals that offer services to children and at 2 social security hospitals; the private sector has not been integrated into this system. Clinical and technical staff, including representatives from various disciplines such as pediatrics, neonatology, general medicine, epidemiology, nursing, and microbiology, participate in the hospital network, as well as follow up on cases in accordance with the standardized guidelines, depending on their areas of expertise. CONCLUSIONS Implementation of the CRS surveillance system requires technical guidelines, laboratory diagnostic capacity, and trained multidisciplinary human resources for its systematization and operation.

BACKGROUND Serologic immunity studies are necessary to evaluate immunization policies for rubella control and prevention of congenital rubella syndrome (CRS), and serologic data from regular testing for clinical follow-up can be used to complement surveillance information. METHODS To assess immunity to rubella after an immunization campaign in 12-29-year-old girls and women, we retrospectively reviewed immunoglobulin (Ig) G tests performed from 2000 to 2003 in 9610 serum samples from pregnant subjects in Niteroi, Rio de Janeiro, Brazil. Serologic tests for rubella were performed using commercial enzyme immunoassays. RESULTS Rubella IgG were positive in 83.9% of serum samples collected before the campaign and in 92.5% after the campaign. The proportion of seropositive subjects was inversely related to age (P < .001). The proportion of immune girls or women aged 12-29 years, targeted by the campaign, was significantly increased after the campaign, whereas women aged ≥ 30 years, not targeted by the campaign, had no change in serologic immunity. Geometric mean titers for rubella IgG were significantly higher among pregnant girls and women after the vaccination campaign. CONCLUSIONS The convenience sample provided evidence of increased population immunity among the girls and women targeted by the campaign, but with a coverage of only 83% there remains a significant population at risk for rubella and thus congenital rubella syndrome.

BACKGROUND Rubella during pregnancy can cause serious fetal abnormalities and death. Peru has had integrated measles/rubella surveillance since 2000 but did not implement congenital rubella syndrome (CRS) surveillance until 2004, in accordance with the Pan American Health Organization recommendations for rubella elimination. The article describes the experience from the CRS sentinel surveillance system in Peru. METHODS Peru has maintained a national sentinel surveillance system for reporting confirmed and suspected CRS cases since 2004. A surveillance protocol was implemented with standardized case definitions and instruments in the selected sentinel sites. Each sentinel site completes their case investigations and report forms and sends the reports to the Health Region Epidemiology Department, which forwards the data to the national Epidemiology Department. CRS surveillance data were analyzed for the period 2004-2007. RESULTS During the period 2004-2007, 16 health facilities, which are located in 9 of the 33 health regions, representing the 3 main geographical areas (coast, mountain, and jungle), were included as sentinel sites for the CRS surveillance. A total of 2061 suspected CRS cases were reported to the system. Of these, 11 were classified as CRS and 23 as congenital rubella infection. Factors significantly associated with rubella vertical transmission were: (1) in the mother, maternal history of rash during pregnancy (odds ratio [OR], 12.0; 95% confidence interval [CI], 3.8-37.8); (2) and in the infant, pigmentary retinopathy (OR, 18.4; 95% CI, 3.2-104.6), purpura (OR, 14.7; 95% CI, 2.8-78.3), and developmental delay (OR, 4.4; 95% CI, 1.75-11.1). CONCLUSIONS The surveillance system has been able to identify rubella vertical transmission, reinforcing the evidence that rubella was a public health problem in Peru. This system may serve as a platform to implement surveillance for other congenital infections in Peru.

BACKGROUND Brazil conducted mass rubella vaccination campaigns to meet disease elimination goals by 2010. An analysis of rubella vaccination opportunities was conducted to target population groups with concentrations of unvaccinated individuals. METHODS Rubella vaccination strategies for all 27 states were reviewed between 1992 and 2006. Yearly vaccination coverage was calculated by dividing number of doses of measles-rubella or measles-mumps-rubella vaccines administered by census estimates of target populations. For annual birth cohorts (1967-2005), percentages of persons not vaccinated prior to 2007 were estimated by subtracting the highest coverage obtained in any vaccination strategy (routine or campaign) from 100%. Cohort analysis results were compared with rubella incidence by population group. RESULTS An estimated 28.9 million males and 7.7 million females aged 2-40 years in 2007 remained unvaccinated against rubella, corresponding to 43.0% of males and 11.5% of females of these ages in Brazil. The highest percentages of unvaccinated birth cohorts (93.6%-98.1%) were identified among males aged 26-40 years. In rubella outbreaks reported during 2007, the highest disease incidence (22 cases per 100000 population) occurred among males aged 20-29 years. CONCLUSIONS Analysis of rubella vaccination opportunities identified concentrations of unvaccinated adults and adolescents for targeting mass vaccination to eliminate rubella and congenital rubella syndrome in Brazil.

