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LETTERS: G Giannakos, M Pirounaki, and C Hadjichristodoulou Incidence of congenital rubella in Greece has decreased BMJ 2000; 320: 1408 [Full text]

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Congenital rubella birth in UK - link to Greek outbreak

Pat Tookey, Pamela Molyneaux, Peter Helms   (8 June 2000)

Incidence of congenital rubella in Greece

Takis Panagiotopoulos   (8 September 2000)

Congenital rubella birth in UK - link to Greek outbreak 8 June 2000
Pat Tookey, coordinator, National Congenital Rubella Surveillance Programme Dept Epidemiology and Biostatistics, Institute of Child Health, 30 Guilford St, London WC1N 1EH, Pamela Molyneaux, Peter Helms Send response to journal: Re: Congenital rubella birth in UK - link to Greek outbreak	Editor - Giannakos et al(1) reported four infants with congenital rubella syndrome born in Greece following an outbreak of rubella which peaked in January 1999. We report a congenital rubella birth in Scotland late in 1999 which can also be linked to this outbreak. At least four universities in the UK (three in England, one in Scotland) reported outbreaks of rubella early in 1999, all of which included students from Greece.(2) In Grampian, Scotland, 39 laboratory confirmed cases were reported and two Greek students were among the first five cases.(3) The only infant reported with congenital rubella in the UK for 1999 was born in the Grampian Health Board area in December.(4) He was admitted to hospital in Aberdeen at the age of 3 months with a purpuric rash and failure to thrive, and was found to be rubella IgM positive. The baby's mother was immunised as a schoolgirl, had rubella antibodies detected in pregnancy in 1996, and had no symptoms or known contact with rubella early in this pregnancy. However, reinfection in pregnancy was retrospectively confirmed by tests on stored antenatal bloods. The estimated risk of foetal infection following first trimester maternal reinfection is 8%,(5) considerably lower than that following primary maternal infection. The baby is developmentally delayed, and has intracranial calcification, but no detectable eye or cardiac abnormalities. He also has severe gastrointestinal reflux which resulted in aspiration pneumonia. Since 1990, 46 live births and two still births have been reported to the National Congenital Rubella Surveillance Programme in the UK. Twelve of these occurred in 1996, following a resurgence of rubella infection, mainly affecting young men.(6) None were reported in 1997 or 1998. The dramatic reduction in congenital rubella births and rubella associated terminations in the UK in the last 20 years has been achieved by maintaining high immunisation uptake rates. Indeed, in the Grampian area, the uptake of MMR vaccine by 2-year olds is currently 91.0%. However, MMR coverage in the UK as a whole has declined since 1995 to 87.8% (range 63.6% - 100%) in 2-year olds at the end of 1999, a level which is insufficient to prevent renewed circulation of rubella infection in the long term. Meanwhile, although women who travel abroad during early pregnancy, or who have recently arrived here from countries with less successful, or disrupted vaccination programmes (for example Eastern Europe), are likely to be at higher risk, this case shows that you don't have to travel to find rubella. Yours sincerely, Pat Tookey, coordinator, National Congenital Rubella Surveillance Programme, Department of Epidemiology and Biostatistics, Institute of Child Health, London Email p.tookey@ich.ucl.ac.uk Pamela Molyneaux, consultant virologist Department of Medical Microbiology, Aberdeen Royal Infirmary. Peter Helms, professor of child health Department of Child Health, University of Aberdeen No competing interests. References 1. Giannakos G, Pirounaki M, Hadjichristodoulou C. Incidence of congenital rubella in Greece has decreased. BMJ 2000; 320:1408 2. Rubella in University students. Commun Dis Rep CDR Wkly 1999; 9;113,116 3. Rubella in Grampian Health Board. SCIEH Weekly Report 1999; 33: 77 4. Molyneaux P. Congenital rubella infection following documented maternal reinfection. SCIEH Weekly Report 2000; 34: 85 5. Morgan-Capner P, Miller E, Vurdien JE, Ramsey MEB. Outcome of pregnancy after maternal reinfection with rubella. Communicable Disease Report Review 1991; 1: R57-R59 6. Tookey PA, Peckham CS. Surveillance of congenital rubella in Great Britain, 1971-96. BMJ 1999; 318:769-70 Editorial note The mother of the infant whose case history of congenital rubella is described here has given her signed informed consent to publication.
