Manual 18140467

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ISSN 0382-232X
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Canada Diseases
Weekly Report
Date of publication: 8 June 1991
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Rapport hebdomadaire des
maladies au Canada
JUL ·1 f3 1991
Date de publication: 8 juin 1991
Vol. 17-23
Contenu du present numaro:
Contained In this Issue:
Case Report: Non-01 Vibrio cholerae • Nova Scotia
115
Rapport de cas : Vibrio cholerae non-01 -Nouvelle-Ecosse
115
Rubella Surveillance to December 1990 ·England And Wales
116
Surveillance de la rubeole jusqu'en dt\cembre 1990 -Angleterre et Pays de Galles
116
Un rapport de cas
A Case Report
NON·01 VIBRIO CHOLERAE • NOVA SCOTIA
VIBRIO CHOLERAE NON·01 • NOUVELLE-ECOSSE
Vibrio cho/erae infection in Cariada is a rare disease. Most
infections are acquired during travel outside the country and are
imported. V. cholerae infections are classically caused by
toxin-producing 01 serotypes resulting in severe diarrhea, dehydration
and electrolyte imbalance. Non-01 serotypes of V. cholerae are
known to produce relatively mild self-limiting enteric infections, as
well as systemic diseases. We report here a case of enteric non-01
V. cholerae infection.
L'infection aVibrio cholerae est une maladie rare au Canada. La plupart
des infections sont contracrees !ors de voyages al' exterieur du pays et sont
importees. Les infections
cholerae sont en general causees par des
serotypes 01 produisant une toxine et provoquant une grave diarrhee, une
deshydratation et un desequilibre e]ectrolytique. Les serotypes non-01 de
cholerae sont reconnus pour causer des infections enteriques spontanement
resolutives relativement oonignes, de meme que des maladies systemiques.
Nous faisons ici etat d'un cas d 'infection enterique V. cholerae non-01.
Case Report
Rapport de cas
A 28-year-old male presented at a walk-in family practice clinic
complaining of diarrhea of 5 days' duration. He developed diarrhea
while vacationing in Mexico with some friends who also had diarrhea
but decided to be treated by local physicians at the resort. Our patient
had previously been in good health and could not associate the onset
of his diarrhea with any specific type of food. He admitted to eating a
variety of poultry and fish dishes. His diarrhea consisted of 5-6 loose
stools per day and he had mild accompanying abdominal discomfort.
He was not distressed or dehydrated and a physical examination was
unremarkable. A stool culture was ordered. He was prescribed
vibramycin 100 mg po twice daily but was lost to follow-up shortly
after his visit to the clinic and did not present to other physicians in
Nova Scotia or in the province to which he relocated.
Unjeune homme de 28 ans s'est presente dans une clinique sans
rendez-vous de medecine familiale en se plaignant d'avoir la diarrhee depuis
5 jours. 11 avait contracte cette diarrhee au cours de vacances au Mexique avec
quelques amis qui souffraient egalement de diarrhee, mais qui avaient decide
d'etre traites sur place par des mooecins de l'endroit. Notre patient etait
auparavant en bonne sante et ne pouvait associer l' apparition de sa diarrhee
la gestion d' aucun type d' aliments precis. II a signale avoir mange une variere
de plats contenant de la volaille et du poisson. II faisait des selles molles de 5
a 6 fois par jour et souffrait d 'un leg er malaise abdominal concomitant. Il
n' etait ni Souffrant, ni deshydrate et }'examen physique n' a rien revele de
remarquable. On a commande une coproculture et on lui a prescrit de la
vibramycine araison 100 mg par voie orale 2 fois par jour. Mais ii ne s 'est pas
presenre pour le suivi apres sa visite la clinique et n'a consul re aucun autre
medecin en Nouvelle-Ecosse ou dans la province ou ii s'est installe par Ia suite.
V. cholerae was isolated from the blood agar-ampicillin (30 mg/L)
plate routinely used for the detection of Aeromonas spp from stool
specimens. The isolate was beta-hemolytic, oxidase-positive,
fermentative, susceptible to 0/129, and grew in nutrient broth
supplememted with 0% and 1% NaCl, but failed to grow in 6%. It was
mannitol, sucrose, and Voges-Proskauer-positive, and caused
decarboxylation oflysine and ornithine; however, dihydrolysation of
arginine did not occur. Confirmation of the identification and
serotyping was performed at the National Laboratory for Enteric
Pathogens, Laboratory Centre for Disease Control, Ottawa.
cholerae a ete isole a partir de la plaquette de gelose au sang ampicilline
(30 mg/L) normalement utilisee pour la detection de Aeromonas spp a partir
d'echantillons de selles. L'isolat etait beta-Mmolytique, oxydase-positif,
fermentaire, sensible a 0/129, et croissait dans un bouillon de culture enrichi
0%et1 % de NaCl, mais non 6 %. Il etait positif dans des milieux
mannitol, sucrose et Voges-Proskauer et provoquait une decarboxylation de la
lysine et de l'ornithine; la dihydrolase-arginine demeurait cependant inactive.
