Vaccine Preventable Diseases in Australia, 2005 to 2007

3.14 Rubella

Page last updated: 24 December 2010

Rubella is caused by the rubella virus (family togaviridae). It is usually a mild febrile viral disease characterised by a non-confluent maculopapular rash, conjunctivitis, coryza, headache, nausea, and post-auricular, suboccipital and cervical lymphadenopathy. However, subclinical infection occurs in up to 50% of cases. Arthralgia and arthritis may also occur, particularly in post-pubertal females. More severe disease manifestations, such as encephalitis, haemorrhage and Guillain-Barré syndrome, may also rarely occur. Rubella is of public health significance because, when acquired in the first trimester of pregnancy, it is associated with spontaneous abortion, or, in survivors, with abnormalities of the congenital rubella syndrome (CRS) in up to 80% of cases. These include cataract, retinopathy, deafness, heart defects and neurological deficit.1

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Case definitions

Notifications

See Appendix 6.6 for pre-2004 definition

Rubella – national definition from January 2004:2

Both confirmed and probable cases are notifiable. A confirmed case requires laboratory definitive evidence. A probable case requires clinical evidence and either laboratory suggestive evidence or an epidemiological link to a laboratory-confirmed case.

  1. Laboratory definitive evidence Isolation of rubella virus; or
    • Detection of rubella virus by nucleic acid testing; or
    • IgG seroconversion or a significant increase in antibody level or a ≥4-fold rise in titre to rubella virus in the absence of recent rubella vaccination in paired sera tested in parallel; or
    • Detection of rubella-specific IgM antibody in the absence of recent rubella vaccination (must be confirmed in a reference laboratory in pregnant women).
  2. Laboratory suggestive evidence
    • In a pregnant patient, the detection of rubella-specific IgM antibody that has not been confirmed in a reference laboratory, in the absence of recent rubella vaccination.
  3. Clinical evidence
    • A generalised maculopapular rash and fever, and one or more of: arthralgia/arthritis or lymphadenopathy or conjunctivitis.

Congenital rubella syndrome (CRS) – national definition from January 2004:2

Both confirmed and probable cases are notifiable. A confirmed case requires laboratory definitive evidence and clinical evidence. A probable case requires laboratory suggestive evidence (either maternal or infant) and clinical evidence.

  1. Laboratory definitive evidence
    • Isolation of rubella virus from the infant; or
    • Detection of rubella virus in the infant by nucleic acid testing; or
    • Detection of rubella-specific IgM antibody in the serum of the infant and confirmation of the result in a reference laboratory.
  2. Laboratory suggestive evidence
    • Isolation of rubella virus from the mother; or
    • Detection of rubella virus in the mother by nucleic acid testing; or
    • IgG seroconversion or a significant increase in antibody level or a ≥4-fold rise in titre to rubella virus in paired sera of the mother tested in parallel; or
    • Detection of rubella-specific IgM antibody in the mother in the absence of recent rubella vaccination (must be confirmed in a reference laboratory); or
    • Detection of rubella-specific IgM antibody in the blood of the infant using capture enzyme-linked immunosorbent assay; or
    • Infant rubella-specific antibody that persists at a higher level and for a longer period than expected from passive transfer of maternal antibody (rubella titre that does not drop at the expected rate of a 2-fold dilution per month).
  3. Clinical evidence
    • A live or still born infant with any of the following compatible defects: cataracts, congenital glaucoma, congenital heart disease, hearing defects, microcephaly, pigmentary retinopathy, mental retardation, purpura, hepatosplenomegaly, meningoencephalitis, radiolucent bone disease.

Hospitalisations and deaths

The ICD-10-AM/ICD-10 code B06 (rubella [German measles]) was used to identify hospitalisation and deaths. However, hospitalisations coded as congenital rubella syndrome (ICD-10-AM code P350) are not included in this report, as all were in cases aged >10 years in which secondary diagnosis codes suggested long-term sequelae or complications of the condition.

