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Susceptibility to Measles, Mumps, and Rubella in Newly Arrived Adult Immigrants and Refugees

Christina Greenaway, MD, MSc; Pierre Dongier, MD; Jean-François Boivin, MD, ScD; Bruce Tapiero, MD; Mark Miller, MD, MSc; and Kevin Schwartzman, MD, MPH
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From Sir Mortimer B. Davis Jewish General Hospital, Côte-des-Neiges local community health center, McGill University, and Saint Justine Hospital, Montreal, Quebec, Canada.

Acknowledgments: The authors thank Dr. Alexander Zinca at the Clinique Diamant for referring many of his clinic patients to our study; Ms. Marie Morahan, serology technologist at the Jewish General Hospital, for her hard work running all of the study samples; and the Ontario Public Health Laboratories for running serologic testing for many of the study serum samples to verify the testing and the functioning of the ELISA kits.

Grant Support: By the Fonds de la Recherche en Santé du Québec (grant no. 24002-1836) and GlaxoSmithKline (protocol no. 208133-177). Drs. Greenaway and Schwartzman are recipients of research career awards from the Fonds de la Recherche en Santé du Québec.

Potential Financial Conflicts of Interest: Grants received: C. Greenaway (GlaxoSmithKline). The Fonds de la Recherche en Santé du Québec is a peer-reviewed organization.

Requests for Single Reprints: Christina Greenaway, MD, Division of Infectious Diseases, SMBD-Jewish General Hospital, 3755 Côte Ste. Catherine Road, Room G-143, Montreal, Quebec H3T 1E2, Canada; e-mail, ca.greenaway@mcgill.ca.

Current Author Addresses: Dr. Greenaway: Division of Infectious Diseases, SMBD-Jewish General Hospital, 3755 Côte Ste. Catherine Road, Room G-143, Montreal, Quebec H3T 1E2, Canada.

Dr. Dongier: Clinique Santé Acceuil, CLSC Côte-des-Neiges, 5700 Chemin de la Côte-des-Neiges, Montreal, Quebec H3T 2A6, Canada.

Dr. Boivin: Epidemiology and Biostatistics, McGill University, 1020 Pine West, Montreal, Quebec H3A 1A2, Canada.

Dr. Tapiero: CHU Mère-Enfant Sainte-Justine, Service de Maladies Infectieuses, 3175 Cote Ste. Catherine Road, Montreal, Quebec H3T 1C5, Canada.

Dr. Miller: Infectious Diseases, SMBD-Jewish General Hospital, 3755 Côte Ste. Catherine Road, Room G-139, Montreal, Quebec H3T 1E2, Canada.

Dr. Schwartzman: Respiratory Epidemiology Unit, McGill University, Montréal Chest Institute Room K1.23, 3650 St. Urbain, Montreal, Quebec H2X 2P4, Canada.

Author Contributions: Conception and design: C. Greenaway, P. Dongier, J.-F. Boivin, M. Miller, K. Schwartzman.

Analysis and interpretation of the data: C. Greenaway, J.-F. Boivin, M. Miller, K. Schwartzman.

Drafting of the article: C. Greenaway.

Critical revision of the article for important intellectual content: C. Greenaway, J.-F. Boivin, B. Tapiero, M. Miller, K. Schwartzman.

Final approval of the article: C. Greenaway, P. Dongier, J.-F. Boivin, B. Tapiero, M. Miller, K. Schwartzman.

Provision of study materials or patients: C. Greenaway, P. Dongier, B. Tapiero.

Statistical expertise: J.-F. Boivin.

Obtaining of funding: C. Greenaway, J.-F. Boivin.

Administrative, technical, or logistic support: C. Greenaway, P. Dongier, J.-F. Boivin, M. Miller.

Collection and assembly of data: C. Greenaway.

Ann Intern Med. 2007;146(1):20-24. doi:10.7326/0003-4819-146-1-200701020-00005
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We invited 1619 individuals to participate in the study, and 139 (9.2%) of these individuals declined to participate. We had no information on the immigration status or origin of those who declined, but they more often came from the postpartum ward than from other care settings. Serologic testing results for measles, mumps, and rubella were available for the remaining 1480 immigrants. Table 1 presents the sociodemographic characteristics. Almost half the participants were refugees, but only 0.8% had lived in a refugee camp and most refugees had applied for asylum after first arriving in Canada. Participants were well-educated (mean years of education, 13.9 years [SD, 4]; 47% had a university education) and were of relatively high socioeconomic class (94% described their families of origin as middle or upper income).

