An outbreak of rubella among hospital personnel

Post-exposure passive immunisation for preventing rubella and congenital rubella syndrome

BACKGROUND

Control of rubella is desired because infection in early pregnancy can result in miscarriage, foetal death or congenital abnormality. Primary studies examining the effectiveness of immunoglobulins for post-exposure prophylaxis of rubella have small sample sizes and varying results. National public health recommendations suggest a degree of effectiveness.

OBJECTIVES

To assess the effectiveness of intramuscular injection or intravenous infusion of polyclonal immunoglobulins of human sera or plasma origin for preventing rubella and congenital rubella syndrome when administered to exposed susceptible people before the onset of disease.

SEARCH METHODS

We searched CENTRAL (2014, Issue 7), MEDLINE (1946 to August week 2, 2014), EMBASE (1974 to August 2014), CINAHL (1981 to August 2014), LILACS (1982 to August 2014) and Web of Science (1955 to August 2014). We searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry on 16 October 2014. We searched the reference lists of relevant retrieved reviews and studies and identified national public health guidelines.

SELECTION CRITERIA

For the outcome 'preventing cases of rubella', we included randomised controlled trials (RCTs) and quasi-RCTs. We found several studies addressing this outcome where the design was a controlled clinical trial (CCT) (with exposure to rubella virus controlled by the investigators) but the method of allocation of participants to groups was not reported. We found an alternative report of one of these studies that indicated participants were assigned to groups randomly. We therefore included such studies as meeting criteria for RCTs or quasi-RCTs and undertook sensitivity analyses. For the outcomes, 'congenital rubella infection' and 'congenital rubella syndrome', we included RCTs, quasi-RCTs and prospective controlled (cohort) studies. Participants were necessarily susceptible and exposed to rubella. Polyclonal immunoglobulins derived from human sera or plasma must have been administered intramuscularly or intravenously as the only intervention in at least one group.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by The Cochrane Collaboration.

MAIN RESULTS

We included 12 studies (430 participants) in the review: seven RCTs and five CCTs where it was not clear whether participants were randomly allocated to groups. We did not include any unpublished studies. Participants included children and adults of both sexes. Only one study included pregnant women. All studies were conducted in high-income countries.The quality of the 11 studies in the initial meta-analysis was moderate, although we classified no study as having a low risk of bias on all criteria.We included 11 studies in the initial meta-analysis of gamma-globulin (concentrated polyclonal immunoglobulins) versus control (saline or no treatment) for rubella cases. The result favoured the intervention group (risk ratio (RR) 0.61, 95% confidence interval (CI) 0.45 to 0.83) but was heterogenous (Chi² test = 36.59, df = 10 (P value < 0.0001); I² statistic = 73%). Heterogeneity was explained by subgrouping studies according to the estimated volume of gamma-globulin administered per pound of bodyweight and then removing those studies where the intervention was administered more than five days after participant exposure to rubella (post hoc analysis). The test of subgroup differences demonstrated heterogeneity between subgroups according to our protocol definition (P value < 0.1; I² statistic > 60%) and there appeared to be greater effectiveness of the intervention when a greater volume of gamma-globulin was administered ('0.027 to 0.037 ml/lb' RR 1.60 (95% CI 0.57 to 4.52); '0.1 to 0.15 ml/lb' RR 0.53 (95% CI 0.29 to 0.99); '0.2 to 0.5 ml/lb' RR 0.20 (95% CI 0.04 to 1.00)).None of the studies reported the outcome 'congenital rubella infection'. One included study reported on congenital rubella syndrome, with no cases among participants who were fewer than nine weeks pregnant at enrolment and who were randomised to one of two gamma-globulin groups ('high' or 'low' rubella titre). However, the study did not report how congenital rubella syndrome was measured and did not report the length of follow-up according to intervention group. This study did not include a non-treatment group.No included study measured adverse events.