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Secular trends

During 2006–2007, there were 94 notified cases of rubella, of which 77 (82%) were confirmed and 17 (18%) were probable cases. Overall, the average annual notification rate was 0.23 per 100,000 population (Table 3.14.1). The annual number of rubella notifications has remained relatively stable over the last 5 years following the marked decline in the late 1990s and early 2000s (Figure 3.14.1). The 59 notifications in 2006 (0.29 per 100,000) was higher compared with the 31 in the previous year (0.15 per 100,000) and 35 in 2007 (0.17 per 100,000). The median number of notifications per month over the review period was 3.5 (range 0–11). Notifications peaked in late winter and early spring in 2006 and mid winter in 2007, which contrasted slightly to the mid spring peak in activity observed earlier in the decade.3

Figure 3.14.1: Rubella notifications and hospitalisations, Australia, 1993 to 2007,* by month of diagnosis or admission

Figure 3.14.1:  Rubella notifications and hospitalisations, Australia, 1993 to 2007, by month of diagnosis or admission

Note varying scales between notifications and hospitalisations.

* Notifications where the date of diagnosis was between January 1993 and December 2007; hospitalisations where the date of admission was between July 1993 and June 2007.

Nine confirmed cases of CRS have been notified to the NNDSS since 2002, with none in 2006 and two diagnosed in 2007. Both of these cases were diagnosed at age <1 year. The Australian Paediatric Surveillance Unit (APSU) also operates a surveillance system for CRS in Australia. Each month, the APSU contacts approximately 1,250 clinicians requesting them to report children who were newly diagnosed with a range of uncommon conditions, including CRS. A brief follow-up questionnaire is then sent to the clinician by the CRS study investigator, requesting further de-identified information for each new case.4 The APSU identified 8 confirmed cases of CRS between 2002 and 2007. However, all of these occurred prior to 2005.4–8

A very low rate of rubella hospitalisation has been maintained with only 18 hospitalisations coded as being due to rubella between July 2005 and June 2007, an average annual rate of 0.04 per 100,000 population.

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Severe morbidity and mortality

For the period July 2005 to June 2007, 57 hospital bed days were recorded for patients with an ICD-10-AM code for rubella. Of the 18 hospital separations, 9 (50%) had a principal diagnosis of rubella (average annual rate 0.02 per 100,000). The median length of stay in hospital was 2 days for all hospitalisations and 1 day for those with a principal diagnosis of rubella (Table 3.14.1). There were no deaths with rubella recorded as the underlying cause in 2005 or 2006.

Table 3.14.1: Rubella notifications, hospitalisations and deaths, Australia, 2002 to 2007,* by age group

Age group
(years)
Notifications
2 years
(2006–2007)
Hospitalisations
2 years
(July 2005–June 2007)
LOS per admission
(days)
Deaths
2 years
(2005–2006)
n Rate n (§) Rate (§) Median (§) n Rate
0–4
8
0.30
9
(7)
0.35
(0.27)
1.0
(1.0)
0
5–14
4
0.07
1
(0)
0.02
(–)
n.p.
(–)
0
15–24
20
0.34
3
(1)
0.05
(0.02)
n.p.
(n.p.)
0
25–59
60
0.30
4
(1)
0.02
(<0.005)
2.5
(n.p.)
0
60+
2
0.03
1
(0)
0.01
(–)
n.p.
(–)
0
All ages
94
0.23
18
(9)
0.04
(0.02)
2.0
(1.0)
0

* Notifications where the date of diagnosis was between January 2006 and December 2007; hospitalisations where the date of separation was between July 2005 and June 2007; deaths where the death was recorded between January 2005 and December 2006.

† LOS = length of stay in hospital.

‡ Average annual age-specific rate per 100,000 population.

§ Principal diagnosis (hospitalisations).

n.p. Not published.

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Complications arising from rubella infection were recorded for 4 (22% of 18) hospitalisations (Table 3.14.2). One of the 4 hospitalisations with complications was recorded in a child <5 years of age, while the remaining 3 were in adults aged 25–59 years. This is comparable to the previous 3 years, during which complications were recorded for 5 of 44 hospitalisations with rubella, including one aged <5 years.9

Table 3.14.2: Indicators of severe morbidity* for hospitalised cases of rubella, Australia, 2005 to 2007,* by age group

Age group
(years)
Rubella with neurological complication Rubella with other complications Rubella without complications
n % Total n % Total n % Total
0–4
0
1
11.1
8
88.9
5–14
0
0
1
100
15–24
0
0
3
100
25–59
1
25.0
2
50.0
1
25.0
60+
0
0
1
100
All ages
1
5.6
3
16.7
14
77.8

* Based on National Hospital Morbidity data where the date of hospital separation was between July 2005 and June 2007.