La confirmation de I 'identification et du serotypage a ete effectuee nu
Laboratoire national pour !es pathogenes enteriques, au Laboratoire de Jutte
contre la maladie Ottawa.
Discussion
Analyse
Non-01 V. cholerae organisms are morphologically and
biochemically indistinguishable from 01 positive strains. They were
known as non-agglutinable (NAG) vibrios or non-cholerae vibrios
(NCVs). The ability of some V. cholerae strains to agglutinate !Ri~
somatic type 1 antiserum was first described by Gardner in 1935 .
He demonstrated at least 6 0 somatic serotypes of V. cho/erae and
Les organismes V. cholerae non-01 ne peuvent etre differencies, sur Jes
plans morphologique et biochimique, des souches positives 01. On Jes
designait comme des vibrions non agglutinables (NAG) ou vibrions non
choleriques (VNC). La capacite de certaines souches V. cholerae de
s'agglutiner dans un antiserum 0 sw1atique de type 1 a ete decrite pour la
premiere fois par Gardner en 1935 . Celui-ci a demontre au moins 6
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115
Canada
recognized that classical cholera disease was caused ahnost
exclusively by 01 positive serotypes. While not lmown to be
associated with specific disease patterns, non-01 serotypes are more
frequently associated with extraintestinal infections, particularly in
immunosuppI~fsed patients, e.g. septicemia, meningitis and
osteomyelitis . Bowel disease caused by NAGs is usually non-life
threatening and self-limiting. Electrolyte imbalance and
dehydration are rare.
serotypes somatiques 0 de v. cholerae et a etabli que le cholera classique
etait cause presque exclusivement par des serotypes positifs 01. Bien qu'ils
ne soient pas connus pour etre associes ades evolutions maladives
specifiques, les serotypes non 01 sont quand meme frequemment associes a
des infections extra-intestinales, notamment chez !es patients
immunodep~~f· p. ex., ceux qui souffrent de septicemie, de meningite et
d'osreomyelite .. La maladie intestinale causee par les NAG ne met
habituellement pas la vie en danger et est autoresolutive. Le desequilibre
electrolytique et la deshydratation sont rares.
The laboratory detection of enteric V. cholerae infection
requires use of selection/differential media, e.g. TCBS
(thiosulphate, citrate, bile-salt, sucrose agar). In our case V.
cholerae infection was not suspected and TCBS medium was not
used. However, despite notable salt tolerance, most NAGs grow
well on blood-containing media and our strain, being resistant to
ampicillin (MIC >32 µg/mL), grew on the blood agar-ampicillin
plate. NAG vibrio ampicillin lvlICs are variable and using media
othe~ than ~fBS is an unreliable method for their detection in stool
spec1IDens .
Pour detecter en laboratoire l 'infection enrerique aV. cholerae, il faut
utiliser des milieux selectifs/differentiels, p. ex., TCBS (thiosulphate,
citrate, sel biliaire, gelose sucrose). Dans le cas qui nous inreresse,
I' infection aV. cholerae n'etait pas soup~nnee et le milieu TCBS n'a pas
ere utilise. Toutefois, en depit d'une tolerance notoire au sel, la plupart des
NAG croissent bien clans des milieux contenant du sang et notre souche,
etant resistante al'ampicilline (lvlIC > 32 µg/mL), a crfi sur la plaque de
gelose au sang-ampicilline. Les lvlIC ampicilline des vibrions NAG sont
variables et le recours ades milieux autres que TCBS s 'aver~ ~ne methode
non fiable pour leur detection dans des. echantillons de selles 3 .
Mechanisms of disease production by NAGs are not well
understood. They are lmown to produce a variety of cholera-like
toxins, hemolysins, enterotoxins and cytotoxins. Not all strains
produce all toxins and geographic variations in toxin production by
NAG vibrios has been shown to occucl4 l. Most North American
cases of NAG enteric infections have been described from regions
bord%~ the Gulf of Mexico, including Mexican east-coast resort
areas ' , and it is suggested that diarrheal illness originating from
these areas should have TCBS cultures routinely performed on
stools.
Les mecanismes par lesquels les NAG provoquent la maladie ne sont
pas bien compris. On sait qu 'ils produisent une variete de toxines de type
cholera, des hemolysines, des enterotoxines et des cytotoxines. Toutes les
souches ne produisent pas toutes les toxines et des variations
geograpj-%ues clans la production de toxines par les vibrions NAG ont ete
signalees . La plupart des cas nord-arnericains d 'infection enterique a
NAG ont ete decrits dans les regions bordant le Golfe du ¥.ie~ique, y
compris les lieux de villegiature de la cote est du Mexique • . On suggere
de soumettre sysrematiquement les malades atteints de diarrhee provenant
de ces regions ades coprocultures sur TCBS.
