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Rubella

 

Date Last Rev'd: March 9, 1995
IMMUNIZATION INFORMATION - RUBELLA (GERMAN MEASLES)
OVERVIEW

The Disease

Rubella is also called German measles or 3-day measles. When children get it, it is usually a mild disease. Rubella also strikes adults, and outbreaks can occur among teenagers and young adults who have not been immunized.

Rubella usually occurs in the winter and spring and spreads very easily. People catch it through contact with other people who are infected. It is spread through coughing, sneezing, or talking.

Usually rubella causes a slight fever which lasts for about 24 hours, and a rash on the face and neck that lasts two or three days. Young adults who get rubella may get swollen glands in the back of the neck and some pain, swelling, or stiffness in their joints (arthritis). Most people recover quickly and completely from rubella. However, the greatest danger from rubella is not to children or adults, but to unborn babies. If a woman gets rubella in the early months of her pregnancy, her chance of giving birth to a deformed baby may be as high as 80%. These babies may be born deaf or blind. They may have damaged hearts or unusually small brains. Many are mentally retarded. Miscarriages are also common among women who get rubella while they are pregnant. The last big rubella epidemic was in 1964. As a result of that epidemic about 20,000 babies were born with severe birth defects. We can protect mothers and their babies from the tragic effects of rubella in two ways. One is to make sure that women are immune to rubella before they become pregnant. This keeps them from getting rubella while they are pregnant, which also protects their unborn children. The second way is to immunize all children. This protects the children themselves, but it also protects others. Children who can't catch rubella can't spread it to their mothers or to other pregnant women.

Rubella Immunization

Rubella vaccine can be given by itself, but it is usually given together with measles and mumps vaccines in a shot called MMR. You can read about MMR vaccine on page __.

State Immunization Requirements

All 50 States have laws requiring school children to be immunized against rubella. Forty-nine states have laws requiring children entering day care to be immunized against rubella.

MMR Vaccine

Your child will usually get measles, mumps and rubella vaccines all together in one shot called MMR. This shot is usually given between 12 and 15 months of age. All three of these vaccines work very well, and will protect most children for the rest of their life. However, for about 5% of children the first dose of MMR does not work. For that reason, a second dose is recommended to give these children another chance to become immune. Some doctors give this second dose when the child enters kindergarten or first grade. Others prefer to wait until the child enters middle or junior high school. Your doctor will tell you when to bring your child in for the second dose of MMR. Measles, mumps, and rubella vaccines can each be given separately. There is also an MR vaccine, which protects against measles and rubella, but not mumps. These vaccines are not as common as MMR, and your doctor will tell you if your child should get any of them. Sometimes ¾ usually during a measles outbreak ¾ children are given measles or MMR vaccine before their first birthday. These children should be given another dose of MMR at 12-15 months and then a third dose when it would normally be given.

Possible Side Effects and Adverse Reactions to Measles, Mumps, and Rubella Immunization

MEASLES

About 1 child in 5 will get a rash or fever beginning a week or two after vaccination. These reactions last for a few days and usually do not harm the child.
MUMPS. Side effects from mumps vaccine are very rare. Occasionally a child will get a mild fever one or two weeks after vaccination, or swollen glands in the cheeks or under the jaw. Serious reactions are extremely rare.

RUBELLA

About 1 child out of 7 will get a rash or swelling in the lymph glands after getting rubella vaccine. This usually happens within a week or two after the shot and lasts 1 or 2 days. Also, about 1 child out of 100 will have some pain or stiffness in the joints, which can last from a few days to a few weeks. There is also a slight chance (less than 1 in 100) that a child will have painful swelling of the joints (arthritis) after getting rubella vaccine. This usually lasts only a few days, but it can last longer, and can come and go. Joint problems occur more often in adults, especially women.

