Prevention of intrauterine rubella infection, which can result in miscarriage, stillbirth and congenital rubella syndrome, is the primary goal of rubella immunization programs. Up to 85% of infants infected with rubella in the first trimester of pregnancy are affected. Rubella presents with postauricular and suboccipital adenopathy, arthalgias, low fever, and a transient and sometimes pruritic erythematous rash. Joint manifestations can be expected to occur in 70% of infected adults and CNS complications occur in 1 per 3,000 cases.
In 1988, 225 cases of rubella (0.1 cases/100,000 population) were reported in the U.S., the lowest rate since rubella became a nationally reportable disease in 1966. However, the number of cases increased twofold in 1989 and the 1093 cases for 1990 was the highest total since 1982. California reported half of U.S. cases in 1990 with a fourfold increase from 1989. Persons > 15 years of age accounted for 55% of cases in 1990, and an estimated 10% to 15% of young adults remain susceptible to rubella. In addition, there was only one case of congenital rubella syndrome reported to the CDC in 1988, but for 1990, 10 confirmed cases and six additional compatible cases were reported. Nine of the CRS babies were born in southern California. Outbreaks were reported from schools, universities, places of employment, hospitals, correctional facilities and religious communities. There were 160 cases of rubella reported to the CDC in 1992 and 11 cases of CRS. In 1993, preliminary data show that 195 rubella cases and 7 cases of CRS were reported.
Rubella vaccine is indicated for all susceptible adults with special consideration given to women of childbearing age, personnel working in medical settings and men and women entering college. Health care workers who might be at risk for exposure to patients infected with rubella or who might have contact with pregnant patients should be immune. Nine separate rubella outbreaks since 1981 have had a medical student, resident or physician as the index case.
Serologic tests with hemagglutination-inhibition antibody tests have been replaced in most laboratories by more sensitive commercial assays such as the enzyme immunoassay. Serologic testing of all women of childbearing age is an expensive strategy that has been questioned because follow-up rates of immunization are low. Thus, rubella vaccination of women who are not pregnant and have no history of vaccination is justifiable without serologic testing.
The live attenuated rubella virus vaccine is prepared in human diploid cells and is administered in a single 0.5 ml dose subcutaneously. Lifetime immunity is provided to over 90% of vaccine recipients and protection is effective against clinical disease and asymptomatic viremia.
Adverse effects of rubella vaccine include low-grade fever, rash and lymphadenopathy. Susceptible adults are more likely to develop arthralgias of the peripheral joints in about 25% and signs and symptoms of arthritis occur in 10%. Transient neuritic symptoms occur rarely and there is insufficient evidence to indicate a causal relation. Symptoms begin 3 to 25 days after immunization and last from 1 to 21 days. Persistent or chronic arthritis was reported to be as high as 5% to 11%, but most clinical experience is that chronic arthritis is rare. However, the evidence is consistent with a causal relation. Rubella vaccine should not be given to persons who are immunocompromised, pregnant women, or to persons with anaphylactic reactions after receipt of neomycin.
From January 1971 to April 1989, the CDC maintained a registry to monitor the risks to the fetus of exposure to the rubella vaccine virus. A total of 321 susceptible vaccinees have given birth to 324 normal infants without any malformation compatible with congenital rubella syndrome. Approximately one-third of the susceptible mothers were vaccinated during the highest risk period for viremia and fetal defects (1 week before to 4 weeks after conception). If rubella vaccine is inadvertently administered during pregnancy, the estimated risk of fetal malformations attributable to the vaccine is from 0% to 1.2%. The risk is negligible and ordinarily should not be considered a reason for pregnancy termination.
Immunizations in Adults
Eliseo J. Pérez-Stable, M.D.
UCSF Division of General Internal Medicine
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