Since this initial case was found, another case was detected,
again by isolating the organism from the blood agar-ampicillin
plate. This second patient also had a self-limiting gastrointestinal
episode but had no travel history outside the province of Nova
Scotia.
Depuis que le premier cas a ete observe, un autre a ere signale, encore
une fois par isolation de l' organisme sur une plaque de gelose au
sang-ampicilline. Ce deuxieme patient avait egalement connu un episode
gastro-intestinal spontanement resolutif, mais n' avait pas voyage hors de
Nouvelle-Ecosse auparavant.
References
1. Gardner AD, Venkatrarnan KV. The antigem of the cholera
group ofvibrios. J Hyg Camb 1935;35:262-82.
2. Morris }G, Black RE. Cholera and other vibrios in the United
States. N EnglJMed 1985;312:343-5.
3. Morris JG, Temy JH, Drusano GL. In vitro susceptibility of
patho¥enic Vibrio species of nonfloxacin and six other
antimicrobial agents. Antimicrob Agents Chemother
R9ferences
1. Gardner AD, Venkatraman KV. The antigens Qftbe cholera group Qf
1985;28:442-5.
4. FinchMJ, Valdespino JL, Wells JG, et al. Non-01 Vibrio
cholerae infection in Cancun, Mexico. Am J Trap Med Hyg
1987;36:393-7.
5. Safrin S, Morris G, Adams M, et al. Non-01 Vibrio cholerae
bacteraemia: case report and review. Rev Infect Dis
1988;10:1012-7.
Source: MF Dalton, MB, BCh, JM Haldane, MB, ChB,
Departments of Microbiology, Dalhousie University and
Victoria General Hospital, GW Homer, MD, Med-Pro
Clinic, Halifax, Nova Scotia.
International Notes
RUBELLA SURVEILLANCE TO DECEMBER 1990 •
ENGLAND AND WALES
~ J Hyg Camb 1935;35:262-82.
2. Morris JG, Black RE. Cbolera and other yibrios in the United States.
NEn~l JMed 1985;312:343-5.
3. Morns JG, Temy JH, Drueano Gl. In Vitro susceptibilizy of
vathogenic Vibrio l![lecies Qf nonfloxacin and six other anl1microbial
~ Antimicrob Agents Chemother 1985;28:442-5.
4. Finch MJ, VAldespino JL, Wells JG, et coll. Non-OJ Vibrio cholera
infection in Cancun, Mexico. Am J Trap Med Hyg 1987;36:393-7.
5. Safrin S, Morris G, Adams M, et coll. Non-OJ Vibrio cholerae
bacteraemia,· casergportandreview. RevinfectDis 1988;10:1012-7.
Source: MF Dalton, MB, BCh, JM Haldane, MB, ChB, Departments of
MicrobioloN,V, Dalhousie Universizy et Victoria General
Hol![lital, G Horner, MD, Med-Pro Clinic. Halifax,
Nouvelle-'Bcosse.
Notes lnternatlonales
SURVEILLANCE DE LA RUBEOLE JUSQU'EN DECEMBRE 1990 •
ANGLETERRE ET PAYS DE GALLES
Introduction
Introduction
Rubella immunisation was introduced in the UK in 1970 with
the aim of preventing congenital rubella syndrome (CRS) by the
selective vaccination of schoolgirls and susceptible adult women.
An augmented immunisation policy, aimed at eliminating
circulating rubella by the mass vaccination of children of both
sexes, was adopted in October 1988 with the introduction of the
combined measles/mumps/rubella (MMR) vaccine. MMR vaccine
was targeted at 2 age groups: 1-2-year-old children who were
formerly given measles vaccine and 4-5-year-olds who present for
pre-school booster doses of diphtheria/tetanus vaccine. Rubella
vaccination of schoolgirls and susceptible adult women continues.
La vaccination contre larubeole a commence au Royaume-Uni en 1970
et visait aprevenir la rubeole congenitale par la vaccination selective des
ecolieres et des femmes adultes receptives. En octobre 1988, on a adopre
une politique plus vaste afin d' eliminer,la rubeole en circulation par la
vaccination de masse des enfants des 2 sexes au moyen du vaccin
antirougeoleux, antiourlien et antirubeoleux (ROR). Ce vaccin est destine
a 2 groupes : les enfants de 1 a2 ans qui ont deja ere vaccines contre la
rougeole et ceux de 4 a5 ans qui doivent recevoir des doses de rappel du
vaccin contre la diphtene et le tetanos avant d'aller al'ecole. La
vaccination des ecolieres et des femmes adultes receptives se poursuit.
