Cessation of rubella susceptibility screening in pregnancy Annual CARIS meeting 15th November 2016 Cessation of rubella susceptibility screening in pregnancy Dr Sharon Hillier, Deputy Director of Screening, Public Health Wales Thanks to: Dr Pat Tookey Epidemiologist, Institute of Child Health, UCLH London for the data in this presentation Insert name of presentation on Master Slide

What I will cover:- Rubella and Congenital Rubella Why antenatal screening was introduced in 1976 Vaccine policy and changing epidemiology Why antenatal screening stopped from the 3rd October 2016

Rubella and Congenital Rubella Why antenatal screening was introduced in 1976 Vaccine policy and changing epidemiology Why antenatal screening stopped from the 3rd October 2016

Rubella infection Mild disease, often asymptomatic, and easily confused with other infections and rashes Up to half of all infections sub-clinical Symptoms may include: Maculopapular rash Mild fever Lymphadenopathy Sore throat Runny nose Cough Conjunctivitis

Rubella in pregnancy Possible outcomes include: Uninfected infant Spontaneous abortion Infant with congenital rubella infection but no apparent rubella defects Infant with congenital rubella and associated rubella defect(s) (commonly known as Congenital Rubella Syndrome, CRS)

Signs of Congenital Rubella CLASSIC Sensorineural deafness Heart abnormalities Eye abnormalities OTHER SIGNS Growth retardation Microcephaly LATE APPEARING PROBLEMS Diabetes mellitus Evolving hearing loss and eye conditions Possibly psychiatric and behavioural disorders Thyroid dysfunction

Risk of defects following serologically confirmed rubella in pregnancy Based on c.400 infants born 1976-78, 1983-87; Miller et al, Lancet 1982

Congenital Rubella: the pre-vaccine era Before vaccine an estimated 200-300 infants born with CRS each non-epidemic year in the UK Many more born in epidemic years (every 5 or 6 years) Responsible for ~15-20% of significant congenital hearing loss, 2% of congenital heart disease At least 20,000 children were born with CRS in the USA following 1964/65 pandemic

Rubella and Congenital Rubella Why antenatal screening was introduced in 1976 Vaccine policy and changing epidemiology Why antenatal screening stopped from the 3rd October 2016

Antenatal Screening for rubella susceptibility An adjunct to the newly introduced rubella vaccination programme for schoolgirls Most mothers of congenitally infected infants had acquired rubella in their second or later pregnancy, from their own children Established to identify rubella susceptible women in order to protect their next pregnancy through post-partum vaccination Vaccination in pregnancy contraindicated

Antenatal Screening for rubella susceptibility Offered to all pregnant women, regardless of individual risk factors N.B. Not designed to identify recent or current rubella infection in pregnancy Investigating possible rubella in pregnancy Individual pregnant women with specific signs, symptoms or rubella contact require investigative or diagnostic testing Screening test is not appropriate or helpful in these circumstances No effective treatment to prevent transmission of maternal rubella to the fetus Termination of pregnancy recommended following confirmed rubella infection (or contact) in first trimester

Rubella and Congenital Rubella Why antenatal screening was introduced in 1976 Vaccine policy and changing epidemiology Why antenatal screening stopped from the 3rd October 2016

Rubella vaccines Developed in 1960s and first licensed in UK in 1970 Not given to women known to be pregnant because of a theoretical risk of transmission to the fetus Women advised to wait three months after vaccination before conceiving

Immunisation strategies and epidemiology Without vaccine, most people caught rubella in childhood Selective vaccination of older girls and susceptible women provides individual protection without changing epidemiology – most people still protected by naturally acquired immunity, and circulating virus probably boosts vaccine induced immunity Mass vaccination of all toddlers changes epidemiology by preventing circulation of infection – herd immunity protects susceptible individuals, and aim is to eradicate disease (no animal reservoir)

