PUBLIC HEALTH BRIEFS
were no male-female differences. Health-profession students did not differ in rubella immune status from the general population. History was not helpful in assessing immune status. Approximately one-half of persons with low antibody titres had considered themselves immune, while one-half with moderate to high antibody titres had considered themselves at risk. Less than one-half of students with low antibody titres available themselves of immunization which was recommended and offered. With a high percentage of adult females at risk for rubella even in a health-motivated population and with poor follow-up on recommended immunization, current immunization practices must be improved if congenital rubella syndrome is to be further reduced. Mass inoculation of school age males and prepubertal school age females without prior determination of rubella antibody titres is suggested as a cost-effective means of decreasing incidence of congenital rubella syndrome.
REFERENCES 1. Modlin JF, Brandling-Bennett AD, Witte JJ, et al: A review of five year's experience with rubella vaccine in the United States. Pediatrics 55:20-29, 1975. 2. American Academy of Pediatrics: Report of committee on infectious diseases, 18th Edition, Evanston, IL: AAP, 242-248, 1977. 3. U.S. Public Health Service Advisory Committee on Immuniza4. 5.
6. 7.
8.
tion Practices: Collected recommendations. Morbidity and Mortality Weekly Reports. 21 (supl 25): 30-31, 1972. Witte JJ, Karchmer AW, Case G, et al: Epidemiology of rubella. Am J Dis Child 118: 107-111, 1969. Phillips CA, Maeck JVS, Rogers WA, et al: Intrauterine rubella infection following immunization with rubella vaccine. JAMA 213: 624-625, 1970. Larson HE, Parkman PD, Davis WJ, et al: Inadvertent rubella virus vaccination during pregnancy. N Eng J Med 284: 870-873, 1971. Wyll SA and Herrmann KL: Inadvertent rubella vaccination of pregnant women. JAMA 225: 1472-1476, 1973. Ebbin AJ, Wilson MG, Chander SB, et al: Inadvertent rubella immunization in pregnancy. Am J Obstet Gynecol 117: 505-512, 1973.
9. Fleet WF, Benz EW, Karzon DT, et al: Fetal consequences of maternal rubella immunization. JAMA 227: 621-627, 1974. 10. Vaheri A, Vesikari T, Oker-Blom N, et al: Transmission of attenuated rubella vaccines to the human fetus. Am J Dis Child 118: 243-246, 1969. 11. Furukawa T, Miyata T, Kondo K, et al: Clinical trials of RA 27/ 3 (Wistar) rubella vaccine in Japan. Am J Dis Child 118: 262263, 1969. 12. Katz SL, in discussion: Immunization of man against rubella. Am J Dis Child 118: 317, 1969. 13. Center for Disease Control: Rubella surveillance July, 1973-December, 1975. Atlanta, GA: CDC, 7-11, 1976. 14. Evans PC and Reisinger KS: Rubella susceptibility in Navajo women. J Repro Med 14: 84-85, 1975. 15. Freis PC, Sussman EK, and Shearin R: Sero-immunity screening of adolescent girls in a military population to determine susceptibility to the rubella virus. Military Med 141: 684-685, 1976. 16. Stoffman JM and Wolfish MG: The susceptibility of adolescent girls to rubella. Clinical Ped 15: 625-626, 1976. 17. McKusick MJ: Screening for rubella on a university campus. Post-grad Med 59: 202-205, 1976. 18. Klock KE and Rachelefsky GS: Failure of rubella herd immunity during an epidemic. JAMA 288: 69-72, 1973. 19. Halstead E, Halstead SB, Jackson RS, et al: Rubella vaccination: fertility control in a large-scale vaccination program for post-pubertal women. Am J Obstet Gynecol 121: 1089-1094, 1975. 20. Benenson AS, Ed.: Control of Communicable Diseases in Man, 12th Edition. Washington, DC: Am Pub Hlth Assoc, 272-276, 1975. 21. Schoenbaum SC, Hyde JN, Bartoshesky L, et al: Benefit-cost analysis of rubella vaccination policy. N Eng J Med 294: 306310, 1976. 22. Deseda-Tous J, Cherry JD, Spencer MJ, et al: Measles revaccination. Am J Dis Child 132: 287-290, 1978.