AUTHORS' CONCLUSIONS

Compared to no treatment, polyclonal immunoglobulins seem to be of benefit for preventing rubella. The available evidence suggests that this intervention may be of benefit up to five days after exposure, and that effectiveness is dependent on dose. Considering the attack rate for rubella cases in the control group of the highest volume gamma-globulin subgroup (333 per 1000), the absolute risk reduction (calculated from the RR) for this volume of gamma-globulin was 266 (95% CI 0 to 320) and the number needed to treat to benefit is four (95% CI 3 to incalculable).The included studies did not measure rubella-specific antibodies in the immunoglobulin products used in a standard way and thus estimation of the dose of rubella-specific antibodies in international units administered was not possible. As the concentration of rubella-specific antibodies in today's polyclonal immunoglobulin products may vary from those products used in the studies in the review, the volume required per pound of bodyweight to produce similar results may also vary.There is insufficient evidence to make direct conclusions about the effectiveness of polyclonal immunoglobulins for preventing congenital rubella syndrome. This is an area requiring further research.

Rubella in Hospital Employees

In early 1982, 15 hospitals in Los Angeles County reported one or more serologically confirmed rubella cases among their employees. Secondary cases occurred at eight hospitals; overall, 56 cases were identified among employees, of which 28 were serologically confirmed. Testing of 2,061 employees revealed 1,770 (86%) with detectable antibody. A survey of 83 hospitals offering obstetrical services indicated only 42% (33 of 78) had an established rubella screening policy. Based on the results of this survey, the Los Angeles County Department of Health Services published recommendations for hospital rubella screening and immunization policies.

Healthcare providers as sources of vaccine-preventable diseases

Vaccine-preventable infectious diseases may be introduced into the healthcare setting and pose a serious risk to vulnerable populations including immunocompromised patients. Healthcare providers (HCPs) are exposed to these pathogens through their daily tasks and may serve as a reservoir for ongoing disease transmission in the healthcare setting. The primary method of protection from work-related infection risk is vaccination that protects not only an individual HCP from disease, but also subsequent patients in contact with that HCP. Individual HCPs and healthcare institutions must balance the ethical and professional responsibility to protect their patients from nosocomial transmission of preventable infections with HCP autonomy. This article reviews known cases of HCP-to-patient transmission of the most common vaccine-preventable infections encountered in the healthcare setting including hepatitis B virus, influenza virus, Bordetella pertussis, varicella-zoster virus, measles, mumps and rubella virus. The impact of HCP vaccination on patient care and current recommendations for HCP vaccination against vaccine-preventable infectious diseases are also reviewed.

Are healthcare workers immune to rubella?

Healthcare workers (HCW) have high exposure to infectious diseases, some of which, such as rubella, are vaccine-preventable. The aim of this study was to determine the immunity of HCW against rubella. We performed a seroprevalence study using a self-administered survey and obtained blood samples to determine rubella Immunoglobulin G (IgG) antibody levels in HCW during preventive examinations by five Primary Care Basic Prevention Units and six tertiary hospitals in Catalonia. Informed consent was obtained. IgG was determined using an antibody capture microparticle direct chemiluminometric technique. The odss ratio (OR) and 95% confidence intervals (CI) were calculated. Logistic regression was made to calculate adjusted OR. Of 642 HCW who participated (29.9% physician, 38.8% nurses, 13.3% other health workers and 18% non-health workers), 46.6% were primary care workers and 53.4% hospital workers. Of total, 97.2% had rubella antibodies. HCW aged 30-44 years had a higher prevalence of antibodies (98.4%) compared with HCW aged<30 years (adjusted OR 3.92; 95% CI 1.04-14.85). The prevalence was higher in nurses than in other HCW (adjusted OR: 5.57, 95% CI 1.21-25.59). Antibody prevalence did not differ between females and males (97.4% vs. 97.1%, P 0.89), type of center (97.7% vs. 96.8%, P 0.51) or according to history of vaccination (97.3% vs. 96.8%, P 0.82). Seroprevalence of rubella antibodies is high in HCW, but workers aged<30 years have a higher susceptibility (5.5%). Vaccination should be reinforced in HCW in this age group, due to the risk of nosocomial transmission and congenital rubella.