† % of total in the age group.

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Age and sex distribution

The significant decrease in rubella notifications, and to a lesser extent hospitalisations, achieved earlier in the decade has been maintained, with a low incidence of both across age and sex categories over recent years (Figures 3.14.2 and 3.14.3). Adults aged 25–59 years accounted for almost two-thirds of the rubella notifications for the 2-year review period 2006–2007 (Table 3.14.1). Notification rates were highest in the 25–29 years age group, who accounted for over a quarter (26/94, 28%) of all cases (average annual rate 0.91 per 100,000). Males predominated in this latter age group (male:female ratio 1.8:1) and were the only group where the notification rate was over 1 per 100,000 (Table 3.14.3). The declining rates of rubella in children and higher proportions in adults have led to an increase in the median age of both notified and hospitalised cases since the Measles Control Campaign (in which the MMR vaccine was used) in 1998.9 This trend continued with a median age of notified cases of 27 years during the review period, which represented an increase from the median age of 25 years over the previous review period (2003–2005).

Figure 3.14.2: Rubella notification rates, Australia, 1999 to 2007,* by age group, sex and year of diagnosis

Figure 3.14.2:  Rubella notification rates, Australia, 1999 to 2007, by age group, sex and year of diagnosis

* Notifications where the date of diagnosis was between January 1999 and December 2007.

Figure 3.14.3: Rubella hospitalisation rates, Australia, 1998/1999 to 2006/2007,* by age group, sex and year of separation

Figure 3.14.3:  Rubella hospitalisation rates, Australia, 1998/1999 to 2006/2007, by age group, sex and year of separation

* Hospitalisations where the date of separation was between July 1998 and June 2007.

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Table 3.14.3: Rubella notifications and hospitalisations, Australia, 2005 to 2007,* by sex and selected age groups of interest

Age group
(years)
Notifications
2 years
(2006–2007)
Hospitalisations
2 years
(July 2005–June 2007)
Male Female Male Female
n Rate n Rate n Rate n Rate
<1
2
0.72
1
0.38
4
1.48
2
0.78
1–4
2
0.19
3
0.29
1
0.09
2
0.20
15–19
0
5
0.36
0
1
0.07
20–24
8
0.53
7
0.48
0
2
0.14
25–29
16
1.11
9
0.64
0
2
0.14
30–34
6
0.41
6
0.40
0
0
35–39
5
0.32
6
0.39
1
0.07
0
40–44
0
2
0.13
0
0

* Notifications where the date of diagnosis was between January 2006 and December 2007; hospitalisations where the date of separation was between July 2005 and June 2007.

† Average annual age-specific rate per 100,000 population.

‡ There was 1 notification where gender was not reported.

The overall male:female ratio of notified cases was 1:1 for the 2-year review period. There were 35 notifications of rubella in females of child-bearing age (15–44 years) in 2006–2007, resulting in an average annual rate of 0.4 per 100,000, which is comparable to the previous review period. Those aged 25–44 years were the cohort in which females but not males were recommended to receive rubella vaccine at age 10–14 years since 1971 before the implementation of the adolescent MMR vaccination for both sexes in 1994–1996 and the Measles Control Campaign in 1998. In this cohort, the male:female ratio was 1.3:1. In particular, the male:female ratio was 1.7:1 among those aged 25–29 years, although the number of notifications was small (Table 3.14.3). The male:female ratio among those aged <25 years was 0.84:1.

For the 2 years from July 2005 to June 2007, children aged 0–4 years continued to have the highest hospitalisation rate (average annual rate 0.35 per 100,000). However, two-thirds (6/9) of the hospitalisation episodes in this age group were in children too young to be vaccinated (<1 year of age) (Table 3.14.3). While there were twice as many males in this age group, the overall male:female ratio for rubella hospitalisations was 0.5:1.

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Geographical distribution

The majority of cases in 2006–2007 were notified from New South Wales (n=45; rate 0.33 per 100,000) and Queensland (n=26; rate 0.31 per 100,000), analogous to the previous review period. Notifications were highest in New South Wales in 2006 (n=37; rate 0.54 per 100,000), with the majority of cases in south eastern and central Sydney in those aged 15–44 years.10 No source was identified for this increase in notifications. Victoria notified 13 cases during the review period, including a cluster of 3 cases in one family in 2006.11 Five cases were notified in Western Australia, three in South Australia and two in the Australian Capital Territory. No rubella notifications were recorded in Tasmania or the Northern Territory in either 2006 or 2007 (Appendix 6.2).

