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Rubella is eliminated from the Americas
The Pan American Health Organization has announced elimination of rubella from the Americas.
But why haven’t other regions achieved this? Tony Kirby reports.
On April 29, 2015, the Pan American
Health Organization was able to
announce a landmark achievement: the
elimination of rubella and congenital
rubella syndrome (CRS) from the WHO
Americas region. This announcement,
from an expert group at the 13th annual
Vaccination Week in the Americas,
meant that these diseases are the third
and fourth to be officially eliminated
from this region, following smallpox in
1971 and poliomyelitis in 1994.
The achievement culminates a
15-year effort that involved wide-
spread administration of the measles,
mumps, and rubella (MMR) vaccine
throughout the western hemisphere.
“The elimination of rubella from the
Americas is a historic achievement
that reflects the collective will of our
region’s countries to work together
to achieve ambitious public health
milestones”, said PAHO/WHO Director
Carissa Etienne. “Ours was the first
region to eradicate smallpox, the first
to eliminate polio, and now the first to
eliminate rubella. All four achievements
prove the value of immunisation and
how important it is to make vaccines
available even to the remotest corners
of our hemisphere.”
For those who might view rubella as
a disease of the past, think again. The
Ton Kinsbergen/Science Photo Library
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virus is transmitted by airborne droplets
when infected people sneeze or cough;
human beings are the only known
host. A contagious—yet generally
mild—infection that affects mainly
children and young adults, it is most
dangerous when it infects pregnant
women, potentially causing fetal
death or the congenital defects of CRS.
WHO estimates that 110 000 babies
worldwide are born with CRS every year.
However, the continuing problems
with rubella worldwide take nothing
away from PAHO’s remarkable efforts.
Louis Cooper, professor emeritus
at Columbia University (New York,
NY, USA), has spent half a century
“The elimination of rubella from
the Americas is a historic
achievement that reflects the
collective will of our region’s
countries...”
involved in efforts to eliminate
rubella, measles, and other vaccine-
preventable diseases. He believes
that the elimination of rubella in the
Americas was made possible by the
leadership of former PAHO chief Ciro
de Quadros. “PAHO is 120 years old
and has expertise and credibility in
the Americas. De Quadros understood
the necessity of national political
commitment at the highest level
and PAHO provided the technical
assistance in each country on the range
of activities necessary for successful
immunisation programmes.”
Cooper also believed that stable
funding through PAHO’s Revolving
Fund mechanism definitely contri-
buted to the process, and paid tribute
to the US Centers for Disease Control
and Prevention, which he describes as a
“sensitive and supportive partner”.
Some eyebrows must have been
raised across Europe when South
America, with its mixture of middle-
income countries, was able to declare
itself rubella free before Europe, with its
abundance of high-income nations and
excellent health-care systems. However,
it is not just the less developed nations
in the WHO Europe region that continue
to experience rubella transmission.
Wherever rubella remains, it is
accompanied by sporadic outbreaks of
measles, since the two are prevented by
a vaccine against both diseases. “There
are problems with measles right now
in several countries in Europe including
Germany, France, and Italy”, says
Professor Ronald de Groot, president
of the European Society for Paediatric
Infectious Diseases and actively involved
in WHO’s Measles and Rubella Initiative,
which aims to eliminate both diseases
from at least five of WHO’s six regions
by 2020. “WHO held a meeting with
the Italian Ministry of Health in March
to support a programme for higher
vaccination coverage in Italy. As well
as measles, cases also of rubella and
congenital rubella are a result of failures
to vaccinate. These problems should no
longer be an issue in rich nations”, adds
de Groot.
“Europe became complacent”, says
Cooper. “WHO’s Europe Region has not
had the history, resources, or impetus
to stimulate national action among
what is essentially a group of fiercely
independent countries. WHO Europe is
tantalisingly close to elimination, but
stronger national leadership is definitely
needed to push them over the goal line.”
“The absence of a strong central
steering of national immunisation
programmes in many European
countries contributes to the problems”,
says de Groot. “In addition, minority
groups including Roma and immigrants
who are undervaccinated, combined
with unwillingness in parents from
certain religious groups or with
www.thelancet.com/infection Vol 15 July 2015

alternative lifestyles to vaccinate their
children, create problems because of
suboptimal vaccination coverage.” He
also laments the lack of willingness
across individual European countries
to be part of any general European or
supranational action. “The European
Centre for Disease Prevention and
Control and WHO Europe, are so far
unable to exert any influence on this”,
he adds.
Europe’s problems are compounded
by having a wide range of health-
care professionals responsible for
vaccination, rather than solely
paediatricians as in the USA. “This
makes it more difficult to find vaccine
advocates who act with the support of
a strong national organisation as is the
situation in America”, says de Groot.
