Don't risk your baby

By Hiranthi Fernando

An epidemic of Ru- bella can be ex- pected to occur in Sri Lanka in the year 2000 unless the ongoing immunization programme is a success. This was revealed at a seminar on Rubella and Rubella Immunization, organized by the Health Education Bureau this week.

Addressing media personnel at the seminar, Dr. Wimal Jayakuru, Director of the Epidemiology Unit said the incidence of Rubella also known as German Measles in Sri Lanka, increased between 1980 and 1994. In 1994, there was a high incidence of Congenital Rubella Syndrome in new born babies, caused by Rubella contracted by the mothers during pregnancy. Since an epidemic usually occurs every six to seven years, it is important to ensure that all females of child bearing age are vaccinated against Rubella, to avert such an epidemic in the millennium.

Rubella, an epidemic viral disease of mild course, was first discovered in 1841, following an outbreak in India. A close study of epidemics in Germany in the 19th Century gave rise to the popular name German Measles. Milder than Measles, Rubella is most commonly seen in older children and young adults. It would not be of much concern except for the effect the disease has on the unborn child, when pregnant mothers are infected by it. In 1941, an Australian ophthalmologist, Dr. N.M. Gregg discovered that Rubella contracted during early pregnancy, may lead to foetal defects especially of the eyes and heart. It was found that mothers who had been infected by Rubella during early pregnancy, produced babies with Congenital Rubella Syndrome, the main symptoms of which are eye diseases, deafness, heart disease and mental retardation. The virus causing Rubella was isolated in 1962.

During a major epidemic of Rubella in the United States in 1964 -1965, 15 million people were affected. 20,000 babies were born with Congenital Rubella syndrome. There were also a large number of still births and terminated pregnancies. It was seen that children born with CRS may manifest any of the following additional abnormalities such as growth retardation, encephalitis, glaucoma, liver and spleen enlargements, jaundice, thrombocytopenic purpura and lesions of the long bones. In fact it has been found that Rubella is capable of causing extensive damage to almost any organ of the infant's body. With the development of the Rubella vaccine in 1969, the incidence of CRS began to decline in the 1970s.

Dr. Jayakuru explained the agent of the disease is the Rubella virus which is present throughout the world in both developed and developing countries. Infection is by direct contact with infected persons, some of whom may show no symptoms whatsoever. Rubella can also be acquired from new born babies with CRS. The infectious period is about 14 - 20 days extending from about a week before the symptoms appear until two weeks after the symptoms. A CRS infected infant carries the infection for about a year after birth. Anyone can be susceptible to the disease. Human beings are the only carriers of Rubella.

Dr. Jayakuru says the best preventive is vaccination. It is advisable to avoid contact with those with skin rashes during pregnancy. However, it is often not possible to identify someone suffering from Rubella. Children can be immunized at 15 months or at the child bearing age. "Due to the increased incidence of Rubella in 1994, we started a programme in 1996, to immunize all females between 11 and 44 years of age,", she said. "Vaccines have been imported and health officials trained. Initially immunization campaigns commenced in three provinces, Western, Southern and Sabaragamuwa. In 1997, vaccines were distributed to all provinces."

The vaccines are usually not given during pregnancy and it is best to ensure that women get vaccinated before they get pregnant. Once the vaccination is given they are advised to avoid getting pregnant for a period of three months. However, Dr. Jayakuru dismissed fears that an unborn child could develop CRS if the mother is vaccinated during the pregnancy. "It is a theoretical risk," she said. "What one has to fear most is contracting Rubella if one is pregnant." Since the programme commenced, 462,035 women have been vaccinated. Of these only 169 became pregnant within three months. Following up on 51% of these cases, the number of infants born with congenital deficiencies was found to be nil.

"The symptoms of Rubella are similar to measles," said Dr. Sarath Silva, consultant Paediatrician, Lady Ridgeway Hospital. "It is usually mild in adults and 50% of the symptoms go unnoticed." Describing the symptoms, Dr. Silva said that the patient may feel a weakness in the body. Enlargement of the lymph glands behind the head, neck and ears may be seen. A fever lasts for about two or three days accompanied by headache and red eyes. A rash on face and chest may last three to five days.

