Surveillance And Outbreak Reports Congenital Rubella Still .

2y ago
23 Views
2 Downloads
375.12 KB
10 Pages
Last View : 1m ago
Last Download : 2m ago
Upload by : Lilly Andre
Transcription

Surveillance and outbreak reportsCongenital rubella still a public health problem in Italy:analysis of national surveillance data from 2005 to 2013C Giambi (cristina.giambi@iss.it)1, A Filia1, M C Rota1, M Del Manso1, S Declich1, G Nacca1, E Rizzuto2, A Bella1, regional contactpoints for rubella31. Communicable Disease Epidemiology Unit, National Centre for Epidemiology, Surveillance and Health Promotion, IstitutoSuperiore di Sanità, Rome, Italy2. Communicable Diseases Unit, Directorate General of Health Prevention, Ministry of Health, Rome, Italy3. The contact points are listed at the end of the article.Citation style for this article:Giambi C, Filia A, Rota MC, Del Manso M, Declich S, Nacca G, Rizzuto E, Bella A, regional contact points for rubella. Congenital rubella still a public health problemin Italy: analysis of national surveillance data from 2005 to 2013. Euro Surveill. 2015;20(16):pii 21103. Available online: rticleId 21103Article submitted on 17 November 2014 / published on 23 April 2015In accordance with the goal of the World HealthOrganization Regional Office for Europe, the Italiannational measles and rubella elimination plan aimsto reduce the incidence of congenital rubella casesto less than one case per 100,000 live births by theend of 2015. We report national surveillance data forcongenital rubella and rubella in pregnancy from 2005to 2013. A total of 75 congenital rubella infectionswere reported; the national annual mean incidencewas 1.5/100,000 live births, including probable andconfirmed cases according to European Union casedefinition. Two peaks occurred in 2008 and 2012 (5.0and 3.6/100,000 respectively). Overall, 160 rubellainfections in pregnancy were reported; 69/148 womenwere multiparous and 38/126 had had a rubella antibody test before pregnancy. Among reported cases,there were 62 infected newborns, 31 voluntary abortions, one stillbirth and one spontaneous abortion. Atotal of 24 newborns were unclassified and 14 womenwere lost to follow-up, so underestimation is likely. Toimprove follow-up of cases, systematic procedures formonitoring infected mothers and children were introduced in 2013. To prevent congenital rubella, antibodyscreening before pregnancy and vaccination of susceptible women, including post-partum and post-abortumvaccination, should be promoted. Population coverage of two doses of measles-mumps-rubella vaccination of 95% should be maintained and knowledge ofhealth professionals improved.IntroductionRubella is an acute contagious viral illness; if contractedearly in pregnancy, it can spread from the mother toher developing baby and result in miscarriage, stillbirth or severe birth defects including deafness, blindness, cataracts, heart defects and mental retardation(congenital rubella). The risk of fetal malformation varies according to the time of onset of maternal infectionand is estimated to be 90% for infants born to womeninfected within the first 10 weeks of pregnancy [1].www.eurosurveillance.orgRubella infection can be prevented by a safe and effective vaccine and the main aim of rubella control programmes is to prevent infection in pregnant women.In accordance with the objectives of the World HealthOrganization (WHO) Regional Office for Europe [2], theItalian national measles and rubella elimination planaims to eliminate rubella (incidence to less than onecase per 1,000,000 live births) and reduce the incidence of congenital rubella cases to less than one caseper 100,000 live births by the end of 2015 [3].Congenital rubella prevention relies on maintaininghigh levels of immunity ( 95%) in the general population and on identifying and immunising susceptible women of childbearing age. This strategy allowedthe elimination of rubella in the WHO Region of theAmericas, where the last confirmed cases of endemicrubella and congenital rubella syndrome (CRS) werereported in 2009 [4].In Italy, a monovalent rubella vaccine was first available in 1972; vaccination was initially recommendedonly for adolescent females. The monovalent vaccinewas replaced in the early 1990s by the combined measles-mumps-rubella (MMR) vaccine and in 1999 universal vaccination with one dose of MMR vaccine wasincluded in the national immunisation programme. In2003, when Italy approved the first national measlesand congenital rubella elimination plan, a two-doseschedule was adopted in all regions. Currently, a firstdose of MMR vaccine is recommended at the age of 12to 15 months and a second dose at 5 to 6 years of age.MMR vaccination is also offered free of charge to allsusceptible adolescents and adults [5].Uptake of one dose of MMR vaccine remained below80% until 2002; uptake increased after implementation of the first national elimination plan (2003–07)and national vaccination coverage assessed in childrenat 24 months of age was 88% in 2013 [6]. Immunisationcoverage of adolescents and adults is not routinely1

