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What is the History of Rubella in America and Other Countries?


disease history

Recognition of Rubella

The earliest accounts of rubella in the medical literature date back to the mid-18th century when clinical symptoms of the illness were described by two German physicians who considered the illness to be a variation of measles or scarlet fever.1

In 1814, another German physician, George de Maton, recognized the illness as unique from measles. By this time, the illness was referred to as ‘German measles’ or rötheln. In 1866, British Army Surgeon Henry Veale renamed the infection to rubella, the Latin term for reddish thing.2 3

By 1914, rubella infections were assumed to be caused by a virus and in 1938, rubella was found to be transmissible between individuals. This was confirmed by two researchers who exposed children to the nasal washings of individuals infected with rubella.4

In 1941, Norman Gregg, an ophthalmic surgeon from Australia, noted a significant increase in the number of infants with congenital cataracts that were frequently associated with other anomalies. A thorough evaluation of maternal health history would reveal that these cases occurred in mothers who developed rubella in the first trimester of pregnancy. This was the first time a virus was found to be associated with birth defects; however, his findings would not become widely known until 1947, when a comprehensive review of rubella was written by Dr. Conrad Wesselhoeft and published in the New England Journal of Medicine. These congenital anomalies would be referred to as congenital rubella syndrome (CRS).5

Additional information on rubella was gained through testing on human subjects in the early 1950s, but further experiments were halted due to ethical concerns related to human experimentation.6

The virus responsible for rubella was first isolated by two independent research teams in 1962, and vaccine development began shortly after this discovery.7 Rubella gamma globulin use also began as a treatment for pregnant women with possible rubella exposure, but early studies questioned the effectiveness of this product for the prevention of CRS.8

Incidence in U.S.

In 1964, an epidemic of rubella occurred in the U.S. and while the illness was not nationally notifiable, 448,796 cases9 and 53 deaths10 were reported. In the mid-1960’s, most cases occurred among school-aged children between 5-9 years and 10-14 years of age. While public health officials reported that an estimated 20,000 cases of CRS likely occurred during this epidemic, the exact number is not known because CRS did not become nationally notifiable until 1966.11

During the rubella epidemic of 1964, public health officials also discovered that infants exposed prenatally to rubella could shed the virus for the first 6 to 9 months of life.12

In 1966, when rubella and CRS became nationally notifiable illnesses, there were 46,975 cases of rubella and 11 cases of CRS reported.13

Vaccine Introduction

The CDC’s Advisory Committee on Immunization Practices (ACIP) recommended the use of rubella vaccines in April of 1969, prior to vaccine licensing. This vaccine was not developed due to the seriousness of rubella, but rather because of the impact of rubella on the developing infant.14

In 1969, the rubella vaccine was recommended for all children 12 months and older but children in kindergarten and grade school were considered the priority target for vaccination due to the high outbreak rates among this population. ACIP also stated that children previously diagnosed with rubella infection should still be vaccinated and reported that “A history  of rubella illness is usually not reliable enough to exclude  children from immunization.”15

The use of blood testing to confirm a previous diagnosis of rubella was cautioned because the test was “a complex procedure which must be performed by well trained,  experienced individuals.”16

The first vaccine was approved for use in June of 1969 and by June 1970, two additional vaccines became available for use in the U.S.17

In 1975, there were 16,652 reported cases of rubella and 30 reported cases of CRS.18 There were also 21 rubella associated deaths.19

Rubella Decline and Eradication Efforts

In 1980, the CDC published a report regarding rubella in the U.S and noted that most of the decline in rubella cases had occurred among persons under 15 years of age; however, in 1977, rubella cases had increased among persons between the ages of 20 and 29 years of age and the highest number of cases had occurred among persons 15 to 19 years of age. Most rubella outbreaks were occurring in high schools, military establishments, workplaces, and hospitals.20 These increases among older populations prompted ACIP to update its rubella vaccine recommendations in January of 1979 to emphasize the need to ensure that older individuals, especially women of childbearing age, be vaccinated or have evidence of immunity to rubella.21