Brief convulsions have occasionally been reported among children who have gotten MMR vaccine. These usually happen 1 or 2 weeks after the shot and come from the fever caused by the vaccine rather than the vaccine itself. Once in a great while a child will get encephalitis (inflammation of the brain) after getting an MMR shot. This happens less than once out of every million shots, and experts are not sure that the MMR vaccine is the cause of this problem. Remember, though, if that same million children got measles, about 1,000 of them would get encephalitis, 6,000 to 7,000 would have convulsions, and several hundred would die. Doctors agree that the benefits of MMR vaccine are very much worth any slight risk.

There are several reasons why some people might need to put off getting MMR vaccine, or not get the shot at all. If your child has any of the following conditions, tell the doctor or nurse.

  • If the child is sick with something more serious than a common cold.
  • If the child has ever had a serious (life-threatening) allergy problem after eating eggs.
  • If the child has had a serious allergy problem to an antibiotic called neomycin.
  • If the child has any disease that makes it hard to fight infection, such as cancer, leukemia, or lymphoma.
  • If the child is taking special cancer treatments such as x-rays or drugs, or other drugs such as prednisone or steroids that make it hard for the body to fight infection.
  • If the child has received gamma globulin during the past 3 months. If the child has a serious or unusual problem after getting this vaccine, call a doctor or get the child to a doctor right away.

MEASLES OR RUBELLA VACCINATION FOR ADULTS

Measles. Some adults should be vaccinated against measles. Anyone who got their measles shot before their first birthday should get another measles shot. So should anyone who was vaccinated between 1963 and 1967 with certain vaccines that didn't work as well as those used today. Anyone entering college, working in a medical facility, or planning to travel overseas should also be vaccinated. If you are in one of these groups, or aren't sure, check with your doctor.

Rubella. Experts recommend that all adolescents and adults should be immune to rubella. This is especially important for women who might become pregnant. Even if you think you have had rubella you might not be immune, because rubella is easy to confuse with other diseases. If you are not sure whether you are immune to rubella, it is a good idea to check with your doctor. Women should not get rubella vaccine if they are pregnant or might become pregnant within 3 months. However, if you are vaccinated and then find out you were pregnant at the time, it shouldn't be a cause for concern. Rubella vaccine has never been known to harm an unborn child. It is safe to have a child immunized even if there is a pregnant woman in the household. The rubella vaccine virus will not spread from the vaccinated child to the pregnant woman.

RUBELLA DISEASE INFORMATION

Rubella, also called German measles, is a viral infection of children and adults, and most often occurs in late winter and early spring. Before rubella vaccine was used in the United States, children 5 to 9 years old accounted for most of the cases. The most serious consequence of rubella infection is the birth defects (called congenital rubella syndrome or CRS) which commonly occur if a woman is infected in the first trimester (the first three months) of her pregnancy. Since the licensure of rubella vaccine, rubella and CRS have declined dramatically. However, recently, there has been a moderate increase in rubella and a dramatic increase in CRS. The increase in rubella has occurred in unvaccinated adolescents and adults as well as in children and adults in religious communities with low levels of vaccination.

Rubella is only a moderately contagious illness compared to more infectious diseases such as measles. It is passed directly from person to person via coughing, sneezing, and talking. The disease is most contagious as the rash is appearing, but can be spread from 1 week before to 5-7 days after rash onset. Infants with congenital rubella syndrome, who were infected with rubella before birth, may be able to infect others for usually about a year, and can therefore transmit rubella to those susceptible persons caring for them. Rubella may be transmitted by infected persons who exhibit no signs or symptoms, and 30%-50% of all rubella infections are not recognized as rubella disease.

The period from exposure to rubella to actual onset of rubella symptoms, called the incubation period, varies from 12-23 days, with an average of 16- 18 days.

Children are apt to have a milder case of rubella than adults. For rubella illness developed after birth, symptoms are often mild with 30-50% of cases having no sign of symptoms. In children, rash is often the first manifestation. In older children and adults, there is often 1-5 days of low-grade fever, tiredness, and upper respiratory infection preceding the rash.

There are a number of common symptoms.

