A rubella vaccination program for women entering the U.S. Army

A voluntary rubella vaccination program for female basic trainees was initiated on April 21, 1975, at Fort Jackson, S.C. A total of 29,852 women were tested for rubella titers between April 21, 1975, and December 31, 1977, and 6,167 were found to be nonimmune. An average of 53 percent of the susceptible women were vaccinated. The best results were obtained from August 1 to December 31, 1977, when 67 percent of the susceptible women were vaccinated. During this period, blood specimens for rubella titer and for pregnancy testing were obtained simultaneously. This procedure reduced the number of referrals to the Obstetrics-Gynecology Clinic, as well as the amount of training time lost when pregnancy testing and rubella titer testing were done on separate days. Despite the vaccination program, however, rubella epidemics occurred among female trainees at Fort Jackson in 1975, 1976, and 1977. A significant number of women are still susceptible to rubella. To reduce morbidity and the risk of congenital rubella syndrome, rubella titer testing and immunization of susceptibles should be considered for women-especially where they can be screened, counseled, and vaccinated en masse.     

Rubella susceptibility among pregnant women in North London, 1996-1999

BACKGROUND: Rubella infection and congenital rubella are currently rare in the United Kingdom, although sporadic cases occur, often associated with travel abroad. Uptake of the combined measles, mumps and rubella (MMR) vaccine has declined in recent years, and there is a danger that rubella infection could start to circulate again, with serious implications for susceptible pregnant women. This could be a particular problem in communities where there are relatively high rubella susceptibility rates because of either poor vaccine uptake over several years or the presence of significant numbers of recent immigrants from countries without routine rubella vaccination programmes. METHODS: Routinely collected data on rubella susceptibility in pregnant women in the former North West Thames region were available for 1996-1999. Associations between year of delivery, maternal age, parity and ethnic group, and rubella susceptibility were explored. RESULTS: Overall rubella susceptibility declined significantly from 2.6 per cent to 2.4 per cent between 1996 and 1999. Whereas less than 2 per cent of British-born women were susceptible, overall susceptibility for other women was about 5 per cent. African and Asian women had particularly high susceptibility rates, and patterns of susceptibility by age and parity varied across ethnic groups. CONCLUSIONS: If rubella were to re-establish itself in the United Kingdom, women who had come to Britain in later childhood or adult life would be at higher risk of acquiring infection in pregnancy than indigenous women. Appropriate local and national strategies should be devised to ensure that all such women are offered rubella vaccination at the earliest opportunity.     

Rubella susceptibility in inner-city adolescents: the effect of a school immunization law.

In order to improve the immune status of girls in our medical clinic, we conducted a prospective sero-survey to identify susceptibles and developed a system for vaccinating non-immune girls. Over an 18-month period, 481 inner-city adolescents were screened. Susceptibility rate defined by a titer less than 1:8 was 12 per cent and did not differ significantly with regard to age or race. Nine months into the study period, the State of Wisconsin enacted a "no immunization-no school" law. The susceptibility rate dropped from 22 per cent prior to the enactment of the law, to 5 per cent after. Of the 60 girls identified as susceptible, 54 (90 per cent) kept their follow up appointments for vaccinations. Enforced state immunization laws appear to be effective in lowering rubella susceptibility.     

Public Health Implications of Rubella Antibody Levels in California

Rubella hemaggluttination inhibition (HI) antibody determinations were performed in 1977 on a sample of California school children and in 1977-1979 on young women who were about to be married or who were pregnant. Among the pupils, 66 per cent reported prior rubella immunization; immunization history was more common in younger pupils. Seventy-seven per cent had detectable antibody, with little trend of greater seropositivity at older ages. Over 86 per cent of those with a written record of immunization had detectable antibody. There was no consistent indication of loss of seropositivity with increasing time since immunization. Children immunized at 12-14 months of age tended to have a lower seropositivity rate than those immunized at older ages. Among young women, the prevalence of detectable antibody was 80-83 per cent. Comparison with data obtained in 1968-1969 indicates that rubella immunization has had a marked impact on antibody levels in children but less impact on levels in teenagers and adults. The pool of rubella-susceptibles entering secondary schools will probably not decrease soon, so that rubella outbreaks may continue in high school and college-age populations. Ultimately, school entry immunization requirements should drastically curtail disease activity. In the interim, programs to immunize teenagers and young adult females must be strengthened. (Am J Public Health 1982; 72:167-172.)     