There were 8 notified cases (9%) in the NNDSS recorded as being acquired overseas (age range 22–38 years) and 55 (59%) recorded as locally acquired; no information was available for the remaining 31 cases.

Of the 2 cases of CRS in 2007 that were notified to the NNDSS, one was recorded as acquired overseas and the other as not imported.

The geographical distribution of rubella hospitalisations reflected that of the notifications (see Appendix 6.3). However, there were too few hospitalisations in each jurisdiction to identify any trends.

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Vaccination status

Vaccination status is required in the NNDSS for all notifications of rubella in women of child-bearing age (i.e. 15–44 years). Although this field was completed for 34 of 35 cases in this category, the vaccination status was recorded as ‘unknown’ for 16 (47%). Of those women with known vaccination status, the majority were unvaccinated (12/18; 67%), one was partially vaccinated (i.e. had received 1 dose of rubella-containing vaccine), and five (28%) were reported as fully vaccinated (i.e. had received 2 doses). Two of the five reported as fully vaccinated had valid written records. The vaccination status of the partially vaccinated woman was also validated.

Of the 9 notified cases in 2006–2007 who were aged <7 years, 6 were aged 1–3 years, and 3 were aged 4–7 years. Of those 6 cases aged 1–3 years, 2 had been vaccinated with 1 dose of rubella-containing vaccine (validated), and 2 were reported to be unvaccinated. Of the 3 cases aged 4–7 years, 1 had received 2 vaccine doses (validated), 1 was reported to be unvaccinated, and the vaccination status of the remaining case was unknown.

Overall, vaccination status was recorded for 55 cases, of which 11 (6 validated) were fully vaccinated, 4 (1 validated) partially vaccinated, and 40 unvaccinated.

The vaccination status of the mothers of the 2 notified cases of CRS in 2007 was not available from the NNDSS.

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Comment

The successful control of rubella in Australia over the last decade through mass school-based MMR vaccination has been sustained, and rubella notification and hospitalisation rates continue to remain at very low levels. Young men no longer appear to be at greater risk for rubella infection as previous surveillance and serology data have indicated.3,12 In fact, the male:female ratio in persons aged <25 years in 2006–2007 was about 1:1. However, despite these achievements, some challenges still remain.

Evidence suggests that Indigenous women in the Northern Territory have inadequate immunity to rubella.13 Serological evidence from women of child-bearing age also indicates that migrants from countries without an established rubella vaccination program, particularly Asia, South America and sub-Saharan Africa, are at greater risk of not being immune to rubella compared with the general Australian population.14,15 A study in Victoria found that self-reported rubella vaccination prior to arrival in Australia for adult migrants from East Africa was less than 1%.16 In the majority of cases (89%), vaccination status was unknown. Serological testing of African refugees living in Melbourne in the first half of 2005 demonstrated that 32% of those aged <15 years and 4% of those aged ≥15 years were not immune to rubella.17 Targeted rubella screening and vaccination of high-risk groups remains an important component of ongoing rubella control.

The epidemiology of CRS in Australia from 1992 to 1997 has been described and discussed by Sullivan et al (1999).18 More recently, 6 of the 8 cases of CRS identified by the APSU since 2002 were born to immigrant mothers who had incomplete vaccination or unvaccinated mothers who had travelled to rubella prevalent countries during pregnancy.5,6,19 The other 2 CRS cases were born to Australian-born mothers who missed school-based MMR immunisation.5,19 Of the 2 CRS cases in 2007 notified to NNDSS, 1 was recorded as acquired overseas and the other as not imported. Details on the vaccination status of the mothers of these cases were not available. The identification of different cases of CRS at different times from the APSU and the NNDSS, which utilise different reporting sources and mechanisms, indicates that both systems are complementary and important for surveillance of CRS in Australia.