Immunization programs for infants, children, adolescents, and adults: clinical practice guidelines by the Infectious Diseases Society of America

Evidence-based guidelines for immunization of infants, children, adolescents, and adults have been prepared by an Expert Panel of the Infectious Diseases Society of America (IDSA). These updated guidelines replace the previous immunization guidelines published in 2002. These guidelines are prepared for health care professionals who care for either immunocompetent or immunocompromised people of all ages. Since 2002, the capacity to prevent more infectious diseases has increased markedly for several reasons: new vaccines have been licensed (human papillomavirus vaccine; live, attenuated influenza vaccine; meningococcal conjugate vaccine; rotavirus vaccine; tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis [Tdap] vaccine; and zoster vaccine), new combination vaccines have become available (measles, mumps, rubella and varicella vaccine; tetanus, diphtheria, and pertussis and inactivated polio vaccine; and tetanus, diphtheria, and pertussis and inactivated polio/Haemophilus influenzae type b vaccine), hepatitis A vaccines are now recommended universally for young children, influenza vaccines are recommended annually for all children aged 6 months through 18 years and for adults aged > or = 50 years, and a second dose of varicella vaccine has been added to the routine childhood and adolescent immunization schedule. Many of these changes have resulted in expansion of the adolescent and adult immunization schedules. In addition, increased emphasis has been placed on removing barriers to immunization, eliminating racial/ethnic disparities, addressing vaccine safety issues, financing recommended vaccines, and immunizing specific groups, including health care providers, immunocompromised people, pregnant women, international travelers, and internationally adopted children. This document includes 46 standards that, if followed, should lead to optimal disease prevention through vaccination in multiple population groups while maintaining high levels of safety.

An outbreak of rubella in a hilly district of Kangra-Chamba, Himachal Pradesh, India, 2006

OBJECTIVE

Rubella is a minor disease that often goes unnoticed and seldom results in significant morbidity and mortality. However, the infection among pregnant women is associated with serious consequences for the fetus. On 5th November, 2006, a local community leader reported cases of fever with rash in three villages of Chamba district to Shahpur hospital. No death was reported. We investigated the outbreak as a suspected outbreak of measles with the objectives of confirming diagnosis, estimating the magnitude of outbreak and formulating recommendations for control and prevention.

METHODS

We defined a case of the rubella as occurrence of fever with rash in any resident of these three villages between 20th October to 9th December, 2006. We line listed the cases and collected information on age, sex, residence, date of onset, symptoms, signs, treatment history, traveling history, vaccination status and pregnancy status. We described the outbreak by time, place and person characteristics. Sera of a sample of case patients were tested for IgM antibodies to measles and later rubella viruses.

RESULTS

We identified 61 cases in three villages - 39 cases in Hattli, 17 in Thulel and 5 in Dramman. The overall attack rate (AR) was 8.7%. Sex specific AR for males was 10% and females 7.4%. All case patients were less than 20 years of age and the attack rate was highest in the age group 11-20 years (median age 12 years). The index case was traced in Hattli Bengali slum and occurred on 20th October 2006 where majorities (41%) of the cases were reported. No pregnant woman was found to be affected. The number of cases peaked on 19th November and the last case was reported on 9th December 2006. Of 61 case-patients, 50 (82%) were immunized against measles while proportions of children vaccinated for measles were 96% (672/700) and none of them were immunized against rubella (including two (3%) who had MMR immunization privately). Out of six blood samples tested, all tested negative for measles IgM antibodies but four were positive for IgM antibodies to rubella. Only 36% (22/61) of the cases took the treatment from modern system of medicine.

CONCLUSION

An outbreak of rubella was confirmed and was possibly due to the frequent traveling of Bengali colony patients to other areas for selling the food items. We advised the local health authorities to provide MMR vaccination to the unexposed and energetic IEC in three affected and neighboring villages.

Prevalence of serological markers against measles, rubella, varicella, hepatitis B, hepatitis C, and human immunodeficiency virus among medical residents in Mexico

BACKGROUND

Vaccination programs among health care workers are based on seroprevalence studies, which seldom include medical residents or students. The objective of this study was to determine the seroprevalence of antibodies against measles, rubella, varicella, hepatitis B (HBV), hepatitis C (HCV), and human immunodeficiency virus (HIV) among medical residents.