Background Prior to introduction of rubella vaccine in Haiti's national immunization program, the Haitian government conducted a nationwide rubella-measles immunization campaign targeting persons 1-19 years of age to accelerate elimination of rubella and congenital rubella syndrome, while strengthening measles elimination. The national immunization campaign was conducted in phases by geographic region and combined multiple interventions to reach high coverage in all districts. Methods We analyzed reported data on number of doses administered and results of rapid monitoring by "commune" (district) to evaluate coverage for each vaccine and intervention in target populations. We reviewed measles and rubella surveillance data from Haiti's national surveillance system. Results Immunization registers recorded 4.7 million doses of measles-rubella (MR) vaccine administered to persons 1-19 years of age, reaching 80.2% of the estimated population of 1-4 year-olds and surpassing the target among 5-19 year-olds. In addition, 1 million children under 5 years of age received oral polio vaccine and vitamin A supplements, 1.5 million school children received deworming treatment nationwide, and over 500000 women 15-49 years old in 2 major population centers received diphtheria-tetanus vaccine. Based on administrative data, 102 (76.7%) of 133 communes attained 95% or greater coverage with MR vaccine among persons 1-19 years of age. Rapid monitoring in 118 communes indicated that coverage targets were reached in 52.5%. From 2007 to 2010, no confirmed cases of measles or rubella were reported from Haiti. Conclusions The experience in Haiti suggests that rubella and congenital rubella syndrome can be eliminated through mass vaccination in countries with weak national immunization programs. However, high routine immunization coverage and improved surveillance are urgently needed to maintain measles and rubella elimination.

With the success of the rubella vaccination program, a goal for the elimination of rubella and congenital rubella syndrome (CRS) by 2010 has been established. To monitor the progress toward elimination, surveillance is critical. The laboratory plays an important role in both diagnostics and surveillance for rubella and CRS. In the elimination phase, there are particular issues and challenges that are important to consider when undertaking rubella diagnostics and surveillance activities. Although immunoglobulin (Ig) M serological testing is the primary diagnostic test used to confirm acute rubella infection, additional tests, such as paired IgG serological testing, molecular detection of rubella virus, and rubella IgG avidity testing need to be considered for confirming cases, depending on the clinical and epidemiologic context of a particular suspected rubella case. With the success of the measles-mumps-rubella (MMR) childhood immunization program in Canada, a goal to eliminate rubella and congenital rubella syndrome (CRS) by 2010 has been established. As a result of high measles immunization coverage, Canada has documented the elimination of endemic measles transmission [1] and now presents similar evidence for rubella [2]. To document elimination of rubella/CRS, the laboratory plays an important role in the diagnosis of rubella and CRS cases, the surveillance of rubella and CRS, and in immunity screening. The purpose of this article is to describe the specific laboratory-related rubella and CRS diagnostics and surveillance issues and challenges in Canada. Rubella immunoglobulin (Ig) M serological testing is the standard method for confirming acute rubella infection. However, additional testing, such as rubella IgG serological testing, and rubella virus detection and/or isolation are also useful for the laboratory confirmation of rubella infection. The epidemiologic context of rubella disease elimination efforts, as well as the laboratory diagnosis of rubella in pregnant women, present challenges, and multiple diagnostic approaches are often required.

