Rubella primary prevention

Prevention
Rubella infections are prevented by active immunization programs using live, disabled virus vaccines. Two live attenuated virus vaccines, RA 27/3 and Cendehill strains, were effective in the prevention of adult disease. However their use in prepubertile females did not produce a significant fall in the overall incidence rate of CRS in the UK. Reductions were only achieved by immunisation of all children.

The vaccine is now given as part of the MMR vaccine. The WHO recommends the first dose is given at 12 to 18 months of age with a second dose at 36 months. Pregnant women are usually tested for immunity to rubella early on. Women found to be susceptible are not vaccinated until after the baby is born because the vaccine contains live virus.

The immunization program has been quite successful with Cuba declaring the disease eliminated in the 1990s. In 2004 the Centers for Disease Control and Prevention announced that both the congenital and acquired forms of rubella had been eliminated from the United States.

Characteristics
The RA 27/3 rubella vaccine is a live attenuated virus. It was first isolated in 1965 at the Wistar Institute from a rubella-infected aborted fetus. The virus was attenuated by 25–30 passages in tissue culture, using human diploid fibroblasts. It does not contain duck, chicken or egg protein.

Vaccine virus is not communicable except in the setting of breastfeeding, even though virus may be cultured from the nasopharynx of vaccinees.

Rubella vaccine is available combined with measles and mumps vaccines as MMR, or combined with mumps, measles, and varicella vaccine as MMRV (ProQuad). The Advisory Committee on Immunization Practices (ACIP) recommends that combined measles-mumps-rubella vaccine (MMR) be used when any of the individual components is indicated. Single-antigen rubella vaccine is not available in the U.S.

MMR and MMRV are supplied as a lyophylized (freeze-dried) powder and are reconstituted with sterile, preservative-free water. The vaccines contains a small amount of human albumin, neomycin, sorbitol, and gelatin.

Vaccination schedule and use
At least one dose of rubella-containing vaccine, as combination MMR (or MMRV) vaccine, is routinely recommended for all children 12 months of age or older. All persons born during or after 1957 should have documentation of at least one dose of MMR. The first dose of MMR should be given on or after the first birthday. Any dose of rubella-containing vaccine given before 12 months of age should not be counted as part of the series. Children vaccinated with rubella-containing vaccine before 12 months of age should be revaccinated when the child is at least 12 months of age.

A second dose of MMR is recommended to produce immunity to measles and mumps in those who failed to respond to the first dose. Data indicate that almost all persons who do not respond to the measles component of the first dose will respond to a second dose of MMR. Few data on the immune response to the rubella and mumps components of a second dose of MMR are available. However, most persons who do not respond to the rubella or mumps component of the first MMR dose would be expected to respond to the second dose. The second dose is not generally considered a booster dose because a primary immune response to the first dose provides long-term protection. Although a second dose of vaccine may increase antibody titers in some persons who responded to the first dose, available data indicate that these increased antibody titers are not sustained. The combined MMR vaccine is recommended for both doses to ensure immunity to all three viruses.

The second dose of MMR vaccine should routinely be given at age 4 through 6 years, before a child enters kindergarten or first grade. The recommended health visit at age 11 or 12 years can serve as a catch-up opportunity to verify vaccination status and administer MMR vaccine to those children who have not yet received two doses of MMR (with the first dose administered no earlier than the first birthday). The second dose of MMR may be administered as soon as 1 month (i.e., minimum of 28 days) after the first dose. The minimum interval between doses of MMRV is 3 months.

All older children not previously immunized should receive at least one dose of rubella vaccine as MMR or MMRV if 12 years of age or younger.

Adults born in 1957 or later who do not have a medical contraindication should receive at least one dose of MMR vaccine unless they have documentation of vaccination with at least one dose of measles-, mumps-, and rubella-containing vaccine or other acceptable evidence of immunity to these three diseases. Some adults at high risk of measles and mumps exposure may require a second dose. This second dose should be administered as combined MMR vaccine. Efforts should be made to identify and vaccinate susceptible adolescents and adults, particularly women of childbearing age who are not pregnant. Particular emphasis should be placed on vaccinating both males and females in colleges, places of employment, and healthcare settings.