In 1980, the U.S. public health service set a goal that by 1990, there would be less than 1,000 cases of rubella in the U.S.22 This goal was reached in 1983, and between 1981 and 1990, there were an average of 935 cases of rubella and 9 cases of CRS reported each year.23

In 1989, health officials set a goal of rubella elimination from the U.S. for the year 2000 and one year later, ACIP updated its rubella vaccine recommendation from one dose to two doses. This recommendation was made following the introduction of a 2-dose schedule for the measles-mumps-rubella (MMR) vaccine.24 25

Rubella was declared eliminated from the U.S. in 200426 and from the western hemisphere in 2015.27 Between 2004 and 2011 an average of 10 rubella cases per year were reported in the U.S. Four cases of CRS were also reported, and of those four cases, two occurred in infants born outside the U.S., one occurred in an infant born to a woman with an unknown vaccination status and one was born to a mother who had been previously vaccinated and who had no history of international travel.28 Between 2012 and 2018, there were 41 reported cases of rubella (an average of six cases per year) and 13 cases of CRS in the U.S.29 30 31 32 33 34 35

In 2018, there were four reported cases of rubella in the U.S. and between 2009 and 2017, there were an average of five rubella cases per year. There were no reported cases of CRS in the U.S. in 2018.36 37 That same year the World Health Organization (WHO) reported 14,621 rubella cases, with 151 countries reporting. This was documented as a 97 percent decrease from the year 2000, when 670,894 cases were reported from 102 reporting countries.38

IMPORTANT NOTE: NVIC encourages you to become fully informed about Rubella and the Rubella vaccine by reading all sections in the Table of Contents, which contain many links and resources such as the manufacturer product information inserts, and to speak with one or more trusted health care professionals before making a vaccination decision for yourself or your child. This information is for educational purposes only and is not intended as medical advice.

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References

1 Lee JY, Bowden DS. Rubella virus replication and links to teratogenicity. Clin Microbiol Rev. Oct. 2000; 13(4):571-87.

2 Lee JY, Bowden DS. Rubella virus replication and links to teratogenicity. Clin Microbiol Rev Oct. 2000; 13(4):571-87.

3 Cooper LZ. The history and medical consequences of rubella. Rev Infect Dis Mar-Apr. 1985; 7 Suppl 1:S2-10.

4 Dudgeon JA. Maternal Rubella and its effect on the Foetus Arch. Dis. Childh 1967, 42: 110-125.

5 Lee JY, Bowden DS. Rubella virus replication and links to teratogenicity. Clin Microbiol Re. October 2000;13(4):571-87.

6 Dudgeon JA. Maternal Rubella and its effect on the Foetus. Arch. Dis. Childh 1967, 42: 110-125.

7 Lee JY, Bowden DS. Rubella virus replication and links to teratogenicity. Clin Microbiol Rev October 2000; 13(4):571-87.

8 Advisory Committee on Immunization Practices. Minutes – May 25-26, 1964. U.S. Centers for Disease Control and Prevention July 6, 1954.

9 National Communicable Disease Center. Rubella Surveillance. U.S. Centers for Disease Control June 1969; no. 1:1-26.

10 U.S. Centers for Disease Control and Prevention. Rubella status report. 1971: 1-16.

11 National Communicable Disease Center. Rubella Surveillance. U.S. Centers for Disease Control June 1969; no. 1:1-26.

12 U.S. Centers for Disease Control and Prevention. Epidemiologic Reports - Rubella. MMWR Feb. 6, 1965; 14 (5):44-45.

13 U.S. Centers for Disease Control and Prevention. Reported Incidence of Notifiable Diseases in the United States 1966. MMWR November 1967; 15(53): 1-60.

14 U.S. Department of Health, Education, and Welfare. Recommendation of the Advisory Committee on Immunization Practices. MMWR Apr. 12 1969; 18(15):124.

15 U.S. Department of Health, Education, and Welfare. Recommendation of the Advisory Committee on Immunization Practices. MMWR Apr. 12 1969; 18(15):124.

