. ABSTRACTS AND REPORTS 395
RUBELLA PREVENTION IN THE UNITED STATES
The administration of more than 123 million doses of rubella vaccine since 1969, the year of licensure, has successfully prevented epidemics of rubella and congenital rubella syndrome (CRS) from occurring in the United States.
Reported U. S . cases of rubella and CRS are at all-time lows. The provisional 1984 totals for rubella cases and for confirmed and compatible cases of CRS are 745 and two, respectively. Compared to prevaccine years, the number of reported rubella cases has decreased 98.7% overall, with declines of 90% or higher recorded for all age groups. Similarly, the number of reported confirmed and compatible CRS cases has declined by 97.1% since 1970, the year in which the highest number of such cases was reported. Although there is thought to be under- reporting of both rubella and CRS, these figures represent considerable progress.
Rubella vaccination has had a dramatic effect on the occurrence of rubella and CRS. Nonethe- less, CRS cases continue to be reported at a low endemic level because the current lo-20% sus- ceptibility rate to rubella in the population of childbearing age has changed little from that noted in prevaccine years. The initial vaccina- tion strategy adopted by the United States was aimed at controlling rubella in preschool-age and young school-age children, the known reservoirs for rubella transmission. The intent was to pre- vent exposure of susceptible pregnant women to rubella virus. Accordingly, children of both sexes were the primary target group for vaccina- tion. Secondary emphasis was placed on vac- cinating susceptible adolescents and young adults, especially women. While more than 95% of all school entrants now provide evidence of immunization against rubella, comparable levels of rubella immunization have not been achieved in the postpubertal population. As a result, there is continuing endemic rubella activity among adolescents and young adults.
As the highly immune cohorts of young chil- dren enter their childbearing years, CRS can be expected to disappear from the U.S. Since this process will take lo-30 years, however, during
the interim potentially preventable cases of CRS will persist. It is estimated that each case incurs an average lifetime cost of over US$200,000. Furthermore, unnecessary instances of miscar- riages, stillbirths, and induced abortions result- ing from congenital infection will continue to occur.
Recent concentration on this continued occur- rence of rubella in populations of childbearing age has led to increased efforts to effectively vaccinate this population and thus hasten the elimination of CRS. The number of doses of rubella vaccine administered in the public sector to postpubertal individuals doubled between 1978 and 1981, and this trend of increasing vaccina- tions in that population is continuing. Such vac- cination has been accomplished at schools and among clients of family planning clinics, hospi- tal personnel, college and university students, women following premarital screening, and women immediately after delivery.
However, there are still gaps in the effort to hasten CRS elimination. A number of states do not require proof of rubella immunity for post- pubertal female elementary and secondary school students. The same is true of many col- leges, universities, and health profession institu- tions. When women are seen by internists, obstetricians, or gynecologists the rubella im- mune status of these patients is not commonly considered. When women are screened for rubella immunity premaritally, prenatally, or in family planning clinics, only a low proportion of the susceptibles so identified are subsequently vaccinated.
396 PAHO BULLETIN l vol. 19, no. 4, 198.5
Vaccination of a population not attending pact of CRS and the other outcomes of rubella school poses many logistic problems. A multifa- infection during pregnancy, virtually any effort ceted approach that involves both the public and that can hasten the elimination of CRS should private sectors will be needed. Furthermore, in- be undertaken.
formation that may help identify select groups at increased risk of not being vaccinated will
have to be sought as a guide to vaccination ef- Saurce: United States Centers for Disease Control, Mar- forts. However, considering the economic im- bidity and Mortality Weekly Report 34(5), 1985.
COMMUNICABLE DISEASES IN THE CARIBBEAN, 1983
Changes in the communicable disease situa- tion in 27 countries and territories’ of the Carib- bean (including the mainland countries of Belize, French Guiana, Guyana, Suriname, and Ven- ezuela) are highlighted in the annual review for 1983 conducted by the Surveillance Unit of the Caribbean Epidemiology Center (CAREC). At the time the review was compiled in March 1984, reporting for nine countries was incom- plete. Therefore, estimates were made for those countries on the basis of data available for shorter periods. The review compares the 1983 figures with those for 1982 and, in most cases, for 198 1. In addition, the report presented here makes use of additional information contained in earlier CAREC annual reviews and reports made di- rectly to the World Health Organization.
Diseases Subject to the International Health Regulations
No reports of cholera, plague, or yellow fever were received during 1983. Neither cholera nor plague has ever been reported from the Carib- bean. The last four cases of yellow fever in that region were reported from Venezuela in 1980; the last epidemic involved some 18 cases of jungle yellow fever in Trinidad and Tobago in
1979.
‘Hereafter the term “country” should be taken to include the term “territory,” where appropriate.
Diseases Covered by the Expanded Program on Immunization
Poliomyelitis
Poliomyelitis was reported only from Haiti and the Dominican Republic. The rate per 100,000 population in Haiti was 2.1, triple the 1982 rate and 12 times that prevailing in the adjacent Dominican Republic in 1983. However, the Dominican Republic had a provisional rate of 1.7 in 1982. Since 1976, nine countries have reported cases; but rates have only exceeded 1 .O per 100,000 during that period in a few in- stances-once in Belize, Jamaica, and the Turks and Caicos Islands; twice in Haiti; and three times in the Dominican Republic.
Coverage of children less than one year old with trivalent oral polio vaccine (three doses or more) was only 7% in Haiti and 39% in the Dominican Republic. In fact, coverage reached 90% in more than one country only in 1982, and has been maintained at that level since then in only three-Antigua and Barbuda, the Cayman Islands, and St. Christopher/Nevis. In five countries, coverage actually declined in
1983 as compared to 1982.
Diphtheria
