Vaccinarsi in Sardegna

The elimination of rubella by 2023: this was one of the main goals of the National Plan for the Elimination of Measles and Congenital Rubella - PNEMoRc approved in the state-region conference in 2019. Four years later and despite the humanitarian, political and social crisis caused by the COVID-19 Pandemic, this objective has been met. This is an important milestone for our country, one that was achieved thanks to prophylactic vaccination, which has once again demonstrated its effectiveness in protecting individuals from dangerous, life-threatening and debilitating diseases.

It was on 13 July that the World Health Organisation's (WHO) Regional Verification Committee (RVC) for the elimination of measles and rubella in the European Region declared rubella elimination status in Italy [1]. In this regard, it is important to emphasise that when we speak of 'elimination' we are not referring to the disappearance of the aetiological agent from the geographical area of reference, but rather to the absence of clinical cases in the population of that same area for a period of at least 12 months (in the presence of an efficient surveillance system). However, in order to be able to officially state that the disease has been eliminated, it is necessary for the absence of new cases to continue for at least 36 months in the presence of an adequate surveillance system.

Italy has worked intensively over the past two decades to meet the rubella elimination criteria set by WHO. Several measures have been implemented, including the improvement of measles-mumps-rubella (MPR) vaccination coverage, the introduction of a second dose of vaccine, the compulsory notification of rubella in pregnancy and congenital rubella, the establishment of an integrated surveillance system for measles and rubella, and improved diagnostic confirmation. Thanks to the efforts of health professionals at national, regional and local level and the increase in vaccination coverage, rubella cases in Italy have decreased dramatically over the last two decades, with an incidence of less than 1 case per million inhabitants. In the Italian context, there were 23 reported cases of rubella in 2019, which then fell to 15 in 2020 and then to no reported cases in 2021, just as no cases of congenital rubella syndrome were detected in the three-year period 2019-2021. These data, therefore, ruled out the presence of a chain of infection for more than 12 months, allowing the disease's elimination status to be declared [3].

Questa importante notizia, già preannunciata lo scorso novembre 2022 dell’European Regional Verification Commission (RVC) for Measles and Rubella Elimination (Commissione di verifica regionale dell'OMS per l'eliminazione del morbillo e della rosolia nella Regione europea) rappresenta un grande traguardo per

This important news, already announced last November 2022 by the WHO European Regional Verification Commission (RVC) for Measles and Rubella Elimination in the European Region, represents a great achievement for Italy [2]. In fact, rubella is the third disease eliminated from Italy by means of preventive vaccination after smallpox (eradicated in 1980) and poliomyelitis (eliminated from the WHO European Region in 2002).

In order that the much sought-after goals of elimination and eradication of all other vaccine-preventable diseases may be pursued at a rapid pace, the Istituto Superiore della Sanità recommends i) continuing to carry out adequate and decisive prophylactic vaccination activities by maintaining high vaccination coverage rates, ii) strengthening information systems and surveillance networks, and iii) guaranteeing a rapid and effective response in the event of the appearance of new cases in order to prevent the reintroduction of infection.

In this regard, it is worth remembering that the surveillance flow for reporting rubella cases is as follows:

• ogni caso sospetto deve essere segnalato alla ASL di competenza entro 12 ore;
• la ASL che riceve la segnalazione, previa compilazione, ha dovere di trasmettere la scheda di sorveglianza integrata alla Regione entro 24 ore dalla segnalazione;
• entro 24 ore dalla ricezione della segnalazione da parte della ASL, la Regione ha dovere di trasmettere i dati agli organi di competenza (Istituto Superiore di Sanità);
• contestualmente, la ASL ha dovere di condurre l’indagine epidemiologica e predisporre la raccolta dei campioni biologici per la conferma della diagnosi (i campioni vanno inviati al Laboratorio Regionale di Riferimento - LRR appartenente alla rete “MoRoNet”, o, in assenza di un LRR al Laboratorio Nazionale di Riferimento presso l’ISS);
• il Ministero della Salute trasmette mensilmente i dati di sorveglianza al Centro Europeo per il Controllo delle Malattie (ECDC) che condivide i dati con l’OMS.

But what causes rubella? And why is it so important to prevent it?

Rubella is an acute exanthematous disease caused by Rubella virus, a virus belonging to the Rubivirus genus and the Togaviridae family [4,5].

For this virus, interhuman transmission occurs by airborne contact with aerosol particles emitted by infected individuals, or direct contact with the nasopharyngeal secretions of sick individuals. Infected persons are usually contagious from 7 days before until 7 days after the appearance of the exanthema; the virus may still be present in nasopharyngeal secretions up to 14 days after the appearance of skin manifestations [5].

