Kerala - Thiruvananthapuram   

Needed: a national plan to tackle Congenital Rubella Syndrome

Thiruvananthapuram: Congenital Rubella Syndrome (CRS) is emerging as a major cause of childhood morbidity in the State, prompting paediatricians and public health activists to renew the call for administering rubella vaccine to infants, adolescent girls and generally, to all women of child-bearing age in the State.

Even though there is very little awareness in the State about rubella, more outbreaks are being picked up now thanks to the Measles Surveillance Project that was kicked off in April last year. Since then, at least four outbreaks of rubella have been reported from Thiruvananthapuram, Wayanad, Kasaragod and Palakkad. However, the disease still remains under-reported and under-diagnosed.

Though rubella is considered a mild viral disease, it is highly dangerous for pregnant women. Infants born to mothers who contracted rubella during the early stages of pregnancy have CRS, characterised by multiple defects including heart diseases, hearing and vision impairment or are mentally challenged.

Rubella infection results in damage to organs in a developing foetus, while in adults its manifestation is mild and hardly lasts more than three days. Hence, rubella diagnosis is often missed or mistaken for mild measles. Often, the mother herself would not recall having had fever with mild rashes while she was pregnant.

All cases of fever with rashes are now being reported and outbreaks investigated as part of the Measles Surveillance Project in the State. Thanks to the increased reportage, Health officials were able to pick up an outbreak of rubella at Poonthura in Thiruvananthapuram district in early May, where a cluster of 24 cases of mixed infection of measles and rubella had occurred.

The MMR (Mumps-Measles-Rubella) vaccine has been available in the country since 1985, however, it is not part of the national immunisation schedule. At present, only a single dose of measles vaccine is administered to infants free of cost as part of the Universal Immunisation Programme. From a public health perspective the strategy is hardly enough to tackle the problem of CRS.

Between October and December 2005, 22 infants with various congenital abnormalities associated with CRS were admitted in the newborn intensive care unit in SAT Hospital in Thiruvananthapuram, out of whom two died.

Padmaja Ramdas, ENT consultant at the National Institute of Speech and Hearing here, says that at least 20 per cent of the cases of congenital hearing impairment in children that come to the institute can be traced back to rubella infection during pregnancy.

A study conducted by Dr. Padmaja from 2003 to 2006, with funding from the State Council for Science, Technology and Environment, looked at the ‘sero’ prevalence of immunity to rubella in the community. Serum samples from 431 women in the first trimester of pregnancy were collected from three major government obstetric centres in the city and studied. It was found that the immunity to rubella in the women was just 65.7 per cent. Dr. Padmaja points out that an earlier study conducted in 1982 had reported the immunity to rubella as 74.1 per cent.

“The fact that immunity to rubella decreased in the community from 74.1 per cent in 1982 to 65.7 per cent in 2006, even though MMR vaccine is being administered to a sizeable number of infants since 1985, is a cause for concern. It shows that partial immunisation coverage in the community actually increases the incidence of CRS,” Dr. Padmaja says.

The World Health Organisation (WHO) guidelines on the elimination of rubella and CRS say that along with vaccination of infants, the immunity of all women of child-bearing age should also be ensured. WHO suggests that rubella vaccination can be introduced in the national immunisation schedule only in countries where the measles vaccination coverage is high. The measles vaccine coverage in Kerala is above 80 percent. But the surveillance project has observed that the effect of this vaccination seems to wane by the time the child crosses 10 years.

“We want to push the government to introduce a second dose of measles vaccine for children as part of routine immunisation. The Indian Academy of Paediatrics has also endorsed this suggestion,” a senior health official points out. The National Technical Advisory Group on Immunisation which met in New Delhi recently has now recommended that a second dose of measles vaccine along with rubella vaccine be introduced in States where the coverage of the first dose of measles vaccine is above 80 per cent. Kerala and Tamil Nadu would be the leading contenders for the MMR vaccine if these recommendations were to go through.

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