  1. A fever of 99-101 F, which lasts about 2 days, is common.
  2. The rash usually begins on the face, progresses from head to foot, and lasts about 3 days. The rash, which is usually fainter than a measles rash and is often itchy, may not be easy to identify as a rubella rash. Rubella can be confused with many other rash illnesses.
  3. The lymph nodes may begin swelling 1 week before the rash and remain swollen for several weeks.
  4. Joint pain and temporary arthritis, which are uncommon in children, occur frequently in adults, especially in women.

Complications of rubella infection occurring after birth are uncommon but tend to occur more often in adults than in children. Arthritis and joint pain may occur in up to 60% or more of adult women who contract rubella. Fingers, wrists, and knees tend to be affected. These effects may take up to months to resolve, but rarely lead to long-term problems.

Swelling of the brain occurs rarely, and is more frequently found in adults (especially in females) than in children. Problems with blood clotting can occur more often in children than in adults. Effects may last weeks to months.

The developing unborn child is at high risk to develop severe rubella with lasting consequences, if the illness is passed from the mother to the unborn baby early in the pregnancy. Developing unborn infants infected with rubella in utero have a number of problems and symptoms which are called congenital rubella syndrome or CRS. Some common manifestations of congenital rubella syndrome include: deafness; eye problems, including cataracts and glaucoma; congenital heart disease; mental retardation; and many others.

After an attack of rubella, lifelong protection against the disease develops in most persons. However, reinfection with rubella virus can occur. The overwhelming majority of these reinfections occur without symptoms, but occasionally rash or joint pain have been observed. Rubella reinfection has also occurred in persons who received the rubella vaccine. Rubella reinfection during pregnancy can rarely result in transmission of the virus to the unborn child. Rare cases have been reported in which infants with congenital rubella syndrome were born to mothers who were reinfected during pregnancy.

PROOF OF IMMUNITY

Persons can be considered immune only if they have documentation of:

  1. Laboratory evidence of rubella immunity, or
  2. Documented evidence of adequate immunization with at least one dose of rubella vaccine on or after their first birthday.

Unlike measles, neither birth before 1957 nor physician diagnosis of rubella constitute proof of immunity.

Persons who may be immune to rubella, but who lack adequate documentation of immunity, should be vaccinated.

Rubella vaccine may be given alone, but is preferably given in combination with measles and mumps vaccines. The combined measles-mumps-rubella vaccine is called MMR, and it is routinely given to children 15 months of age or older.

CONGENITAL RUBELLA SYNDROME (CRS)

Rubella can be a disastrous disease early in pregnancy, leading to miscarriages, stillbirths, or birth defects. The severity and risk of the effects of rubella virus on the unborn baby depend on the time during pregnancy when the rubella infection occurs. Up to 85% of infants infected in the first three months of pregnancy (first trimester) will be found to be affected after birth. Even an inapparent rubella infection in the mother can result in birth defects. While infection in the unborn child may occur throughout pregnancy, defects are rare when infection occurs after the 20th week of pregnancy. The overall risk of defects during the third trimester is probably no greater than that associated with normal pregnancies.

Common manifestations of congenital rubella include: deafness, which is the most common of the defects; eye problems including cataracts, and glaucoma; congenital heart disease; mental retardation; and many other defects. Some manifestations of CRS may not be apparent for up to 2-4 years after birth.

Infants infected with rubella before birth often shed the virus for as long as 12 months after birth, or, rarely, longer. Infants with congenital rubella syndrome, who were infected with rubella before birth, may be able to infect others for usually about a year and can therefore transmit rubella to those susceptible persons caring for them.

After an attack of rubella or vaccination against rubella most mothers are protected against the disease for their whole life. However, reinfection with rubella virus can occur. The overwhelming majority of these reinfections occur without symptoms, but occasionally a rash or joint pain have been observed. Rubella reinfection during pregnancy rarely results in transmission of the virus to the unborn child. Rare cases have been reported in which infants with congenital rubella syndrome were born to mothers who were reinfected during pregnancy.

