S U P P L E M E N T A R T I C L E
Elimination of Rubella and Congenital Rubella
Syndrome in the Americas
Carlos Castillo-Solo ´rzano,1Christina Marsigli,1Pamela Bravo-Alca ´ntara,1Brendan Flannery,2Cuauhte ´moc Ruiz
Matus,1Gina Tambini,1Socorro Gross-Galiano,1and Jon Kim Andrus1
1Pan American Health Organization, Washington, D.C.; and2Pan American Health Organization, Brasilia, Brazil
In 2003, the Pan American Health Organization (PAHO) adopted a resolution calling for rubella and
congenital rubella syndrome (CRS) elimination in the Americas by the year 2010. To accomplish this goal,
PAHO advanced a rubella and CRS elimination strategy including introduction of rubella-containing vaccines
into routine vaccination programs accompanied by high immunization coverage, interruption of rubella
transmission through mass vaccination of adolescents and adults, and strengthened surveillance for rubella
and CRS. The rubella elimination strategies were aligned with the successful measles elimination strategies. By
the end of 2009, all countries routinely vaccinated children against rubella, an estimated 450 million people had
been vaccinated against measles and rubella in supplementary immunization activities, and rubella
transmission had been interrupted. This article describes how the region eliminated rubella and CRS.
to 50% of rubella infections being asymptomatic. How-
ever, congenital rubella infection during the early stages
of fetal development leads to severe birth defects with
The rubella elimination initiative in the Americas was
developed after the strengthening of measles surveillance
clearly highlighted how significant rubella and CRS were
The availability of a safe, affordable, and efficacious
vaccine, the lessons learned from vaccinating large and
heterogeneous population groups with measles-rubella
vaccine (MR), and the existing cost-benefit and cost-
effectiveness data prompted PAHO’s Directing Council,
in 2003, to adopt a resolution calling for rubella and
CRS elimination in the Americas by the year 2010 .
To accomplish this goal, PAHO developed a rubella and
CRS elimination strategy , which is aligned with the
measles elimination strategies (Table 1). This strategy
calls for the (1) introduction of rubella-containing vac-
cine (RCV) into calls for the routine vaccination pro-
grams of all countries for children aged 12 months and
reaching $95% coverage in all municipalities, (2) im-
plementation of a one-time mass campaign among
adolescents and adults (‘‘speed up’’ campaigns) and
periodic ‘‘follow-up’’ campaigns among children aged
,5 years , and (3) the integration of rubella sur-
veillance with measles surveillance and implement CRS
surveillance. All countries in the region implemented
components of the PAHO strategy from 1994 to 2010.
Rubella elimination in the Americas is defined as the
interruption of endemic rubella virus transmission in all
the countries of the Americas for a period $12 months
without the occurrence of CRS cases associated with
endemic transmission, in the presence of high-quality
An extensive review and analysis of epidemiological
and vaccination coverage data was conducted among 48
PAHO Member States, which include 35 countries and
Potential conflicts of interest: none reported.
Correspondence: Carlos Castillo-Solo ´rzano, MD, MPH, Pan American Health
Organization, 525 23rd St, NW Washington, DC 20037 (firstname.lastname@example.org).
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Elimination of Rubella and CRS
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countries are encouraged to provide a second opportunity
through follow-up campaigns to monitor and reduce the ac-
cumulation of susceptibles for rubella and measles, and in
prevention of importations and secondary cases associated with
imported cases. The continuous monitoring of recommended
standardized measles/rubella and CRS surveillance indicators
ensures high-quality surveillance among the countries in order
to avoid complacency. Complacency could lead to the de-
terioration of surveillance systems or of immunization ac-
tivities, thus increasing the risk for outbreaks following
importations and the reestablishment of transmission.
In an effort to further strengthen surveillance, countries
should improve the coordination with the dengue surveillance
system and private sector. The latter is to rapidly detect and
respond to outbreaks by preparing national plans detailing
outbreak response measures and containment strategies.
PAHO has issued several epidemiological alerts recommending
vaccination against measles and rubella for all travelers visiting
countries in the Americas. In the alert, PAHO has also recom-
mended that any resident of the Americas planning to travel to
other regions should be protected against these diseases prior to
departing on their trip. These alerts have been disseminated in the
proximity of various cultural and sporting events that have been
hosted by countries in the region. Such special global alerts have
helped the Americas maintain rubella and measles elimination.
Additionally, countries should monitor confirmed CRS cases
for virus excretion with at least 2 consecutive negative speci-
mens, to document interruption of rubella endemic virus in
their territories. Countries should follow the established algo-
rithms for the final classification and follow-up of special cases
(ie, false positive/negative laboratory results). Finally, countries
are encouraged to obtain specimens for virus detection/isolation
for the purpose of documenting the importation.
The rubella and CRS elimination initiative in the region of
the Americas has proven to be an achievable and cost-effective
intervention. The experience of the Americas demonstrates that
endemic rubellatransmission can be interrupted whencountries
fully commit to an effective regional strategy. In light of the
intense mobilization of resources and efforts to efficiently re-
spond to an outbreak it is vital that PAHO Member States
continue to advocate for other regions to implement the nec-
essary interventions to eliminate endemic rubella and measles
The PAHO’s Comprenhensive Family Immunization Project acknowl-
edges the efforts of health staff at all levels in the ministries of health in the
Americas for successfully reaching the rubella and CRS elimination goal by
2010. The valuable knowledge and experience being generated will benefit
global immunization initiatives. We also want to thank PAHO’s strategic
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