ACKNOWLEDGMENTS The authors are grateful to Dr. Carl S. Hacker, University of Texas School of Public Health at Houston, for analysis of data.
Evaluation of an Employee Health Service as a Setting For a Rubella Screening and Immunization Program KE WEISS, RNc, MS, CE FALVO, MD, MPH, E BuIMovIcI-KLEIN, MD, JW MAGILL, MD, AND LZ COOPER, MD
Introduction The main objective of rubella immunization campaigns is to prevent fetal damage. In an effort to offer protection to adult women, several states have instituted rubella screening programs.1' 2 New York State, in its Health Code, requires From the Virus Research Laboratory, Pediatric Service, The Roosevelt Hospital, New York City; and the Employee Health Service, Memorial-Sloan Kettering Cancer Center (Dr. Magill). Address reprint requests to Karen E. Weiss, RNc, MS, Virus Research Laboratory, Pediatric Service, the Roosevelt Hospital, New York, NY 10019. This paper, submitted to the Journal October 6, 1978, was edited and accepted for publication October 30, 1978.
AJPH March, 1979, Vol. 69, No. 3
that all women of childbearing years who work in health institutions be screened for rubella and offered immunization against rubella.3 In compliance with the New York State Health Code, a large urban hospital instituted such a program in the fall of 1975. The results of this screening and immunization program are evaluated for the two year period from January 1, 1976 to December 31, 1977.
Method The Screening Program encompassed three groups. All new female employees, 18 years and older, were tested for 281
PUBLIC HEALTH BRIEFS
TABLE 1-Acceptance of Rubella Vaccination Among Susceptible Women Hospital Workers by Age Groups, 1976-1977 Susceptible %
Screened
37
110 454 272 134 51
21 83 50 31 8
(18.3) (18.4) (23.1) (15.7)
10 62 31 18 5
1021
193
(18.9)
126
TOTAL
(19.1)
Description of Reaction
Number
Per Cent of All Vaccinees (N:126)
(47.6) (74.7) (62.0) (58.1) (62.5)
All Complaints Arthralgia/Pain-Stiffness
(65.3)
Swollen Glands Painful Injection Site
20 12 7 5 4 4 3 2 1 1
15.9 9.5 5.6 4.0 3.2 3.2 2.4 1.6 0.8 0.8
Vaccinated* %
Age Groups (Years)
*Three additional women vaccinated by private physicians are not included
rubella antibody as part of their initial employment medical assessment. Previously employed women were screened during their annual physical examination or prior to receiving immune serum globulin (ISG) for hepatitis exposure. Finally, an exploratory memorandum was circulated stating that rubella screening was available to any employee upon request. The Employee Health Service (EHS) staff collected basic demographic information on each individual screened. Past history, past vaccination, and recent exposure to rubella were also noted. Rubella hemagglutination inhibition (HAI) antibody tests were performed by the Virus Research Laboratory using the standardized method established by the Center for Disease Control.4 Persons whose HAI titers were less than 1:8 were considered "susceptible." Susceptible adults were informed by letter of their "'susceptibility"; an appointment was made for discussion of rubella and rubella immunization. During the appointment, written, informed consent was obtained and a brief medical history was taken; if there was no contraindication, vaccine was administered. Special emphasis was placed on contraceptive practices during the ensuing weeks.