Figure 1Notification flow for congenital rubella and rubellainfections in pregnancy in ItalyWho?What?When?National Public HealthInstitute (ISS)Ministry of HealthNotification formAggregate reportMonthlyRegional HealthAuthorityLocal HealthAuthorityNotification formWithin two daysAggregate reportMonthlyNotification by email,telephone, fax orthrough the officialnotification formWithin two daysClinicianmeasured in Italy; in 2008, an epi-cluster survey conducted in 18 of the 21 Italian regions, found that rubellavaccine coverage was 75% in 16 year-old adolescents[7].The national elimination plan recommends strengthening surveillance of rubella and congenital rubella cases.In Italy, postnatal rubella has been a notifiable diseasesince 1934, within a statutory surveillance systemincluding 46 other infectious communicable diseases[8]; however, this system does not collect informationon pregnancy status or on congenital rubella cases.A national surveillance system for congenital rubellaand rubella in pregnancy was implemented in 2005[9]. This system is mandatory, passive, case-basedand relies on reporting by clinicians (it is not laboratory based). Data flow is shown in Figure 1. Cliniciansmust notify suspected cases within two days to thelocal health authorities, who in turn are responsiblefor case investigations and monitoring newborns andpregnancy outcomes over time. Separate notificationforms are used for congenital rubella and rubella infections in pregnancy and the notification form for congenital rubella also includes a section regarding themother’s history. Forms are forwarded to the regionalhealth authorities who in turn send monthly reports tothe Ministry of Health and the National Public HealthInstitute (Istituto Superiore di Sanità, ISS). Individualdata are collected in a central database at the ISS andare regularly analysed. Case classifications are periodically updated based on follow-up data received bylocal health authorities [10]. A cross-check between thenational database and regional archives of statutorynotifications is performed yearly.2Surveillance systems for congenital rubella are activein 28 of 29 European Union (EU)/European EconomicArea countries that participated in a survey conductedby the European Centre for Disease Prevention andControl (ECDC) in 2012 [11] and information on rubellainfections in pregnancy was collected in 25 countries [11]. Although congenital rubella is notifiable atEuropean level, incidence data are not collected byECDC. They are reported from European countries tothe WHO Regional Office for Europe through the WHO/United Nations Children’s Fund Joint Reporting Formand are made available on the WHO website on a yearlybasis [12]. However, congenital rubella is not includedin the list of vaccine-preventable diseases currentlymonitored at European level by ECDC through TESSy(The European Surveillance System).In this paper we analyse Italian national surveillancedata for congenital rubella and rubella infection inpregnancy from 2005 to 2013, in order to monitor progress towards congenital rubella elimination and provide public health recommendations. Additionally, wediscuss strengths and weaknesses of the surveillancesystem. Given the regional elimination goal, these datamay be helpful to other public health actors in Europe.MethodsCongenital rubella infectionsWe carried out a descriptive analysis of congenitalrubella cases reported to the national surveillancesystem from 1 January 2005 to 31 December 2013. Weclassified cases as probable or confirmed according tothe 2012 EU case definition for congenital rubella [13].Cases for whom information was insufficient to confirmor exclude the diagnosis were excluded from the analysis. We calculated the incidence of congenital rubellaby year and region, including confirmed and probablecases.We described newborns with congenital rubella infection in terms of median gestational age, median weightat birth, sex, nationality and clinical manifestations.We also calculated the proportion of cases that satisfythe clinical criteria for CRS [13,14], that is (i) at leasttwo of the category A conditions; or (ii) one categoryA and one category B condition (where category A conditions include cataract, congenital glaucoma, congenital heart disease, loss of hearing and pigmentaryretinopathy, and those in category B include purpura,splenomegaly, microcephaly, developmental delay,meningo-encephalitis, radiolucent bone disease, jaundice that begins within 24 hours after birth).In order to compare the incidence with the target ofless than one case per 100,000 live births, we calculated the incidence of congenital rubella using the WHORegional Office for Europe case definition (clinical CRS,epidemiologically linked CRS and laboratory-confirmedCRS) [14], which does not fully overlap with the EUcase definition. The difference relates to asymptomaticwww.eurosurveillance.org

