With mumps spreading through the National Hockey League this season and measles making its way cross-country from Disneyland, the third member of the MMR team — the “R” in rubella — has been easy to overlook. While the symptoms and acute complications of rubella, or German Measles, are much milder than those of measles (high fever, cough, congestion, conjunctivitis, pneumonia, encephalitis, death) and mumps (swollen salivary glands, meningitis, deafness, inflamed and profoundly painful testicles or ovaries, possible sterility), the persons we are trying to protect with immunizations against rubella are the unborn.
German Measles is mild enough if children are unlucky enough to get it: A low-grade fever, and a rash that begins on the face and spreads to the rest of the body — all coming and going within just a few days. (Rubella is also referred to as “Three-Day Measles.”) Some young women complain of aching joints during the brief illness. Half of infected persons remain asymptomatic; they have no symptoms but can still spread the infection to others. This presents a terrible problem if those “other” persons are pregnant.
The effects of rubella on fetuses are extremely dire — a veritable horror show of birth defects and damage that provide material for questions which invariably show up on pediatric board exams:
A women in the eighth month of her first pregnancy comes to your office for a prenatal visit. She informs you that the newborn baby she is expecting has been diagnosed with a severe form of congenital heart disease. A laboratory evaluation determined that her newborn would most likely have a low birth weight, small head, and enlarged liver and spleen at birth. Upon taking the family and social histories, the mother-to-be goes on to say that the maternal grandmother practiced homeopathic care with naturopathic remedies, and never took her to a doctor.
What are other expected outcomes this baby will experience as a result of this vaccine-preventable infection?
D. Severe cognitive delay (previously referred to as mental retardation) and other developmental delays
E. All of the above
The answer, of course, is E — all of the above.
Congenital Rubella Syndrome occurs when a pregnant woman with no immunity to rubella becomes infected with the virus. Symptoms in the mother (if there are any) are very mild. Consequences to the fetus and newborn baby are, as described above, simply devastating. A brief history of rubella suggests the relief my own parents felt when, in 1969, the first vaccine to prevent this terrible infection became available:
From 1964-1965, before the development of a vaccine against the disease, a rubella epidemic swept the United States. During that short period there were 12.5 million cases of rubella. Twenty thousand children were born with CRS: 11,000 were deaf, 3,500 blind, and 1,800 mentally retarded. There were 2,100 neonatal deaths and more than 11,000 abortions – some a spontaneous result of rubella infection in the mother, and others performed surgically after women were informed of the serious risks of rubella exposure during their pregnancy.
Along with other public service announcements on television back in the day — Smokey The Bear’s “Only You Can Prevent Forest Fires,” a tear rolling down the weathered face of a Native American (“Keep America Beautiful”), Woodsy The Owl’s plea to “Give a hoot, don’t pollute” — was the image of the “Rubella Umbrella,” with the unmistakable message to run, not walk, to get your child immunized against it.
In 2004, rubella was declared eliminated from the United States. No such declaration has occurred globally, where more than 100,000 cases of congenital rubella syndrome still occur annually. As we’ve seen with measles, where endemic infection was declared eradicated from the U.S. in 2000, resurgence of disease is merely a plane ride away, ready to prey on those who forget the importance of staying protected with safe vaccines.
Today, blood tests are used to determine if a woman has immunity to rubella. Hopefully, appropriate immunization or blood tests confirming immunity are done before the moment of conception, because MMR vaccine is contraindicated during pregnancy. (It must be noted that in the United States in 2015, not all women have access to, or make themselves available for, gynecologic or prenatal care.) The CDC is clear on it’s recommendations for preventing congenital rubella syndrome:
For women of childbearing age, regardless of birth year, rubella immunity should be determined. If there is no evidence of immunity, women who are not pregnant should be vaccinated. Pregnant women who do not have evidence of immunity should receive MMR vaccine upon completion or termination of pregnancy and before discharge from the health care facility.
Tomorrow, we’ll look at another triad of vaccine-preventable infections that adults need to make sure they stay immune against: tetanus, diphtheria, and pertussis.