1. Rubella and Rubella Vaccine
Epidemiology and Prevention of Vaccine-Preventable Diseases
National Immunization Program
Centers for Disease Control and Prevention
Dr Esteghamati EPI Manager

2. Rubella From Latin meaning "little red"
Discovered in 18th century - thought to be variant of measles
First described as distinct clinical entity in German literature
Congenital rubella syndrome described by Gregg in 1941

3. Rubella Virus Togavirus RNA virus One antigenic type
Rapidly inactivated by chemical agents, low pH, heat and ultraviolet light

4. Rubella Pathogenesis Respiratory transmission of virus
Replication in nasopharynx and regional lymph nodes
Viremia 5-7 days after exposure with spread to tissues
Placenta and fetus infected during viremia

5. Rubella Clinical Features
Incubation period 14 days (range days)
Prodrome of low grade fever
Lymphadenopathy in second week
Maculopapular rash days after exposure

6. Rubella Complications
Arthralgia or arthritis children adult female
Thrombocytopenic purpura
Encephalitis
Neuritis
Orchitis
rare
up to 70%
1/3000 cases
1/6,000 cases

7. Congenital Rubella Syndrome
Infection may affect all organs
May lead to fetal death or premature delivery
Severity of damage to fetus depends on gestational age
Up to 85% of infants affected if infected during first trimester

8. Congenital Rubella Syndrome (CRS)

9. Congenital Rubella Syndrome
Deafness
Cataracts
Heart defects
Microcephaly
Mental retardation
Bone alterations
Liver and spleen damage

10. CRS case definitions (1)
Suspected CRS: A child <1 year with
maternal history of rubella in pregnancy
and/or
heart disease, or deafness, or eye signs:
white pupil (cataract); diminished vision; pendular eye movement (nystagmus); squint; smaller eye ball (micropthalmos);larger eye ball (congenital glaucoma)

11. CRS case definitions (2)
Clinically confirmed CRS: A child <1 year with two complications in group (a) or
one from (a) and one from (b)
(a) cataract(s), congenital glaucoma, congenital heart disease, loss of hearing, pigmentary retinopathy
(b) purpura, splenomegaly, microcephaly, mental retardation, meningoencephalitis, radiolucent bone disease, jaundice with onset within 24 hours after birth.

12. CRS case definitions (3)
Laboratory-confirmed CRS:
An infant with a positive blood test for rubella-specific IgM and clinically-confirmed CRS.
Congenital rubella infection (CRI):
An infant with a positive blood test for rubella-specific IgM who does not have clinically-confirmed CRS.

13. TOP PRIORITY: Use rubella vaccine to prevent CRS
To prevent CRS introduce rubella vaccine for women of childbearing age
Define age of target group
consider local fertility rates
Where to offer vaccine
postpartum and family planning
mass campaigns (Cuba, Malaysia)

14. Epidemic Rubella – United States, 1964-1965
12.5 million rubella cases
2,000 encephalitis cases
11,250 abortions (surgical/spontaneous)
2,100 neonatal deaths
20,000 CRS cases
Deaf - 11,600
Blind - 3,580
Mentally retarded - 1,800

15. Rubella Laboratory Diagnosis
Isolation of rubella virus from clinical specimen (e.g., nasopharynx, urine)
Significant rise in rubella IgG by any standard serologic assay (e.g., enzyme immunoassay)
Positive serologic test for rubella IgM antibody

16. Rubella Epidemiology Reservoir Human
Transmission Respiratory Subclinical cases may
transmit
Temporal pattern Peak in late winter and spring
Communicability 7 days before to 5-7 days
after rash onset Infants with CRS may shed
virus for a year or more

17. Rubella - United States, 1966-2002

18. Rubella - United States, 1980-2002

19. Rubella - United States, 1980-2002 Age Distribution of Reported Cases
15-39 yrs
<5 yrs
5-14 yrs
>40 yrs

20. Rubella and CRS in the United States
Most reported rubella in the U.S. since the mid-1990s has occurred among foreign-born Hispanic adults
Rubella outbreaks have occurred in workplaces where most employees are foreign-born
Majority of CRS since 1997 occurred in children of unvaccinated women born to Hispanic women, most born in Latin America

21. Rubella Case Definition
Acute onset of generalized maculopapular rash, and
Temperature of >37.2 C (>99 F), if measured, and
Arthralgia or arthritis, or lymph-adenopathy, or conjunctivitis

22. Rubella Outbreak Control Guidelines
Laboratory diagnosis of rubella and CRS
Step-by-step guidelines on evaluation and management of outbreak
Rubella prevention and control among women of childbearing age
Rubella and CRS surveillance
MMWR 2001;50(RR-12)

23. *Only vaccine currently licensed in U.S.
Rubella Vaccine
Vaccine
GMK-3:RK53
HPV-77:DK12
HPV-77:DE5
RA 27/3*
Trade Name
Cendevax
Rubelogen
Meruvax
Meruvax II
Licensure
1969
1979
Only RA 27/3 vaccine available now. Less reactive than earlier vaccines. Terminal abbreviations refer to cell line used – RK=rhesus kidney, DK=duck kidney, DE=duck embryo. RA 27/3 grown on human diploid cells.
*Only vaccine currently licensed in U.S.

24. Rubella Vaccine Composition Live virus (RA 27/3 strain)
Efficacy 95% (Range, 90%-97%)
Duration of Immunity Lifelong
Schedule >1 Dose
Should be administered with measles and mumps as MMR

25. Rubella Vaccine (MMR) Indications
All infants >12 months of age
Susceptible adolescents and adults without documented evidence of rubella immunity
Emphasis on non-pregnant women of childbearing age, particularly those born outside the U.S.

26. Rubella Immunity
Documentation of one dose of rubella-containing vaccine on or after the first birthday
Serologic evidence of immunity
Birth before 1957 (except women of childbearing age)

27. Rubella Immunity
Birth before 1957 is not acceptable evidence of rubella immunity for women who might become pregnant
Only serology or documented vaccination should be accepted

28. MMR Adverse Reactions Fever 5%-15% Rash 5% Joint symptoms 25%
Thrombocytopenia <1/30,000 doses
Parotitis rare
Deafness rare
Encephalopathy <1/1,000,000 doses
Joint symptoms usually associated with the rubella component of MMR.

29. Rubella Vaccine Arthropathy
Acute joint symptoms in about 25% of susceptable adult women
Frank arthritis occurs in about 10%
Rare reports of chronic or persistent symptoms
Population-based studies have not confirmed association

30. MMR Vaccine Contraindications and Precautions
Severe allergic reaction to vaccine component or following prior dose
Pregnancy
Immunosuppression
Moderate or severe acute illness
Recent blood product

31. Vaccination of Women of Childbearing Age
Ask if pregnant or likely to become so in next 4 weeks
Exclude those who say "yes"
For others
Explain theoretical risks
Vaccinate
Pregnancy testing not routinely recommended by ACIP.

32. Vaccination in Pregnancy Study 1971-1989
321 women vaccinated
324 live births
No observed CRS
95% confidence limits 0%-1.2%

33. Rubella Vaccine Recommendations for Increasing Coverage
Continued routine vaccination of children at age >12 months with vaccination required for school entry
Screen and vaccinate susceptible persons
healthcare workers
college entry
prenatal with postpartum vaccination
other healthcare visits
workplace