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OGY PUBLICATION OF THE PUBLIC HEALTH DIVISION
ORECON DEPATMENT OF HUMAN SERVICES
OREGON PUBLIC HEALTH DIVISION OREGON HEALTH AUTHORITY
July 30, 2013
Vol. 62, No. 16
I
n 1941, an astute Australian oph-
thalmologist noticed an unusual
number of infants with cataracts
in his practice. He suspected rubella
afer overhearing two mothers in the
waiting room talking about rubella
they both contracted during the Aus-
tralian outbreak of 1940.
1
Afer several
ensuing years of inatention and skep-
ticism, epidemiologists and teratolo-
gists confrmed the congenital rubella
syndrome (CRS) triad of congenital
cataracts, heart disease and deafness.
During the 19641966 U.S. pan-
demic, additional CRS pathology was
noted in the brain, lungs, liver, spleen,
kidney, bone marrow, bones, and en-
docrine organs. It is now well known
that, particularly during the frst 16
weeks of pregnancy, rubella can result
in miscarriage, still birth or CRS;
during the frst ten weeks, transmis-
sion from mother to fetus is as high as
90%.
1
The primary purpose of rubella
vaccination is the prevention of CRS.
And vaccination has been a stun-
ning public health success: to date
during 2013, only six cases of ru-
bella have been reported in the U.S.
Measles, too, despite its remarkable
contagiousness, is on the brink of
elimination: only 132 cases to date
this year in the United States. How-
ever, while these diseases have nearly
vanished from the U.S., other coun-
tries have been sorely aficted. This
issue of the CD Summary shares trends
in vaccine-preventable diseases and
immunization strategies from selected
developed countries.
JAPAN
Rubella. In 1976, Japan introduced
single-antigen rubella vaccine into
its national immunization program,
targeting junior high school girls so
as to prevent CRS. In 1989, a measles-
mumps-rubella (MMR) vaccine was
introduced, but this combination
vaccine was withdrawn in 1993 afer
unexpectedly high rates of aseptic
meningitis were associated with the
mumps component. A major change
occurred in 1994: the requirement of
vaccination for school atendance was
withdrawn.
2,3
Until the early 2000s, rubella was
endemic in Japan, with seasonal
increases in the spring and summer
and epidemics roughly every 5 years.
In 2012, the number of rubella cases
increased sharply to 2,392, with the
rise in cases continuing into 2013. The
Japanese National Institute of Infec-
tious Diseases has logged 11,991 cases
of rubella during January 1 July 3,
2013 (Figure 1). Most cases were in
males (9,237; 77%); of these 7,944 (86%)
were 1549 years of age. Among the
female cases, 2,093 (76%) were 1549
years of age. Perhaps most concern-
ing is that 10 infants with CRS were
reported during October 2012 May
1, 2013. For cases with known vac-
cination status, 3,527 (76%) occurred
in persons who had NOT received
rubella vaccine.
The good news: with the introduc-
tion of 2 doses of measles and rubella
(MR) vaccine into the national vacci-
nation schedule in 2006 for both boys
and girls, and a successful catch-up
vaccination program, children <15
years of age account for only 5.6% of
the cases.
Live, atenuated vaccines, includ-
ing against rubella, are generally
contraindicated during pregnancy.
In response to the current outbreak,
Japanese authorities have recommended
vaccination for family members of preg-
nant women and for women who plan to
get pregnant.
3,4

Measles. During 20072008, Japan suf-
fered an outbreak of over 27,000 cases of
measles.*