METHODS

This study was designed as a prospective survey. A self-reported questionnaire was used to obtain the information. Serum samples were tested for antibodies by commercial immunoenzymatic assays. Statistical analysis was descriptive; history of exposure was evaluated as a diagnostic test and sensitivity, specificity, and predictive values were calculated according to Bayes theorem.

RESULTS

Eighty-nine residents were included, the median age was 27 years, and 58 (65.2%) were female. Seventy-two (79.7%) had been vaccinated against HBV, but vaccination was complete in only 30/72 (41.6%). All were positive for measles and varicella, with the exception of one case for each. The serology for rubella was negative in 12 residents (10 women). Three residents had anti-core against HBV, with negative surface antigen. One positive case for HCV was confirmed by Western blot. All were negative for HIV. A history of prior varicella had a 100% positive predictive value; in contrast, the negative predictive value was quite low (7%).

CONCLUSIONS

Negative serology for rubella among women and incomplete vaccination against HBV support the implementation of vaccination programs in medical schools in Mexico.

Exposure Workups

Exposure workups are an important responsibility for infection control personnel. A well-designed plan for investigating exposures, which includes appropriate algorithms, will enable infection control personnel to evaluate exposures rapidly and consistently so that nosocomial transmission is minimized. Infection control personnel should use their own data to develop policies and procedures that suit the needs of their facility. After they have imple-merited the plan, infection control personnel should continue to collect data on exposures so they can continuously improve their performance.

Primary prevention and rubella immunity: overlooked issues in the outpatient obstetric setting

OBJECTIVE

To determine the knowledge of rubella immune status among practicing obstetrician-gynecologists in the United States and of rubella immunity policies covering healthcare workers in the obstetric-care office setting.

DESIGN

Mailed survey questionnaire, August through December 1994.

SETTING

Physicians from multiple-practice sites including private office, public institution, university or teaching hospital, and closed panel health maintenance organization settings.

PARTICIPANTS

3,302 practicing obstetrician-gynecologists, chosen by a systematic random sample from the AMA national physician database.

MAIN OUTCOME MEASURES

Participants were defined as rubella immune if they reported knowledge of prior rubella vaccination or positive antibody titer. Knowledge of a policy for documenting rubella immunity among employees in the office-based practice setting also was assessed.

RESULTS

Questionnaires were returned from 50% (1,666) of the 3,302 surveyed, and 96% (1,599) were evaluable. Approximately 20% (304/1,599) of the responding obstetrician-gynecologists did not have knowledge of documented rubella immunity, and the majority of office-based practices did not require documentation of rubella immunity in the following groups: physicians, 66% (723/1,094); office nurses, 62% (666/1,070); and other office staff, 69% (728/1,063). Sixty-two percent (993/1,599) of responding physicians had individual rubella serologies performed, with 916 known to be positive, 53 reported negative, and 24 reported unknown. Fifty-seven percent (918/1,599) reported receiving monovalent rubella vaccine or trivalent measles-mumps-rubella vaccine. Multiple logistic regression analysis revealed the following to be independent predictors of positive immune status among respondents: female gender (odds ratio [OR], 2.4; 95% confidence interval [CI95], 1.8-3.1), medical school graduation since 1980 (OR, 2.6; CI95, 2.0-3.3), providing obstetric or fertility services (OR, 1.5; CI95, 1.2-1.9), and group practice setting (> or = 5 physicians; OR, 1.2; CI95, 1.1-1.4).

CONCLUSIONS

Nationally, nearly one of every five practicing obstetricians may not have documented rubella immunity, and the majority of office-based practices have no system for assuring such immunity. Rubella immunity should extend beyond the hospital setting, with consideration for requiring rubella immunity as a condition for employment. Methods for effective implementation and documentation of current guidelines need to be addressed, particularly in the office setting.