RUBELLA POST-EXPOSURE TREATMENT

There is no conclusive evidence that giving rubella vaccine following an exposure to rubella will prevent illness. However, vaccination is still recommended for those who can receive the vaccine. This will ensure protection against future exposures.

Immune globulin, known as IG, given after exposure to rubella will not prevent infection, but, unfortunately, it may suppress symptoms and create an unwarranted sense of security. Furthermore, IG does not protect the unborn child from rubella illness. IG is only given rarely in the case of pregnant women exposed to rubella who have a high risk of delivering a child with CRS, but who will not consider termination of pregnancy for any reason. This IG treatment is not recommended by the ACIP and there is no evidence that it will prevent infection in the unborn child.

RUBELLA VACCINE

Rubella vaccines were first licensed for use in the U.S. in 1969. In January 1979, a new more potent vaccine was licensed and the other vaccines were discontinued. Use of rubella vaccine has had an impressive impact on disease: in 1969 over 55,000 cases of rubella and 29 rubella deaths were reported. In 1988, rubella dropped to an all time low of 225 reported cases. But between 1988 and 1990 a moderate resurgence of rubella occurred. In 1990 over 1000 cases were reported.

About 95% of those who receive rubella vaccine develop protective immunity. To date, vaccine protection appears life-long for most persons.

The vaccine virus cannot be transmitted from person to person except through breastfeeding. Breast feeding mothers should be vaccinated against rubella, even though they may rarely pass vaccine virus to their infants. While the infant may develop a mild case of rubella, serious illness should not occur and the infant should respond well to vaccine at 15 months of age.

Rubella vaccine may cause side effects that include fever, swollen lymph nodes, joint pain, and a rash. A rash occurs in about 10% of those receiving the vaccine. About 25% of adult women report joint pain after vaccination; men and children report such symptoms much less commonly. A true arthritis has been reported in only about 10% of susceptible female vaccinees. When joint symptoms do occur, they generally begin 7-21 days after immunization, persist for 1-3 days and rarely recur. Recurrences have been rarely reported for up to 8 years.

After an attack of rubella, lifelong protection against the disease develops in most persons. However, reinfection with rubella virus can occur. The overwhelming majority of these reinfections occur without symptoms, but occasionally rash or joint pain have been observed. Rubella reinfection has also occurred in persons who received the rubella vaccine. Rubella reinfection during pregnancy can rarely result in transmission of the virus to the unborn child. Rare cases have been reported in which infants with congenital rubella syndrome were born to mothers who were reinfected during pregnancy.

WHO SHOULD BE VACCINATED

The goal of rubella vaccination is to prevent congenital rubella infection, which can result in still births, miscarriages, and severe birth defects. This goal can be achieved only by protecting all women of child-bearing age, as well as other people who come in contact with them, such as family members, co-workers, and other contacts.

Adequate vaccination consists of one dose of rubella vaccine; no booster dose is needed or recommended, although many person will receive 2 doses because of the 2 dose measle-mumps-rubella combined vaccine schedule.

The rubella vaccine is recommended for the following individuals:

  1. All children 12 months of age or older, preferably using rubella vaccine in combination with measles and mumps vaccines (MMR vaccine). If the rubella vaccine is part of a combination that includes measles, such as MMR vaccine, the combination vaccine should generally be given to children 15 months of age or older.
  2. All older children not previously immunized.
  3. All susceptible adolescents and adults, particularly women of childbearing age who are not pregnant.

A person is considered susceptible to rubella if they have no record of vaccination on or after 12 months of age or have no laboratory test result proving immunity. If vaccination or immune status is not known, the recommendation is to vaccinate without prior laboratory testing. Immune persons who are revaccinated are not at any increased risk of adverse events from the revaccination.

Infants vaccinated with the MMR vaccine before their first birthday should be considered unvaccinated, and should be revaccinated with MMR vaccine at age 15 months or older.

After puberty, a woman with no documented evidence of rubella immunity may be vaccinated if she says she is not pregnant and is counseled about the need to avoid pregnancy for 3 months following vaccination. Neither a pregnancy test nor a test for rubella immunity need to be performed first.

