VACCINATION, RUBELLA AND CONGENITAL RUBELLA SYNDROME

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http://www.redflagsweekly.com/yazbak/2003_nov04.htmlVACCINATION, RUBELLA AND CONGENITAL RUBELLA SYNDROMESeparating Fact From FictionBy RFD Columnist, F. Edward Yazbak, MD, FAAP.TL Autism Research Falmouth, Massachusetts E-mail: tlautstudyThe health authorities have insisted that the monovalent vaccines againstmeasles, mumps and rubella would not be made available in the UnitedKingdom. By doing so, they have effectively forced parents who had seriousconcerns about the MMR vaccine not to vaccinate their children altogether.As vaccination rates fell and the threat of measles outbreaks became real,the health authorities blamed Andrew Wakefield and his research. Obviouslyno one mentions the fact that Dr. Wakefield has always supported measles,mumps and rubella vaccination of toddlers and that he has only suggestedthat the monovalent vaccines be made available, alongside the MMR vaccine,just to give parents a choice. Dr. Simon Murch in a recent interview introduced the threat of a rubellaoutbreak and the resulting Congenital Rubella Syndrome (CRS) cases in hissupport of the MMR vaccine. This represents a whole new front. It is morethan likely that the health authorities will now find a poor family thathas been devastated by having a child with CRS to demonstrate how sad thisdisease is. Having cared for these children, I can testify that CRS is aterrible disease and that we must do everything we can to prevent it. Onthe other hand, autism is just as awful a disease and like CRS, it destroysthe child and the family. The only difference is that presently autism inEngland must outnumber CRS by 5000 to 1 conservatively. So if journalistsare going to be interviewing CRS parents, it is only fair that they alsowrite stories about the equivalent number of families that have beendestroyed by regressive autism and who have witnessed their perfectlyhealthy normal toddlers disappear. One must remember that in 2002 inCalifornia (Population 34.5 millions), TEN new cases of autism accessedservices every day. Had the monovalent vaccines been made available 2 years ago as suggested byDr. Wakefield and had the single rubella vaccine been administered to everychild in the UK, ONE WHOLE YEAR after the single measles vaccine, thevaccination rates of both measles and rubella would be at 95% right now.Obviously the health authorities could have also chosen a shorter waitingperiod. After all, the single vaccines used to be administered every 3months in the pre-MMR days. Let’s consider some statistics from the U.S. The following is from theCDC’s “Epidemiology and Prevention of Vaccine-Preventable Diseases,” 5thEdition (1999) starting on page 176. The editors of that issue wereAtkinson, W, Humison S, Wolfe C and Nelson R.“ Rubella and congenital rubella syndrome became nationally notifiablediseases in 1966. The largest annual total of cases of rubella in theUnited States was in 1969, when 57,686 cases were reported (58 cases per100,000 population). Following vaccine licensure in 1969, rubella incidencefell rapidly. By 1983, fewer than 1,000 cases per year were reported (<0.5cases per 100,000 population). A moderate resurgence of rubella occurredin 1990-1991, primarily due to outbreaks in California (1990) and among theAmish in Pennsylvania (1991).Until recently there was no predominant age group for rubella cases. From1982 to 1992, approximately 30% of cases occurred in each of three ag: < 5, 5-19, and 20-39 years. Adults > 40 years of age typicallyaccounted for < 10% of cases. However, since 1994, persons 20-39 of agehave accounted for more than half of the cases. In 1997, this age groupaccounted for 77% of all reported cases. Most persons with rubella in thisage group were born outside the United States, in areas where rubellavaccine is not routinely given. In the pre vaccine era, epidemics of rubella occurred every 6-9 years, withthe last major U.S. epidemic occurring in 1964-1965. No large epidemicshave occurred since the vaccine was licensed for use in 1969…. CRS surveillance is maintained through the National Congenital RubellaRegistry which is managed by the National; Immunization program. Thelargest annual total of reported CRS cases to the Registry was in 1970 (67cases). An average of 5-6 CRS cases have been reported annually since 1980.Although reported rubella activity has consistently and significantlydecreased since vaccine has been used, the incidence of CRS has onlyparalleled the decrease in rubella cases since the mid 1970’s. The fall inCRS since the mid-1970’s was due to an increased effort to vaccinatesusceptible adolescents and young adults, especially women.Rubella outbreaks are almost always followed by an increase in CRS.Rubella outbreaks