He suggests one way forward could be
the formation of a fully independent
European Committee for Immunisation
Practices, based on the US model, which
could provide the European Commission
and the public across Europe with expert
advice on issues regarding vaccination,
and help to optimise and harmonise
vaccine coverage in Europe.
Unsurprisingly, CRS rates are highest
in the WHO African and Southeast
Asian regions where vaccine coverage
is lowest. In those nations, a wide range
of conditions already dismissed from
high-income countries remain endemic.
Yet regarding rubella, Cooper explains
that other countries with problems
are those that have not used rubella
vaccination until recently, and especially
when the vaccine programme is focused
solely on young children rather than the
broader population, such as happened
in Japan and Poland. As reported in
The Lancet last year, between 2012 and
2014, more than 15 000 cases of rubella
and 43 of CRS were reported in Japan,
in an outbreak mainly affecting adult
men aged 35–51 years, who had not
received routine rubella vaccine during
their childhood when only girls were
vaccinated, and men and women aged
24–34 years—whose vaccine coverage
rates were quite low. Geographically,
more than 80% of rubella cases in
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this Japan outbreak were reported in
Tokyo, Osaka, and their neighbouring
prefectures—showing the higher
susceptibility of areas with dense
populations.
Researchers at the Tuberculosis and
Infectious Diseases Control Division,
Health Service Bureau, Ministry of
Health, Labour and Welfare (Tokyo,
Japan), pointed out then that although
vaccination is the best strategy to
prevent further outbreaks, it can be
difficult to encourage adults to receive
vaccinations (when a typical measles-
rubella vaccination would cost US$100),
especially once an outbreak is over.
So is it simply a matter of vaccinate,
prevent? Many experts say essentially,
yes. “When rubella vaccine was
combined with measles and mumps
vaccines to give MMR vaccine, many
countries elected to immunise boys
and girls in infancy and later to add a
second booster dose”, says David Isaacs,
Clinical Professor in Paediatric Infectious
Diseases, University of Sydney, Australia.
“There are no animal reservoirs for these
three viruses and little genetic variation,
so all three virus infections could
theoretically be eliminated using this
approach. For example, Australia has no
endemic circulating measles, although
cases are sometimes introduced from
overseas and may spread temporarily.”
Even in Australia’s Indigenous
population, which has a much shorter
life expectancy and a higher risk of
contracting infections and developing
chronic diseases than the general
population, the number of rubella cases
has fallen to nearly zero. Australia can
effectively say it has eliminated rubella
(and measles) at a national level, but
since it is part of the WHO Western
Pacific Region, it is not in an elimination
region. Isaacs says that the few cases of
rubella recorded in Australia are almost
exclusively imported from overseas.
He emphasises the importance of
immunising widely. He says, “without
this, the mean age of infection with
rubella can be pushed up from the
typical peak of 5–9 years, and women of
childbearing age could be at increased
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risk”. Isaacs explains that this happened
in Greece, where poor uptake of vaccine
actually led to an increase in CRS. What
was meant to be a universal coverage
of vaccine at age 1 year was only taken
up by 50% of children, leading to more
circulating virus and ultimately more
women of childbearing age exposed
to the virus. Cooper also stresses the
importance of widespread vaccination,
adding “the success in Brazil came only
after what we call a wide age range
supplemental immunisation campaign
that included men and women up to
age 39 years”.
Cooper agrees that the rubella vaccine
is so good that the disease is simply
swept away by mass immunisation.
“Fortunately, rubella is not as contagious
as measles, so a good programme to
eliminate measles will also take care
of rubella—and earlier.” He highlights
that every year, a new cohort of rubella-
susceptible infants is born. “Eternal
vigilance is mandatory if we are to
maintain the Americas’ success and take
it through to global eradication.” Recent
outbreaks of measles at Disneyland, CA,
USA, have underlined the importance
of ensuring high vaccination rates.
“Antivaccine groups must be addressed,
and in locally specific ways”, says Cooper.
“But strong programmes will not be
ruined by such groups where being
immunised against measles and rubella
is normative behaviour. Public trust in
immunisation remains key.”
Above and beyond this, rubella must
remain on the radar of both existing
physicians and nurses, and those of
the future. “As with many infectious
diseases, with rubella we can become
a victim of our own success”, explains
Cooper. “Rubella is easily overlooked For the Lancet report on rubella
and most newborns with CRS look in Japan see Correspondence
Lancet 2014; 383: 1460–61
normal in the early days of life. Thus
the magnitude of the problem is not
appreciated. In the developed world,
most doctors, even in the later stages
of their careers, are too young to
remember how devastating measles
and rubella were before vaccines.”
Tony Kirby
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