Results Among the 1,225 female employees screened during the first two years of this program, 17.7 per cent were found to be rubella susceptible. Susceptibility rates varied erratically when women were grouped by year of birth (10.9-27 per cent) but when combined into five year cohorts, there were no statistical differences (Table 1). A further analysis based on exposure to rubella epidemics during the school years revealed no significant differences in susceptibility rates. In almost one-half of the 1,225 women tested historical recall of rubella failed to agree with the laboratory results. Forty-seven (21.7 per cent of 217 women who had no detectable HAI antibody) gave a positive response to the question, "Have you had rubella (German Measles) in the past?" Conversely, 544 (53.9 per cent of 1,008 women who were HAI positive) were unaware of having had rubella. In addition, of the 49 women responding positively to the question, ""Have 282
TABLE 2-Distribution of Side Reactions after Rubella Vaccination in 126 Women Hospital Workers, 1976-1977
Fatigue/Malaise Fever Rash Sore Throat Headache
"Shocky"
you received rubella vaccine?", 12 (42.5 per cent) were HAI negative. Of the 217 women who were rubella susceptible, it was possible to contact 193 (88.9 per cent).* Of the group contacted, 168 (87.0 per cent) came to the EHS to discuss rubella vaccination (25 women have never come to clinic despite repeat appointments). One hundred twenty-nine women (66.8 per cent of those contacted) have been vaccinated. One case of clinical rubella occurred in a susceptible woman who had received ISG. Of the 36 women seen but not vaccinated, eight were pregnant and three were planning to conceive. Thus, only 5.7 per cent of the susceptible women were ineligible for vaccination because of pregnancy. Twelve women declined to be vaccinated or postponed vaccine for personal reasons, six declined because of age, four because of medical contraindications, and three felt they had already been vaccinated and refused revaccination. Young (s20) women were more likely to reject rubella immunization than those older than 20 years (X2 13.72, p.05, Table 1). Reactions were reported by 20 patients (15.9 per cent) and did not constitute a major problem. Three women (2.4 per cent) reported to EHS for medical attention.** Of those who experienced a reaction, 9.5 per cent had two or more identifiable symptoms. The most commonly reported reaction was myalagia/arthralgia, described as "pain and stiffness" (Table 2). No one under age 20 or over age 36 complained of a reaction, but the numbers were small. There were no special age groups associated with side reactions.
Disciussion Two important considerations in planning programs to protect women of childbearing age against rubella have been reinforced by our study. First, rubella serologic testing is the only reliable method of determining rubella immunity. This *The remaining 24 women were not available because their employment had been terminated. **Each of these individuals was found to have a previously undiagnosed medical problem, including severe allergy, carpal tunnel syndrome, and shin splints due to jogging. AJPH March, 1979, Vol. 69, No. 3
PUBLIC HEALTH BRIEFS
confirms the observations of many others.5 6 Second, an active EHS was a suitable location for establishing a rubella screening and immunization program. The screening was easily incorporated into the routine pre-employment health examination. Most importantly, we have been reasonably successful in vaccinating the susceptible women in our program. In post-pubescent rubella vaccine campaigns, both pregnancy and vaccine reactions are of concern. Pregnancy was infrequent in our study population. Overall, in the United States, pregnant workers comprise 8.8 per cent of the ".ever-married women" of reproductive age currently employed.7 Thus a program which is based in the work force could provide an acceptable area for rubella screening and vaccination programs. Side reactions were not a problem in our study population. Those individuals with complaints serious enough to report to EHS for medical attention had conditions unrelated to rubella immunization. A study to follow both an immunized and a control group for concurrent symptoms would be a useful contribution. Our experience demonstrates that a rubella screening and immunization program for women employees, which includes an informed consent and discussion period, successfully captures an "at-risk" population and provides continuing health education.
REFERENCES 1. Judson FN, Shaw BS and Vernon TM: Mandatory premarital rubella serologic testing in Colorado: A preliminary report. JAMA 729:1200-1202, 1974. 2. Fox JP, Rainey HS, Hall CE, et al: Rubella vaccine in postpubertal women: Experience in western Washington state. JAMA 236:837-843, 1976. 3. New York State Public Health Law 2803; Section 720.6. 4. Center for Disease Control. A Procedural Guide to the Performance of the Standardized Rubella Hemagglutination-Inhibition Test. U.S. Department of Health, Education, and Welfare, Mental Services and Mental Health Administration. Center for Disease Control, Atlanta, GA, October 1970. 5. Bottiger M and Heller L: Experiences from vaccination and revaccination of teenage girls with three different rubella vaccines. J Biol Stand 4:107-114, 1976. 6. Freis PC, Sussman EK and Shearin R: Sero-immunity screening of adolescent girls in a military population to determine susceptibility to the rubella virus. Milit. Med 141 (10):684-5, 1976. 7. Hendershot GE: Pregnant Workers in the United States. Advance data (Vital & Health Statistics of NCHS, DHEW, USPHS, HRA) 11:1-4, 1977.
ACKNOWLEDGMENTS Special thanks to the Memorial-Sloan Kettering Cancer Center's Employee Health Service staff and D. Robinson. Parts of this study were funded by Merck, Sharp & Dohme. The original version of this paper was presented at the Annual Meeting of the Society for Epidemiologic Research, June 1978, Iowa City, IA.