Endemic transmission of rubella in the USA was declared to be eliminated in October 2004, on the basis of evidence showing high levels of vaccine coverage and population immunity, and low disease incidence over a number of years.20,21 Rubella genotyping was also an important tool in the USA elimination effort as it could be demonstrated that local strains were no longer circulating.22 The WHO strategic plan for Europe has set a target of <1 case of CRS per 100,000 live births and <1 case of rubella per 100,000 population across the region by 2010.23

Despite the progress made in countries with high vaccination coverage, travellers remain at risk of rubella exposure in many other countries where high vaccination coverage has not been achieved. By the end of 2006, 123 countries, covering 27% of that year’s birth cohort, included a rubella vaccine in their immunisation schedule.24 Globally, there were 85,158 cases of rubella and 206 CRS cases notified to the WHO in 2007, of which 46% and 83%, respectively, were in the Western Pacific region.25 However, these figures are an underestimate as a high proportion of cases are asymptomatic and many countries do not undertake routine surveillance for rubella. The potential for global rubella control continues to improve on the back of intensive measles elimination efforts and the opportunity to increase coverage of combined vaccines. Individual countries must evaluate the burden of disease caused by rubella through appropriate surveillance mechanisms and assess the cost-effectiveness of introducing rubella vaccine into national immunisation programs, either targeted at adolescent and adult females or universal vaccination of all children.26 Although only 8 cases in the review period were identified in NNDSS as being imported from overseas, this information was missing for a further 31 cases.

The low level of rubella notifications in Australia, combined with serology data demonstrating that <5% of both women of child-bearing age and children aged 2–14 years are seronegative,27 indicate that the potential for endemic transmission in this country is very limited. In addition, the high level of immunity to rubella and sustained low disease incidence indicates that Australia is moving towards rubella elimination. However, despite this, 55 cases during the review period were recorded in the NNDSS as ‘not imported’. In order for Australia to eliminate endogenous rubella transmission, a strong regional approach must be taken, similar to the Pan American approach that resulted in the elimination of rubella in the USA.28 This approach involved intensive mass immunisation campaigns that achieved high immunity and low incidence of both rubella and CRS across the Americas.29 Rubella genotyping, which is not routinely available in Australia, may also facilitate a better understanding of circulating strains and assist in determining if indigenous strains have been eliminated. Nevertheless, maintaining high coverage and improved timeliness of MMR vaccination among children should remain an important goal of Australia’s rubella elimination strategy.

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References

1. Best JM. Rubella. Semin Fetal Neonatal Med 2007;12(7):182–192.

2. Communicable Diseases Network Australia. Surveillance case definitions for the Australian National Notifiable Diseases Surveillance System. 2004. Available from: http://www.health.gov.au/internet/main/publishing.nsf/Content/cdna-casedefinitions.htm Accessed on 17 February 2009.

3. Brotherton J, McIntyre P, Puech M, Wang H, Gidding H, Hull B, et al. Vaccine Preventable Diseases and Vaccination Coverage in Australia, 2001 to 2002. Commun Dis Intell 2004;28(Suppl 2):S1–S116.

4. Mahajan D, Zurynski Y, Peadon E, Elliott E, eds. Australian Paediatric Surveillance Unit Biannual research report 2005–2006. Sydney: Australian Paediatric Surveillance Unit, 2008. Available from: http://www.apsu.org.au/download.cfm?DownloadFile=27119164-BA46-5241-B54125C1E4397604 Accessed on 17 October 2008.

5. Elliott E, Cronin P, Rose D, Zurynski Y, eds. Australian Paediatric Surveillance Unit surveillance report 2002–2003. Sydney: Australian Paediatric Surveillance Unit (APSU), 2005. Available from: http://www.apsu.org.au/index.cfm?objectID=B4CB23FF-0526-FEED-ADCF260415B6A052 Accessed on 27 July 2009.

6. Elliott E, Cronin P, Zurynski Y, eds. Australian Paediatric Surveillance Unit annual report 2004. Sydney: Australian Paediatric Surveillance Unit (APSU), 2006. Available from: http://www.apsu.org.au/index.cfm?objectID=B4CB23FF-0526-FEED-ADCF260415B6A052 Accessed on 27 July 2009.

7. Zurynski Y, Elliott EJ. Australian Paediatric Surveillance Unit annual report, 2006. Commun Dis Intell 2008;32(1):52–56.

8. Zurynski YA, Mahajan D, Elliott EJ. Australian Paediatric Surveillance Unit annual report, 2007. Commun Dis Intell 2008;32(4):430–434.

9. Brotherton J, Wang H, Schaffer A, Quinn H, Menzies R, Hull B, et al. Vaccine Preventable Diseases and Vaccination Coverage in Australia, 2003 to 2005. Commun Dis Intell 2007;31(Suppl):S1–S152.

