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CLINICAL REVIEW: Nilesh M Mehta and Roslyn M Thomas Lesson of the week: Antenatal screening for rubellainfection or immunity? BMJ 2002; 325: 90-91 [Full text]

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Rubella Alert......

Velur Balasubramaniam, David Newsom   (15 July 2002)

MMR protects against birth defects

Tony Floyd   (16 July 2002)

Rubella - tip of the iceberg?

Roslyn M Thomas, Nilesh m Mehta   (17 July 2002)

Who would we blame for future outbreaks of Congenital Rubella Syndrome in the UK

Waleed A Rashid   (20 July 2002)

Does rubella vaccination prevent congenital rubella syndrome?

Sandy L Mintz   (21 July 2002)

Congenital rubella - recent reports and women at risk

Pat A Tookey   (24 July 2002)

Rubella Alert...... 15 July 2002
Velur Balasubramaniam, SHO in Neonatology Northwick Park Hospital,Harrow,HA1 3UJ, David Newsom Send response to journal: Re: Rubella Alert......	The controversy over MMR vaccine produced by Dr Wakefield and colleagues may ultimately lead to a reappearance of congenital rubella syndrome in the UK.(1) Reduced vaccine uptake may leave women in child- bearing age increasingly susceptible. Currently congenital rubella occurs most commonly amongst recent immigrants who may have been infected before arrival. We are surprised that more cases of congenital rubella aren’t reported in London, as many hospitals serve large immigrant populations including Lewisham,Whipp’s Cross and The Royal London Hospitals.(2) Paediatricians should remember to examine all neonates for signs of congenital rubella and ask mother about recent travel. If she had a rash during the first trimester, even in the presence of Rubella IgG, blood for a rubella IgM should be sent from the baby to confirm the diagnosis. Furthermore, at risk communities should be offered rubella immunisation to prevent spread of this infection. 1) A J Wakefield et al.(1998)Ileal-lymphoid-nodular hyperplasia, non- specific colitis, and pervasive developmental disorder in children Lancet;351:637-641 2) E Sheridan et al.(2002)Congenital rubella syndrome: a risk in immigrant populations Lancet;359:674-675
MMR protects against birth defects 16 July 2002
Tony Floyd, Medical Student Newcastle University Australia Send response to journal: Re: MMR protects against birth defects	The recent Clinical Review by Mehta and Thomas(1) heralds a possible increase in the rubella-associated birth deformities that the MMR vaccine protects against, thanks to the ill-founded scare campaign currently propogated by the media. Concerns in the UK were initially raised by Wakefield et al in a 1998 Lancet paper suggesting a causal association between this vaccine (or another environmental trigger) and a new syndrome of chronic inflammatory bowel disease and autism.(2) Those who quote this limited study fail to appreciate that there were no controls, no blinding of investigators, only 12 subjects (none of which were chosen at random) and many appear to overlook the fact that the conclusion stated "We did not prove an association between measles, mumps, and rubella vaccines and the syndrome described". A far more comprehensive study was later performed examining children born with autism since 1979, which should have found a change in trend of incidence or age at diagnosis associated with the introduction of MMR vaccination to the UK in 1988. The results were that there was no sudden "step-up" or change in the trend line after the introduction of MMR vaccination. There was also no difference between the age of diagnosis of autism amongst children whether vaccinated before or after 18 months of age, or when compared to those never vaccinated.(3) Other studies in Finland(4), Sweden(5) and California(6) all proved that there was no link between MMR Vaccine and autism. Investigations by the World Health Organisation(7) and a large scale epidemiological study(8) also support the safety of this vaccine. In spite of the overwhelming evidence in favor of the safety of vaccines and the well-documented history of death and disease caused by previous scare campaigns, the media seems happy to feed on the public's like for conspiracy theories with scant regard for the facts. As immunisation rates fall and death results it is a sad irony that parents who avoid vaccination for fear of autism may be causing preventable birth defects by allowing rubella to make a come back. Sincerely, Tony Floyd Medical Student 1. Mehta NM, Thomas RM Lesson of the week: Antenatal screening for rubella infection or immunity? CLINICAL REVIEW BMJ 2002; 325: 90-91 2. Wakefield AJ, Murch SH, Anthony A, et al. Ileal-lymphoid-nodular hyperplasia, non-specific colitis, and pervasive developmental disorder in children. Lancet 1998; 351: 637-41. 