Protecting women against rubella: Guidance on the use of MMR vaccine

Main Category: Pregnancy / Obstetrics
Article Date: 31 May 2004 - 22:00 PDT


Rubella (German measles) is a mild illness in most people but if caught in the early stages of pregnancy, it can severely damage the unborn child. If a pregnant woman catches it early in her pregnancy, it can seriously harm her unborn baby's sight, hearing, heart and brain. This condition is called congenital rubella syndrome (CRS).

WHO NEEDS TO BE PROTECTED AGAINST RUBELLA?

Children are recommended to have measles-mumps-rubella (MMR) vaccine around 13 months of age and again before starting school. The reason rubella is included in the childhood immunisation programme is to prevent children passing rubella virus to their pregnant mothers or mothers' pregnant friends.

It is also important to immunise women of childbearing age who have either not been immunised with a rubella-containing vaccine or who have been found to be rubella seronegative (not having protective antibodies to rubella) either through pre-conception screening, or antenatal screening.

Those found to be unprotected should be immunised with MMR vaccine to avoid the risk of transmitting rubella to pregnant patients. All health professionals, both male and female, should be screened.

WHY HAVE WE SWITCHED FROM USING SINGLE RUBELLA VACCINE TO MMR VACCINE?

Demand for single rubella vaccine has declined around the world as other countries use MMR vaccine as the internationally recognised vaccine to protect women of childbearing age not previously protected against rubella.

WHAT HAPPENS IN OTHER COUNTRIES?

Other countries use MMR as the internationally recognised vaccine against measles, mumps and rubella diseases as a two-dose schedule in childhood and as protection for women of childbearing age not previously protected against rubella.

The WHO strongly supports the use of MMR vaccine on the grounds of its convincing record of safety and efficacy. Using MMR to protect women of childbearing age is in line with WHO recommendations

BUT I HAVE ALREADY HAD MEASLES AND MUMPS DISEASES SO I DON'T NEED TO BE IMMUNISED AGAINST THEM.

If you have already had measles or mumps, you will not have a problem with being exposed to those viruses again. It's like any one of us who is immune meeting someone with the disease - the infection can't get established. If by chance you are not immune to measles or mumps, then you will benefit from MMR vaccination. Once immune to these diseases, you are no longer able to catch and pass these infections to your baby.

SHOULD WOMEN WHO ARE FOUND TO BE RUBELLA SERONEGATIVE RECEIVE ONE OR TWO DOSES OF MMR VACCINE?

97-99% of people will be immune to rubella after one dose of MMR vaccine so only one dose of MMR vaccine is necessary to give good protection against rubella 1, 2.

Two doses of MMR vaccine are required to give good protection against measles and mumps and can be given 3 months apart 3, 4, 5.

HOW LONG SHOULD A WOMAN AVOID BECOMING PREGNANT AFTER RECEIVING MMR VACCINE?

Because of the known association between wild rubella virus and congenital rubella syndrome (CRS), there is a theoretical risk that rubella vaccine could cause CRS. The possibility that rubella vaccine could cause CRS has been carefully studied and the results are very reassuring that nobody has found any evidence that MMR vaccine can cause congenital rubella syndrome.

Nevertheless, women are advised to avoid pregnancy for one month after receiving a rubella-containing vaccine. This advice is the same in the UK and the US.

BUT I HAVE BEEN TOLD I SHOULD WAIT FOR 3 MONTHS BEFORE GETTING PREGNANT.

The US Advisory Committee on Immunization Practices (ACIP) carried out a review recently of data from the US, UK, Sweden and Germany on 680 live births to susceptible women who were inadvertently vaccinated either 3 months before or during the early weeks of pregnancy with rubella vaccine. They found that none of the infants were born with congenital rubella syndrome (CRS). Following this review, ACIP changed their guidance of avoiding pregnancy following MMR vaccine from 3 months to 28 days in 2001 , 6. The UK has recommended a one-month interval since 1996. The Summary of Product Characteristics (SPC) for some MMR vaccines may still recommend that a 3 month gap be left between MMR vaccine and becoming pregnant but the UK and US advice is the most up to date and should be followed.