Measurement of serum rubella antibody titers in Korean children, female adolescents, and pregnant women

IgG antibody titers to rubella virus in serum of 322 nuchal cord blood, 1,473 children, and 1,103 reproductive and pregnant women were detected in Soonchunhyang University Hospital in Korea. Positive rate of IgG antibody to rubella virus was 86.3% (278/322) in nuchal cord blood, 68.0% (991/1,458) in children. The IgG antibody from the mother disappeared between the 7th to 11th month after birth, and then the positive rate increased as age increased. In the reproductive age group including pregnant women, positive rate of IgG antibody was 81.8% (894/1,103). Therefore, it was known that there was a possibility that 18.9% of this group would be attacked with rubella in Korea.

Increasing rubella seronegativity despite a compulsory school law

To determine if lower rubella susceptibility persisted five to seven years after immunization legislation, we retrospectively reviewed the serologic status of 341 outpatients from 1985 to 1987 in an inner-city school age population. Seronegative rates increased significantly during the two-year study period from 4.2 to 24.5 percent (17 percent overall). (Beta = 6.8%, 95% CI = 3.3, 10.3). Charts were reviewed for 57 of 58 seronegative and 114 seropositive controls. Estimates were then made to the population of 341 subjects. Those with documented rubella immunization had a seronegative rate of 13 percent compared to 19 percent if the immunization status was unknown. For patients who received care in our clinic for less than two years, 32 percent were seronegative compared to 10 percent for those treated greater than or equal to 2 years (odds ratio = 0.31, 95% CI = 0.16, 0.60). Among patients immunized in 1977 or 1978, 33 percent were seronegative compared to 7 percent immunized at other times (OR = 0.21, 95% CI = 0.07, 0.63). Factors associated with increased rubella seronegativity include immunization in 1977 or 1978 and lack of continuity of care in our clinic. Much of the increase remains unexplained.

The six classic childhood exanthems: a review and update

The six classic exanthems of childhood have many similar physical findings. Familiarity with them, as well as with important laboratory data, allows early and accurate diagnosis of these often confusing diseases. Recognition and treatment of possible sequelae also improve prognosis. In this review we discuss epidemiology, etiology, clinical manifestations, pathologic and laboratory findings, differential diagnosis, therapy, and prevention of each of the exanthems.

Determination of immune status to measles, rubella, and varicella-zoster viruses among medical students: assessment of historical information

We examined the serological susceptibility of entering medical students to measles, rubella, and varicella-zoster (VZV) viruses over a four-year period. Serological results were then compared to historical information to ascertain whether undocumented histories of disease or vaccination could be used to identify students who may not need serological testing. For measles, historical information was of no benefit in predicting immunity. For VZV and, to a greater extent, rubella, a higher seropositive rate was seen in students claiming a positive history.

[Immunity to rubella: seroepidemiologic survey at hospitals, State of São Paulo-Brazil]

Os títulos de anticorpos no soro pela reação de inibição da hemaglutinação para rubéola, empregando o caulim para adsorção de beta-lipoproteínas bloqueadores inespecíficos, foram determinados em funcionárias do Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo (Brasil), no período de 1982-1983 e confrontados com idade, cor, unidade hospitalar, local, cargo, tempo de emprego, antecedentes de rubéola ou comunicante na vigência ou não de gravidez. Participaram do estudo 1.886 funcionárias (88,9% de 2.121) tendo títulos com a distribuição: 9,6% <10,1,3% -10,3,5% -20, 5,8% -40,10,6% -80, 20,7% -160, 27,8% -320,12,6% -640, 7,3% -1.280 e 0,8% -2.560. Houve fraca associação entre títulos e quaisquer das variáveis de confrontação (P <FONT FACE=Symbol>@</font> 0); 87,1% das funcionárias negaram antecedentes de rubéola e destas 73,9% tiveram títulos > 20; 57,6% negaram ser comunicantes e apresentaram títulos <FONT FACE=Symbol>³</FONT> 20; em 1,1% que referiram história de rubéola, os títulos foram <FONT FACE=Symbol>£</FONT>20; 97% negaram contacto com rubéola durante a gravidez. Houve somente um caso de malformação congênita após rubéola no primeiro trimestre da gravidez. Das 351 funcionárias sãs, e com títulos <FONT FACE=Symbol>³</FONT> 640, em 9,4% demonstrou-se IgM específica. Não foi notada flutuação significativa dos títulos em diferentes amostras em período de observação de até um ano. Conclui-se que a maioria das funcionárias é imune à rubéola (título > 20) independente de quaisquer parâmetros analisados; a presença de IgM específica em algumas funcionárias pode ser compatível com doença subclínica. Este inquérito foi considerado útil na orientação de funcionárias grávidas comunicantes de caso suspeito ou confirmado de rubéola, e para as não-grávidas e não-imunes a indicação da profilaxia pela vacina.