Rubella and MMR vaccine time line 1970 1972 1976 1980 1983 1988 1994 1996 2000s Rubella vaccine licensed in the UK, offered to schoolgirls aged 11-14 Rubella vaccine offered to seronegative women on request; then extended to some ‘high risk groups’, healthcare and teaching staff Antenatal screening introduced with post-partum vaccination for susceptible women; vaccination for healthcare staff extended Schoolgirl vaccination programme extended to 10-14 year olds National Rubella Vaccination Campaign (health and charity sector) MMR for all children in second year of life (replaced measles vaccine for 12-18 month olds introduced in 1968, single mumps never routine, rubella vaccine never offered to boys) Mass measles/rubella immunisation of 5-16 year olds to avert predicted measles epidemic End of schoolgirl programme; MMR pre-school 2nd dose introduced MMR – local initiatives (eg London, students)

Congenital rubella births (reported to NCRSP) 1971-2014 and rubella associated terminations* (ONS) 1971-2000 CR births (n) Terminations (n) MMR *Terminations data not published since 2000 because of very low numbers

Congenital rubella births 2005-2015, UK NCRSP, unpublished data 12 congenital rubella births reported (active reporting) All mothers born abroad, three came to UK in childhood Half acquired infection in country of origin, half in UK At antenatal screening seven women ‘immune’ Two screen susceptible women investigated antenatally when presenting with symptoms Three more women had symptoms in pregnancy, but investigations not followed through for two of them Not ‘failures’ of the antenatal screening / post-partum vaccination policy – none had a previous pregnancy in the UK

Rubella and Congenital Rubella Why antenatal screening was introduced in 1976 Vaccine policy and changing epidemiology Why antenatal screening stopped from the 3rd October 2016

“Screening for rubella in pregnancy does not give any protection to the unborn baby in that pregnancy. The best preventative measure a woman can take to protect herself from rubella is to ensure she is immunised with the MMR vaccine before she gets pregnant.” Dr Anne Mackie, Director of Screening Programmes at Public Health England Insert name of presentation on Master Slide

Antenatal screening for rubella susceptibility Established programme with high uptake But UK National Screening Committee recommended based on the evidence presented that the programme should not continue Screening test result does not address risk in current pregnancy Low-level antibodies detected at screening are probably protective MMR uptake rates in childhood are high

Project established Multi professional project group convened- Antenatal Screening Wales, PHW Immunisation, Welsh Government, GPC Wales, Health Board Head of Midwifery, Senior Health Visitor, Senior School Nurse Collaboration with PHE on strategy and lessons learned Also focused on wider issues around immunisation, management of rashes in pregnancy and consistency of public health messages, in addition to managing cessation of the offer of screening. Insert name of presentation on Master Slide

Derived from COVER data: MMR1 reported uptake by 24 months, 1996-Sept 2015

MMR data in Wales 2008-9 to 2014-15

Decision for Wales The Minister for Health & Social Services agreed that screening should cease in Wales Welsh Health Circular: this was issued on the 11 August 2016 detailing that the antenatal rubella susceptibility screening for pregnant women in Wales was to be discontinued for women who have their booking bloods taken on or after 3 October 2016.

Communication ASW held workshop in July 2016 for antenatal screening co-ordinators to enable cascade professional awareness within the health boards in Wales Further emails with factsheets were sent to key lead midwives to disseminate to key staff Information for women leaflets updates Press release sent out on the 29 September Information sent out to list of stakeholders with FAQ information Insert name of presentation on Master Slide

Explore New Information for Women ASW and PHW Immunisation Team Worked closely with PHE to produce a new leaflet for pregnant women which includes: vaccination in pregnancy advice in rashes in pregnancy. Worked with WG colleagues to feed into updated ‘ pregnancy – how to protect you and your baby.’ leaflet

Infections in Pregnancy Guidance Multi professional all Wales Workshop in June to review and amend 2012 guidance Rashes in Pregnancy to be updated Immunisation in Pregnancy to be added. Other infections Will be online prior to cessation.

Antenatal Screening Wales Changes Changes have been made to current ASW literature: Policy, Standards and Protocols. Information for Women Leaflets Public Health Wales and Antenatal Screening Wales website

Summary UK National Screening Committee decision to stop rubella susceptibility screening in pregnancy England stopped screening for women who booked on or after 1st April 2016; Scotland stopped on the 1st June 2016. Wales has stopped on 3rd October 2016 This has run smoothly and a focus on vaccination and management of infections and rashes in pregnancy has enabled wider benefit from the work.