16 U.S. Department of Health, Education, and Welfare. Recommendation of the Advisory Committee on Immunization Practices. MMWR Apr. 12 1969; 18(15):124.

17 U.S. Centers for Disease Control. Rubella Surveillance. August 1970; no. 2: 1-26.

18 U.S. Centers for Disease Control and Prevention. Reported Morbidity and Mortality in the United States 1975. MMWR 1976; 24(54):1-66.

19 U.S. Centers for Disease Control and Prevention. Reported morbidity and Mortality in the United States 1976. MMWR 1977; 25(53):1-74.

20 U.S. Centers for Disease Control and Prevention. Rubella Surveillance June 1976 to December 1978. May 1980.

21 U.S. Centers for Disease Control and Prevention. Recommendation of the Public Health Service Advisory Committee on Immunization Practices - Rubella Vaccine. MMWR Nov. 17, 1978; 27(46): 451-460.

22 U.S. Centers for Disease Control and Prevention. Elimination of Rubella and Congenital Rubella Syndrome--United States, 1969-2004. MMWR Mar. 25, 2005; 54(11): 279-82.

23 U.S. Centers for Disease Control and Prevention. Summary of Notifiable Diseases, United States, 1990. MMWR Oct. 4, 1991; 39(53): 1-76.

24 U.S. Centers for Disease Control and Prevention. Achievements in Public Health: Elimination of Rubella and Congenital Rubella Syndrome --- United States, 1969—2004. MMWR Mar. 25, 2005; 54(11):279-282.

25 U.S. Centers for Disease Control and Prevention. Rubella Prevention -- Recommendations of the Immunization Practices Advisory Committee (ACIP). MMWR Nov. 23, 1990; 39(RR15):1-18.

26 U.S. Centers for Disease Control and Prevention. Rubella in the U.S. In: Rubella (German Measles, Three-Day Measles). Dec. 31, 2020.

27 Pan American Health Organization. Americas region is declared the world's first to eliminate rubella. Apr. 29, 2015.

28 U.S. Centers for Disease Control and Prevention. Documentation and verification of measles, rubella and congenital rubella syndrome elimination in the region of the Americas. In: United States national report. Mar. 28, 2012.

29 U.S. Centers for Disease Control and Prevention. Summary of notifiable diseases -- United States, 2012. MMWR Sept. 19, 2014; 61(53);1-124.

30 U.S. Centers for Disease Control and Prevention. Summary of notifiable infectious diseases and conditions -- United States, 2013. MMWR Oct. 23, 2015; 62(53): 1-124.

31 U.S. Centers for Disease Control and Prevention. Summary of notifiable infectious diseases and conditions -- United States, 2014. MMWR Oct. 14, 2016; 63(54): 1-156.

32 U.S. Centers for Disease Control and Prevention. Summary of notifiable infectious diseases and conditions -- United States, 2015. MMWR Aug. 11, 2017; 63(53): 1-148.

33 U.S. Centers for Disease Control and Prevention. TABLE 2l. Reported cases of notifiable diseases, by region and reporting area - United States and U.S. territories, 2016. In: National Notifiable Diseases Surveillance System. 2017.

34 U.S. Centers for Disease Control and Prevention. TABLE 2l. Reported cases of notifiable diseases, by region and reporting area - - United States and U.S. territories, 2017. In: National Notifiable Diseases Surveillance System. 2018. 

35 U.S. Centers for Disease Control and Prevention. TABLE 2l. Annual reported cases of notifiable diseases, by region and reporting area - - United States and U.S. Territories, 2018. In: National Notifiable Diseases Surveillance System. 2019.

36 U.S. Centers for Disease Control and Prevention. TABLE 2l. Annual reported cases of notifiable diseases, by region and reporting area - - United States and U.S. Territories, 2018. In: National Notifiable Diseases Surveillance System. 2019.

37 World Health Organization (WHO). Incidence time series for United States of America (USA). In: WHO vaccine-preventable diseases: monitoring system. Oct. 12, 2020.

38 World Health Organization (WHO). Rubella. In: Fact Sheets. Oct. 4, 2019.


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