Particular emphasis should be placed on vaccinating both males and females in colleges, places of employment, health-care settings, prisons, or other areas in which unvaccinated adolescents or adults may congregate.

WHO SHOULD NOT BE VACCINATED

Rubella vaccine is not known to cause special problems for pregnant women and their unborn babies, even though natural rubella disease does cause birth defects. However, doctors usually avoid giving any drugs or vaccines to pregnant women unless there is a specific need. Therefore, to be safe, pregnant women should not be vaccinated with rubella vaccine. If a pregnant women is vaccinated or if she becomes pregnant within 3 month of vaccination, she should see her physician for a thorough explanation of the risks and concerns for the unborn baby. Rubella vaccination during pregnancy is not a reason in itself to consider interruption of the pregnancy. However, the decision whether to continue a pregnancy is always a personal and medical decision which can only be made by the pregnant woman and her physician.

Persons with defective immune systems should not be given rubella vaccine. This includes persons with certain cancers, leukemias, lymphomas, or persons undergoing therapy with certain cancer treatments, radiation, or large doses of steroids. A physician should be consulted before a patient who may have a defective immune system is given rubella vaccine. On the other hand, a person who has contact or lives in a household with an immunosuppressed person may be given rubella vaccine as usual.

Susceptible children infected with the HIV virus, but who do not have disease caused by HIV, should receive rubella vaccine. Persons with symptomatic HIV infection, for whom MMR vaccine is indicated, may be considered for vaccination. Asymptomatic children do not need to be evaluated and tested for HIV infection before decisions concerning vaccination are made.

All preparations of rubella vaccine contain trace amounts of neomycin. Persons who have experienced life threatening allergic reactions to neomycin should not be given the vaccine. Severe allergy means an intense life-threatening reaction requiring medical attention. A history of simple skin reaction to neomycin is not a reason to avoid receiving the vaccine unless that rash was part of a life threatening reaction such as hives. Live rubella vaccine does not contain penicillin, so a history of penicillin allergy is not a concern for vaccination.

Rubella vaccine given by itself can be administered with safety to persons with egg allergies. However, if the vaccine is combined with measles and mumps vaccines, it should not be administered to persons with severe allergy to eggs. (Egg products are used to make measles and mumps vaccines.) Persons who have egg allergies that are not life threatening in nature can be vaccinated with MMR vaccine. If a person can eat eggs, then the allergy is not considered to be severe.

Vaccination of persons with a high fever should be postponed until recovery. However, susceptible children with mild illnesses, such as an upper respiratory infections should be vaccinated, whether or not fever is present.

Rubella vaccine should not be given within 14 days before the administration of immune globulin (IG), or for at least 6 weeks, and preferably for 3 months, after a person has been given IG, whole blood, or other antibody-containing blood products. However, women may receive rubella vaccination after delivery. Persons vaccinated after receiving whole blood or other blood products, such as Rho-Gham after delivery should be tested 6 to 8 weeks after vaccination to see if they are immune.

Persons who receive the vaccine do not transmit rubella to others, except in the case of the vaccinated breastfeeding mother. In this situation, the infant may be infected through breast milk and may develop a mild rash illness, but serious effects have not been reported and the infant can be vaccinated later without problems. These infants should receive rubella vaccine at 15 months of age as usual. Breastfeeding mothers without documented evidence of immunity to rubella should receive rubella vaccine.

PREGNANCY

For the developing unborn baby, rubella can be a devastating illness with consequences that last a lifetime. Infants born to mothers who become ill with rubella during pregnancy have an increased risk of birth defects that include hearing loss, loss of sight, heart defects, mental retardation, and even death. By receiving the rubella vaccine, a woman can protect her unborn child from rubella. Therefore, all women of child-bearing age should be immunized against rubella. Because it is not recommended that rubella vaccine be given during pregnancy, vaccination should occur at least three months before conception.