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susceptibilty to measles, mumps and rubella in newly arrived migrants and refugees
Posted on April 1, 2007
Adrian K Thomas
Deafness Foundation, Victoria, Australia P.O. Box 42, Nunawading, Victoria, Australia 3121
Conflict of Interest: None Declared

Our own experience is similar to that of Greenaway, at least in respect of rubella.

In an extensive study, over 25 years of 65,227 records of pregnant and non-pregnant women attending a public teaching hospital in Melbourne, Australia, and where 44% of the women were born overseas, we showed that women born in developing countries, especially nulliparous Asian women <30 years of age had significantly increased odds of being susceptible to rubella compared to Australian born women (1). In 2000, the last year of our study, women born in sub-Saharan Africa and South America, in addition to Asian-born women, had five times the odds of being seronegative compared to all other women in the study. This increased susceptibility is reflected in the fact that in Australia for the years 1993 - 2003, of the 28 cases of congenital rubella infection, nine of the mothers had nationalities other than Australian, and six of these were known to have been born overseas (2). These findings also show that current vaccination programmes do not adequately serve immigrant women from developing countries where rubella vaccination is not widely practiced. Furthermore, the potential exists for importation of disease by unvaccinated locals who have been infected while travelling in these countries, such as happened in Indiana in 2005 when 34 cases of measles were caused by one unvaccinated US resident returning home (3).

We believe that the most efficient and effective way of addressing this issue is for prospective migrants and refugees to be informed about rubella and other vaccine preventable diseases and formally offered vaccination if there are no contraindications, as part of their pre-entry health assessment. We do not believe it is necessary to make such vaccination a pre-requisite for entry to the country "“ in a rubella education/ vaccination program targeting Vietnamese refugees during 1989 "“ 1991 only two patients declined to be vaccinated out of 791 who were offered it (4). We believe there is a lack of knowledge about the dangers of the infections rather than opposition to vaccination.

Since 1983 the Deafness Foundation (Victoria, Australia) with the support of the Victorian State Government, has been conducting an on-going rubella prevention/education program amongst migrant and refugee women in Melbourne using materials developed in a range of languages, (pamphlets in 18 languages, posters in 5 languages and videos in 14 languages). This information is well received and we would be most willing to share our experiences with other interested parties.

We also believe that a forceful but voluntary policy on vaccinations should be implemented for travellers departing developed countries, similar to that recommended by the Public Health Agency of Canada in response to the requirements recently implemented by the Venezuelan Government (which they have made compulsory), for those travelling outside the Americas (5).


1.Francis B H, Thomas AK, McCarthy CA. The impact of rubella immunization on the serological status of women of childbearing age: a retrospective study in Melbourne, Australia. Am J Public Health 2003 1274 -1276

2.Forrest JM, Burgess M, Donovan T A. A resurgence of congenital rubella in Australia? Communicable Diseases Intelligence 2003; 27:533-536

3.Centers for Disease Control and Prevention (CDC). Measles- United States, 2005. Morb Mort Wkly Rep 2006 Dec 22;55(50): 1348-51.

4.Yeates K. Vietnamese rubella education program 1989-1991. Deafness Foundation Victoria, 1992. Nunawading, Victoria, Australia 3121.

5.Public Health agency of Canada. Travel Health Advisory. Measles and rubella Vaccination Departure Requirements "“ Venezuela. http://www.phac_asp.gc.ca/tmp-pmv/2006/measvene060519_e.html

Conflict of Interest:

None declared

Immunity to measles in female immigrants and refugees
Posted on February 7, 2008
Taufiek K Rajab
Imperial College London
Conflict of Interest: None Declared

In their study population of recent immigrants and refugees Greenaway and colleagues found that women were more likely than men to be susceptible to measles (1). From this data they infer that immigrant women had higher odds of being immune to measles compared with immigrant men. However we draw the opposite conclusion from this data, namely that women in the study population had higher odds of being nonimmune to measles.

1. Greenaway C, Dongier P, Boivin J, Tapiero B, Miller M, Schwartzman K. Susceptibility to Measles, Mumps, and Rubella in Newly Arrived Adult Immigrants and Refugees. Ann Intern Med. 2007; 146:20-24

Conflict of Interest:

None declared

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