116
The impact of the selective immunisation program prior to the
introduction of MMR vaccine is assessed using fuformati<in from
several sources. These include vaccine coverage figures, the
prevalence of rubella infection and rubella susceptibility in
pregnant women and in the general population, and reports of
congenital rubella and rubella-associated terminations of
pregnancy. The aim is to establish a baseline for the 3 years from
1987to1989 from which to evaluate the future impact oftheMMR
vaccination program.
Pour connai:tre les effets du programme d'immunisation selective avant
I'introduction du ROR, nous avons puise a plusieurs sources : statistiques
concemant la couverture v accinale, frequence de la rubeole et receptivite a
la rubeole chez les femmes enceintes et dans l 'ensemble de la population,
signalements de cas de rubeole congenitale et d'interruptions de grossesse
reliees a la rubeole. L'objectif est d'etablir, pour la penode de 1987 a1989,
une base de reference a partir de laquelle on pourta mesurer I' effet ulterieur
du programme de vaccination par le ROR.
Vaccine Coverage
Couverture vacclnale
The most recent information shows that 86% of schoolgirls had
received rubella vaccfue by age 14 itl 1987-88, There has been no
change in uptake since 1984 suggesting that schoolgirl
immunisation rates may have reached a plateau below the target
rateof95%.
Selan les dernieres statistiques, en 1987-1988, 86 % des ecolieres ont
deja reyu le vaccin contre larubeole a l'age de 14 ans. Ce taux n'a pas varie
depuis 1984, ce qui donne a penser qu'il a atteint un plateau en deya du taux
vise de95 %.
Data from the COVER program (Cover of Vaccine Evaluated
Rapidly) administered by the Comnmnic.~ble Disease Surveillance
Centre (CDSC) indicate that update for MMR vaccine by
1-2-year-olds is at least 8% higher than the previous uptake for
measles vaccine. By November 1990 coverage of MMR vaccine
by age 2 years was 89%. Sales figures for MMR vaceine indicate
that uptake rate~ by presc}iool children have also been high and that
many doses have been given to children outside the 2 targeted age
groups (Dr. David Salisbury: personal communication, 1991).
Les donnees provenant du programme COVER (Cover of Vaccine
Evaluated Rapidly) adrninistre par le Communicable Disease Surveillance
.c&ntm (CDSC) montrent que le taux de vaccination par le ROR chez les
enfants de 1 a 2 ans depasse d' au moins 8 % le taux anterieur pour le vaccin
antirougeoleux. En novembre 1990, 89 % des enfants ont deja reyu le ROR
a l'iige de 2 ans. Les chiffres des ventes pour le vaccin ROR revelent en
outre que le pourcentage d'enfants d'age prescolaire qui se sont fai.t vacciner
est egalement eleve .et que de nombreuses doses ont ere adrninistrees a des
enfants n' appartenant pas aux 2 groupes vises (D' David Salisbury :
communicationpersonnelle, 1991).
Acquired Rubella
Rubeole acqulse
The numbers of confirmed rubella infections in pregnant
women and children reported to CDSC by laboratori~s in England
and Wales are available from 1975 (Figure 1). These; and
clinically diagnosed rubella cases reported to the Royal College of
General Practitioners (RCGP) by 'sentinel practices'(Figure 2),
provide information on the epidemiology of acquired rubella before
the introduction of MMR vaccination. (Rubella only became a
statutory notifiable disease in October 1988). All 3 indices show
an epidemic paJtern wi_th an approximate 4-yelil" cycle, and a
declining annual incidence since 1986. The cyclical pattern since
1975 suggests that 1990 should have been an epidemic year.
However, the numbers of confirmed cases in pregnant women and
children in 1990 were the lowest annual totals recorded.
Les donnees sur le nombre de cas confirmes d'kfection par le virus
rubeoleux chez les femmes enceintes et les enfants qui ont ete signales au
CDSC par des laboratoires en Angleterre et au pays de Galles sont
consignees depuis 1975 (Figure 1). Ces donnees, de meme que les
declarations des cas cliniques de rubeole au Royal Colle~e of General
Practitioners (RCGP) par des "centres sentinelles" (Figure 2), foumissent
des renseignernents sur l 'epidemiologie de la rubeole acquise avant
!'introduction du vaccin ROR. (La rubeole n'est devenue une maladie a
declaration obligatoire qu 'en octobre 1988.) Les 3 indices font ressortir un
cycle epidemique d'line duree d'environ 4 ans, ainsi que le declin du taux
annuel de survenue depuis 1986. Selon le pM1;mmene cyclique qui s'etait
repete depuis 1975, l'annee 1990 aurait du etre une annee d'epidemie. Or le
nombre de cas confirmes d'infection chez les femmes enceintes et les
enfants cette annee-Ia n' a jamais ete aussi foible.