PREGNANCY AND THE RUBELLA VACCINE

While it is not recommended that pregnant women receive the rubella vaccine, some women have been inadvertently vaccinated while pregnant. When rubella vaccine was licensed, this situation was of concern. Therefore, from 1971-1989, the Centers for Disease Control maintained a list of reported women vaccinated during pregnancy to determine the vaccination effects, if any, on the infants of such mothers. This list of women was called the Vaccine in Pregnancy Registry. Because enough reports had been received and analyzed, CDC discontinued the VIP registry on April 30, 1989.

Based on data in the Vaccine in Pregnancy Registry (VIP), there is no evidence that defects consistent with congenital rubella syndrome have occurred in offspring of women vaccinated during or close to the time of pregnancy. Therefore, the observed risk of birth defects for vaccination in pregnancy is zero. However, since the vaccine consists of a weakened live virus, it is theoretically possible that the vaccine could rarely damage the unborn child, although such an effect has never been observed. It is believed that if vaccination occurs within 3 months before or after conception, there is a theoretical risk of CRS, but it is so small as to be negligible. Inadvertent vaccination of a pregnant woman should not be a reason in itself to consider interruption of pregnancy. However, the patient and her physician should make the final decision about continuing the pregnancy.

In summary, rubella vaccine is not known to cause special problems for pregnant women and their unborn babies. However, doctors usually avoid giving any drugs or vaccines to pregnant women unless there is a specific need. Therefore, to be safe, pregnant women should not be vaccinated with rubella vaccine.

RUBELLA STATISTICS

Most cases of rubella occur in the late winter and early spring. In the pre-vaccine era, epidemics of rubella occurred every 6 to 9 years, with the last major U.S. epidemic occurring in 1964-1965. The 1964 epidemic resulted in an estimated 12.5 million cases of rubella infection and 20,000 infants born with congenital rubella syndrome (CRS). The estimated financial cost of the epidemic was $840 million.

Rubella and CRS have declined dramatically since rubella vaccine was licensed in 1969. Limited outbreaks continue to occur among groups of susceptible persons in close contact with each other, for example, in schools, colleges, hospitals, and other places of employment. Prisons have also been affected by rubella outbreaks in recent years.

Although reported rubella activity in the United States decreased after vaccine licensure, a similar decline in rubella in women of childbearing age and in CRS cases did not occur until after the mid-1970's. This decrease in the 1980's was due to decreased transmission among children and from children to adult contacts and increased efforts to vaccinate susceptible adolescents and young adults, especially women.

More recently, there has been a moderate resurgence of rubella and a dramatic increase in CRS between 1988 and 1990. A provisional total of over 1000 cases of rubella was reported in the United States in 1990. While the incidence of rubella has declined by more than 99% since vaccine licensure, the 1990 annual total represents a four-fold increase since 1988. The increase in rubella occurred in settings in which unvaccinated adolescents and adults congregate, such as colleges, prisons, and the work-place. The increase was also due to rubella cases in children and adults in religious communities with low levels of vaccination, such as Amish communities.

GOALS FOR RUBELLA VACCINE PROGRAM

Efforts should continue to vaccinate all infants 12 months of age or older against rubella and to require rubella vaccination for school entry. It is hoped that the use of combination vaccines such as MR and MMR vaccines and the two-dose schedule of MMR vaccine for measles control will contribute to efforts to increase rubella immunity.

  1. To eliminate rubella and congenital rubella syndrome (CRS), efforts to vaccinate susceptible teenagers and adults of childbearing age should be intensified. These efforts should include:
  2. Vaccination in family planning and other clinics serving women.
  3. Premarital rubella screening.
  4. Immunization requirements for college students.
  5. Postpartum and post-abortion vaccination of women.
  6. Immunization of prison staff, and when possible, prison inmates, especially women.
  7. Vaccination of hospital personnel, both male and female - volunteers, trainees, nurses, physicians, etc. Ideally, all hospital employees should be immune. It is important to note that screening programs alone are not adequate. Vaccination of susceptible staff must follow.

 

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