A Rubella Screening and Immunization Program In an Adolescent Clinic CATHEY E. FALVO, MD, MPH, KAREN E. WEISS, RN, MS, and SHARI M. Liss The present United States practice concerning rubella vaccine emphasizes immunization of preschool children. This approach appears to have prevented epidemic spread of rubella but has not adequately protected susceptible* women of childbearing age who are at risk of having babies with congenital rubella (CR). The rubella outbreak in Casper, Wyoming2 among junior and senior high school children, after a campaign to vaccinate the preschool and elementary school children in that city, indicated a potential problem in control of rubella. The recent outbreak in Hawaii3 among From the Virus Research Laboratory, Department of Pediatrics, The Roosevelt Hospital, New York City. Address reprint requests to Dr. Cathey E. Falvo, Virus Research Laboratory, Department of Pediatrics, The Roosevelt Hospital, 428 West 59 Street, New York, NY 10019. Ms. Weiss has recently completed the American Nurses' Association's certification program in Community Health Nursing Practice. This paper, submitted to the Journal April 17, 1978, was revised and accepted for publication October 6, 1978. *The term "susceptible(s)" will be used to indicate a person(s) with a rubella Hemagglutination Inhibition Antibody (HAI) titer of less than 1:8 as tested by the CDC method.'
AJPH March, 1979, Vol. 69, No. 3
young adults, despite a 95 per cent vaccination rate among school children, emphasizes the continuing risk of rubella among susceptible adults, especially the pregnant woman. Adolescent girls represent one potential high-risk group for contracting rubella during pregnancy. A rubella screening and vaccination program was developed for this group during 1974 at the Roosevelt Hospital in New York City. The purpose of the program was: a) to screen all women (10 to 21 years of age) attending the pediatric outpatient department (OPD) for rubella susceptibility*; b) to vaccinate all those found to be susceptible and who were not likely to become pregnant in the next three months. This paper outlines the results of this program.
Methods The adolescent outpatient program is part of the comprehensive care program within the pediatric OPD. Most of the patients are Hispanic and come from low income families. They are usually seen by the same primary care team 283
were no male-female differences. Health-profession students did not differ in rubella immune status from the general population. History was not helpful in assessing immune status. Approximately one-half of persons with low antibody titres had considered themselves immune, while one-half with moderate to high antibody titres had considered themselves at risk. Less than one-half of students with low antibody titres available themselves of immunization which was recommended and offered. With a high percentage of adult females at risk for rubella even in a health-motivated population and with poor follow-up on recommended immunization, current immunization practices must be improved if congenital rubella syndrome is to be further reduced. Mass inoculation of school age males and prepubertal school age females without prior determination of rubella antibody titres is suggested as a cost-effective means of decreasing incidence of congenital rubella syndrome.
REFERENCES 1. Modlin JF, Brandling-Bennett AD, Witte JJ, et al: A review of five year's experience with rubella vaccine in the United States. Pediatrics 55:20-29, 1975. 2. American Academy of Pediatrics: Report of committee on infectious diseases, 18th Edition, Evanston, IL: AAP, 242-248, 1977. 3. U.S. Public Health Service Advisory Committee on Immuniza4. 5.
6. 7.
8.
tion Practices: Collected recommendations. Morbidity and Mortality Weekly Reports. 21 (supl 25): 30-31, 1972. Witte JJ, Karchmer AW, Case G, et al: Epidemiology of rubella. Am J Dis Child 118: 107-111, 1969. Phillips CA, Maeck JVS, Rogers WA, et al: Intrauterine rubella infection following immunization with rubella vaccine. JAMA 213: 624-625, 1970. Larson HE, Parkman PD, Davis WJ, et al: Inadvertent rubella virus vaccination during pregnancy. N Eng J Med 284: 870-873, 1971. Wyll SA and Herrmann KL: Inadvertent rubella vaccination of pregnant women. JAMA 225: 1472-1476, 1973. Ebbin AJ, Wilson MG, Chander SB, et al: Inadvertent rubella immunization in pregnancy. Am J Obstet Gynecol 117: 505-512, 1973.