Rubella in the workplace: the need for employee immunization.

From 1983 to 1985, the New York City Department of Health investigated five workplace outbreaks of rubella. Approximately 40 per cent of the 265 cases were detected among women of child-bearing age (15-44 years). Data are reviewed from the 1983 Financial District outbreak to illustrate the continued susceptibility of young adults, the missed opportunities for rubella immunization, and the danger of congenital infection. A comprehensive rubella immunization program is required to protect pregnant women and eliminate congenital rubella. As one important component of this effort, employee health physicians are urged to assess the immune status of women of child-bearing age and to vaccinate all susceptibles who are not pregnant.     

Interruption of rubella virus transmission in Australia may require vaccination of adult males: evidence from a Victorian sero-survey.

Prior to the introduction of rubella vaccine to Australia in 1970 rubella was primarily a disease of primary school aged children. Vaccination programs have subsequently altered rubella age and sex susceptibility. Between July 2001 and June 2002, 85 per cent of the 32 laboratory-confirmed cases of rubella ascertained from enhanced surveillance in Victoria were males aged 20-42 years. This study aimed to determine rubella susceptibility by age group and sex in Victoria and to examine the implications of susceptibility for the interruption of circulating rubella virus. Rubella immunoglobulin G concentrations were determined for 934 residual diagnostic sera stored at the Victorian Infectious Diseases Reference Laboratory using a standard commercial enzyme immunoassay. Susceptibility was analysed by age groups defined by previous and current Australian rubella immunisation schedules. Among all subjects aged 1-55 years, males were more susceptible to rubella infection than females (10.2% vs 2.6%, p < 0.0001). Although this sex difference occurred in all age groups, it was unlikely to be explained by sampling variation in sera from subjects aged 23-44 years, for whom rubella vaccine had been recommended only for girls aged 10-14 years and rubella susceptible women post-partum. Australia's past rubella immunisation policies have resulted in a susceptible cohort of adult males. If rubella virus transmission is to be interrupted in Australia, consideration needs to be given to a rubella vaccination program targeting men aged 17-44 years. A campaign, targeting both men and women in a similar age group has recently been successful in Costa Rica.     

Reasons for rubella susceptibility among pregnant women in west Lambeth.

One hundred and thirty-three pregnant women who delivered at St Thomas' Hospital, in 1990 were noted to require rubella vaccination post partum. Fifty-three (39%) had completed a telephone questionnaire in order to determine reasons for susceptibility to rubella. Laboratory reports confirmed that 92 women were rubella seronegative and 27 had low levels of antibody. Of the 53 women interviewed, 25 gave a history of one or more rubella immunizations, 20 had no history of immunization and vaccination history was unknown for eight. Eleven of the 20 unvaccinated women had not been at school in the UK between 11 and 14 years of age. Eighty-seven per cent of the patients' general practitioners had no knowledge of their patients' rubella antibody status. Ninety-four per cent of the 133 women received rubella vaccine post partum. The Department of Health guidelines should be more vigorously implemented in order to identify and immunize remaining rubella susceptible women of child-bearing age. Susceptibility among women with a history of rubella immunization suggests that the seroconversion rate following rubella immunization in clinical practice may be lower than in vaccine trials.     

Increasing rubella seronegativity despite a compulsory school law.

To determine if lower rubella susceptibility persisted five to seven years after immunization legislation, we retrospectively reviewed the serologic status of 341 outpatients from 1985 to 1987 in an inner-city school age population. Seronegative rates increased significantly during the two-year study period from 4.2 to 24.5 percent (17 percent overall). (Beta = 6.8%, 95% CI = 3.3, 10.3). Charts were reviewed for 57 of 58 seronegative and 114 seropositive controls. Estimates were then made to the population of 341 subjects. Those with documented rubella immunization had a seronegative rate of 13 percent compared to 19 percent if the immunization status was unknown. For patients who received care in our clinic for less than two years, 32 percent were seronegative compared to 10 percent for those treated greater than or equal to 2 years (odds ratio = 0.31, 95% CI = 0.16, 0.60). Among patients immunized in 1977 or 1978, 33 percent were seronegative compared to 7 percent immunized at other times (OR = 0.21, 95% CI = 0.07, 0.63). Factors associated with increased rubella seronegativity include immunization in 1977 or 1978 and lack of continuity of care in our clinic. Much of the increase remains unexplained.     