The risk of infection in anaesthetic practice

Infectious hazards to anaesthesia personnel are real but the appropriate use of immunization, universal blood and body fluid precautions, and respiratory precautions where appropriate, should minimize the risk of infection at work. In particular, the resistance of physicians to immunization, especially to hepatitis B, needs to be changed. Protection against other blood-borne pathogens for which immunization is not available, such as HIV, may also depend on the willingness of anaesthesia personnel to accept and carry out recommendations for universal blood and body fluid precautions. Regulatory agencies and compensation boards are likely to look closely at adherence to established guidelines when determining benefits for work-related infections. Complaints that the routine use of gloves interferes with anaesthetic practice are frequent but unacceptable in the current climate and it behooves the profession to ensure that compliance with currently accepted infection control guidelines is complete.

Combined testing for antibodies to rubella non-structural and envelope proteins sentinels infections in two outbreaks

Two separate outbreaks of Rubella occurred in Hamilton, Ontario, Canada, 7 yrs apart, with a peak incidence for both in the month of April. A total of 138 cases, 51 in 1978 and 87 in 1985, was observed, the majority being in adolescents and young adults 15-25 years of age. Cases were diagnosed by the presence of Rubella IgM antibody or the combination of a negative passive hemagglutination (Rubacell-Abbott) and a positive enzyme immunoassay (EIA) or hemagglutination inhibition (HI) test on a single serum or by seroconversion for Rubella IgG antibody. Routine screening of sera with the Rubacell test, which measures antibodies to nonstructural rubella proteins together with HI or EIA testing of the negatives, served as a sentinel for rubella infection in the community during both outbreaks. Rubacell antibodies usually appeared 2-3 wk after onset of infections, and when present contained either or both IgG and IgM. Only 8/103 cases had a history of Rubella vaccination. Two of three products of conception yielded rubella virus in cell culture.

Measles (rubeola) infection in a hospital setting

Although acquisition of measles infection in medical facilities is well documented, hospital outbreaks have been rare. During a recent community measles epidemic, one patient and four employees of the Mary Hitchcock Memorial Hospital developed the disease. Two of the employees were born before 1956, the year recommended by the Centers for Disease Control as an appropriate cutoff year for routine measles vaccination. Screening of 456 hospital employees for measles immunity demonstrated a 5% incidence of susceptibility in 135 individuals born between 1950 and 1956. This experience demonstrates the significant potential for the spread of a community measles outbreak into the hospital setting. Because of the high transmissibility of this disease and its potentially serious consequences in hospitalized patients, we suggest that all hospital employees born after 1950 who have significant patient contact should have documented immunity against measles.

Nosocomial outbreak of hand-foot-and-mouth disease among operating suite personnel

In the fall of 1983 an outbreak of hand-foot-and-mouth disease occurred in a large urban hospital. The outbreak began among surgical nurses confined to one area of the operating suite and appeared to spread by direct contact to personnel working in the other areas. No cases were diagnosed among hospital patients. There was no evidence to support an ongoing community epidemic as only three of 98 physicians surveyed had seen hand-foot-and-mouth disease in their practices, and none occurred among family members of 94 unaffected employees. The outbreak resulted in 82 lost workdays at an estimated cost to the hospital of $5,676. Existing infection control guidelines do not address the issue of transmission of hand-foot-and-mouth disease from hospital personnel to patients; our experience suggests that the risk of transmission, at least in the operating suite environment, may be greater for other personnel than for patients.