In response, Japanese authorities
initiated a fve-year MR catch-up vaccina-
tion program, aiming for immunization
coverage of >95% among persons 1222
years of age in 2013.
3
Measles continues
at endemic rates in Japan with 228 cases
reported in 2012.
5
EUROPE
Measles. During April 2012 March
2013, 8,127 cases of measles were reported
from 30 European countries. France,
Germany, Italy, Romania, Spain and the
United Kingdom accounted for 95% of the
reported cases. Of the 7,757 cases whose
vaccination status was known, 82% were
unvaccinated. The highest reported inci-
dence was among infants under one year
of age (224.6 cases per million popula-
tion), followed by children 14 years of
age (101.1 cases per million population);
among the later, 78% were unvaccinated.
Six cases were complicated by acute
measles encephalitis.
6
Rubella. From JanuaryApril 2013,
21,283 cases were reported in Poland
the nations highest tally since 2007. Most
cases (81%) were among 1529 year
old males; among those with known
vaccination status, 13,501 (89%) were
unvaccinated. In 1989, Poland began to
administer monovalent rubella vaccine to
13-year-old girls. In 2004, MMR vaccine
was recommended to all children in a
two-dose schedule. Susceptibility among
adolescent males and young adults keeps
the outbreak going, increases the risk of
congenital rubella infections, and jeop-
ardizes the World Health Organization
(WHO) Regional Ofce for Europes goal
of measles elimination by 2015.
7
UNITED KINGDOM
Measles. More than a decade ago,
many British parents declined to give
* CD Summary. A Tale of Two Countries 2008;
57(7). See htp://public.health.oregon.gov/Dis-
easesConditions/CDSummary Newsleter/Docu-
ments/2008/ohd5707.pdf
MEASLES AND RUBELLA: LEARNING A LESSON THE HARD WAY
0
500
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2012 2013
Figure 1. Number of rubella cases by
month, Japan, Jan 2012Jul 2013
CD SUMMARY The CD Summary (ISSN 0744-7035) is published fortnightly free of
charge, by the Oregon Health Authority, Public Health Division, 800 NE
Oregon St., Portland, OR 97232
Periodicals postage paid at Portland, Oregon.
Postmastersend address changes to:
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.
July 30, 2013
Vol. 62, No. 16
MMR vaccine to their children fol-
lowing a highly publicized but bogus
association with autism. Sadly, but
predictably, afer endemic transmis-
sion was eliminated in 1990s, measles
re-emerged; the disease has been on a
spree in the U.K. since 2006 (Figure 2),
primarily in England and Wales.
Since November 2012, 1,219 cases
have been reported throughout Wales.
During the frst quarter of 2013, 587
cases were reported in England. Most
heavily afected have been children
1014 years of age; 20% of cases in this
age group were associated with school
outbreaks.
Young people born in the U.K.
between 1997 and 2003, who were not
vaccinated as toddlers, remain under-
vaccinated. To address this, Public
Health England has launched a catch-
up measles vaccination campaign that
aims to immunize at least an estimated
330,000 unvaccinated people in the
1016-year-old age group. More than
75,000 non-routine vaccinations have
been given across Wales during the
outbreak, but an estimated 30,000
persons remain unvaccinated.
Finally recovering from sagging vac-
cination rates during the late 1990s thru
early 2000s, Englands MMR rate for
children reaching their second birth-
day hit 91% during 20112012. Despite
increases in recent years, MMR coverage
remains a bit below the WHO target of
95%.
6,8
ELSEWHERE IN EUROPE
While the outbreak in Wales is now
declared to be over, a new measles
outbreak was detected in the Nether-
lands; and outbreaks in Germany are
still on-going.
6
SOUTH AMERICA
In Brazil, Chile, and Argentina,
where only adolescent or adult females
have been targeted through national
immunization campaigns, similarly
large outbreaks have occurred among
adolescent and adult males, with a con-
comitant increase in CRS cases.
3
NEW OREGON IMMUNIZATION LAW
These outbreaks are sobering re-
minders of what happens when coun-
tries allow their immunization rates to
sag. These same diseases remain rare
in the U.S., where the blessings of herd
immunity have been secured by wide-
spread, consistent vaccination. It is well
to know that Oregon leads the nation
in parental belief-based exemptions to
vaccinations required for school, with
6% of kindergartners recently claim-
ing exemption to one or more required
shots and such exemptions have
been climbing steadily for a decade. In
some Oregon schools, exemption rates
exceed 50%.
To address this and ensure that par-
ents are making an informed decision,
a new law

will go into efect March 1,

www.leg.state.or.us/13reg/measpdf/sb0100.
dir/sb0132.en.pdf
2014 changing the process for parents
to claim a non-medical exemption
to school/childcare immunization
requirements. The new law will re-
quire parents choosing a non-medical
exemption to discuss the risks and
beneft of immunization with a health
care practitioner or to watch an online
interactive educational video.
Patients and parents may beneft
from the knowledge that measles,
mumps, and rubella are still out there,
potentially serious, and eminently
preventable as the citizens of Japan,
the United Kingdom, and many other
countries have lately been so intimate-
ly reminded.
REFERENCES:
1. Reef SE, Plotkin SA. Rubella vaccine. In:
Plotkin,SA, Orenstein WA, Offt PA.Vaccines 6th
ed. 2013: 689717.
2. Gomi H, Takahashi H. Why is measles still en-
demic in Japan? Lancet 2004; 364: 3289.
3. CDC. Nationwide Rubella Epidemic Japan,
2013. MMWR 2013; 62(23); 45762.
4. National Institute of Infectious Diseases, Japan.
Available at: www0.nih.go.jp/niid/idsc/idwr/dis-
eases/rubella/rubella2013/rube13-26.pdf.
5. Immunization Profle Japan. Available at http://
apps.who.int/immunization_monitoring/global-
summary/countries?countrycriteria%5Bcountry
%5D%5B%5D=JPN .
6. ECDC Surveillance. Available at: www.ecdc.eu-
ropa.eu/en/activities/surveillance/Pages/index.aspx
7. Paradowska-Stankiewicz I, Czarkowski MP, Der-
rough T, Stefanoff P. Ongoing outbreak of rubella
among young male adults in Poland: increased
risk of congenital rubella infections. Euro Sur-
veill. 2013;18(21). National Statistics, England
201112. Available at: https://catalogue.ic.nhs.
uk/publications/public-health/immunisation/nhs-
immu-stat-eng-2011-2012/nhs-immu-stat-eng-
2011-12-rep.pdf
8. National Statistics, England 201112. Avail-
able at: https://catalogue.ic.nhs.uk/publications/
public-health/immunisation/nhs-immu-stat-
eng-2011-2012/nhs-immu-stat-eng-2011-12-rep.
pdfeng-2011-2012/nhs-immu-stat-eng-2011-12-
rep.pdf
Figure 2. Measles cases by year, United
Kingdom, 19982013
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