The epidemiology of rubella and congenital rubella in Australia, 1992 to 1997.

Selective rubella vaccination of schoolgirls commenced in 1971 and was followed by a significant reduction in congenital rubella. Infant vaccination with MMR was introduced in 1989 to interrupt circulation of the virus in young children, and in 1994/95 the adolescent school based rubella vaccination program was changed to MMR for both boys and girls. This report reviews the epidemiology of rubella and congenital rubella between 1992 and 1997 using reports to the National Notifiable Diseases Surveillance System (NNDSS) and the Australian Paediatric Surveillance Unit (APSU). Notification rates for rubella exceeded 20 per 100,000 in 1992, 1993 and 1995 and declined to 7.2 per 100,000 in 1997. Sixty-one per cent of notifications occurred between September and December and 68% occurred in males. The incidence rate in males aged 15-22 years peaked at 152.6 per 100,000 in 1995 reflecting the lack of immunisation in this cohort. From 1993 to 1997, 19 children were reported with congenital rubella syndrome, representing 1 in 67,000 live births. Of these, 17 had multiple defects (4 died) and 2 had deafness only. There were also 5 infants with congenital rubella infection but no defects. Australia's rate of congenital rubella syndrome exceeded that of the United Kingdom and the United States of America but this may be partly attributable to differences in reporting practices. The impact of changing the second dose of MMR vaccine to 4 years of age in 1998 will require careful monitoring.     

Invasive pneumococcal disease in Australia, 2001.

There were 1,681 cases of invasive pneumococcal disease (IPD) notified to the National Notifiable Diseases Surveillance System in Australia in 2001; a rate of 8.6 cases per 100,000 population. The notification rate varied between states and territories and by geographical region with the highest rates in the north of the country. Pneumococcal disease was reported most frequently in children aged less than 5 years (47.3 cases per 100,000 population). Enhanced surveillance for IPD was carried out in the Northern Territory, Western Australia, South Australia, Victoria, Tasmania and metropolitan areas of New South Wales, encompassing 72 per cent of the population and providing additional data on 86 per cent of all notified cases. Enhanced surveillance data revealed high rates of pneumococcal disease in Indigenous Australians. Rates of IPD in Indigenous children aged less than 5 years were as high as 483 cases per 100,000 population in the Northern Territory. The clinical presentation of IPD was most commonly pneumonia (56%) and bacteraemia (36%). There were 125 deaths attributed to IPD resulting in an overall case fatality rate of 8.6 per cent. More than half (54%) of all cases had a recognised risk factor for IPD. Eighty-six per cent of serotypes identified in non-indigenous children compared with only 55% of serotypes in Indigenous children were in the 7-valent vaccine. Antibiotic susceptibility testing showed reduced susceptibility to penicillin in 12 per cent, and to third generation cephalosporins in 5 per cent of isolates. These are the first national data available on IPD in Australia and will assist in evaluating the impact of the newly introduced conjugate vaccine and guide overall pneumococcal vaccine strategies.     

Managing alcohol and drug problems in general practice: a survey of trainees' knowledge, attitudes and educational requirements

Abstract: To establish baseline data on Family Medicine Programme trainees' knowledge of and attitudes to drug and alcohol problems, we posted questionnaires to all trainees in New South Wales, Queensland, Victoria and South Australia. A total of 1647 trainees was surveyed, with a response rate of 55 per cent ( n =908). The mean age of respondents was 29 years and 54 per cent were female. The majority of respondents (58 per cent) were in their final year of training. Overall knowledge levels were reasonably good (the mean score was 76 per cent), but there were significant areas of deficit. Senior trainees generally performed better than their junior counterparts. Knowledge was best for alcohol and weakest for opiates. Attitudes towards involvement with drug and alcohol problems were very positive; however, confidence in the efficacy of various interventions was mixed.     

Rubella in Seattle-King County Washington.

Assessment of the results of rubella hemagglutination-inhibition tests from women of child-bearing age in Seattle-King County suggests no community susceptibility problem except among women age 19 in 1976. Within this cohort 23 per cent were susceptible, probably because these women were too young to experience a full exposure to natural rubella prior to introduction of rubella vaccine and too old to be immunized against rubella in the elementary schools in 1970. Follow-up of women under age 25 who were seronegative for rubella antibody indicated that one-third subsequently received rubella vaccine.     

