Canadian Paediatric Surveillance Program - 2003 Results

Congenital rubella syndrome

(January 1996 to December 2004)

Highlights

• There were no new CRS cases in 2003.
• From 1996 to 2003, zero to two newborns with CRS per year were identified through the surveillance systems in Canada (0 to 0.5 per 100,000 births).
• Canada's very low incidence of rubella and CRS is a reflection of the impact of rubella elimination strategies.
• This study reinforces the need for all children to receive their rubella vaccine at the recommended ages.
• Standing orders for vaccination of all rubella susceptible women in the immediate postpartum period are essential.

Background

In Canada, rubella immunization programs were introduced in the 1970s. However, the program strategies varied; some provinces initially opted for selective immunization of pre-adolescent females and others opted for immunization of all infants. By 1983, all provinces and territories across Canada had implemented routine measles-mumps-rubella combined vaccine (MMR) at 12 months. During 1996 and 1997, all provinces and territories introduced a routine second dose MMR or measles-rubella combined vaccine (MR) given at 18 months or four to six years. Some jurisdictions used MR vaccine for their second dose catch-up campaigns.

Since 1970 the incidence of rubella in Canada has declined markedly; fewer than 30 cases were reported annually in the past three years. During a national consensus conference in 1994, a goal of eliminating indigenous rubella infection during pregnancy by the year 2000 was established. In November 2001, a National Expert Working Group on Rubella recommended that all rubella infections be included for enhanced surveillance.

In Canada, passive reporting of congenital rubella syndrome (CRS) to the Notifiable Diseases Reporting System (NDRS) began in 1979. Active surveillance of CRS began in 1992 through a network of tertiary-care paediatric hospitals (now representing more than 90% of paediatric tertiary-care beds in Canada) participating in IMPACT (Immunization Monitoring Program ACTive) and through the CPSP since 1996.

Objectives

1. To estimate the incidence of congenital rubella syndrome.
2. To obtain detailed epidemiological data, including maternal histories, on reported cases of congenital rubella syndrome and infection.

Case definitions

Confirmed case Live birth

Two clinically compatible manifestations (any combination from Table 13, columns A and B) with laboratory confirmation of infection:

• isolation of rubella virus from an appropriate clinical specimen;

or

• detection of rubella-specific IgM in the absence of recent immunization with rubella-containing vaccine;

or

• rubella-specific IgG persisting at elevated levels for longer than would be expected from passive transfer of maternal antibody, or in the absence of recent immunization.

Stillbirth

Two clinically compatible manifestations with isolation of rubella virus from an appropriate clinical specimen.

Note: The following cannot be classified as a CRS case:

• rubella antibody titre absent in the infant;

or

• rubella antibody titre absent in the mother;

or

• rubella antibody titre declining in the infant consistent with the normal decline after birth of passively transferred maternal antibody.
  

Congenital rubella infection
Confirmed case

A case with laboratory confirmation of infection but with no clinically compatible manifestations:

• isolation of rubella virus from an appropriate clinical specimen;

or

• detection of rubella-specific IgM in the absence of recent immunization with rubella-containing vaccine;

or

• persistence of rubella-specific IgG at elevated levels for longer than would be expected from passive transfer of maternal antibody, or in the absence of recent immunization.

Rubella in clinical illness
Confirmed case

Laboratory confirmation of infection in the absence of recent immunization with rubella containing vaccine:

• isolation of rubella virus from an appropriate clinical specimen;

or

• significant rise in serum rubella IgG antibody levels by any standard serological assay;

or

• positive serologic test for rubella-specific IgM;

or

• clinical illness* in a person who is epidemiologically linked to a laboratory confirmed case.
  

* Clinical illness is characterized by fever and rash, and at least one of the following: arthralgia/arthritis, lymphadenopathy, conjunctivitis. Up to 50% of rubella infections are reported to be subclinical.

Results and discussion

In 2003, there were two reports of the same 20-month-old adopted child from Asia, who had the following clinical conditions: congenital cataract, patent ductus arteriosus, and microcephaly. No information was available on the mother. This case did not meet the Canadian CRS case definition as the diagnosis was confirmed beyond infancy. The very low incidence of CRS and rubella infection suggests that Canada is getting closer to achieving the goal of eliminating indigenous rubella infection during pregnancy.