in California and Pennsylvania in 1990-1991 resulted in25 cases of CRS in 1990 and 33 cases in 1991. A provisional total of 9 CRScases were reported in 1997. The mothers of all these infant s were bornoutside the United States, primarily in Latin America and the Caribbean,where rubella vaccine is not routinely used.”The population of the Unites States was 248.5 million in 1990 and 281.4million in 2000. The population of the United Kingdom was about 57 millionin 1990 and 59 million in 2000. Assuming that the population of the UK ismore than one fourth that of the USA and stipulating that the incidence ofrubella and CRS is about the same in the two countries, then, it is likelythat before the introduction of the rubella vaccine, there may have been atmost 13,000-14,000 cases of rubella and 15-16 cases of CRS in the UK in anyyear. The 33 cases of CRS in one year (1991), the highest in the US sincethe vaccine, would translate to 6 cases in one year in the UK and theaverage of 6-7 cases per year in the US would be an average of one to twocases in the United Kingdom; there were 4 cases of CRS in The USA in 1995and 2 in 1996. For the record, I firmly believe that ONE case a year of CRSis one too many. The following statement is important: “From 1982 to 1992, approximately 30% of cases occurred in each of threeage groups: < 5, 5-19, and 20-39 years… However, since 1994, persons 20-39of age have accounted for more than half of the cases. In 1997, this agegroup accounted for 77% of all reported cases. Most persons with rubella inthis age group were born outside the United States, in areas where rubellavaccine is not routinely given”. Whatever the reason, it is alarming thatrubella, a childhood disease, is now occurring more frequently insusceptible women. It can be argued that if the women in that group hadcontracted rubella as children, when the disease is fairly benign, theywould have acquired solid lifetime immunity. This appears to be supportedby the fact that in 1969, when the rubella vaccine was licensed, there were57,686 cases of rubella (reported) and 62 (0.1%) cases of CRS while in1997, there were 181 reported cases of rubella and 9 (5%) cases of CRS.A study from Greece by T. Panagiotopoulos T. et al. published in theBritish Medical Journal (BMJ 1999;319:1462-1467) reports that: MMR has been administered to children in Greece since 1975 In 1993, the incidence of rubella in young adults was higher than in anyother recent year That there were 25 serologically confirmed cases of CRS {24.6/100 000 livebirths, largest since 1950) that year. “With low vaccination coverage, the immunization of boys and girls aged 1year against rubella carries the theoretical risk of increasing theoccurrence of congenital rubella” wrote the authors On page 175 of the same CDC publication quoted earlier, the authors statethat presently “Up to 85% of infants infected in the first trimester ofpregnancy will be found to be affected if followed after birth.” It isnot clear whether the authors refer to CRS or to other less seriouscomplications. Older pediatricians, this one included, did not see 80-85%of children whose mothers developed rubella in the first trimester ofpregnancy, come down with CRS. In the late 50s we believed that incidenceto be around 25% and we thought that even those odds were awful.The following comprehensive review of rubella in pregnant Danish Women(1975-1984), by M. Mitsch, was published in the Danish Medical Bulletin inMarch1987 (34:46-49). It is one of the largest studies ever done and italso shows how just few years ago, the clinical picture was different. Itsresults are summarized in the following table from WAVES, the New Zealandvaccine review.WAVES Vol. 11 No. 4 p. 21RUBELLA RISKS FOR PREGNANT WOMEN DANISH MEDICAL BULLETIN MARCH 1987A study of pregnancy outcomes of 1346 women serologically identified withrubella between 1975 and 1984.Group 1 Group 2 623 chose abortion672 chose to continue pregnancy 113 lost to follow-upNo further data – assumed no foetal autopsies559 total 35 aborted spontaneously 4 stillbirths Total foetal deaths = 39 (6.97%)623 deaths520 live births – cord samples taken for rubella testing. 