Rubella Immunization: Present Status and Future Perspectives

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1174 PEDIATRICS Vol. 65 No. 6 June 1980

patient fees and hospital service guilds or boards, some of which have endowment funds and are

seeking ways to improve the quality of care.

2. Training residents and students in

ambula-tory care should be the pediatrician’s forte. The center should make the outpatient service more attractive for the practitioner by involving him in team activities and giving him the opportunity for formulating new policies and objectives.

3. Most pediatricians, whether in academics or

practice, have not received formal education in learning how to be effective teachers. Teacher de-velopment workshops are now being offered, and

full-time and volunteer faculty should be encour-aged to participate.

4. Problem-solving as an approach to teaching is not being emphasized. Too often problems are discussed when the diagnosis has already been

sug-gested for the learner. Dissecting how to approach

a problem before the diagnosis is made and admis-sion decided is essential in resident training. This is an area in which the practitioner could supplement

and complement the expertise of the specialists. 5. Since the advent of primary care and

corn-munity pediatrics in the 1960s and the birth of affiliations between universities and community hospitals, practitioners can teach at hospitals in close proximity to their practice while maintaining

ties to the center.’ The practitioner is usually the primary teacher in the community setting and he can provide approaches to patients that are differ-ent from those taught at the center. He is able to share aspects of his lifestyle with residents and students, and if he is a strong role model, they will want to emulate him. This interaction can have a significant influence on career choices.

6. Teaching residents in the office as part of a pediatric training program is an alternative to their working as attending physicians on an inpatient rotation.2 In this environment pediatricians can pro-vide expertise to residents on the subject matter with which they are most familiar. This can be an invaluable educational experience for residents planning to enter practice or research/academics. Teaching in the office does not necessarily imply loss of income for the practitioner. In our program, residents in their second year of training (PL-2)

rotate through pediatric offices and have chosen to be observers in this setting. They spend 50% of their time in patient care activities and the remainder is devoted to the structure of the office (records, ap-pointments, billing, etc), a subject that an office manager or nurse can teach. More active resident participation would be more appropriate in the third year of training when career goals may be better established. However, an efficient resident

does not obviate the need for close supervision by the pediatrician.

There is definitely a place for the practicing pe-diatrician in resident education, whether it be in the academic center, a community hospital, or his

Own practice. The pediatric practitioner’s approach to the total care of the family and child and to problem solving are essential components of an effective residency training program.

REFERENCES

LARRIE W. GREENBERG, MD Office of Medical Education The Children’s Hospital National

Medical Center

Washington, District of Columbia

1. Greenberg LW: Pediatric training in a community hospital:

A four and a half year experience. Clin Proc Children s Hospital National Medical Center 35:143, 1979

2. Greenberg LW: Teaching primary care pediatrics to pediatric residents through an office rotation. J Med Educ 54:340,

1979

Rubella

Immunization:

Present

Status

and

Future

Perspectives

Sixteen years have elapsed since the last major epidemic of rubella in the United States. Prior to 1964, extensive outbreaks occurred at about six- to nine-year intervals. These outbreaks were associ-ated with the birth of many thousands of infants with one or more of the following defects: cataracts, deafness, cardiac malformations, and brain damage causing mental retardation, cerebral palsy, or severe

behavior disorders. In addition, many pregnancies were terminated by spontaneous or therapeutic abortions. This devastating “rubella problem” pro-vided the motivation for the development of rubella vaccine.

The live attenuated rubella vaccine was licensed

for use in 1969-two to four years before the next anticipated epidemic. At that time, the strategy for the control of rubella and congenital rubella

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COMMENTARIES 1175 volved two goals: (1) routine immunization of all

infants and children before puberty, and (2) selec-tive immunization of adolescents and women of childbearing age.

The objective of large-scale routine immunization of children was to prevent future epidemics of ru-bella and their disastrous consequences. This

objec-tive has been achieved. Since licensure of the vac-cine in 1969, more than 100 million doses have been

used, predominantly in children. The extensive use of rubella vaccine has confirmed its safety and efficacy and it has been associated with a progres-sive decline in the number of reported cases of rubella and congenital rubella. The change in the

epidemiology of rubella since the last major epi-demic in 1964 has been extraordinary.