In the children, the disease is characterised by the presence of a maculo-papular rash accompanied by a set of symptoms such as fever (usually no higher than 39C°), mild conjunctivitis, lymphadenopathy (enlarged lymph nodes) of the head and neck that may precede the appearance of the rash by up to 5-10 days; red dots may also appear on the soft palate and, although infrequent, the child may develop acute thyroiditis.

In adults, and in adolescents, the disease has a longer course and is characterised by the appearance of fever and other general symptoms that anticipate the appearance of cutaneous signs. Other symptoms detectable in the adult population are joint pain, conjunctivitis, testicular pain and orchitis [4].

Particularly serious is the occurrence of the disease in pregnant women, as it may cause a disease known as congenital rubella syndrome in the foetus. The Rubella virus can cross the placental barrier and cause embryo-fetal abnormalities. The type and extent of damage caused depends largely on the gestational age at the time of infection. Infection can result in miscarriage, intrauterine fetal death or even severe malformations. The most frequent foetal malformations are sensory deafness, eye diseases (cataracts, retinopathy and micro-ophthalmia), congenital cardiac malformations, intellectual deficiency and liver and spleen damage. In view of the above, it is very important for women of childbearing age to know their immunisation status against rubella in order to be able to intervene promptly with the administration of the vaccine according to the vaccine schedule or with a booster dose (where necessary). This is now possible by means of the specific IgG test (rubeo-test); this test is free of charge in Italy both as a pre-conception test and during pregnancy itself, but it is important to bear in mind that in the event of susceptibility to the infection it is a good idea to have the vaccination at least one month before becoming pregnant [5]. Pregnancy is in fact an absolute contraindication for vaccination with live, attenuated viruses such as rubella. On the other hand, the evidence tells us that in cases where the vaccine has been mistakenly administered during pregnancy, it has not caused embryo-fetopathy: therefore, although precautionarily contraindicated, if a woman discovers that she is pregnant after having been vaccinated, this is not a cause for termination of the pregnancy.

Rubella together with congenital rubella syndrome, in fact, is effectively preventable through vaccination. The vaccine used is a live attenuated vaccine administered in a tetravalent MPR-V formulation (guarantees immunisation not only against rubella but also against measles, mumps and varicella). The administration of MPR-V has been mandatory since 2017 [6] for all children aged between 11 months and 16 years. According to the vaccination calendar, a first dose is to be administered in the second year of life (13th-15th month of life) and then a second dose during the sixth year of life. In adults, the same type of vaccine can be used, but the time between the administration of the two doses is much shorter, only 4 weeks [7]. The immunisation rate in children is estimated to be 95% already after the first dose, and then up to 98% after the second [8].

In this context, therefore, Vaccinarsinsardegna.org would like to remind users to consciously adhere to the vaccinations and boosters foreseen by the vaccination schedule, which also obviously includes the anti-rubella vaccination.

In order to achieve such an important goal as the elimination of a debilitating and sometimes life-threatening disease such as Rubella, although transversal factors such as the changes made to the vaccination schedule in recent years, home isolation due to COVID-19 and the use of personal protective equipment have contributed, much of the credit must be given to the availability of a safe vaccine [6].

Therefore, the levels of vaccination coverage achieved in recent years, even more so following this important achievement, must be maintained, increased and preserved in the near future.

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Bibliography:

[1] «Oms: l’Italia ha eliminato la rosolia, non è più endemica - ISS». https://www.iss.it/-/oms-l-ita... (consultato 22 luglio 2023).

[2] «Rosolia news». https://www.epicentro.iss.it/r... (consultato 22 luglio 2023).

[3] «Eleventh meeting of the European Regional Verification Commission for Measles and Rubella Elimination». [Online]. Disponibile su: http://apps.who.int/bookorders.

[4] «Rubella - UpToDate». https://www.uptodate.com/conte... (consultato 22 luglio 2023).

[5] «Rosolia - Istituto Superiore di Sanità». https://www.epicentro.iss.it/r... (consultato 22 luglio 2023).

[6] «DECRETO LEGGE 7 giugno 2017, n. 73». https://www.gazzettaufficiale....

[7] «Calendario vaccinale». https://www.salute.gov.it/port... (consultato 22 luglio 2023).

[8] «Vaccino MPRV (Morbillo - Parotite - Rosolia - Varicella): che cosa è e quali sono i benefici? | Mario Negri». https://www.marionegri.it/maga... (consultato 22 luglio 2023).

*By Dr. Andrea Pischedda 

Specialist in Hygiene and Preventive Medicine – Università degli Studi di Sassari