Only doses of vaccine with written documentation of the date of receipt should be accepted as valid. Self-reported doses or a parental report of vaccination is not considered adequate documentation. A healthcare provider should not provide an immunization record for a patient unless that healthcare provider has administered the vaccine or has seen a record that documents vaccination. Persons who lack adequate documentation of vaccination or other acceptable evidence of immunity should be vaccinated. Vaccination status and receipt of all vaccinations should be documented in the patient’s permanent medical record and in a vaccination record held by the individual.

MMRV is approved by the Food and Drug Administration for children 12 months through 12 years of age (that is, until the 13th birthday). MMRV should not be administered to persons 13 years or older.

For the first dose of measles, mumps, rubella, and varicella vaccines at age 12 through 47 months, either MMR vaccine and varicella vaccine or MMRV vaccine may be used. Providers who are considering administering MMRV vaccine should discuss the benefits and risks of both vaccination options with the parents or caregivers. Unless the parent or caregiver expresses a preference for MMRV vaccine, CDC recommends that MMR vaccine and varicella vaccine should be administered for the first dose in this age group. For the second dose of measles, mumps, rubella, and varicella vaccines at any age (15 months through 12 years) and for the first dose at 48 months of age or older, use of MMRV vaccine generally is preferred over separate injections of its equivalent component vaccines (i.e., MMR vaccine and varicella vaccine).

Contraindications and precautions
Persons who have experienced a severe allergic reaction (anaphylaxis) to a vaccine component or following a prior dose of rubella vaccine should generally not be vaccinated with MMR.

Women known to be pregnant or attempting to become pregnant should not receive rubella vaccine. Although there is no evidence that rubella vaccine virus causes fetal damage, pregnancy should be avoided for 4 weeks (28 days) after rubella or MMR vaccination.

Persons with immunodeficiency or immunosuppression, resulting from leukemia, lymphoma, generalized malignancy, immune deficiency disease, or immunosuppressive therapy should not be vaccinated. However, treatment with low-dose (less than 2 mg/kg/day), alternate-day, topical, or aerosolized steroid preparations is not a contraindication to rubella vaccination. Persons whose immunosuppressive therapy with steroids has been discontinued for 1 month (3 months for chemotherapy) may be vaccinated. Rubella vaccine should be considered for persons with asymptomatic or mildly symptomatic HIV infection.

Persons with moderate or severe acute illness should not be vaccinated until the illness has improved. Minor illness (e.g., otitis media, mild upper respiratory infections), concurrent antibiotic therapy, and exposure or recovery from other illnesses are not contraindications to rubella vaccination.

Receipt of antibody-containing blood products (e.g., immune globulin, whole blood or packed red blood cells, intravenous immune globulin) may interfere with seroconversion to rubella vaccine. Vaccine should be given 2 weeks before, or deferred for at least 3 months following administration of an antibody-containing blood product. If rubella vaccine is given as combined MMR, a longer delay may be necessary before vaccination.

Previous administration of human anti-Rho(D) immune globulin (RhoGam) does not generally interfere with an immune response to rubella vaccine and is not a contraindication to postpartum vaccination. However, women who have received anti-Rho immune globulin should be serologically tested 6–8 weeks after vaccination to ensure that seroconversion has occurred.

A personal or family (i.e., sibling or parent) history of seizures of any etiology is a precaution for MMRV vaccination. Studies suggest that children who have a personal or family history of febrile seizures or family history of epilepsy are at increased risk for febrile seizures compared with children without such histories. Children with a personal or family history of seizures of any etiology generally should be vaccinated with MMR vaccine and varicella vaccine because the risks for using MMRV vaccine in this group of children generally outweigh the benefits.

Although vaccine virus may be isolated from the pharynx, vaccines do not transmit rubella to others, except occasionally in the case of the vaccinated breastfeeding woman. In this situation, the infant may be infected, presumably through breast milk, and may develop a mild rash illness, but serious effects have not been reported. Infants infected through breastfeeding have been shown to respond normally to rubella vaccination at 12–15 months of age. Breastfeeding is not a contraindication to rubella vaccination and does not alter rubella vaccination recommendations.