.
.
Susceptlbllity and Infection According to Parity
Receptlvite et Infection chez las gestantes en fonctlon du nombre de
nalssances anterleu.res
Antenatal rubella serology data from 6 public health
laboratories shows a decrease in the percentage of women
susceptible from 2.2% in 1987 to 1.4% in 1989 (p < 0.0001, ChisqUaie test for trend). Susceptibility in parous women was lower
than in nulliparous women, reflecting the effect of posq>artum
vaccination; in both groups there was a decline in susceptibility
over the 3-year period (p < 0.0001 ). A decline was also observed
in all age groups. Since the prevalence of rubella infection in the
population was declining over the period, the reduction in
susceptibility in pregnant women must reflect the continued effects
of selective vaccination rather than naturally acquired immunity.
Les resultats des depistages serologiques prenatals de la rubeole
effectues par 6 laboratoires de sante publique indiquent que de 1987 a 1989,
le pourcentage de femmes receptives est passe de 2,2 % a1,4 %
(p < 0,0001, test du chi carre pour une tendance). La receptivire chez les
femmes ayant deja eu des enfants est plus faible que chez les nullipares, ce
qui atteste l 'efficacite de la vaccination post-natale. Au cours de ces 3
annees, la receptivite a diminue dans les 2 group es (p < 0,0001 ). Cette
diminution s'observe egalement dans toutes les tranches d'0.ge. Vu que la
frequence de I 'infection rubeoleuse dans la population accusait une baisse
au cours de la periode, la reduction de la receptivire chez les femmes
enceintes doit etre due aux effets cumulatifs de la vaccination selective
plutOt qu'a une immunite acquise naturellemerit.
The incidence of laboratory-confirmed primary rubella irifection
in susceptible pregnant women tested by the same 6 public health
laboratories decreased over the 3years.In1987 and 1988 the
incidence in susceptible parous women was i.:nore than double ~t
in nulliparous women. This trend has been reported previciusly
and.has been attributed to exposure of parous women to their own
children with rubella. In 1989, however, the trend was reversed;
suggesting that the MMR vaccination program has already reduced
the risk of exposure of pregnant women to children with rubella.
Le taux de survenue de primo-infection confirmee en Iaboratoire chez
les femmes enceintes receptives qui ont ete examinees par les 6 rnemes
laboratoires de sante publique a diminue au cours des 3 ans. En 1987 et
1988, le taux chez les femmes enceintes receptives est plus de 2 fois
superieure ~Belui observe chez les nullipares. Cette teildance, qui a deja
ere signalee , a ete attribuee. aI' exposition des femmes enceintes a leurs
enfants atteints de i:ubeole. En 1989, toutefois, on a8siste lt un renversernent
de la tendance, ce qui laisse croire que le pro gramme de vaccination par le
ROR deja fait baisser le risque d' exposition des femmes enceintes ades
enfants atteints de rubeole.
117
Figure 1
Laboratory reports of rubella Jan 1975 • Dec 1990 pregnant women and children aged 1 to .14 years
Confirmations en laboratolre de cas de rubeole, de Janvier 1975 adecembre 1990, chez les femmes encelntes et lea enfants de 1 a14 ans
Pregnant women/Femmes enceintes
240
en
s 200
:0
1\1
.....~
11
0
g.
k
0
.... u
......
t))
ti!
t))
160
120
0 'O
~1
zz
80
. 40
0
90
4-weekly periods/Periode de 4 semaines
Children/Enfants
120
100
80
60
40
20
4-weekly periods/Periode de 4 semaines
Congenital rnbella
Rubeo le congenltale
The NatiOnal Congenital Rubella Surveillance Pro gram
(NCRSP) was Set up in 1971 tb monitor the effectiveness of rubella
vaccination through passiv(l reporting of congenital rubella cases
from Scotland, England and Wales.
Le pro gramme national de surveillance de la rubeole congenitale
(NCRSP) a ere mis sur pied en 1971 en vue de contrOler l' efficacite de la
vaccination contre la ruooole par la declaration passive de cas de rubeole
congenitale en Ecosse, en Angleterre et au pays de Galles.
Since January 1990, congenital rubella has been included in the
British Paediatric Surveillance Unit's (BPSU) active monthly
reporting scheme<2>with a 90% response rate. There has been a
downward trend observed in the annual number of cases over the
20-year period (p < 0.0001, Poisson regression with correction for
overdispersion). To date, there have been 64 reports of children
with congenital rubella born between January 1987 and December
1989.