An important aspect of laboratory surveillance for measles and rubella is the genetic characterization of circulating wild-type viruses to support molecular epidemiologic studies and to track transmission pathways. Virologic surveillance that is sufficient to document the interruption of transmission of measles and rubella viruses will be an essential criterion for verification of elimination. Laboratories in the World Health Organization (WHO) Measles and Rubella Laboratory Network have worked to improve and expand virologic surveillance as many regions move toward elimination of measles and rubella/congenital rubella syndrome. As countries approach elimination, it will be necessary to obtain genetic information from as many chains of transmission as possible. In addition, baseline virologic surveillance, especially for rubella, needs to be improved in many countries. This report contains a summary of recent improvements to the methods used for virologic surveillance.

Background. All Member States of the World Health Organization (WHO) European Region have endorsed rubella elimination and congenital rubella syndrome (CRS) prevention. However, Poland has continued high levels of reported rubella.Methods. We reviewed rubella incidence in Poland since 1966 and analyzed national aggregated surveillance data from the period 2003–2008 and case-based data from 4 provinces from the period 2006–2008. We described CRS cases since 1997 and assessed maternal receipt of vaccine. We reviewed national vaccination coverage from 1992 through 2008.Results. Since 1966, rubella outbreaks have occurred every 4–6 years in Poland. Aggregate and case-based data from the period 2003–2008 indicate that rubella virus transmission has occurred across wide age ranges (from

Background The World Health Organization European Region has a goal for rubella elimination and congenital rubella syndrome (CRS) prevention. Although all Member States recommend a rubella-containing vaccine in their national immunization programs, rubella and CRS continue to occur, and surveillance quality varies throughout the region. Methods To describe the status of regional rubella and CRS surveillance and assess progress toward elimination, we reviewed surveillance practices by surveying all 53 Member States and analyzed rubella and CRS surveillance data during 2005-2009. Results Overall, 41 (91%) of 45 responding Member States have nationwide rubella surveillance, and 39 (87%) have nationwide CRS surveillance. During 2005-2009, rubella cases reported in the region decreased by 94% from 206,359 cases to 11,623 cases. The greatest decrease (99%) was observed in newly independent states of the former Soviet Union. In the rest of the region, high rubella incidence was observed in Poland, Romania, Italy, and San Marino during 2005-2008 and in Poland, Bosnia and Herzegovina, and Austria in 2009. A total of 68 CRS cases were reported during 2005-2009. Conclusions As the foundation to achieving and verifying rubella elimination, high-quality rubella and CRS surveillance needs to be implemented and sustained in all Member States.

Since 1984, the World Health Organization (WHO) European Region has had targets for reducing the burden of a number of communicable diseases. While some countries have already met the targets for interrupting indigenous measles transmission and for reducing the incidence of congenital rubella syndrome to

Data from the regional measles surveillance system have documented widespread rubella virus circulation in many different countries in the Americas. In response to the ongoing endemic incidence of the disease and the potential for a major rubella epidemics in the region, the Pan American Health Organization Technical Advisory Group on Vaccine Preventable Diseases recommended the implementation of a regional initiative to strengthen rubella and congenital rubella syndrome (CRS) preventive efforts in 1997. This article summarizes and highlights the progress toward accelerated rubella control and CRS prevention in the English-speaking Caribbean and in Chile, Costa Rica, and Brazil. Useful knowledge is being generated for the adaptation of similar rubella strategies elsewhere. The findings also document the feasibility of implementing the recommended strategies and their rapid impact on disease burden.

E1 gene nucleotide sequences of 63 rubella virus isolates from North America, Europe, and Asia isolated between 1961 and 1997 were compared phylogenetically. Two genotypes were evident: Genotype I contained 60 viruses from North America, Europe, and Japan, and genotype II contained 3 viruses from China and India. The genotype I isolates prior to 1970 grouped into a single diffuse clade, indicating intercontinental circulation, while most post-1975 viruses segregated into geographic clades from each continent, indicating evolution in response to vaccination programs. The E1 amino acid sequences differed by no more than 3%; thus, no major antigenic variation was apparent. Among 4 viruses from congenital rubella syndrome that occurred following reinfection, only one amino acid substitution occurred in several important epitopes, indicating that antigenic drift is not important in this phenomenon. However, 2 viruses isolated from chronic arthritis exhibited changes in these epitopes. Isolates of the RA 27/3 vaccine strain were readily identifiable by nucleotide sequence.