Incidence of congenital rubella in Greece has decreased

BMJ 2000; 320 doi: https://doi.org/10.1136/bmj.320.7246.1408 (Published 20 May 2000) Cite this as: BMJ 2000;320:1408
  1. G Giannakos, director, communicable diseases clinic,
  2. M Pirounaki, infection specialist,
  3. C Hadjichristodoulou, director (hadjich{at}ath.forthnet.gr)
  1. Hellenic Army Medical Corps Directorate, Katchaki and Mesogeion 138, 11525 Athens, Greece
  2. National Center of Surveillance and Intervention, Makedonias 6–8 Str, 10433 Athens, Greece

    EDITOR—In their paper on the increase in congenital rubella occurring after immunisation in Greece, Panagiotopoulos et al used information that covered the period only until 1995.1 Since then the surveillance of rubella and immunisation policies have changed. In 1998 the National Center for Surveillance and Intervention was established and a new computerised surveillance system was introduced.

    In September 1998 an outbreak of rubella was detected in army camps; it peaked in January 1999. Altogether 1174 cases were reported among unvaccinated male recruits aged 18–22 years. In January 1999 the outbreak spread to the community and an additional 1306 cases were reported. Related cases in other European countries were also reported.2 The average age of cases was 17.12 (SD 5.5) years; 96% of cases occurred among people who had not been vaccinated, and 60% of cases occurred among men. Four confirmed cases of congenital rubella syndrome were reported after the outbreak.

    Although there continue to be outbreaks, the total number of cases has decreased and the interval between the outbreaks has gradually increased (figure). Our data do not show a real increase in the incidence of congenital rubella. We believe that Panagiotopoulos et al's 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.


    Distribution of cases of rubella reported to the health ministry and the military medical services in Greece, 1982-99

    The ongoing outbreaks and subsequent cases of congenital rubella can be only partially explained by comparatively low vaccine coverage and inconsistencies in immunisation policies. The existence of high risk unvaccinated groups that can trigger a community outbreak is important. The outbreaks which occur in the community in Greece every 3–6 years correspond to outbreaks in the army (figure). Analysis of the data indicated that the recent outbreak in the military preceded the one in the community. Spatial analysis of the geographical distribution of cases showed that community outbreaks started in districts of the country where army camps were located.3 Crowding and other stressful conditions among unvaccinated recruits within military camps can alter the effectiveness of the herd immunity there, which is different from that in the community.4

    In April 1999 the Greek advisory committee for immunisations lowered the age for children receiving the second dose of MMR (measles-mumps-rubella) vaccine from 11–12 years to 4–6 years and recommended vaccinating all children and young adults younger than 18 years who had not yet been vaccinated.5 Vaccinating all recruits who have not been vaccinated is also being considered.

    We believe that these measures will prevent future outbreaks and eliminate subsequent cases of congenital rubella syndrome.


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