Depuis janvier 1990, la ruooole congenitale est inscrite au programme de
declarati£n active mertsuelle du British Paediatric Surveillance Unit
(BPSUf ); le taux de reponse est de 90 %. On avait observe une tendance
la baisse dans le nombre annuel de cas au tours de la periode de 20 ans
(p < 0,0001, regression de Poisson avec correction pour compenser la trop
grande dispersion). Ace jour, 64 cas d' enfants victimes de rubeole
congenitale nes de janvier 1987 a decembre-1989 ont ere signales.
Vaccination History
Antecedents de vaccination
Nine of the mothers of the 64 children with congenital rubella
were reported tb have been immtinised against rubella; 4 of these
had documentary evidence of imrnuajsation. The immunisation
status of 13 women was unknown. The remaining 42 women were
reported not tb have received rubella immunisation. Only 3 of
these 42 women fell outside the target groups for the selective
Parmi les meres de ces 64 enfants, 9 ont ere vaccinees contre la rubeole,
dont 4 possedent des documents pour le prouver. On ignore les antecedents
vaccinaux de 13 femmes. Les 42 restantes n'ontpas reyu, selon les
rapports, le vaccin contre la rubeole. Seules 3 de ces 42 femmes
n' appartiennent pas au groupe cib1e vise par le programme de vaccination
selective. Les 39 aulres sontnees en 1958 ou apres, ou avaient deja eu des
a
118
Flgure2
RCGP 4·weekly consultation rates per 100,000 for rubella
Taux de consultation de RCGP pour la rubeole par perlode de 4 semalnes par 100 000 habitants
35
30
00
g8
o'O
25
............
20
lL
15
00
.... ld
P..
.2! ~
"'"'
IZ !-<
10
5
0
4-weekly periods/Periode de 4 semaines
inununisation program. The other 39 women were known to have
been born in 1958 or later and/or to have had previous children.
These women should, therefore, have been eligible for schoolgirl
inununisation, post-partum inununisation or both (unless they had
recently entered the country, see below). Twelve women who were
born in 1958 or later and also had one or more older children appear
to have missed out on both schemes.
enfants, ou encore entrent dans ces 2 categories. Ces femmes auraient done
du etre admises au programme d'inununisation des ecolieres,
d 'inununisation post-natale ou aux 2 (a moins qu' elles n' aient immigre
recemment, Vair ci-dessous). Douze femmes nees en 1958 OU apres et qui
avaient egalement eu tm ou plusieurs enfants semblent n' avoir beneficie ni
de l'un ni de l' autre de ces programmes.
Reinfection
Reinfection
The selective rubella immunisation program was based on the
assumption that congenital rubella could be prevented by
establishing inununity in women prior to pregnancy. However, 6 of
the 64 cases (9%) reported between 1987 and 1989 were the
consequence of confirmed mate:af. reinfection in pregnancy. Five
met the following agreed criteria : at least 2 previous
antibody-positive laboratory reports, or a documented history of
rubella vaccination followed by at least one antibody-positive
report. The sixth was considered to be the result of maternal
reinfection on the basis of one previous antibody-positive report and
the serologic characteristics of the maternal response at the time of
infection. Five of the 6 children had major congenital rubella
defects (4 with multiple defects). The sixth child had an
asymptomatic congenital infection following a clinically apparent
maternal reinfection at 24 weeks gestation. In all 6 children the
diagnosis was confirmed by the detection of rubella-specific IgM ,5
antibody. Three of the 6 children have been reported previousl,}.C4 >.
Le programme d'immunisation selective contre la rubeole etait fonde sur
la premisse que l 'on pouvait prevenir la rubeole congenitale en ere ant une
inununite chez les femmes avant la grossesse. Or, 6 des 64 cas (9 %)
signales de 1987 a1989 sont le fait d'une reinfection confirmee de l~were
au cours de la grossesse. Cinq respectent les criteres etablis suivants : au
moins 2 serologies anterieures positives pour l'anticorps ou des antecedents
reconnus de vaccination contre la rubeole suivis par au mains une stirologie
positive. Le sixieme cas est attribue aune reinfection de la mere sur la foi
d'une serologie anrerieure positive et des caracreristiques serologiques de la
reaction matemelle au moment de !'infection. Cinq des 6 enfants presentent
d 'irnportantes malformations congenitales rubeoleuses (malformations
multiples clans 4 cas). Le sixieme enfant a eu une infection congerutale
asymptomatique apres une reinfection matemelle apparente ala quatrieme
semaine de la gestation. Le diagnostic etabli dans les 6 cas a ete confirme
par detection des antifl?.Ws IgM specifiques de la rubeole. Trois des 6 cas
ont deja ere rapportes '
These cases confinn the need for full serologic investigation of
all pregnant women who present with a rash or a history of rubella
contact regardless of a previous history of inununisation or rubella
antibody.
