Progress Toward Eliminating Rubella Worldwide, 2012–2022

This page summarizes a report in CDC's MMWR by CDC and the World Health Organization (WHO), covering 2012–2022.

Rubella usually causes a mild illness with fever and rash, and it can spread in epidemics. But infection during pregnancy, especially in the first trimester, can cause miscarriage, fetal death, stillbirth or congenital rubella syndrome (CRS): birth defects including cataracts, deafness, heart defects and developmental delay. Rubella is a leading cause of vaccine-preventable birth defects, and a single dose of rubella-containing vaccine (RCV) can protect for life.

The Global Vaccine Action Plan 2011–2020 aimed to eliminate rubella in at least five of WHO's six regions by 2020, and elimination is a key goal of the Immunization Agenda 2030 and its Measles and Rubella Strategic Framework 2021–2030.

How countries introduce the vaccine

WHO recommends starting with a catch-up campaign for people who may not have been naturally exposed, usually children and adolescents up to 14, then reaching and keeping at least 80% coverage with one or more doses through routine services or campaigns. Countries report immunization and surveillance data to WHO and UNICEF each year. Rubella cases are found through measles surveillance of fever-and-rash illness; CRS is tracked separately, often at a few sentinel sites. A country is verified as having eliminated rubella after 36 months with no ongoing local transmission.

Vaccination

• Every country in the Americas, Europe, South-East Asia and the Western Pacific uses RCV; in the African Region 32 of 47 countries (68%) do, and in the Eastern Mediterranean 17 of 21 (81%).
• Regional coverage ranged from 36% in Africa to 93% in Europe. By income, coverage was 27% in low-income, 70% in lower-middle-income, 88% in upper-middle-income and 93% in high-income countries. Among countries that use RCV, coverage was 82%, 81%, 86% and 94%.
• Introductions slowed during COVID-19: only Comoros and Pakistan introduced RCV in 2021.
• 19 countries had yet to introduce it, 15 in Africa and 4 in the Eastern Mediterranean, home to about 25 million infants a year, mostly in low-income, conflict-affected places.

Cases

• Reported rubella cases fell from 93,816 in 2012 to 48,559 in 2019 and 17,407 in 2022.
• Reported CRS cases rose from 301 in 2012 to 418 in 2019 and 1,527 in 2022, mainly because populous countries (Afghanistan, Bangladesh, India, Indonesia and Pakistan) began CRS surveillance. Reports are a vast undercount: modeling suggests more than 32,000 babies are born with CRS each year, mostly where RCV is not used, even after a two-thirds drop in the global burden during 2010–2019.
• Countries reporting rubella cases fell during COVID-19, from 169 (87%) in 2019 to 144 (74%) in 2020, recovering only to 149 (77%) in 2022. Countries reporting CRS rose from 123 (63%) to 133 (69%).
• Of 5,722 rubella virus sequences reported during 2012–2022 from 45 countries, 58% were genotype 1E and 42% genotype 2B, but 67% came from China and 24% from Japan, showing the need for wider virus surveillance.

Elimination

• The Americas were verified free of rubella and CRS as a region in 2015. Five WHO regions now have elimination goals (Africa set one in 2021), and the Eastern Mediterranean has committed to elimination without yet setting a goal.
• 98 of 194 countries (51%) were verified by 2022, up from 84 in 2019: 35 in the Americas (all), 50 of 53 in Europe, 4 of 21 in the Eastern Mediterranean, 4 of 11 in South-East Asia, 5 of 27 in the Western Pacific, and none in Africa.
• Nearly 25% of lower-middle-income countries have been verified, showing elimination is possible in hard circumstances, and no verified country has seen endemic transmission return, thanks to a highly effective vaccine and sustained coverage.

What is needed

The threat of reintroduction remains until every country uses RCV. The 19 remaining countries need support to introduce it. Children who missed vaccines during the pandemic need catching up, and adolescents and adults, including those of childbearing age, need strategies to protect them too.

Limitations

• Surveillance and immunization data can be inaccurate or unreliable, making immunity gaps and interrupted transmission hard to show.
• Reporting fell off during COVID-19, limiting the view of the last 3 years.
• Many countries don't track CRS, and sentinel sites see only infants who reach specialty hospitals.

Sources

• Ou AC, Zimmerman LA, Alexander JP Jr, Crowcroft NS, O'Connor PM, Knapp JK. "Progress Toward Rubella and Congenital Rubella Syndrome Elimination — Worldwide, 2012–2022." MMWR 73(8). https://www.cdc.gov/mmwr/volumes/73/wr/mm7308a2.htm
• The report describes an 81% decline both as "global rubella incidence" during 2013–2021 and as reported cases during 2012–2022, and says 15 countries were verified during 2019–2022 while its counts rise from 84 to 98; this page gives the case and country counts only. Its figures are not reproduced, because the report was prepared jointly with WHO.