"The inhibition of cell division is a dangerous factor of the virus," Dr. Silva said. "When the virus enters a pregnant mother, she can contract the disease. However, only 40% of the pregnant mothers realise they have got the disease. If she has not been immunized, the foetus gets affected. According to Dr.Silva, if the pregnancy is less than eight weeks, the foetus is likely to be aborted. During the first three months, the organs of the foetus get determined. If Rubella is contracted by the mother at this stage, the formation of the organs could get affected. Before 16 weeks of pregnancy, it is found that 60% - 80% of the foetuses are liable to contract CRS. After 20 weeks, the effects on the foetus would be less.

Speaking of infants born with Congenital Rubella Syndrome, Dr. Silva said these babies have a reduced birth weight which continues to be low. They do not gain weight easily. They may also develop eye diseases such as cataract, corneal opacities (partial blindness),glaucoma, and retinitis. The child's hearing could get affected and he may also show mental retardation. "CRS affects every organ," Dr. Silva said. The infant may therefore develop Pneumonia, Hepatitis, Reduction of Platelets, Diabetes and Immune Deficiency. They have no immunity to get rid of the virus which remains in the system for about twelve months.

Dr. Silva stressed that the dreaded Congenital Rubella Syndrome is a preventable disease. It can easily be prevented by immunizing the mothers before pregnancy. "It is the duty of every mother to get immunized," he said.

The Immunization programme which commenced in 1996 is now in progress island- wide, said Dr. Hiranthi de Silva, Director, Maternity & Child Health. The aim of the programme is to immunize every female between 11 and 44 years, which would be the child bearing age group. The immunization is being handled in two groups, 11 -15 years and 16 -44 years. Dr. de Silva explained that the 16 -44 age group need to be given some counselling as well. The purpose of this programme is to prevent infants being born with Congenital Rubella Syndrome," she said. "We have to ensure that every woman has received the vaccine before she becomes pregnant, preferably three months earlier. We have to prevent an epidemic in 2000."

According to Dr. Silva, school children are being vaccinated in Colombo as well as in the provinces. The vaccine has been distributed to all Health Department clinics and government hospitals. It will soon be distributed to private practitioners, to be administered free of charge. Mothers who have not been immunized before, are being vaccinated when they leave hospital after delivering babies, so that they will be better prepared for future pregnancies.

Mr. Nimal Siripala de Silva, Minister of Health and Indigenous Medicine, who also addressed the seminar, said the government is targeting a group of 4.6 million for immunization. All the necessary vaccines have been brought down at a cost of Rs.15/= per person. The funds needed for this programme have been set aside by the Treasury. By the end of this year, they aim to complete the programme in every school in the Colombo district and by the end of the next year, to achieve immunization of 95% - 100% of the target group. Minister De Silva said that an awareness programme conducted for the Free Trade Zone factories had proved to be a success. "We had a good response from the public and the administrators of the factories who gave time off from working hours for vaccination. We have done the needful on the part of the Ministry. The public must be made aware of the dangers of contracting Rubella during pregnancy and the importance of getting vaccinated. The cooperation and dedication of health officials are also needed to make it a success."

The aim of preventing CRS births would seem to be within reach since the Rubella vaccine provides immunity for life and so needs to be administered only once. If the MMR vaccine (Measles, Mumps, Rubella) is given to a child before the age of one year, the Rubella would need to be administered again later. However if either the MMR or Rubella vaccine is given after one year, the immunity lasts for life or throughout the child- bearing period. The vaccine is also given free of charge. So there is no reason why every woman of child bearing age should not get vaccinated before pregnancy. Congenital Rubella Syndrome is preventable by the simple administration of a vaccine which is now freely available. It should be the responsibility of every mother- to -be to ensure that her child is not exposed to the agonies of this disease.

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