Table 1Congenital rubella infections (n 75) and rubella infections in pregnancy (n 160) reported by year and case classification,Italy, 2005–13YearabRubella in pregnancybCongenital 1937405020130330145Total7687549147160Cases were classified according to the 2012 European Union congenital rubella case definition [13].Cases were classified according to a modified version [10] of the 2012 European Union rubella case definition [13], that includes among thelaboratory criteria for case confirmation a positive rubella IgM result supported by a rubella-specific IgG avidity test showing low avidity.congenital infections. In particular, an infant born to amother with confirmed rubella in pregnancy, with laboratory confirmation of infection but no rubella defectsis classified as a confirmed case of congenital rubellaaccording to the EU case definition, while the WHORegional Office for Europe excludes cases without atleast one Group A clinical condition [14]. Therefore, weexcluded asymptomatic laboratory-confirmed cases tocalculate incidence according to the WHO regional casedefinition.In order to compare temporal trends of rubella andcongenital rubella, we also calculated the incidence ofpostnatal rubella cases reported to the statutory surveillance system for communicable infectious diseasesduring 2005 to 2013. Data on postnatal rubella casesare collected in a central database at the Ministry ofHealth.Rubella infections in pregnancyWe also carried out a descriptive analysis of rubellainfections in pregnancy reported to the national surveillance system during 2005 to 2013. Reported casesincluded: (i) those notified through the notificationform for rubella infection in pregnancy; and (ii) thosewhose data was obtained from the newborn’s notification form (from the section regarding the mother’shistory), if mother’s infection had not been previouslynotified.We described cases in terms of median age at infection, nationality, parity, pregnancy trimester of infection, vaccination status, pre-pregnancy testing forrubella susceptibility and clinical manifestations.Cases were classified as possible, probable or confirmed according to a modified version [10] of the 2012www.eurosurveillance.orgEU rubella case definition [13], which includes amongthe laboratory criteria for case confirmation a positive rubella IgM result supported by a rubella-specificIgG avidity test showing low avidity. This criteria wasadded because when rubella infection is suspectedduring pregnancy, confirmation of a positive rubellaIgM result (e.g. a rubella-specific IgG avidity test) isrequired [13].Pregnancy outcomesWe matched data on congenital rubella cases andrubella infections in pregnancy (archived in two separate databases) in order to link pregnant women withtheir babies. We classified outcomes of pregnancy aslive birth (infected, not infected or unknown state ofinfection), voluntary abortion, miscarriage and stillbirth. We also calculated the proportion of infectedwomen who were lost to follow-up (for whom pregnancy outcome is unknown) and the proportion ofinfants, born to mothers with a possible, probable, orconfirmed infection, who we were unable to classifyeither because they were lost to follow-up or becauseof insufficient data.Statistical analysisWe summarised categorical variables using frequenciesand proportions, and continuous variables as medianand range. We used a chi-squared test or Fisher’s exacttest to compare proportions. We defined statistical significance as a p value of 0.05.For calculating the incidence of congenital rubella infections and CRS, we used the number of live births ofeach year (2005–13) obtained from the Italian NationalInstitute of Statistics (ISTAT) [15]. For calculating theincidence of rubella cases reported to the statutorysurveillance system for infectious diseases, we used3