3. Taylor, Brent. Miller, Elizabeth. Farrington, C Paddy. Petropoulos, Maria-Christina. Favot-Mayaud, Isabelle. Li, Jun. Waight, Pauline A. Autism and measles, mumps, and rubella vaccine: no epidemiological evidence for a causal association. Lancet. 353(9169):2026- 2029, June 12, 1999. 4. Patja A. Davidkin I. Kurki T. Kallio MJ. Valle M. Peltola H. Serious adverse events after measles-mumps-rubella vaccination during a fourteen-year prospective follow-up. Pediatric Infectious Disease Journal. 19(12):1127-34, 2000 Dec. 5. Gillberg C, Heijbel H. MMR and autism. Autism. 1998;2:423-424. 6. Dales, L. Hammer, S J. Smith, N J. Time Trends in Autism and in MMR Immunisation Coverage in California. Year Book of Psychiatry & Applied Mental Health|Year Book of Psychiatry & Applied Mental Health. 2002:47-48, 2002. 7. World Health Organisation. Expanded programme on immunization (EPI)-association between measles infection and the occurrence of chronic inflammatory bowel disease. Wkly Epidemiol Rec 1998;73:33-40. 8. Immunization Safety Review Committee, Institute of Medicine. Measles-Mumps-Rubella Vaccine and Autism. Washington, DC: National Academy Press; 2001.
Rubella - tip of the iceberg? 17 July 2002
Roslyn M Thomas, consultant paediatrician Northwick Park Hospital, Watford Rd. Harrow , HA1 3UJ, Nilesh m Mehta Send response to journal: Re: Rubella - tip of the iceberg?	Editor - We have diagnosed a third infant with congenital rubella infection after acceptance for publication of our Lesson of the Week (1). The infant was born to a Sri Lankan primipara who has lived in the UK for 6 years and who had had no recent foreign travel and no known history of rubella contact. The mother was found to be rubella susceptible on routine antenatal testing at 12 weeks gestation. A growth restricted infant with thrombocytopaenia but no other serious sequelae was born at 34 weeks gestation. The infant and mother both tested positive for rubella IgM. The mother gave a clear history of a transient, non-itchy rash at 26 weeks gestation. No social or community link between this mother and our two previous cases have been identified. Rubella is highly infectious. This has been demonstrated in a recent case report where there was nosocomial acquistion of rubella virus by an infant being cared for in the same neonatal nursery as an infant with congenital rubella syndrome in another London hospital (2). As there are at least three infants excreting rubella virus in north west London, we are now undertaking rubella IgM testing of all infants with severe intra- uterine growth restriction (birth weight < 3rd centile). With recent decline in uptake of MMR and at least 5 cases of congenital rubella infection in areas of London with large numbers of immigrant women from countries where rubella is endemic and childhood vaccination is not routine, we believe there may be under diagnosis of rubella infection. A recent review of antenatal screening data from maternity units in north London revealed that 23% primipara of Sri Lankan origin were rubella susceptible on routine antenatal screening testing in 1996 - 99 (personal communication Pat Tookey, National Congenital Rubella Surveillance Programme, Feb 2002). A high index of suspicion and appropriate investigation of any suspicious rash in pregnancy are needed if the devastating effects of CRS are to be prevented from becoming more widespread in the UK again. Clear guidelines on the management of, and exposure to, rash in pregnancy are contained in a PHLS working party report (3). Primary health care workers and midwives need to be aware of the need for targeted immunisation prior to pregnancy and extra vigilance, particularly in women of child bearing age who have recently arrived from countries where rubella is endemic. Roslyn Thomas consultant paediatrician Nilesh Mehta specialist registrar Neonatal Intensive Care Unit, Northwick Park Hospital, Watford Rd, Harrow, Middx HA1 3UJ. Email ros.thomas@nwlh.nhs.uk (No competing interest) References 1. Mehta N M, Thomas R M. Antenatal screening for rubella - infection or immunity? BMJ 2002;325:90-1. 