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Correction: Adolescent smokers seen in general practice: health, lifestyle, physical measurements, and response to antismoking advice

Discussion Most of the women in our study should have had at least one opportunity to be protected as a result of the rubella immunisation policy, either at school or postnatally, but had either not received vaccine or had not produced a satisfactory and persistent immune response. Rubella vaccine is known to induce antibody in almost 100% of susceptible subjects6 but occasionally there will be no detectable humoral response despite two or three booster doses. Therefore, even a complete record ofrubella vaccination at school or later is not a guarantee of lasting immunity. Moreover, rubella can occur in previously immune people, and recent findings have shown that when reinfection occurs in pregnancy the fetus is more likely to be affected than was previously supposed.7 This further emphasises the importance of continuing to monitor any possibility of rubella in pregnancy with or without symptoms and regardless of the woman's immune status. We were not surprised that there was a high proportion of older women in our group as these women would not have been eligible for school vaccination. The slight preponderance of very young women was not expected but could have been due to slowing down of the campaign before its boost in 1983,8 or to a lower uptake of preventive services associated with young and single parent groups. Previous studies have shown racial differences both in rubella immunity and in the uptake rate of rubella vaccination in women,9 although our data do not allow us to make this comparison. Special effort may be necessary to achieve satisfactory rubella immunisation levels among women from ethnic minorities and deprived communities. The action taken to protect the women in our study was disappointing. Most of the women who were not vaccinated after the 1987 screening were "overlooked." Many had been pregnant at the time of the screening test, and such women were significantly less likely to be vaccinated than those who had not been pregnant. Even if they were vaccinated they were less likely to be followed up. Failure to vaccinate promptly resulted in seven women becoming pregnant again before being immunised. Even women no longer considered likely to produce children should be vaccinated as they may pass on the infection to someone who is pregnant. A subsequent search of hospital records of the overlooked pregnant women showed that most of these had also missed being vaccinated in the hospital postnatal period, although in seven cases a record of hospital vaccination did exist. However efficient the system of postnatal vaccination in maternity hospitals, the general practitioner will still be involved in immunising patients who are discharged early and testing for seroconversion. Similarly disappointing results were reported from Edinburgh,'" where susceptibility to rubella continued into second and subsequent pregnancies. Such oversight may be due to the necessary delay in vaccination until pregnancy is complete, or to the rarity and irrregularity with which any single general practitioner receives a report of a patient being negative for rubella virus antibody. It would therefore seem that schemes to ensure vaccination of seronegative women will usually be more effective if centrally based rather than limited to individual practices." Our findings have led to the establishment in Grampian Health Board of a prompting mechanism initiated by the virus laboratory, which operates through the primary care register and the computerised immunisation system. This alerts the general practitioner when a recommended adult rubella vaccination has become overdue. If the appropriate action is then taken the immunity gap among pregnant women will be largely closed. This relatively simple mechanism may have application in other areas in the United Kingdom.