TABLE 13 Congenital rubella syndrome: clinically compatible manifestations
Column A		Column B
1	Cataracts or congenital glaucoma (either one or both count as one)	1	Purpura
2	Congenital heart defect	2	Hepatosplenomegaly
3	Sensorineural hearing loss	3	Microcephal
4	Pigmentary retinopathy	4	Micro-ophthalmia
		5	Mental retardation
		6	Meningoencephalitis
		7	Radiolucent bone disease
		8	Developmental or late onset conditions, such as diabetes and progressive panencephalitis and any other conditions possibly caused by rubella virus

From January 1996 to December 2003, with active surveillance in place, nine new reports of newborns with CRS were reported in Canada (Table 14). Of those whose status was recorded, four were born to immigrant women, one to an aboriginal woman, and two to non-aboriginal women. These seven cases illustrate the need for documentation of previously received rubella vaccination, of maternal immunity status by a reliable method, and postpartum rubella vaccine when indicated.

TABLE 14 Cases of CRS by year of birth reported to CPSP/IMPACT and NDRS from January 1996 to December 2003
Year of birth	Reported to NDRS only	Reported to CPSP only	Reported to both NDRS and CPSP	Total
1996	1	0	1	2
1997	0	0	1	1
1998	0	0	1	1
1999	0	0	1	1
2000	0	0	2	2
2001	0	0	0	0
2002*	0	1	1	2
2003*	0	0	0	0
Total	1	1	7	9
* Notifiable Diseases Reporting System data is provisional.

Conclusions and recommendations

The very low incidence of CRS and rubella infections suggest that Canada is getting closer to achieving the goal of eliminating indigenous rubella infection during pregnancy.

Health-care providers are requested to ensure that: (1) all patients receive their rubella vaccinations at the recommended age and (2) all women without documented proof of rubella immunization receive the vaccine. Special attention should be given to the immunization status of women from regions with poor vaccination coverage, including women in immigrant populations. Routine rubella antibody screening antenatally by a reliable method is central to the congenital rubella prevention strategy, and all women found to be susceptible should be vaccinated in the immediate postpartum period. Standing orders for vaccination of susceptible women before discharge from hospital are the most effective way to ensure that the opportunity is not missed.

The degree of under-diagnosis and under-reporting for congenital rubella infection (CRI), CRS with less severe manifestations and CRS with delayed-onset manifestations is unknown. Physicians are reminded that it is important to investigate all infants born to mothers who have confirmed or suspected rubella infection during pregnancy, even if the infants have no obvious abnormalities on examination. Prenatal rubella screening and postpartum vaccination will continue to be essential in the quest to eliminate rubella infection during pregnancy.

Principal investigator

Paul Varughese, DVM, MSc, Immunization and Respiratory Infections Division, Centre for Infectious Disease Prevention and Control, Public Health Agency of Canada, Health Canada, Tunney's Pasture, PL 0603E1, Ottawa ON K1A OK9; tel.: 613-957-1344; fax: 613-998-6413; e-mail: paul_varughese@hc-sc.gc.ca

Early-onset eating disorders

(March 2003 to February 2005)

Highlights

• Eating disorders were identified in 63 children aged 5-12 years old.
• Female to male ratio is 5 to 1 in 5- to 12-year-olds compared to 10 to 1 in older age groups.
• The predominant clinical feature (100%) was food avoidance.
• A substantial weight loss was documented during these important growing years.

Background

Over the last 50 years, the prevalence of anorexia nervosa in children and young adolescents appears to have been increasing while the age of onset of eating disorders has become even younger. However, there is ongoing debate in the literature about how to apply the current diagnostic criteria for eating disorders to children and younger adolescents. What is known though is that significant medical and psychological complications arise from starvation, weight loss or lack of appropriate weight gain during childhood and adolescence, making this group of conditions important to recognize and treat appropriately.