L' existence de tels cas confinne la necessite d' effectuer des enquetes
stirologiques completes aupres de toutes !es femmes enceintes qui
presentent une eruption ou qui ont des antecedents d' exposition au virus de
la rubeole, meme Si el!es ont deja ete VaCCineeS OU Ont deja ere porteuses
d'anticorps.
Terminations of pregnancy for rubella
Interruptions de grossesse 11 cause de la rubeole
Depuis 1971, annee OU l'on a commence aconsigner ces
Terminations for disease or contact show a downward trend
since 1971 when recording of this information commenced
(p< 0.0001). In 1989, there were only 3 terminations for rubella
disease compared with 63 and 36, respectively, in 1987 and 1988.
A decline in terminations for vaccination is seen in recent years.
renseignements, le nombre d'interruptions de grossesse pour cause
d'infection ou d'exposition rubeoleuse a dirninue (p < 0,0001). En 1989, on
ne compte que 3 interruptions motivees par une rubeole, comparativement a
63 et 36 en 1987 et 1988 respectivement. On a assiste ces dernieres annees
aune baisse du nombre d'interruptions de grossesse pour cause de
vaccination.
119
Conclusions
Conclusions
1. When MMR vaccine was introduced, selective rubella
vaccination was continuing to reduce rubella susceptibility in
the antenatal population and, thereby, the incidence of rubella
infection in pregnancy and its sequelae of CRS cases and
therapeutic abortions.
2. With selective vaccination alone, maternal rubella reinfection
was beginning to emerge as a significant cause of CRS. The
MMR vaccination program should prevent this from becoming
an increasingly important problem.
3. There is encouraging evidence from laboratory reports and
RCGP data to suggest that there has already been a substantial
decline in the prevalence of rubella in the community as a
result of the MMR program. This effect is consistent with the
widespread use of MMR vaccine both in and outside the
targeted age groups.
4. Continued surveillance of rubella susceptibility in the antenatal
population is essential in order to assess whether the current
high level of selective rubella vaccination is maintained in the
future.
5. Although the MMR program will help to protect susceptible
women, antibody screening and rubella vaccination of women
who enter the country after the age at which rubella
immunisation is given at school should continue to be
promoted.
6. Comparison of the age-specific rubella susceptibility and
notification rates in future years with those reported here will
allow the epidemiologic effects of the MMR program to be
assessed. Surveillance of rubella susceptibility and
notifications in young adults will be particularly important in
order to assess whether susceptible cohorts are emerging in the
older age groups, indicating the possible need for a 2-stage
MMR vaccination program.
1. Lorsque le vaccin ROR a ete mis en usage, la vaccination selective contre la
rubeole avait deja commence de reduire la receptivite a cette maladie chez le
foetus et, partant, le taux de survenue de ]'infection rubeoleuse durant la
grossesse et de ses sequelles - rubeole congenitale et avortements provoques.
References
1. Miller CL, Miller E, Sequeira PJL, et al. Effect of selective
vaccination on rubella susceptibility and infection in
pregnancy. Br Med J 1985;291:1398-1401.
2. Hall SM, Glickman M. Report from the British Paediatric
Surveillance Unit. Arch Dis Child 1990;65:807-9.
3. Best JM, Banatvala JE, Morgan-Capner P, Miller E. Fetal
infection after maternal reinfection with rubella: criteria for
defining reinfection. Br Med J 1989;299:773-5.
4. Das BP, Lakhani P, Kurtz ffi, et al. Congenital rubella after
previous maternal immunity. Arch Dis Child 1990;65:545-6.
5. Gilbert J, Kudesia G. Petal infection after maternal reinfection
with rubella. Br Med J 1989;299:1211.
Source: CommunicableDiseaseReport, Voll,RevNo4,1991
(published by the PHLS Communicable Disease
Surveillance Centre, London, England).
Tho Canada Disc.B.Ses Weekly Report pzescn!S cummt information an infectious and other direaseJ
for rurvoillanoe purposes and is available Ike of charge upon request. 'Mllll;' of the artlcles
contain pn:limiruuy mrormstion and further confirmation may bo obtained from th_, sourco1
quolcd. Tho Department of Heallh and Welfare docs not 8.!S\UJlO tesporuibility for accuracy or
autlx:nticity. Contnbuticm arc welccmod (in tho official langungo of your choioe) from any<>w
working in the health field and will not precludo publication elsc:wbcro.
ScicntifieAdvisory Board:
Editor:
A.Histant Editor.
Do1lctopPubliJbing
Cimtla lion!