I AM TRYING FOR A BABY AND I DON'T KNOW IF I HAVE BEEN VACCINATED FOR RUBELLA. CAN I ASK MY GP OR CLINIC FOR A TEST?

Yes, you can ask your GP or clinic for a test to check your rubella antibodies before becoming pregnant. This is a wise move particularly if you can't remember if you've been vaccinated. But if you don't have rubella antibodies and need a dose of MMR, make sure that you avoid getting pregnant for one month after the jab.

I AM PREGNANT - IF MY 13 MONTH OLD CHILD HAS THE MMR VACCINE, AM I PUTTING MY BABY AT RISK FROM THE DISEASES FROM THE LIVE VACCINES?

It is not possible for anyone to catch any of the diseases that the vaccine protects against from a child recently immunised with MMR. So both you and your unborn baby are quite safe.

CAN BREAST-FEEDING WOMEN BE GIVEN MMR VACCINE?

MMR vaccine can be given to breast-feeding mothers without any risk to their baby. Very occasionally rubella vaccine virus has been found in breast milk but this has not caused any symptoms in the baby 7, 8, 9. The vaccine does not work when taken orally. There is no evidence of mumps and measles vaccine viruses being found in breast milk.

DOESN'T MMR VACCINATION CAUSE AUTISM?

There is no credible evidence of a link between MMR and autism - and there is an ever-increasing body of research which shows no evidence of a link.

The World Health Organisation describes MMR as a "highly effective vaccine which has an outstanding safety record".

CAN MMR VACCINE BE ADMINISTERED SIMULTANEOUSLY WITH ANTI-RHO (D) (ANTIBODY THAT IS GIVEN TO RHESUS NEGATIVE WOMEN) AFTER GIVING BIRTH?

Yes. It may be administered at the same time as rubella vaccine provided that separate syringes are used. The low dose of anti-Rho (D) globulin has been shown not to interfere with rubella vaccine, 10. Similarly as MMR is now the recommended vaccine the same advice applies, as issued by the Center for Disease Control (CDC) in February 2002, 11. If not given simultaneously, it should be given 3 months after anti-Rho (D).

HOW IS MMR VACCINE MADE?

MMR vaccine is made from live, but weakened measles, mumps and rubella viruses. The weakened viruses are grown either in chick embryo tissue cultures (mumps and measles) or in the human diploid cell line MRC-5 before being extensively purified, removing all traces of the cells. The viruses are then dried to a powder. The final product, in addition to the viruses, contains amino acids, human albumin, lactose, mannitol and sorbitol. It may also contain trace amounts of neomycin. The vaccine is suspended in sterile water before injection.

This article comes from the UK Department of Health

References

1 - Chu SY et al. Rubella antibody persistence after immunisation. JAVA 1988: 259; 3133-6
2 - O'Shea et al. Persistence of rubella antibody 8-18 years after vaccination. BMJ 1984:288; 1043
3 - Morse D et al. Outbreak of measles in a teenage school population: the need to immunise susceptible adolescents. Epidemiol Infect. 1994 Oct;113(2):355-65 Epidemiol Infect. 1994 ;113:355-65
4 - Fescharek R et al. Measles-mumps vaccination in the FRG: an empirical analysis after 14 years of use. Efficacy and analysis of vaccine failure. Vaccine 1990: 8; 333-6.
5 - Calvert et al. Commun Dis Rep CDR Rev. 1994 27;4(6):R70-3
6 - MMWR weekly December 14,2001/50(49); 1117
7 - Buimovici-Klein E et al, Isolation of rubella virus in milk after postpartum immunization. J Pediatr 91:939-943, 1977.
8 - Landes RD et al. Neonatal rubella following postpartum maternal immunisation. J Pediatr 97:465-467, 1980.
9 - Losonsky GA et al. Effect of immunization against rubella on lactation products. Development and characterization of specific immunologic reactivity in breast-milk J Infect Dis 145:654-660, 1982.
10 - Black et al. 1983. Post-partum rubella immunisation: a controlled trial of two vaccines. Lancet 29;2(8357);990-2). 11 - www.cdc.gov/nip/publications/pink/genrec.rtf

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