111 had rubella specific IgM (21.34% infection rate) 14 of those were infected prior to 12 weeks and 7 of those had seriousmalformations (6.3% of 111)OUTCOME:OUTCOME: 513 normal0% healthy child outcome91.77% healthy child outcomeThe Danish study concluded:Not all foetuses are infected (21.34%) Not all infected foetuses have malformations (6.3%) -----------------NOTE: The above table was listed as a historical reference of the incidenceof CRS in Denmark between 1975 and 1984. It does not apply to present timesin the UK and the US. It is probable that, as mentioned, CRS will occurproportionately more frequently now.An argument one hears often is that toddlers must be vaccinated because ifthey are not, they can come down with rubella and infect their susceptiblepregnant mother or teacher. Clearly the best way to prevent that dangeroussituation is to make sure that the female adult herself is immune not allthe children around her. Susceptible pregnant women in their critical first trimester may be exposednot only to children but to infected adults and especially healthcareworkers. The following abstract of a study by Dr. Walter Orenstein , nowChief of the Vaccine Immunization Program at CDC describes such potentialrisks.Rubella vaccine and susceptible hospital employees. Poor physicianparticipation. Orenstein WA, Heseltine PN, LeGagnoux SJ, Portnoy BA serosurvey of 2,456 high-risk employees of the Los AngelesCounty-University of Southern California Medical Center showed that 345(14%) were susceptible to rubella. Of 197 seronegative personnel followedup for participation in a vaccination program, 105 (53.3%) were vaccinated.However, only one of the 11 known susceptible obstetrician-gynecologistswas vaccinated. Thirty-eight seronegative employees who were vaccinatedwith RA 27/3 rubella vaccine were queried four to six weeks aftervaccination and compared with 32 unvaccinated seropositive controlsubjects. Although the reaction rate was 50% among vaccinees and 3% amongcontrol subjects, each vaccinee lost only an average of 0.2 workdayscompared with 0.1 workdays for control subjects. The high rate ofsusceptibility to rubella among hospital employees supports the need forscreening. Although vaccine reactions are common, they are generally mild.Means must be found to ensure greater employee acceptance of vaccine. PMID:7463660, UI: 81120098 JAMA 1981 Feb 20;245(7):711-3Although it is highly advisable that all mothers be immune to rubella,maternal immunity does not always guarantee that the fetus will not developCRS:“Two children developed congenital rubella infection when their mothers hadbeen proven to be satisfactorily immunised against rubella before theaffected pregnancy. One child was severely affected with heart lesions,brain damage, severe deafness, physical retardation, cataracts and rubellaretinopathy. The other child had moderately severe sensorineural deafnessand a mild reduction in visual acuity due to rubella retinopathy” Bott LM,Eizenberg DH.Aust N Z J Ophthalmol 1991 Nov;19(4):291-3“We report a case of a patient who had a subclinical rubella infection inthe first trimester of pregnancy which resulted in the delivery of a babysuffering from congenital rubella. Rubella virus vaccine, live attenuated(Cendevax) vaccine had been administered to the mother nearly three yearsbefore, with proven sero-conversion from a rubellahaemagglutination-inhibition titer of 1:10 to 1:80.” Bott LM, Eizenberg DH.Med J Aust 1982 Jun 12;1(12):514-5“A 2 1/2 year-old girl was found to have congenital rubella syndrome. Shepresented with microcephaly, mild developmental delay, partialsensorineural deafness and cerebellar atrophy. Blood titers of rubellahemagglutinin were 1/256 and 1/512 (exclusively IgG). She had not hadrubella, nor had she been immunized against it. The mother had beenimmunized against rubella 4 years before her pregnancy with this girl and 2years later blood hemagglutinin titers were 1/32 and 1/64. She was neitherexposed to nor suffered from rubella during the pregnancy” Miron D, On A,Harefuah 1992 Mar 1;122(5):291-3 “No population studies have evaluated the effectiveness of screening andvaccinating susceptible individuals in reducing the incidence of CRS. Of the 21 CRScases reported in the U.S. in 1990, 71% of the mothers had a positiveserologic test, while 43% gave a history of vaccination” CarolynDiGuiseppi, MD, MPH, US Preventive Services Task Force. January 1994 . In Summary: Rubella is a rather benign illness in childhood. Rubella vaccination at an appropriate age should be encouraged. The administration of the single rubella vaccine, 3 or 6 months, after themeasles monovalent vaccine was very well accepted for years. Resumption of that schedule may be welcome by those who have MMR concerns. The majority of parents can still request the MMR vaccine for their children. -----------------------Sheri Nakken, R.N., MA, Classical Homeopath Vaccination Information & Choice Network, Nevada City CA & Wales UK$$ Donations to help in the work - accepted by Paypal account vaccineinfo voicemail US 530-740-0561(go to http://www.paypal.com) or by mailVaccines - http://www.nccn.net/~wwithin/vaccine.htmVaccine Dangers On-Line course - http://www.nccn.net/~wwithin/vaccineclass.htmHomeopathy On-Line course - http://www.nccn.net/~wwithin/homeo.htmANY INFO OBTAINED HERE NOT TO BE CONSTRUED AS MEDICALOR LEGAL ADVICE. THE DECISION TO VACCINATE IS YOURS AND YOURS ALONE.