9. Fleet WF, Benz EW, Karzon DT, et al: Fetal consequences of maternal rubella immunization. JAMA 227: 621-627, 1974. 10. Vaheri A, Vesikari T, Oker-Blom N, et al: Transmission of attenuated rubella vaccines to the human fetus. Am J Dis Child 118: 243-246, 1969. 11. Furukawa T, Miyata T, Kondo K, et al: Clinical trials of RA 27/ 3 (Wistar) rubella vaccine in Japan. Am J Dis Child 118: 262263, 1969. 12. Katz SL, in discussion: Immunization of man against rubella. Am J Dis Child 118: 317, 1969. 13. Center for Disease Control: Rubella surveillance July, 1973-December, 1975. Atlanta, GA: CDC, 7-11, 1976. 14. Evans PC and Reisinger KS: Rubella susceptibility in Navajo women. J Repro Med 14: 84-85, 1975. 15. Freis PC, Sussman EK, and Shearin R: Sero-immunity screening of adolescent girls in a military population to determine susceptibility to the rubella virus. Military Med 141: 684-685, 1976. 16. Stoffman JM and Wolfish MG: The susceptibility of adolescent girls to rubella. Clinical Ped 15: 625-626, 1976. 17. McKusick MJ: Screening for rubella on a university campus. Post-grad Med 59: 202-205, 1976. 18. Klock KE and Rachelefsky GS: Failure of rubella herd immunity during an epidemic. JAMA 288: 69-72, 1973. 19. Halstead E, Halstead SB, Jackson RS, et al: Rubella vaccination: fertility control in a large-scale vaccination program for post-pubertal women. Am J Obstet Gynecol 121: 1089-1094, 1975. 20. Benenson AS, Ed.: Control of Communicable Diseases in Man, 12th Edition. Washington, DC: Am Pub Hlth Assoc, 272-276, 1975. 21. Schoenbaum SC, Hyde JN, Bartoshesky L, et al: Benefit-cost analysis of rubella vaccination policy. N Eng J Med 294: 306310, 1976. 22. Deseda-Tous J, Cherry JD, Spencer MJ, et al: Measles revaccination. Am J Dis Child 132: 287-290, 1978.
ACKNOWLEDGMENTS The authors are grateful to Dr. Carl S. Hacker, University of Texas School of Public Health at Houston, for analysis of data.
Evaluation of an Employee Health Service as a Setting For a Rubella Screening and Immunization Program KE WEISS, RNc, MS, CE FALVO, MD, MPH, E BuIMovIcI-KLEIN, MD, JW MAGILL, MD, AND LZ COOPER, MD
Introduction The main objective of rubella immunization campaigns is to prevent fetal damage. In an effort to offer protection to adult women, several states have instituted rubella screening programs.1' 2 New York State, in its Health Code, requires From the Virus Research Laboratory, Pediatric Service, The Roosevelt Hospital, New York City; and the Employee Health Service, Memorial-Sloan Kettering Cancer Center (Dr. Magill). Address reprint requests to Karen E. Weiss, RNc, MS, Virus Research Laboratory, Pediatric Service, the Roosevelt Hospital, New York, NY 10019. This paper, submitted to the Journal October 6, 1978, was edited and accepted for publication October 30, 1978.
AJPH March, 1979, Vol. 69, No. 3
that all women of childbearing years who work in health institutions be screened for rubella and offered immunization against rubella.3 In compliance with the New York State Health Code, a large urban hospital instituted such a program in the fall of 1975. The results of this screening and immunization program are evaluated for the two year period from January 1, 1976 to December 31, 1977.