The aim of selective immunization of women of childbearing age was: (1) to assess susceptibility or immunity by testing their sera for rubella antibody;

(2) to reassure those who were immune; and (3) to immunize those who were susceptible, not pregnant,

and wffling to avoid pregnancy for at least three

months. These precautions were essential because

of the potential teratogenic effect of the

vaccine-virus infection. However, during the past decade it has become apparent that the selective immuniza-tion program has been a dismal failure. Most adults, unlike children, do not participate in immunization programs. In addition, most internists and other

physicians caring for adults appear to be reluctant

to become involved with immunization procedures. For example, in spite of the recommendation that rubella vaccine be administered to susceptible women during the immediate postpartum period,

many obstetricians fail to do so.

The seroepidemiologic survey by Lawless et al (p 1086) identified about 15% ofsixth grade students from “a medically well-served community” as pre-sumably susceptible to rubella. These observations reflect an accurate assessment of rubella

suscepti-biity in both adolescents and adults in the United

States during the late 1970s. This significant

seg-ment of the population includes unimmurnzed

per-Sons as well as those who were vaccine-failures. It

is this group that has been involved in recent out-breaks of rubella in high schools and colleges. It is also this group that includes the future generation of susceptible women of childbearing age.

In a medical progress report that was published in January 1977,’ I discussed future control of ru-bella and congenital rubella. The following

corn-ments extracted from that article are just as

perti-nent today as they were in 1977. At that time I

stated that the experience with the rubella

immu-nization program during the past seven years has revealed the following findings that may have an

impact on future control measures:

Most women of childbearing age have not been

“reach-able” in our health care system. Internists, obstetricians, and other physicians who care for adults are not as “preventive medicine oriented” as pediatricians and

phy-sicians who deal with children.

It is difficult to motivate obstetricians to not only test for rubella susceptibility during the prenatal visit but to

immunize susceptible women during the postpartum pe-nod. Frequently, the serologic test is done routinely but

the obstetrician is reluctant to administer a vaccine that may cause side effects.

Live attenuated rubella vaccine like measles vaccine will not be immunogenic if it is inactivated by poor refrigeration and excessive exposure to light.

However, in spite of these problems, the overall experience with rubella immunization in the United

States has been most encouraging. Immunity fol-lowing successful immunization has persisted, and it is likely that it will be long-lasting. The recent licensure of a more stable and more immunogenic vaccine should decrease the incidence of vaccine-failures. The striking improvement in rubella im-munization levels since 1978 can be attributed to the intensive US Public Health Service immuniza-tion initiative and the cooperation of school health authorities who have enforced the mandate “no vaccine-no school.” If this trend continues, rubella and congenital rubella will cease to be an important problem in this country.

FUTURE PERSPECTIVES

The extensive experience accumulated during the

past decade has provided convincing evidence that

it should be possible to control rubella to the same degree that diphtheria and poliomyelitis have been controlled in this country. The immunogenicity and efficacy of diphtheria toxoid and poliovaccine, like rubella vaccine, exceed 90%. The number of re-ported deaths due to diphtheria declined from more than 5,000 per year during the prevaccine era to less than ten in the late 1970s. The number of reported cases of paralytic poliomyelitis has de-dined from about 15,000 per year in the 1950s to less than ten per year in the late 1970s. In contrast, the number of reported cases of rubella declined from about 57,000 in 1969, when the rubella vaccine was licensed, to about 13,000 in 1979.

I believe that the extraordinary results of the diphtheria and poliovaccine immunization pro-grams were due, in great part, to the fact that

multiple doses (at least four) of vaccine were

ad-ministered in order to achieve optimum immuni-zation. Under these circumstances, vaccine-failures were very unlikely. In contrast, the strategy for the use of rubella vaccine has involved the use of a

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1176 PEDIATRICS Vol. 65 No. June 1980

single inoculation. Under these circumstances, about 10% to 15% of persons who were vaccinated were vaccine-failures. If this trend continues, of about 3 million infants born each year, about

300,000 will be unprotected. This group plus those who are not immunized will comprise the future

segment of the adult population that will be suscep-tible to rubella.