Buro au of Communicable Dbe"'° Bpidomlology
Laboratory Contn> for Disease Control
Tunnoy'1 Pa.s1nzc
OTIAWA, Olllarlo
Canada
KIAOL2
Dr.J.Spika
Dr. K.Rozeo
Eleanor Paulson
Nicolo Beaudoin
Joan.rei Regnier
Gcl1rlldo Tardiff
(613) 957-4243
(613) 957-1329
(613) 957-1788
(613) 957-<l841
(613) 957-7845
(613) 957-0842
2. Lorsque le programme d'immunisation se limitait a cette vaccination
selective, la reinfection matemelle est apparue comme une cause importante
de rubeole congenitale. Le propramme de vaccination par le ROR devrait
ernpecher que le problerne ne s aggrave.
3. Signe encourageant, Jes rapports de laboratoire et ]es donnees du RCGP
semblent indiquer que la frequence de la rubeole a deja beaucoup dinlinue
dans la collect1vite par suite de !'introduction du ROR. Ce phenomene
semble correspondre a I 'usage generalise de ce vaccin al 'interieur comme a
I' exterieur des groupes cibles.
4. Il est essentiel de maintenir une surveillance constante de la receptivire du
foetus a la rubeole afin de savoir s 'il faut poursuivre la vaccination selective
aune echelle aussi grande clans l'avenir.
5. Bien que le programme de vaccination par le ROR doive contribuer a
proreger Jes femmes receptives, il faut continuer de promouvoir le depistage
des anticorps et la vaccination antirubeoleuse dans le cas des femmes qui
immigrent au Royaume-Uni passe l'age OU l'on administre le vaccin a
l'ecole.
6. La comparaison des taux futurs de receptivite ala rubeole selon I 'age et de
declaration de cas avec Jes taux signales ici permettra de mesurer Jes effets
epidemiologiques du programme de vaccination par le ROR. II sera
particulierement important de surveiller Jes taux de receptivite a la rubeole et
de declaration de cas chez Jes jeunes adultes afin de savoir s'il apparfilt des
cohortes de personnes receptives passe l'enfance, auquel cas ii faudrait
peut-etre adopter un programme de vaccination en 2 etapes.
References
1. Miller CL, Miller E, Sequeira PJL, et coll. FJ!ect {selective vaccination on
rubella susce~tibili~ and infection in vregnanc.y. r Med J
1985;291:13 8-1401.
2. Hall SM, Glickman M. Report ftom the British pqediatric Surveillance
flnit. Arch Dis Child 1990;65:807-9.
3. Best JM, Banatvala JE, Morgan-Capner P, Miller E. Fetal infectionter
maternal reinfection with rubella: criteria for definin1 reinfection.
Med
J 1989;299:773-5.
4. Das BP, Lakhani P, Kurtz JB, et coll. Con£enital rubella qfter previous
maternal iUW!uni~. Arch Dis Child 1990; 5:545-6.
5. Gilbert J, Kudesia G. Fetal irifection q,tkr maternal reinfection with rubella.
Br Med J 1989;299:1217.
r
Source : Communicable Disease Report, Voll, Rev No 4, 1991 (ptlblie par le
PHLS Communicable Disease Surveillance Centre. Landres,
Angleterre).
Le Rapport hobdCltllBdilio dos maladlos au Canada, qui foumlt dc1 donn6eB portinonms "111" !cs maladkl1 inlbctiouso1 ct
lei aum:s maladies dam Jo but do facilitcr lour &Ur\"CilJanco, peutStro obtcnu gratuitDmont aur demendo. Un grand
nombro d'articlo1 no conticmnont quo de1 daon6c1 soIIIIIlliml ma.iJ doJ romcignDmcntJ compl6mentairc1fCUVCDt8tm
obtcnUJ en a'addrnnant aux .sources cit6ei. Lo mlniBtro do la Sant6 naticnalo ct du Bicn·8tre aocW no pout 8trc
iespomablo do l'ouctitudo, ni do l'authontlcit6 des articles. Toufl> pononno oouvnnt dans lo domniw> do I.a 181116 ell
invit6: l collaborer (dam lalanguo officlollo do •onchoix) et la publicaticn d'unartlclc d1111J le pre.cm Rapp<rtn'cn
ompBclu> pas la publicatioo ailleun,
Groupe do consoillors sclonlifiques:
Rldactrlcc en chef:
Rldactrice adjoinfl>:
ilditiquo:
Distribution:
Bweau d'6pid6m.ialagio de• ma.la.dio1 trammiuiblos
Labe>:atoirc do lutto contr<> lamaladio
Pnl Tunnoy
OTIAWA(Ontarlo)
Cmad.a
KlAOL2
120
D'J.Spih
DrK.Rozeo
Eleanor Paulsen
Nicolo Beaudoin
Joanno Regnier
Gertrude Tardiff
(613)957-4243
(613)957·1329
(613) 957-1788
(613) 957-0841
(613) 957-7845
(613) 957-0842
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