Method The Screening Program encompassed three groups. All new female employees, 18 years and older, were tested for 281
PUBLIC HEALTH BRIEFS
TABLE 1-Acceptance of Rubella Vaccination Among Susceptible Women Hospital Workers by Age Groups, 1976-1977 Susceptible %
Screened
37
110 454 272 134 51
21 83 50 31 8
(18.3) (18.4) (23.1) (15.7)
10 62 31 18 5
1021
193
(18.9)
126
TOTAL
(19.1)
Description of Reaction
Number
Per Cent of All Vaccinees (N:126)
(47.6) (74.7) (62.0) (58.1) (62.5)
All Complaints Arthralgia/Pain-Stiffness
(65.3)
Swollen Glands Painful Injection Site
20 12 7 5 4 4 3 2 1 1
15.9 9.5 5.6 4.0 3.2 3.2 2.4 1.6 0.8 0.8
Vaccinated* %
Age Groups (Years)
*Three additional women vaccinated by private physicians are not included
rubella antibody as part of their initial employment medical assessment. Previously employed women were screened during their annual physical examination or prior to receiving immune serum globulin (ISG) for hepatitis exposure. Finally, an exploratory memorandum was circulated stating that rubella screening was available to any employee upon request. The Employee Health Service (EHS) staff collected basic demographic information on each individual screened. Past history, past vaccination, and recent exposure to rubella were also noted. Rubella hemagglutination inhibition (HAI) antibody tests were performed by the Virus Research Laboratory using the standardized method established by the Center for Disease Control.4 Persons whose HAI titers were less than 1:8 were considered "susceptible." Susceptible adults were informed by letter of their "'susceptibility"; an appointment was made for discussion of rubella and rubella immunization. During the appointment, written, informed consent was obtained and a brief medical history was taken; if there was no contraindication, vaccine was administered. Special emphasis was placed on contraceptive practices during the ensuing weeks.
Results Among the 1,225 female employees screened during the first two years of this program, 17.7 per cent were found to be rubella susceptible. Susceptibility rates varied erratically when women were grouped by year of birth (10.9-27 per cent) but when combined into five year cohorts, there were no statistical differences (Table 1). A further analysis based on exposure to rubella epidemics during the school years revealed no significant differences in susceptibility rates. In almost one-half of the 1,225 women tested historical recall of rubella failed to agree with the laboratory results. Forty-seven (21.7 per cent of 217 women who had no detectable HAI antibody) gave a positive response to the question, "Have you had rubella (German Measles) in the past?" Conversely, 544 (53.9 per cent of 1,008 women who were HAI positive) were unaware of having had rubella. In addition, of the 49 women responding positively to the question, ""Have 282
TABLE 2-Distribution of Side Reactions after Rubella Vaccination in 126 Women Hospital Workers, 1976-1977
Fatigue/Malaise Fever Rash Sore Throat Headache
"Shocky"
you received rubella vaccine?", 12 (42.5 per cent) were HAI negative. Of the 217 women who were rubella susceptible, it was possible to contact 193 (88.9 per cent).* Of the group contacted, 168 (87.0 per cent) came to the EHS to discuss rubella vaccination (25 women have never come to clinic despite repeat appointments). One hundred twenty-nine women (66.8 per cent of those contacted) have been vaccinated. One case of clinical rubella occurred in a susceptible woman who had received ISG. Of the 36 women seen but not vaccinated, eight were pregnant and three were planning to conceive. Thus, only 5.7 per cent of the susceptible women were ineligible for vaccination because of pregnancy. Twelve women declined to be vaccinated or postponed vaccine for personal reasons, six declined because of age, four because of medical contraindications, and three felt they had already been vaccinated and refused revaccination. Young (s20) women were more likely to reject rubella immunization than those older than 20 years (X2 13.72, p.05, Table 1). Reactions were reported by 20 patients (15.9 per cent) and did not constitute a major problem. Three women (2.4 per cent) reported to EHS for medical attention.** Of those who experienced a reaction, 9.5 per cent had two or more identifiable symptoms. The most commonly reported reaction was myalagia/arthralgia, described as "pain and stiffness" (Table 2). No one under age 20 or over age 36 complained of a reaction, but the numbers were small. There were no special age groups associated with side reactions.
Disciussion Two important considerations in planning programs to protect women of childbearing age against rubella have been reinforced by our study. First, rubella serologic testing is the only reliable method of determining rubella immunity. This *The remaining 24 women were not available because their employment had been terminated. **Each of these individuals was found to have a previously undiagnosed medical problem, including severe allergy, carpal tunnel syndrome, and shin splints due to jogging. AJPH March, 1979, Vol. 69, No. 3
PUBLIC HEALTH BRIEFS
confirms the observations of many others.5 6 Second, an active EHS was a suitable location for establishing a rubella screening and immunization program. The screening was easily incorporated into the routine pre-employment health examination. Most importantly, we have been reasonably successful in vaccinating the susceptible women in our program. In post-pubescent rubella vaccine campaigns, both pregnancy and vaccine reactions are of concern. Pregnancy was infrequent in our study population. Overall, in the United States, pregnant workers comprise 8.8 per cent of the ".ever-married women" of reproductive age currently employed.7 Thus a program which is based in the work force could provide an acceptable area for rubella screening and vaccination programs. Side reactions were not a problem in our study population. Those individuals with complaints serious enough to report to EHS for medical attention had conditions unrelated to rubella immunization. A study to follow both an immunized and a control group for concurrent symptoms would be a useful contribution. Our experience demonstrates that a rubella screening and immunization program for women employees, which includes an informed consent and discussion period, successfully captures an "at-risk" population and provides continuing health education.
