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Rubella Outbreak in the Netherlands, 2004–2005: High Burden of Congenital Infection and Spread to Canada

Hahné, Susan MD*; Macey, Jeannette MSc; van Binnendijk, Rob PhD*; Kohl, Robert BAS*; Dolman, Sharon MSc, RN; van der Veen, Ytje MSc*; Tipples, Graham PhD§; Ruijs, Helma MD; Mazzulli, Tony MD; Timen, Aura MD*; van Loon, Anton PhD**; de Melker, Hester PhD*

The Pediatric Infectious Disease Journal: September 2009 - Volume 28 - Issue 9 - p 795-800
doi: 10.1097/INF.0b013e3181a3e2d5
Original Studies

Background: In The Netherlands and Canada the measles, mumps, rubella vaccine coverage is high. In 2004 a rubella outbreak started in the Netherlands in a population subgroup with low coverage, with subsequent spread to Canada.

Methods: We examined data on rubella cases in the Netherlands and Canada reported between September 2004 and July 2005. In The Netherlands we established enhanced surveillance for congenital rubella while in Canada we carried out a cohort study to estimate vaccine effectiveness.

Results: In The Netherlands and Canada, 387 and 309 rubella cases were reported, respectively. Of these, 97% were in unvaccinated individuals of orthodox protestant denomination. Reported consequences of rubella in pregnancy were 2 fetal deaths and 14 infants with congenital infection. Of the latter, 11 had clinical defects including deafness in all but eye defects in none. The estimated vaccine effectiveness was 99.3% (95% CI: 95.3%–99.9%). Closely related strains of rubella virus genotype 1G were found in Dutch and Canadian cases.

Conclusions: A large rubella outbreak occurred in The Netherlands with spread to Canada in a population subgroup with religious objections to vaccination. Its major public health importance was due to the high burden of congenital disease, international spread and implications for measles and rubella surveillance and elimination. Congenital deafness occurred more frequently and eye defects less frequently than expected. The estimated rubella vaccine effectiveness was very high. Our results demonstrate the risks associated with heterogeneity in rubella vaccine coverage. High rubella vaccine coverage in all population subgroups and sensitive surveillance are crucial for elimination of rubella and CRS.


From the *Centre for Infectious Disease Control, National Institute for Public Health and the Environment (RIVM), The Netherlands; †Infectious Diseases and Emergency Preparedness (IDEP) Branch, Public Health Agency of Canada (PHAC), Canada; ‡Infectious Diseases Branch, Public Health Division, Ministry of Health and Long Term Care of Ontario (MOHLTC), Canada; §National Microbiology Laboratory, PHAC, Canada; ¶Municipal Health Authority (GGD) Rivierenland, The Netherlands; ∥Department of Microbiology, Ontario Public Health Laboratory, Mount Sinai Hospital, Toronto, MOHLTC, Canada; and **Department of Virology, University Medical Centre (UMC) Utrecht, The Netherlands.

Accepted for publication March 4, 2009.

No additional sources of funding were used for this study.

None of the authors have commercial or other interests that might pose a conflict of interest.

Presented at the International Conference on Emerging Infectious Diseases (ICEID), Atlanta, US, 20th March 2006.

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Address for correspondence: Susan Hahné, MD, Centre for Infectious Disease Control, National Institute for Public Health and the Environment, (RIVM-CIb), PO Box 1, 3720 BA, Bilthoven, The Netherlands. E-mail:

© 2009 Lippincott Williams & Wilkins, Inc.