2. Sheridan E, Aitken C, Jeffries D, Hird M, Thayalasekaran P. Congenital rubella syndrome: a risk in immigrant populations. Lancet 2002;359:674-5. 3. Morgan-Capner P, Crowcroft N. Guidance on the management of, and exposure to, rash illness in pregnancy (including consideration of the relevant antibody screening programmes in pregnancy). Report of a Public Health Laboratory Services Working Group. PHLS, November 2000. (http://www.phls.co.uk)
Who would we blame for future outbreaks of Congenital Rubella Syndrome in the UK 20 July 2002
Waleed A Rashid, Senior House Officer in Public Health Medicine Northern Health and Social Services Board, County Hall, 182 Glagorm Road, Ballymena,NI, BT42 1QB Send response to journal: Re: Who would we blame for future outbreaks of Congenital Rubella Syndrome in the UK	A review in this week’s BMJ by N Mehta and R Thomas is a timely warning signal for all of us who are concerned about individual and community health issues(1). The study showing two cases among immigrants, highlights the risk of future outbreaks of congenital rubella syndrome among the cohort of currently unimmunised children when they reach childbearing age. Although both patients were pregnant on arrival to the UK, the issue of offering routine rubella immunisation and screening to a large population group such as immigrants should be considered as a priority. The success of the immunisation programme in the UK is the reason behind the reduction in incidence of rubella. The reappearance of large numbers of cases of congenital rubella syndrome would be a direct consequence of the reduced uptake of MMR vaccine. This in turn is the result of parents’ concern on the safety of the vaccine following the publication of Dr Wakefield who suggested a causal link between MMR vaccine and inflammatory bowel disease or autism(2). This underlines the importance of all health care workers, particularly those in primary care providing patients with up to date information on immunisation issues(3). The involvement of a well informed public in decision making could also favourably assist in service planning and consequently health improvement. This is particularly relevant with ethnic minority groups. Efficient childhood immunisation, more alert frontline health staff, public involvement and organised screening programmes are important steps forward. I believe implementing these actions would minimise the rise of occurrence of future outbreaks of congenital rubella syndrome in the UK and would also reduce the rubella risk for immigrant mothers. References (1)Mehta N, Thomas R. Antenatal screening for rubella-infection or immunity? BMJ 2002; 325:90-91 (2)Wakefield A. MMR vaccination and autism. The Lancet; 354: 9182 - 949 (3)Lindholm L, Ekbom T, Dash C, Eriksson M, Tibblin G, and Schersten B. The impact of health care advice given in primary care on cardiovascular risk. BMJ 1995; 310: 1105-1109
Does rubella vaccination prevent congenital rubella syndrome? 21 July 2002
Sandy L Mintz, independent researcher and writer 99511 Send response to journal: Re: Does rubella vaccination prevent congenital rubella syndrome?	In the Lesson of the Week titled "Antenatal screening for rubella -- infection or immunity?", it is stated that the reported decline in congenital rubella syndrome was the result of rubella vaccination. For another interpretation of the apparent decline, and the reasons for it, please read my recent column " Does rubella vaccination prevent congenital rubella syndrome?" at http://www.vaccinationnews.com/Scandals/July_17_02/Scandal25.htm . Sincerely, Sandy Mintz http://www.vaccinationnews.com
Congenital rubella - recent reports and women at risk 24 July 2002