REFERENCES 1. Judson FN, Shaw BS and Vernon TM: Mandatory premarital rubella serologic testing in Colorado: A preliminary report. JAMA 729:1200-1202, 1974. 2. Fox JP, Rainey HS, Hall CE, et al: Rubella vaccine in postpubertal women: Experience in western Washington state. JAMA 236:837-843, 1976. 3. New York State Public Health Law 2803; Section 720.6. 4. Center for Disease Control. A Procedural Guide to the Performance of the Standardized Rubella Hemagglutination-Inhibition Test. U.S. Department of Health, Education, and Welfare, Mental Services and Mental Health Administration. Center for Disease Control, Atlanta, GA, October 1970. 5. Bottiger M and Heller L: Experiences from vaccination and revaccination of teenage girls with three different rubella vaccines. J Biol Stand 4:107-114, 1976. 6. Freis PC, Sussman EK and Shearin R: Sero-immunity screening of adolescent girls in a military population to determine susceptibility to the rubella virus. Milit. Med 141 (10):684-5, 1976. 7. Hendershot GE: Pregnant Workers in the United States. Advance data (Vital & Health Statistics of NCHS, DHEW, USPHS, HRA) 11:1-4, 1977.
ACKNOWLEDGMENTS Special thanks to the Memorial-Sloan Kettering Cancer Center's Employee Health Service staff and D. Robinson. Parts of this study were funded by Merck, Sharp & Dohme. The original version of this paper was presented at the Annual Meeting of the Society for Epidemiologic Research, June 1978, Iowa City, IA.
A Rubella Screening and Immunization Program In an Adolescent Clinic CATHEY E. FALVO, MD, MPH, KAREN E. WEISS, RN, MS, and SHARI M. Liss The present United States practice concerning rubella vaccine emphasizes immunization of preschool children. This approach appears to have prevented epidemic spread of rubella but has not adequately protected susceptible* women of childbearing age who are at risk of having babies with congenital rubella (CR). The rubella outbreak in Casper, Wyoming2 among junior and senior high school children, after a campaign to vaccinate the preschool and elementary school children in that city, indicated a potential problem in control of rubella. The recent outbreak in Hawaii3 among From the Virus Research Laboratory, Department of Pediatrics, The Roosevelt Hospital, New York City. Address reprint requests to Dr. Cathey E. Falvo, Virus Research Laboratory, Department of Pediatrics, The Roosevelt Hospital, 428 West 59 Street, New York, NY 10019. Ms. Weiss has recently completed the American Nurses' Association's certification program in Community Health Nursing Practice. This paper, submitted to the Journal April 17, 1978, was revised and accepted for publication October 6, 1978. *The term "susceptible(s)" will be used to indicate a person(s) with a rubella Hemagglutination Inhibition Antibody (HAI) titer of less than 1:8 as tested by the CDC method.'
AJPH March, 1979, Vol. 69, No. 3
young adults, despite a 95 per cent vaccination rate among school children, emphasizes the continuing risk of rubella among susceptible adults, especially the pregnant woman. Adolescent girls represent one potential high-risk group for contracting rubella during pregnancy. A rubella screening and vaccination program was developed for this group during 1974 at the Roosevelt Hospital in New York City. The purpose of the program was: a) to screen all women (10 to 21 years of age) attending the pediatric outpatient department (OPD) for rubella susceptibility*; b) to vaccinate all those found to be susceptible and who were not likely to become pregnant in the next three months. This paper outlines the results of this program.
Methods The adolescent outpatient program is part of the comprehensive care program within the pediatric OPD. Most of the patients are Hispanic and come from low income families. They are usually seen by the same primary care team 283
