Dear Dr G,I read with interest your point that HPV vaccination should be given to both boys and girls to help eliminate cervical cancer and other HPV-related malignancies.Although I’m a bit too old to take the HPV vaccine, I can’t help recalling a similar situation with German measles.As a boy, I remember rubella vaccination being recommended only for girls, on the basis that rubella could damage female fertility.Yet the virus also affected males, and it was apparently deemed less serious, so boys were not routinely vaccinated.My understanding is that rubella infection remained widespread until boys were included in vaccination programmes as well.May I take this opportunity to put you on the spot about the similarities between HPV and rubella vaccination?First, what exactly is German measles, or rubella?Does the virus affect fertility in both men and women?Can you explain how girl-only vaccination failed to eliminate the disease?And has gender-neutral vaccination now eliminated the virus?I look forward to your answers.Yours truly,Curious Chris Rubella, also known as German measles, is a viral infection that is generally mild in children and adults, but has profound implications for reproductive health and public health. While the illness itself rarely causes severe disease, infection during pregnancy can be devastating. It can lead to miscarriage, foetal death or a range of serious birth defects collectively known as congenital rubella syndrome (CRS). Over the past few decades, vaccination has dramatically reduced the global burden of rubella. However, how well a programme works depends heavily on whether it targets only females or adopts a gender-neutral approach. Rubella does not directly cause infertility in either males or females, but it can seriously affect reproductive outcomes, particularly in women. If a woman becomes infected during early pregnancy, especially in the first trimester, the virus can cross the placenta and infect the developing foetus. This can result in miscarriage or stillbirth, or lifelong disabilities such as hearing impairment, congenital heart defects, visual problems and neurological damage. In men, rubella has minimal long-term effects on fertility. Although infection may occasionally cause a mild, temporary illness that could affect general health, there is no strong evidence it leads to permanent impairment of sperm production. Globally, rubella has declined dramatically since the introduction of vaccination programmes. At the start of the 21st century, hundreds of thousands of cases were reported annually. By the early 2020s, that number had dropped by about 97%. Despite this progress, rubella has not been eliminated everywhere. Thousands of cases are still reported each year, and an estimated 100,000 infants are born annually with CRS. This is particularly so in regions with lower vaccination coverage such as parts of Africa and South-East Asia. By contrast, regions such as the Americas have eliminated rubella transmission through sustained, high vaccination coverage. Early vaccination strategies in some countries focused on immunising adolescent girls, with the goal of protecting future pregnancies. While this may have seemed logical, it proved insufficient and, in some cases, counterproductive. Vaccinating only girls does not stop the circulation of the virus. Gender-neutral vaccination programmes, which immunise both boys and girls, have been far more effective in controlling and eliminating rubella. By vaccinating all children, these programmes reduce overall virus circulation and lower the risk of exposure for everyone, including pregnant women. This supports herd immunity, in which a sufficiently high proportion of the population is immune. When herd immunity reaches the necessary threshold, typically around 85% to 90% coverage, rubella can be effectively eliminated from a community. Countries that implemented universal vaccination, often through combined vaccines such as the measles-mumps-rubella (MMR) vaccine, saw dramatic reductions. The global success of rubella vaccination underscores the importance of inclusive, population-wide strategies. Today, most countries have incorporated rubella vaccination into their national immunisation schedules. The vaccine is highly effective, providing long-lasting immunity in more than 95% of recipients. These efforts have prevented millions of cases of CRS and reduced the global burden of disease. However, gaps in coverage remain, and sustained work is needed to ensure equitable access in all regions. Rubella is not a direct cause of infertility, but it poses a serious threat to reproductive health through its effects on pregnancy and foetal development. The history of rubella control shows vaccination strategies must extend beyond a single group to be truly effective. Programmes that target only girls fail to interrupt transmission and may even increase risks under certain conditions. Gender-neutral vaccination provides broader protection by reducing circulation and establishing herd immunity. Bill Gates famously said: “Vaccines are miracles of modern medicine!” Dr G is often put on the spot about whether HPV and rubella have demonstrated the same miracle. His view is simple: the miracle is only possible if everyone is protected, and that clearly includes boys.