Pat A Tookey, Lecturer in Paediatric Epidemiology, Co-ordinator National Congenital Rubella Surveillance Programme Institute of Chid Health, 30 Guilford St, London WC1N 1EH Send response to journal: Re: Congenital rubella - recent reports and women at risk	The three infants with congenital rubella reported by Mehta and Thomas (1,2), and another recently reported in the Lancet (3) are among eight infants born in the last three years who have been notified to the National Congenital Rubella Surveillance Programme (1 in 1999, 4 in 2000, 3 in 2001). Mothers of five of the infants acquired infection in their countries of origin, before coming to Britain. A sixth case was epidemiologically linked to an outbreak of rubella infection in Greece, although the baby’s mother was infected in the UK (4). The seventh mother was a Sri Lankan woman who had been in the UK for several years (2), and the eighth a UK born woman with no history of travel in pregnancy. The number of cases is low, but it is likely that there is a degree of under- diagnosis and under-reporting. All eight known cases were reported within 5 months of birth, most had typical rubella defects apparent at birth, and all but one was exposed to first trimester infection. Infants born to women infected after about 12 weeks, who are likely to have sensorineural hearing loss as an isolated problem, are not likely to be diagnosed as congenital rubella cases. Furthermore, it is surprising that three of the recent eight cases were reported from one London hospital. Serosurveillance of pregnant women in North London 1996-1999 shows a continuing disparity in rubella susceptibility between women born and brought up in the UK, and immigrant women (5). Although less than 2% of UK -born women did not have detectable rubella antibody at antenatal screening, about 5% of women from Southern Asia (including 15% of Sri Lankan women), 6% of women of black African origin and 8% of women from Eastern Asia were susceptible. Furthermore, women having their first baby had consistently higher susceptibility rates than parous women. MMR uptake in the UK overall was 83.8% in the first quarter of 2002, and in London only 72.4% (6). Unless vaccine uptake rates recover substantially there is likely to be a resurgence of rubella infection. When this last occurred, in 1996, 12 infants were reported with congenital rubella, and there were a similar number of rubella-associated terminations (7). Ten infants were born to women who acquired infection in the UK, and most of those were UK-born women. If rubella infection reappears, health care workers looking after pregnant women (particularly in areas where there are substantial numbers of recent immigrants) should make specific enquiries about rash illness or contact in early pregnancy, and offer appropriate diagnostic tests (8). But of course by then it would really be too late. Offering rubella screening and immunisation to new and recent immigrants, as other correspondents have suggested, would be a timely intervention. References 1. Mehta NM, Thomas RM. Antenatal screening for rubella – infection or immunity? BMJ 2002; 325:90-91 2. Thomas RM. Rubella – tip of the iceberg? eBMJ letter, 17 July 2002 (accessed 19 July 2002) http://bmj.com/cgi/eletters/325/7355/90#23939 3. Sheridan E, Aitken C, Jeffries D, Hird M, Thayalasekaran P. Congenital rubella syndrome: a risk in immigrant populations. Lancet 2002;359:674-75 4. Tookey P, Molyneaux P, Helms P. UK case of congenital rubella can be linked to Greek cases. BMJ 2000; 321: 766–67 5. Tookey PA, Cortina-Borja M, Peckham CS. Rubella susceptibility among pregnant women in North London, 1996-1999. J Pub Health Med 2002; 24(3), in press 6. PHLS. COVER programme: January to March 2002. Vaccination coverage statistics for children up to five years of age in the United Kingdom. Commun Dis Rep CDR Wkly [serial online] 2002 [cited 19 July 2002]; 12 (26): immunisation. Available from http://www.phls.co.uk/publications/cdr/archive02/immunisationarchive02.html#COVERarch 7. Tookey PA, Peckham CS. Surveillance of congenital rubella in Great Britain, 1976-96. BMJ 1999; 318:769-770 8. Morgan-Capner P, Crowcroft NS, on behalf of the PHLS Joint Working Party of the Advisory Committees of Virology and Vaccines and Immunisation. Guidelines on the management of, and exposure to, rash illness in pregnancy (including consideration of relevant antibody screening programmes in pregnancy). Commun Dis Public Health 2002; 5(1):59 -71