Incidence of congenital rubella in Greece 8 September 2000
Takis Panagiotopoulos Send response to journal: Re: Incidence of congenital rubella in Greece	Editor - Giannnakos et al (1) present data on the rubella epidemic which took place in Greece in 1999. Also, in a very brief comment, they question the main conclusion of our paper on the 1993 rubella epidemic in Greece (2), which indicated an increase in the incidence of congenital rubella syndrome (CRS) in 1993 compared with the pre-vaccination period, due to inconsistent immunisation practices. Their first (indirect) argument is that their data (on the 1999 epidemic) "do not show a real increase in the incidence of congenital rubella". This is clearly irrelevant, as our conclusion pertained to the 1993 epidemic. Besides, the 1999 rubella epidemic was smaller than the 1993 one (by a factor of 5.3 in terms of reported rubella cases) (Y Tselentis, National Centre for Surveillance and Intervention, personal communication, 4/9/2000). The authors comment that our data "do not confirm an increase because data from an active, retrospective surveillance system in 1993-4 were compared with poor quality pre-existing data from passive surveillance". Nevertheless, as mentioned in our paper (p. 1465), an active investigation was carried out by the Ministry of Health to identify CRS cases after the large rubella epidemic of 1983 (the largest ever recorded in Greece) without identifying more than sporadic CRS cases (3). The fact that an active investigation was carried out in 1983 by the Ministry of Health in key Greek hospitals was again affirmed to us by its then Director of Public Health (T Stefanou, personal communication, 5/9/2000). The investigation we carried out after the 1993 epidemic was probably more extensive than the one conducted ten years earlier (2). We identified 25 CRS cases -there was a substantial increase in age at infection during this epidemic (2). Nevertheless, 20 of them had been admitted to either of the two major paediatric hospitals in Athens, two had been admitted to a major hospital in Thessaloniki, and another two had been diagnosed in a central reference laboratory (4). It is highly unlikely that nearly the entirety of such cases were missed in the 1983 investigation. This is in accordance with the findings of a parallel study we carried out retrospectively in the Infectious Disease Department of one of the two major paediatric hospitals in Athens ("Agia Sophia") and in the Neonatal Unit of the other ("A Kyriakou"): two sporadic CRS cases were admitted during the ten-year period 1983-92 (including the epidemic years 1983 and 1986) and 11 cases in 1993 (4,5). Takis Panagiotopoulos, senior researcher Ioanna Antoniadou, senior researcher Eleni Valassi-Adam, director Department of Social Paediatrics, Institute of Child Health, "Agia Sophia" Children's Hospital, 11527 Athens, Greece References 1) Giannakos G, Pirounaki M, Hadjichristodoulou C. Incidence of congenital rubella in Greece has decreased [letter]. BMJ 2000; 320:1408. 2) Panagiotopoulos T, Antoniadou I, Valassi-Adam E. Increase in congenital rubella occurrence after immunisation in Greece: retrospective survey and systematic review. BMJ 1999; 319:1462-6. 3) Hellenic Ministry of Health and Social Security, Directorate of Public Health. Circular A1/12605 (Dec. 12, 1983). Greek. 4) Panagiotopoulos T, Antoniadou I, Valassi-Adam E. [Congenital rubella syndrome epidemic in Greece in 1993. A report of 25 confirmed cases.] Paediatriki 1997; 60:582-9. Greek. 5) Panagiotopoulos T, Papademetriou M, Delagrammatikas H. [Congenital rubella in a neonatal unit in Athens, 1983-1994.] Paediatriki 1998; 61:37- 40. Greek.