This study will document the incidence of early-onset eating disorders (EOED) in Canadian children and provide descriptive data on the abnormal cognitions, behaviours and severity of weight loss and/or other medical sequelae. This data will allow for a better understanding and recognition of this condition in younger children where currently the diagnosis may be delayed or missed. It will also aid in resource allocation and ultimately promote the creation of developmentally appropriate management guidelines to provide improved outcomes.

Objectives

1. To describe the minimum estimated incidence of early-onset eating disorders in children and young adolescents aged five to 12 years in Canada.
2. To describe the range of medical and psychiatric clinical features at presentation.
3. To compare the clinical features in children and young adolescents with existing diagnostic criteria for eating disorders in older patients.
4. To describe current therapeutic interventions used in management.

Case definition

Any child from five to 12 years of age inclusively seen in the previous month, with newly diagnosed early-onset eating disorder where eating disorder is defined as

• determined food avoidance

and

• weight loss or failure to gain weight during a period of expected growth, not due to any identifiable organic cause such as celiac disease.

Exclusion criteria

• Obese children in a supervised weight management program

Results

• Number of confirmed cases is 63
• Estimated incidence is 1.95/100,000
• Female to male ratio is 5:1 (52 girls and 11 boys)
• Mean weight loss is 6.8 kg (± 4.7)

TABLE 15 Ethnicity
Ethnicity	Frequency n (%)
Asian	4 (6%)
Caucasian	55 (89%)
Mixed race	3 (4%)
Unknown	1 (1%)
Total	63 (100%)

TABLE 16 Symptoms or signs present at time of presentation
Symptom	Yes	No	Don't know
Food avoidance	62 (100%)		1
Excessive exercise	36 (58%)	26	1
Self-induced vomiting	7 (11%)	55	1
Fear of weight gain or fat	48 (86%)	8	7
Perception that body is larger	39 (72%)	15	9
Preoccupation with weight	48 (84%)	9	6
Preoccupation with food	53 (88%)	8	2
Laxative use	0	63	0
Diuretic use	0	63	0
Somatic complaints	17 (27%)	45	1
Denial of severity of symptoms	33 (65%)	18	12
Smoking	0	62	1
Weight loss	51 (89%)	6	6

TABLE 17 Comorbid psychiatric diagnosis
Diagnosis	Yes	No	Don't know
Depression	7 (12%)	51	5
Obsessive compulsive disorder	4 (7%)	53	6
Anxiety	18 (32%)	38	7
Other psychiatric illness	8 (13%)	55	0
Psychopharmacologic medication used	10 (17%)	48	5
Family psychiatric history	13 (22%)	47	3
Change in social situation	24 (40%)	36	3

TABLE 18 Physical effects of disorder
Physical symptom	Yes	No	Don't know
Hypothermia	8	51	4
Hypotension	11	51	1
Bradycardia	18	44	1
Admitted to hospital	30	33	0
Nasogastric tube used	5	44	14
Patient alive	60	0	3

TABLE 19 Health-care providers involved
Providers	Yes	No	Don't know
Paediatrician	61	1	1
Psychiatrist	34	19	10
Dietitian	49	7	7
Psychologist	34	17	12
Social worker	36	16	11
Nurse	6	57
Child/youth worker	6	57
Family physician	1	62

TABLE 20 Percent of children with weight loss by age and sex
Sex	5 to 8 years old	9 to 10 years old	11 to 12 years old
Boys	0/1 (0%)	3/3 (100%)	7/7 (100%)
Girls	2/3 (67%)	8/11 (73%)	29/38 (76%)