Figure 2Incidence of congenitala (n 75) and postnatal rubella casesb (n 8,421) and number of cases of rubella in pregnancy(n 160)c, Italy, 2005–1390121080Incidence of postnatal rubella (per 100,000 population)70Incidence of congenital rubella (per 100,000 live births)60850640Number of casesIncidence (number of cases per 100,000)Number of cases of rubella in 22013YearThe data for incidence of postnatal rubella in 2012 and 2013 (marked with a cross) are provisional, due to the ongoing implementation of aweb-based surveillance system for infectious diseases in Italy.abcCased were classified according to the 2012 European Union case definition for congenital rubella [13].Cases were classified according to clinical criteria for rubella [8].Cases were classified according to a modified version [10] of the 2012 European Union rubella case definition [13], that includes among thelaboratory criteria for case confirmation a positive rubella IgM result supported by a rubella-specific IgG avidity test showing low avidity.the resident population data of each year (2005–13)obtained from ISTAT [15]. Statistical analysis was performed using Epi Info software version 3.5.4.ResultsCongenital rubellaA total of 75 congenital rubella infections (7 probableand 68 confirmed cases) were reported during 2005 to2013, according to the 2012 EU congenital rubella casedefinition [13] (Table 1). We received an additional 59reports of suspected cases who could not be classifiedbecause the available information was insufficient.These were excluded from the analysis.symptomatic cases, 37 newborns satisfied the clinicalcriteria for CRS [13,14], 17 had only one group A condition and three had at least one group B condition (butno group A conditions). The most frequently reportedcondition was congenital heart disease (n 41), followed by loss of hearing (n 26), jaundice within 24hours of birth (n 18), meningo-encephalitis (n 11),cataract (n 12), microcephaly (n 10), splenomegaly(n 8), developmental delay (n 7), purpura (n 6),and pigmentary retinopathy (n 1). A total of 20 caseshad multiple defects involving the heart, hearing orvision.The median birth weight of 67 of the cases for whominformation was available was 2,710 g (range: 913–4,330); 49/75 were male and 5/70 were born to foreignmothers. The median gestational age of cases was 38weeks (range: 29–42) and 15/64 were born before the37th week of pregnancy.The national annual mean incidence in the years studied was 1.5 per 100,000 live births (mean annual number of live births in Italy: 553,389), including probableand confirmed cases according to the 2012 EU casedefinition. Two incidence peaks of congenital rubellainfections occurred in 2008 and 2012, with an incidence of 5.0 and 3.6 per 100,000 newborns, respectively (Figure 2).Information on clinical manifestations was available for73 cases. Of them, 16 were asymptomatic, whereas 57had at least one clinical manifestation. Among these 57Statutory notifications of cases of postnatal rubellaalso experienced a peak in 2008 and there was aslight increase in the number of reported cases in 20124www.eurosurveillance.org

