Elimination of rubella and congenital rubella syndrome in the Americas: another opportunity to address inequities in health
Jon Kim AndrusI; Mirta Roses PeriagoII
IPan American Health Organization, Family and Community Health, Immunization Unit, Washington, D.C., United States of America
IIDirector, Pan American Sanitary Bureau, Washington, D.C., United States of America
Two recent articles on rubella and congenital rubella syndrome (CRS) that have appeared in the Revista Panamericana de Salud Pública/Pan American Journal of Public Healthon the global situation, in the November 2003 issue (1), and on Haiti, in this month's issue (2)are extremely timely in terms of rubella control efforts now under way in the Region of the Americas. These two articles come on the heels of a resolution that the Directing Council of the Pan American Health Organization (PAHO) passed in September of 2003, calling for the elimination of rubella and CRS from the Americas by the year 2010 (3). Adopted by the ministers of health of all the PAHO Member States, the Directing Council resolution was ultimately based on those countries' own experiences in controlling rubella and CRS. Therefore, the initiative to eliminate rubella and CRS from the Western Hemisphere is clearly a by-product of field-based experience and the extraordinary groundswell of country-based political commitment.
In their Revista/Journal article on the global situation, Robertson et al. (1) indicate that the disease burden in many developing countries remains significant and that the introduction of rubella vaccine is clearly cost-effective and cost-beneficial in reducing the incidence of rubella and CRS. However, 42% of the countries around the world that report to the World Health Organization (WHO) still have not introduced rubella vaccine into their national immunization programs (1).
Of the PAHO Member States, to date only Haiti and the Dominican Republic have not officially introduced rubella vaccine into their national immunization programs. The Dominican Republic will launch its rubella vaccine program efforts in April 2004, the same month in which all the countries in the Western Hemisphere will be participating in the Vaccination Week in the Americas. Haiti will not be able to introduce the vaccine in 2004 because of its recent civil strife, but hopefully the vaccine will be introduced there in 2005, particularly if routine immunization coverage levels have improved.
Reducing inequities in health services has long been a driving force in PAHO's approach to providing immunization technical cooperation to the PAHO Member States. The PAHO Revolving Fund for Vaccine Procurement strives to do exactly that on behalf of all the countries of the Americas. The Fund provides countries with a reimbursement mechanism for the purchase of vaccines, syringes, needles, and cold chain equipment at affordable prices. Since the Fund was established in 1979, PAHO has allowed countries to participate in the benefits of the Revolving Fund only if they meet several requirements: (1) allocating a national budget line item for the cost of vaccines and syringes; (2) formulating a comprehensive and realistic national plan of action that covers multiple years of operations and that is consistent with PAHO policy; and (3) appointing a national program manager who has the authority to develop and implement the national plan of action (4). So, in addition to facilitating equitable prices through bulk purchases, the Fund helps to ensure that countries develop sustainable programs, ultimately benefiting underserved populations that most need immunization services.
PAHO assists countries in reducing inequities by supporting efforts to target underserved communities with low immunization coverage. Improving coverage in all municipalities will protect the progress made in eliminating measles in the Americas, facilitate the acceleration of rubella elimination, and strengthen health system capacity to improve routine services and to introduce vaccines currently available for children in economically developed countries but not in less-developed ones. Reducing inequities in health will continue to be a top priority in PAHO's future technical cooperation with its Member States, faithful to the commitments taken on to support those countries in achieving Health for All and the Millennium Development Goals, particularly those concerning improving maternal health and reducing child mortality.
The tools to eliminate the devastating consequences of CRS exist and are readily available (5). The vaccine is safe, effective, and relatively inexpensive. The strategies for controlling and ultimately eliminating rubella and CRS include: (1) achieving high coverage with rubella vaccine in the regular immunization program; (2) conducting periodic supplemental immunization activities to increase rubella immunity in the infant, child, adolescent, and adult populations (especially women of childbearing age); (3) implementing high-quality surveillance for rash and fever illness, supported with rapid laboratory confirmation; and (4) conducting rapid outbreak response measures.
The experience that countries throughout the Americas have had in implementing these strategies has proven their effectiveness. The experience also suggests that even in countries with relatively low immunization coverage, rubella vaccine can be safely introduced when accompanied by well-organized supplementary immunization activities aimed at reducing rubella susceptibility in older age groups.
One of the key lessons learned recently with measles control in the Americas is that when measles virus circulation is interrupted, rubella virus circulation becomes readily apparent. This clearly highlights how progress in disease control can create opportunities to learn more about the burden of other vaccine-preventable diseases that are not being fully addressed in the national immunization program. Robertson et al. (1) report that in Brazil between 1993 and 1996 nearly 50% of the cases in which measles was ruled out were subsequently diagnosed as rubella. Similarly, the introduction of Haemophilus influenzae type b vaccine has accelerated efforts to understand other causes of pneumonia and meningitis, such as pneumococcal infection.
The gap between the new vaccine technologies available to industrialized nations and those available to developing countries must be narrowed, and this will be a key priority for the Immunization Unit of PAHO over the next 5 to 10 years. Other priorities for the Immunization Unit will be to help eliminate rubella and CRS, sustain the success of measles elimination, maintain the achievements of polio eradication, and strengthen the management of information within the Region of the Americas. A critical cross-cutting component of these priorities will be strengthening routine immunization services.
For the PAHO team it is an honor to work with the immunization managers of all our Member States, who continue to accomplish amazing things and to break new ground in the field of public health. Our immunization team at PAHO is strongly committed to assisting countries in providing the best immunization services possible to all children of the Americas, regardless of family income or family origin.
1. Robertson SE, Featherstone DA, Gacic-Dobo M, Hersh BS. Rubella and congenital rubella syndrome: global update. Rev Panam Salud Publica. 2003;14(5):306-14.
2. Désinor OY, Ansèlme RJP, Laender F, Saint-Louis C, Bien-Aimé JE. Seroprevalence of antibodies against rubella virus in pregnant women in Haiti. Rev Panam Salud Publica. 2004;15(3):147-50.
3. Pan American Health Organization. Sustaining immunization programs: elimination of rubella and congenital rubella syndrome. EPI Newsl. 2003;25(5):1-2.
4. Andrus JK, de Quadros CA, Tambini G. Global access: deployment, use, and acceptance. In: Khan P, Gust I, Koff W, eds. Accelerating AIDS vaccine development: challenges and opportunities. Norfolk, United Kingdom: Horizon Scientific Press. (Forthcoming 2004).
5. Castillo-Solorzano C, Carrasco P, Tambini G, Reef S, Brana M, de Quadros CA. New horizons in the control of rubella and prevention of congenital rubella syndrome in the Americas. J Infect Dis. 2003;187(Suppl 1):S146-52.