Conclusion

Paediatricians and psychiatrists are identifying children and younger adolescents with eating disorders. The female to male ratio for the diagnosis of an eating disorder in young children between the ages of five and 12 years is 5:1 compared to 10:1 in the older adolescent and adult population. Boys are more likely to be affected in the younger age group. This is the first data set on Canadian children to support the work of three previously published European studies. Although the majority were Caucasian, Asian and mixed race children were also identified. The group's mean weight loss of 6.8 kg (± 4.7) is a substantial weight loss in children between the ages of five and 12 years who should be gaining weight during these important growing years. Almost half (48%) required an inpatient admission for treatment. The average weight loss was 6.82 kg (±4.8) and 6.75 kg (±4.2) in girls and boys, respectively. While the greatest weight loss was found in older children aged 11 to 12 years of age, girls in this age group lost an average of 8.15 kg (+4.9) with a range of one to 21 kg. This was approximately 18% of their total body weight. Boys aged 11 and 12 years old lost an average of 7.57 kg (+4.6) with a range of two to 15 kg. This was approximately 17.5% of their total body weight. Ninety-four percent of cases were identified in children over the age of eight years old. In that group, all of the boys(10/10), but only 76% (37/49) of the girls, had lost weight as part of their symptomatology.

Food avoidance was a predominant clinical feature in all confirmed cases. Many children also displayed a preoccupation with food and weight, and a fear of gaining weight. However, like their older adolescent counterpart, over half of these children denied their symptoms. Finally, one of the criteria for diagnosing anorexia nervosa in females is amenorrhea. Children under 12 years old would not necessarily be at an age where menstruation would be expected and, therefore, the criteria of amenorrhea for three consecutive months may not be useful for the diagnosis of anorexia nervosa in children and younger adolescents. Consequently, the majority of the children did not meet the full criteria for anorexia nervosa or bulimia nervosa as outlined in the DSM-IV.

This data suggests that it may be difficult to apply these diagnostic criteria to the younger age group.There may also be problems in matching clinical populations to the existing classification systems that are based on adults with eating disorders.Children have limited ability for insight that would be required to endorse the full spectrum of symptoms.
Furthermore, children and younger adolescents may present with other types of clinical eating disturbances that are different from the classic eating disorders of anorexia nervosa and bulimia nervosa with respect to core psychopathology. Nonetheless, the presenting symptoms are as medically and psychologically problematic.
Interestingly, some children do endorse the symptoms of vomiting (11%) and fear of gaining weight (86%) that have been thought to be only observed or reported in adolescents. Therefore, since these symptoms are unexpectedly higher than was originally hypothesized, further analysis is required.

The majority of children did not have a history of a comorbid psychiatric diagnosis or a positive psychiatric family history. However, 40% had changes in their social situation. Bradycardia (28%) was the most common medical complication identified, and over 52% of the children were admitted to hospital.

This study is based on a similar data collection undertaken by the Australian Paediatric Surveillance Unit (APSU). After 21 months of surveillance, 45 cases of early-onset eating disorder in Australian children aged five to 13 years (inclusively) have been confirmed. Of the reported cases, 71% are female and 16% are younger than 11 years of age. A decrease in weight in the six months prior to diagnosis was observed in 89% of cases, with a median weight loss of 6 kg.

The profile of clinical features for these identified cases at the time of diagnosis is consistent with those being reported in Canada. However, abnormal medical findings are being reported in a higher proportion of Australian children with temperature less than 35.5^o C reported in 40%, and bradycardia (minimum 36 beats/minute) reported in 53% of children. Concurrent depression is also being reported in a higher proportion of Australian children (40%).

Some international variation in management practices may be emerging, with 60% of the Australian sample receiving nasogastric (NG) feeding. This may be a consequence of a slight variation in reporting criteria during the first year of the APSU study which required only reporting children who were hospitalized. This might explain, in part, why there is a greater proportion of NG feeding reported by the APSU compared to the CPSP study. Surveillance through the APSU will continue until at least 2005.

International comparisons of the data from the EOED studies will enhance our knowledge of this global problem and will contribute to our understanding of early-onset eating disorders throughout the world.

Principal investigators

Debra K. Katzman, MD, Division of Adolescent Medicine, Department of Paediatrics, The Hospital for Sick Children

Anne Morris, MB, Division of Adolescent Medicine, Department of Paediatrics, The Hospital for Sick Children

Leora Pinhas, MD, Eating Disorders Program, The Hospital for Sick Children, 555 University Ave, Toronto ON M5G 1X8; tel.: 416-813-7195; fax: 416-813-7867; e-mail: leora.pinhas@sickkids.ca

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