Nosocomial rubella--consequences of an outbreak and efficacy of a mandatory immunization program

An outbreak of rubella in a large metropolitan hospital is described. Nineteen cases among employees and three secondary cases in family members occurred. Nosocomial cases occurred among the 3,900 employees of an adult medical-surgical unit where a voluntary program of rubella immunization was in effect. No cases occurred among the 1,400 employees of the women's and pediatric units with mandatory policies, despite interfacility and community exposure. Ten pregnant women were among the 377 contacts of the cases. Five were sero-negative to rubella. Two who developed clinical rubella, one asymptomatic sero-conversion and one other, all elected to terminate their pregnancies. The remaining woman, exposed in her third trimester delivered a normal infant. We conclude a policy requiring new employees to be rubella immune is more effective in preventing nosocomial rubella than a voluntary program and is desirable in view of the potential consequences of an outbreak to pregnant employees.

Rubella screening and vaccination follow-up by a hospital employee health office

The data in the present study indicate two major points. One is that the facility under question has an unusually low rate of rubella susceptibility. The other is that the referral of seronegative employees to an outside agency for vaccination (in this case the local CHD) is not nearly as effective, with respect to employee compliance, as an in-house program. Despite the added immediate cost to the hospital for administering the vaccine, the possibility of employee-to-patient transmission of the rubella virus poses the threat of a much higher future cost. It is suggested that facilities that do not currently have an in-house rubella vaccination program should reevaluate the effectiveness of their programs.

Identification and immunization of medical students susceptible to measles and rubella: a nationwide survey

Responses to a questionnaire regarding student immunization from 101 of 129 allopathic medical schools (78.3 per cent) indicated that 16 schools (15.8 per cent) do not request historical information or perform serologic tests on their students. Only 47 of 85 schools (55.3 per cent), who do screen students, utilize antibody titers.

A rubella outbreak among dental students: description of the outbreak and analysis of control measures

From February to April 1982, rubella was diagnosed in 17 Washington University dental students. The affected students represented 4.8% of all dental students and 21% of susceptible students. Because a high likelihood of rubella transmission was perceived, three adjacent university hospitals undertook an emergency program to ensure immunity to rubella in all personnel. The program reached 84.6% of all target personnel, but only 36% of physicians (p less than 0.001). We estimated that the program increased the level of rubella immunity from 92.2% to 98.1%, at a total cost of $140,274 of which $29,990 was in excess of ordinary expenditures. Our experience indicates that schools training health professionals face the possibility of rubella outbreaks unless they ensure rubella immunity in all students. The experience also supports the value of ongoing programs to ensure rubella immunity in hospital personnel. Without such programs, hospitals may be forced to undertake emergency programs that are likely to be disruptive and expensive and may have relatively little immediate measurable impact.

Sentinel Health Events (occupational): a basis for physician recognition and public health surveillance

A Sentinel Health Event (SHE) is a preventable disease, disability, or untimely death whose occurrence serves as a warning signal that the quality of preventive and/or therapeutic medical care may need to be improved. A SHE (Occupational) is a disease, disability, or untimely death which is occupationally related and whose occurrence may: 1) provide the impetus for epidemiologic or industrial hygiene studies; or 2) serve as a warning signal that materials substitution, engineering control, personal protection, or medical care may be required. The present SHE(O) list encompasses 50 disease conditions that are linked to the workplace. Only those conditions are included for which objective documentation of an associated agent, industry, and occupation exists in the scientific literature. The list will serve as a framework for developing a national system for occupational health surveillance that may be applied at the state and local level, and as a guide for practicing physicians caring for patients with occupational illnesses. We expect to update the list periodically to accommodate new occupational disease events which meet the criteria for inclusion.