10. Australian Government Department of Health and Ageing, Surveillance Branch. Communicable diseases surveillance: highlights for 4th quarter, 2006. Vaccine preventable diseases: rubella. Commun Dis Intell 2007;31(1):136.

11. Fielding J. Surveillance report. Vaccine preventable diseases: rubella. Victorian Infectious Diseases Bulletin 2007;10(1):12–13.

12. Gilbert GL, Escott RG, Gidding HF, Turnbull FM, Heath TC, McIntyre PB, et al. Impact of the Australian Measles Control Campaign on immunity to measles and rubella. Epidemiol Infect 2001;127(2):297–303.

13. Hunt JM, Lumley J. Top End rural and remote Indigenous women: an Australian population group vulnerable to rubella. Commun Dis Intell 2004;28(4):499–503.

14. Francis BH, Thomas AK, McCarty CA. The impact of rubella immunization on the serological status of women of childbearing age: a retrospective longitudinal study in Melbourne, Australia. Am J Public Health 2003;93(8):1274–1276.

15. Sathanandan D, Gupta L, Liu B, Rutherford A, Lane J. Factors associated with low immunity to rubella infection on antenatal screening. Aust N Z J Obstet Gynaecol 2005;45(5):435–438.

16. Skull SA, Ngeow JY, Hogg G, Biggs BA. Incomplete immunity and missed vaccination opportunities in East African immigrants settling in Australia. J Immigr Minor Health 2008;10(3):263–268.

17. Tiong AC, Patel MS, Gardiner J, Ryan R, Linton KS, Walker KA, et al. Health issues in newly arrived African refugees attending general practice clinics in Melbourne. Med J Aust 2006;185(11–12):602–606.

18. Sullivan EM, Burgess MA, Forrest JM. The epidemiology of rubella and congenital rubella in Australia, 1992 to 1997. Commun Dis Intell 1999;23(8):209–214.

19. Forrest JM, Burgess M, Donovan T. A resurgence of congenital rubella in Australia? Commun Dis Intell 2003;27(4):533–536.

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20. Centers for Disease Control and Prevention. Elimination of rubella and congenital rubella syndrome—United States, 1969–2004. MMWR Morb Mortal Wkly Rep 2005;54(11):279–282.

21. Plotkin SA. The history of rubella and rubella vaccination leading to elimination. Clin Infect Dis 2006;43(Suppl 3):S164–S168.

22. Icenogle JP, Frey TK, Abernathy E, Reef SE, Schnurr D, Stewart JA. Genetic analysis of rubella viruses found in the United States between 1966 and 2004: evidence that indigenous rubella viruses have been eliminated. Clin Infect Dis 2006;43(Suppl 3):S133–S140.

23. World Health Organization. Eliminating measles and rubella and preventing congenital rubella infection. WHO European Region strategic plan 2005–2010. Geneva, World Health Organization, 2006. Available from: http://www.euro.who.int/document/E87772.pdf Accessed on 28 October 2008.

24. World Health Organization. Immunization surveillance, assessment and monitoring. Rubella and congenital rubella syndrome. Geneva, World Health Organization, 2009. Available from: http://www.who.int/immunization_monitoring/diseases/rubella/en/index.html Accessed on 23 February 2009.

25. World Health Organization. Global and regional data and statistics. Geneva, World Health Organization, 2008. Available from: http://www.who.int/immunization_monitoring/data/data_regions/en/index.html Accessed on 23 February 2009.

26. Muller CP, Kremer JR, Best JM, Dourado I, Triki H, Reef S. Reducing global disease burden of measles and rubella: report of the WHO Steering Committee on research related to measles and rubella vaccines and vaccination, 2005. Vaccine 2007;25(1):1–9.

27. Nardone A, Tischer A, Andrews N, Backhouse J, Theeten H, Gatcheva N, et al. Comparison of rubella seroepidemiology in 17 countries: progress towards international disease control targets. Bull World Health Organ 2008;86(2):118–125.

28. Dayan GH, Castillo-Solórzano C, Nava M, Hersh BS, Andrus J, Rodríguez R, et al. Efforts at rubella elimination in the United States: the impact of hemispheric rubella control. Clin Infect Dis 2006;43(Suppl 3):S158–S163.

29. Castillo-Solórzano 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–S152.

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