The decline in congenital rubella syndrome in Western Australia: an impact of the school girl vaccination program?

Rubella vaccination became available in 1970 in Australia. In Western Australia (WA), a school girl vaccination program was well established by 1971. Mothers under 26 years of age in 1983 would have been eligible for this program and they constitute 40 per cent of WA births. Data on Congenital Rubella Syndrome (CRS) cases were obtained for years of birth 1968-83 inclusive to ascertain if there had been an impact of the program on the CRS rate. Epidemics of rubella occurred in 1970-71, 1974, and 1979-80. The CRS rate has fallen steadily; it did not rise during the 1979-80 epidemic and was less than one in each year after 1977. All CRS cases born since 1974 were to mothers too old to have been eligible for the program. The data suggest that the vaccination program is effective, but this cannot be proven until data become available on pregnancy terminations.     

Premarital rubella vaccination program.

A two-year Vermont program identified 494 (7 per cent) of 6,982 premarital female serologies that were seronegative (less than 1:8) to rubella by hemagglutination inhibition (HI) titer. All 494 susceptible patients and their physicians were notified of their results by letter. The State Health Department received reports that a total of 194 (39 per cent) of the susceptible patients had received rubella vaccinations as a result of their notifications. Intensive follow-up of susceptibles appears to be important factor in the success of premarital rubella screening programs.     

A nutrition/health training program for Peace Corps volunteers

Nutrition and health education is a crucial component of the overall mission of the Peace Corps program. Individuals selected to work as Peace Corps volunteers need to be well prepared to perform this complex and challenging job in recipient countries. This article presents a model for a training program for Peace Corps trainees that was conducted over a 5-week period. The program was planned in accordance with some specific training guidelines that were provided by the Peace Corps. The trainees included nine women ranging in age from 22 to 61 years with diverse backgrounds; however, all had a BA/BS in a health-related discipline. Training curriculum included fundamental nutrition and health-related areas: basic nutrition, foods, clinical nutrition, maternal and child health, communicable diseases and sanitation, health strategies, and community development. Fifty percent of the curriculum was devoted to "hands-on" practical and clinical activities. Maternal and child health was emphasized in the training curriculum as this is an area of concern in all developing countries. The trainees were evaluated by weekly quizzes as well as completion of a special project involving applications of all their newly acquired skills. Implications of the training program are discussed.     

PAP SMEAR USAGE IN NEW SOUTH WALES - IMPACT OF ACTIVE PROMOTION

Less than 25 per cent of eligible Australian women have cervical (‘Pap’) smear tests in any year. Rates are particularly low (<8%) for women over 55 years, the group at highest risk of cervical cancer. A regional program, actively promoting Pap smears by widespread direct community intervention and attention to service needs, targeting women over 55 years and under 25 years, was conducted on the North Coast (population 132,000 women) immediately after a New South Wales State-wide media campaign in February 1988. The number of Pap smears done in the region increased 119 per cent for women over 55 years and 44 per cent for 15–24 year-olds during the promotion (63% overall) compared to New South Wales increases of 58 per cent for women over 55 years and 23 per cent for 15–24 year-olds (31% overall). Differences between the North Coast and New South Wales were statistically significant for all age groups in March and in April for women over 55 years. Differences between New South Wales and Australia (no active promotion) were significant for women over 55 years in March and April. Records from a sample of 152 women attending clinics during the campaign showed 63 per cent had not had a smear test for three or more years, 10 per cent never. The results indicate that an intensive, low-cost public health program, working in conjunction with general practitioners, can be effective in increasing smear rates and that well-designed strategies will have an impact on older women, a high risk group who traditionally are poor users of Pap smear services. The combined impact of the two campaign strategies on Pap smear usage was significantly greater than media alone. A Central New South Wales cervical screening database is essential for evaluation of screening promotion.     

