Bollettino epidemiologico nazionale

Editorial

Marta Ciofi degli Atti and Stefania Salmaso

Laboratory of Epidemiology and Biostatistics, ISS

The objective of vaccination programs against rubella is to prevent congenital rubella, which is considered to be eliminated when the rate falls bellow 1 per 100,000 live births (1). This objective can be attained if the proportion of women of reproductive age who are susceptible is less than 5%. In Italy, despite the fact that rubella vaccine has been recommended for more than 25 years, the proportion of women between 15 and 39 years of age who are susceptible remains 7-10%. This is most likely the result of low vaccine coverage for measles, mumps, and rubella (MMR) during the second year of life, combined with insufficient vaccination of pre-pubertal girls and susceptible women. The international experience shows that to prevent congenital rubella, it is necessary not only to ensure high vaccine coverage in infants but also to monitor the prevalence of susceptible women and to vaccinate this population as well (2).

Even if surveillance data show that rubella continues to circulate in Italy, until now, little information has been available on either rubella in pregnancy or on congenital rubella, which was removed from the list of notifiable diseases in 1992.

The experiences published in this number of the BEN show clearly that congenital rubella is still present in Italy, and closely parallels the epidemics of rubella in the general population. Furthermore, the cases of congenital rubella represent the tip of the iceberg of infections transmitted vertically from mother to fetus; such transmission may result in fetal death or in the choice to have an induced abortion.

In Italy, blood tests for IgG and IgM against rubella are free during the pre-conceptional period as well as during pregnancy, and women found to be susceptible should be vaccinated as quickly as possible, either before pregnancy or shortly after delivery. However, the actual screening and prevention practices are highly inadequate; in Pavia, among 11 women with primary infections in pregnancy, 6 were never screened serologically and the other 5, even though they were known to be susceptible, were never vaccinated. The lack of screening and vaccination is especially disconcerting given the high frequency of medical procedures in pregnancy such as ultrasonography. Recent studies have indeed shown that approximately 25% of pregnant women receive more than 6 sonograms during pregnancy (3); this figure increases to 62% in some areas of the south (4).

While vaccination with MMR of infants is available through a broad network of childhood vaccination clinics that extends throughout the country, vaccination of adult women requires a collaboration between a variety of professional figures, including general practitioners, gynecologists, and midwives. As mentioned in the national plan for the elimination of measles and congenital rubella developed by the interregional coordination group for infectious diseases and vaccines, the involvement of all these health care workers is indispensable if congenital rubella is to be prevented.

Given that the diagnosis of clinical rubella has a low specificity, it is important that accurate laboratory tests for rubella infection be made available during pregnancy. Wherever possible, in the case of a confirmed infection, prenatal diagnostic techniques offer an effective tool to evaluate the risk of transmission to the fetus. Finally, only the presence of a national-level, surveillance system can provide adequate monitoring of the results obtained.

References

1.HEALTH21 - The health for all policy for the WHO European Region. Copenhagen, WHO Regional Office for Europe, 1999 (European Health for All Series, n. 6).

2.Best JM, Banatvala JE. Rubella. In: Zuckerman AJ, Banatvala JE, Pattison JR, editors. Principles and Practice of Clinical Virology. 4th ed. Wiley & Sons Ltd; 2000.

3.ISTAT. Il percorso della maternità: gravidanza, parto e allattamento al seno. Indagine multiscopo sulle famiglie - “Condizioni di salute e ricorso ai servizi sanitari. Anni 1999-2000. Roma: Istituto Nazionale di Statistica; 2002.

4.Maffeo A, Vatiero C. Indagine campionaria sul percorso nascita (Caserta 2001). Not Ist Super Sanità - Inserto BEN: i-ii.