Figure 3Annual mean incidence of congenital rubella infectionsby region, including probable and confirmed casesa, Italy,2005–13 (n 75)0000.51.80.800.701.50007.00.602.62.5Incidence of congenital rubellaper 100,000 live births1.2 5.01.0 –5.0 1.0No case reportedaAccording to the 2012 European Union congenital rubella casedefinition [13].(provisional data) (Figure 2). During 2005 to 2013, atotal of 8,421 cases of postnatal rubella were notified,with a median age of cases of 17.5 years (range: 0–88years).Of the 21 regions of Italy, 11 reported congenital rubellacases, with regional annual mean incidences (confirmed and probable cases) in the years studied varying from 0.5 to 7.0 per 100,000 live births (Figure 3).Most cases of congenital rubella reported in 2012(16/19) were notified by a single region in southern Italy(incidence of 29.2/100,000 live births). In the sameyear, this region also reported 161 postnatal rubellacases, representing 46% of national cases (n 353).The national annual mean incidence of congenitalrubella calculated according to the WHO case definition was 1.1 per 100,000 live births. In 2008, 2009 and2012, it exceeded the threshold fixed by WHO to reachwww.eurosurveillance.orgRubella infections in pregnancyOverall, 160 rubella infections in pregnancy werereported, of whom 147 were classified as confirmed,nine as probable and four as possible cases accordingto the modified version [10] of the 2012 EU rubella casedefinition [13] (Table 1). An additional 105 reports wereunclassified because of incomplete data; these wereexcluded from the analysis.00.5elimination (2.9, 1.8 and 3.2 case per 100,000 livebirths respectively).The median age of the 107 cases for whom informationwas available was 26 years (range: 16–46). Of these,23 were foreign-born.Only three women reported being vaccinated againstrubella, but this information was documented in a vaccination card for only one of the cases; the woman hadreceived two vaccine doses in her country of origin, atthe age of three and 13 years. However, she was foundto have been susceptible to the infection at preconception screening.Of the 107 cases for whom information on gestationalage at infection was available, 45 acquired rubelladuring the first trimester of pregnancy; 69/148 weremultiparous. Only 38/126 women had had a rubellaantibody test before pregnancy; among them, 32 statedthat they had been found to be susceptible, three wereimmunised and the test result was missing for threewomen (Table 2).Characteristics of Italian and foreign-born infectedwomen were similar but the proportion of multiparouswomen was significantly higher among the latter, compared with Italian women (68.2 vs 43.2, p 0.0304).Notification forms of 51 of the 160 women with rubellainfections in pregnancy were not received. In these 51cases, information on demographic characteristics,clinical manifes

toless than one case per 100,000 live births by the end of 2015. We report national surveillance data for congenital rubella and rubella in pregnancy from 2005 to 2013. A total of 75 congenital rubella infections were reported; the national annual mean inci

Related Documents:

Congenital femoral deficiency and fibular hemimelia are rare and complex congenital disorders of the lower limb, with an incidence of approximately one in 50,000 live births for congenital femoral deficiency [12, 19, 30] and between 7.4 to 20 per million live births [6, 11, 33] for fibular hemimelia. Congenital femoral deficiency and fibular

Outbreak vs Pseudo-outbreak Outbreak generally refers to situations in which there is clinical disease or clinically relevant culture results. Pseudo-outbreak is generally used to refer to situations in which there is a rise in positive culture

Arrhythmias in congenital heart disease: a position paperof the European Heart Rhythm Association (EHRA), Association for European Paediatric and Congenital Cardiology (AEPC), and the European SocietyofCardiology (ESC) Working Group on Grown-up Congenital Heart Disease, endorsedby HRS, PACES, APHRS, and SOLAECE

Congenital anomalies of the optic nerve Manuel J. Amador-Patarroyo, Mario A. Pérez-Rueda , Carlos H. Tellez Abstract Congenital optic nerve head anomalies are a group of structural malformations of the optic nerve head and surrounding tissues, which may cause congenital visual impairment and blindness.

Congenital heart disease after childhood: an expanding patient population. 22nd Bethesda Conference, Maryland, October 18-19, 1990. . Repaired congenital heart disease with residual shunts or valvular regurgitation at the site or . Update on Adult Congenital Heart Disease

1.2. Indicator-Based Surveillance (IBS) and Event-Based Surveillance (EBS) Approaches Used to Detect Diseases, Conditions and Events 52 1.3. Standard Case Definitions 52 1.4 Establish Event-Based Surveillance (EBS) at all levels 57 1.5 Update LGA Procedures for Surveillance and Response 58 1.6 Role of the laboratory in surveillance and response 61

Electronic Integrated Disease Surveillance System supports different types of surveillance: passive surveillance (case-based and aggregate) is available for human and veterinary diseases, active surveillance is supported for veterinary disease, vector surveillance is planned to be released in the next version.

American Revolution in 1788, when he and his contemporaries were still riding the wave of patriotism emanating from their fresh victory over the British Empire. These histories, marked by American prominence on a global scale, were written into the early 20th century as American patriotism was reinforced by further victory in the War of 1812 and by western expansion. By the latter point, they .