Rubella screening and immunization of health care personnel: Critical appraisal of a voluntary program

At our health care center 1161 personnel and students were offered rubella antibody testing. Ninety-two percent were serologically screened or had been previously immunized or previously proven seropositive. Males were more likely to refuse serologic screening than females (p less than 0.01). Sixteen percent of the seroscreened individuals were found seronegative to rubella. Eighty-five percent of seronegative women less than or equal to 24 years old accepted immunization, as compared to 62% of older females and 55% of all males (p less than 0.01). The total cost of the program was over $11,000. Literature and data review failed to support an increased risk of rubella transmission and/or major consequences to pregnant patients in the health care setting as compared to the community. Voluntary rubella immunization is well received by seronegative young women. Programs for immunization of other health care personnel are unlikely to decrease the number of cases of congenital rubella, are costly, and are not well accepted. Education and immunization of all young susceptible women remain the best methods to substantially decrease the incidence of congenital rubella in a cost-effective manner in the near future.

Factors influencing participation in a rubella vaccination program

During the course of a 7-day voluntary rubella vaccination program conducted at a large community-teaching hospital, 718 hospital workers were vaccinated, an overall vaccination rate of 29%. During and after the vaccination campaign, physicians, employees, and students were surveyed as to their reasons for accepting or rejecting rubella vaccine. Prior to the campaign few hospital workers realized that rubella vaccination was of importance in their case. Although paycheck notices, newsletters, and poster displays were all effective in publicizing the campaign, hospital workers most frequently cited discussions with other workers as the major factor leading to their acceptance of vaccination. The belief that a history of rubella, diagnosed clinically, was adequate assurance of immunity was common among physicians and employees and was the major obstacle to greater success in the campaign. Vaccine reactions were infrequent and mild and did not lead to excessive employee absenteeism.

Rubella immunity in older children, teenagers, and young adults: a comparison of immunity in those previously immunized with those unimmunized

Because rubella continues to be a common illness in adolescents and young adults and because it has been suggested that booster rubella immunizations should be performed, we studied antibody prevalence in 459 predominantly adolescent patients in a pediatric group practice. Rubella antibody (PHA titer greater than or equal to 1:13.5) in previously immunized patients (89.6% of 385) was significantly more common than antibody in unimmunized patients and patients with a questionable history of immunization (70.3% of 74) (P less than 0.005). Twenty-three seronegative patients with a documented history of prior immunization were reimmunized and 22 had an IgG (secondary) antibody response and only one an IgM (primary) antibody response. Since all but one of our patients with previous immunization had a secondary immune response following revaccination, it seems likely that the level of protection in previously vaccinated individuals is considerably greater than 90%. Attention today should be directed at finding and immunizing unvaccinated teenagers and young adults and not in major booster vaccine programs.

Rubella susceptibility in inner-city adolescents: the effect of a school immunization law

In order to improve the immune status of girls in our medical clinic, we conducted a prospective sero-survey to identify susceptibles and developed a system for vaccinating non-immune girls. Over an 18-month period, 481 inner-city adolescents were screened. Susceptibility rate defined by a titer less than 1:8 was 12 per cent and did not differ significantly with regard to age or race. Nine months into the study period, the State of Wisconsin enacted a "no immunization-no school" law. The susceptibility rate dropped from 22 per cent prior to the enactment of the law, to 5 per cent after. Of the 60 girls identified as susceptible, 54 (90 per cent) kept their follow up appointments for vaccinations. Enforced state immunization laws appear to be effective in lowering rubella susceptibility.

Rubella outbreak in a prenatal clinic: management and prevention

An obstetrician and two staff members developed rubella and exposed 56 susceptible pregnant women in a large prenatal and family planning clinic. Two women (3.6%) developed rubella at 27 and 38 weeks' gestation and delivered uneventfully. Sixteen hundred clinic and hospital employees were tested, with 79% of the total and 48 of 59 (81.4%) OB/GYN personnel showing prior infection and/or immunity (HAI titer greater than or equal to 1:8). Of those susceptible, all obstetrical and most other personnel were vaccinated and removed from high risk areas until immune. Our management of a rubella outbreak and recommendations on hospital and clinic policy to avoid potential health problems are discussed.