I believe that the optimum strategy for the

con-trol of rubella and congenital rubella in the United States will entail the use of two doses of rubella vaccine. Ideally, the first dose should be given at 15 months of age or shortly thereafter, and the second dose should be given at the time of school entry. Children who receive the first dose of vaccine at the time of school entry could receive their second dose when they are in the fourth or fifth grade, just

before puberty. If resources were available to sup-port and implement a program of this type, rubella, like diphtheria and poliomyelitis, could become a rare disease in this country. The solution of the

“rubella problem” is an attainable objective.

The extraordinary progress as well as the prob-lems associated with the rubella immunization pro-gram are essentially the same as those associated with the measles immunization. Therefore, measles and rubella immunization programs should be con-ducted simultaneously, utilizing the combined vac-cine in a single inoculation. This strategy should accelerate the control of both diseases.

REFERENCE

SAUL KRUGMAN, MD

New York University School of Medicine New York

1. Krugman 5: Present status of measles and rubella immuni-zation in the United States: A medical progress report. J Pediatr 90:1, 1977

On Replacing

the

Surfactant

Ever since it was realized that hyaline membrane disease was the consequence of surfactant deficiency, replacing the missing surface-active al-veolar lining layer has been a tantalizing prospect.

The report of Fujiwara et al’ is the first

demonstra-tion in the human of consistent and dramatic suc-cess after a single instillation of an artificial surfac-tant by way of an endotracheal tube. The prompt restoration of a stable alveolar lining layer and the impressive improvement in blood gases are well

documented. The problem of the widely patent ductus producing difficulties in the subsequent days is expected and of course could be approached by

other interventions.

Attempts to aerosolize surface-active phospholip-ids date from the preliminary studies of Robifiard et al2 and Chu et al3 with dipalmitoyl lecithin in the mid-1960s. Both studies with human infants failed to produce convincing benefits, so that over the ensuing years there has been relatively little pursuit of this therapy. A preliminary report by Ivey et al4

suggested some value of a mixture of dipalmitoyl phosphatidylcholine and dipalmitoyl phosphatidyl-glycerol, and Shannon and Bunnell4a tried a 1%

aerosol of dipalmytoyl lecithin in water.

Meanwhile several investigators have studied the possibility of replacement of surface-active mate-rials in an animal model. Enh#{246}rning and Robertson5 reported improved stability of lungs of premature rabbits after tracheal deposition of surfactant de-rived from mature rabbit lungs. Shannon et al6 were encouraged by observing restoration of stable pres-sure-volume relationships after exposure of excised lungs of dogs to a lecithin fog. Homologous surfac-tant suspensions instified into the tracheas of 27-day-gestation rabbits (term = 31 days) improved

the aeration of the premature lung.7 In 1978 Adams and associates described the instillation of a natural surfactant derived from lambs into the trachea of immature animals. This homologous surfactant per-mitted survival of the treated lambs for two hours, whereas all the control animals died prematurely,

usually before 60 minutes. When the animals were ventilated, it was noted that those who had been treated with surfactant required much lower pres-sures than the controls.

Stimulated by these promising studies in lambs, Fujiwara, in Japan, pursued the possibility of a modification of natural surfactant which might have the appropriate physical and chemical prop-erties for achieving alveolar stability with less po-tential hazard from the possibility of reaction to a foreign protein, which was a worry with the natural surfactant. They started with a bovine lung mince that was lyophiized and further concentrated by flotation in the centrifuge at 2,500 g at a density of 1.2 gm/mi. After dialysis, lyophilization, and extrac-tion with acetone, the lipid mixture was enriched by addition of dipalmitoyl lecithin and phosphati-dylglycerol. The final product, called “artificial

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1980;65;1174

Pediatrics

Saul Krugman