Traumatic deaths during U.S. Armed Forces basic training, 1977-2001

BACKGROUND: A Recruit Mortality Registry, linked to the Department of Defense Medical Mortality Registry, was created to provide comprehensive medical surveillance data for deaths occurring during enlisted basic military training. METHODS: Recruit deaths from 1977 through 2001 were identified and confirmed through redundant sources. Complete demographic, circumstantial, and medical information was sought for each case and recorded on an abstraction form. Mortality rates per 100,000 recruit-years were calculated by using recruit accession data from the Defense Manpower Data Center. RESULTS: There were 276 recruit deaths from 1977 through 2001 and age-specific recruit mortality rates were less than half of same-age U.S. civilian mortality rates. Only 28% (77 of 276) of recruit deaths were classified as traumatic (suicide, unintentional injury, and homicide), in comparison to three quarters in both the overall active duty military population and the U.S. civilian population (ages 15-34 years). The age-adjusted traumatic death rates were highest in the Army (four times higher than the Navy and Air Force, and 80% higher than the Marine Corps). The majority (60%) of traumatic deaths was due to suicide, followed by unintentional injuries (35%), and homicide (5%). The overall age-adjusted traumatic mortality rate was more than triple for men compared with women in all military services (rate ratio=3.9; p=0.01). CONCLUSIONS: There was a lower proportion of traumatic deaths in recruits compared to the overall active duty military population and same-age U.S. civilian population. This finding could be attributed to close supervision, emphasis on safety, and lack of access to alcohol and motor vehicles during recruit training.     

Invasive pneumococcal disease in Australia, 2004

There were 2,375 cases of invasive pneumococcal disease (IPD) notified to the National Notifiable Diseases Surveillance System in Australia in 2004; a notification rate of 11.8 cases per 100,000 population. The rate varied between states and territories and by geographical region with the highest rates in the Northern Territory. Invasive pneumococcal disease was reported most frequently in children aged less than 5 years (55.4 cases per 100,000 population). Enhanced surveillance for IPD was carried out in all states and territories, in 2004, providing additional data on 2,023 (85%) cases. The overall rate of IPD in Indigenous Australians was 3.2 times the rate in non-Indigenous Australians. There were 154 deaths attributed to IPD resulting in an overall case fatality rate of 7.6 per cent. Rates of IPD in the Indigenous and non-Indigenous under 2-year-old population were similar in 2004 (91.5 and 93.6 cases per 100,000 population, respectively) following a targeted introduction of the 7-valent pneumococcal conjugate vaccine (7vPCV) in mid-2001 for Indigenous infants and children. Serotypes of isolates were identified from 80 per cent of all notified cases, with 72 per cent of isolates belonging to serotypes represented in the 7vPCV and 91 per cent in the 23-valent polysaccharide pneumococcal vaccine (23vPPV). Comparison of serotypes in the 7vPCV target population showed that the rate of IPD due to 7vPCV serotypes decreased by 74 per cent between 2001-02 and 2003-04. Of 216 isolates with reduced penicillin susceptibility, 83 per cent belonged to pneumococcal serotypes in the 7vPCV and 95 per cent in the 23vPPV.     

Epidemiology of rubella and congenital rubella syndrome in Japan before 1989

Epidemiological studies of rubella and congenital rubella syndrome (CRS) in Japan have been conducted since the first nationwide rubella epidemic of 1965–1969 and subsequent epidemics of 1975–1977, 1982, 1987–1988, and 1992–1993. Rubella was non-endemic in Japan before the 1975–1977 epidemic, and endemic thereafter. Japan started a selective rubella vaccination program for junior high school girls in 1977, and universal rubella vaccination of children of both sexes in 1989. No nationwide rubella epidemics have occurred since 1994.Only three children with CRS were reported in Japan before 1964; however, many children with CRS were identified in 1965 when a rubella epidemic struck Okinawa, which has many the United States military bases. After the 1965–1969 and 1975–1977 rubella epidemics on the Japanese mainland, small numbers of children with CRS were identified (hospital survey). These findings led to the hypothesis that, compared to U.S. rubella virus strains, Japanese strains of rubella virus are less teratogenic. This hypothesis strongly affected the development of rubella vaccines in Japan. However, retrospective seroepidemiological studies attributed the CRS in many children in Okinawa to the high rate of rubella infection in pregnant women. According to the survey conducted at special schools for the deaf, 83, 232, 77, and 167 children were born with CRS on the Japanese mainland respectively after the 1965–1969, 1975–1977, 1982, and 1987–1988 nationwide rubella epidemics, suggesting that the incidence of CRS in Japan is in fact comparable to that in the U.S. and Europe.Rubella epidemics in children have been effectively prevented since 1994. However, a rubella outbreak among adult males and CRS occurred between 2012 and 2014.