Rubella in children is even milder than mumps. However, rubella can be dangerous for pregnant women in their first trimester.
Unlike the whooping cough, when adults and children are vaccinated to protect infants, in case of rubella, infants are vaccinated to protect pregnant women. Or, to be more precise, babies are vaccinated to protect the unborn babies.
CDC Pinkbook Rubella
50% of rubella cases are asymptomatic. Most rubella cases in adult women are accompanied by arthralgia (joint pain) and arthritis.
Rubella rarely has any complications, but they occur more often in adults than in children.
Rubella in the first trimester of pregnancy can cause birth defects and spontaneous abortion.
30% of rubella cases in the 80s occurred in adults (aged 15-39 years). After the beginning of vaccination, 60% of registered cases occurred in the age group of 20-49 years (median age was 32 years).
25% of postpubertal women develop acute arthralgia following the vaccination, and 10% develop acute arthritis.
Although one dose of the vaccine is enough for rubella immunity, children should receive two doses of MMR. Just because a separate rubella vaccine is no longer produced.
There is not enough data on how immune system responds to the second dose of mumps and rubella vaccine.
Rubella is usually impossible to differentiate from parvovirus B19, human herpesvirus 6, dengue fever, group A streptococcus, measles, and other viral diseases. Therefore, laboratory verification is essential for the correct diagnosis.
Rubella can be contracted more than once. Probability of repeat infection after vaccination is higher than after the disease exposure.
RA27/3 strain, which has been used since 1979 in all rubella vaccines (except for Japan and China – they use their own strains), was first isolated in 1965 from an aborted fetus. RA means Rubella Abortus (i.e. fetus aborted due to rubella in mother). 27/3 means the third tissue (kidney) of the 27th fetus. Previous 26 fetuses aborted due to rubella did not have the virus. The isolated virus was attenuated by 25-30 consecutive passages in aborted lung cells (WI-38).
Studies of immunization with living rubella virus. Trials in children with a strain of cultured from an aborted fetus.
Am J Dis Child
Here is a more detailed description of how the virus was isolated, how the vaccine was produced, and how it was tested on orphans in Philadelphia.
Nasal delivery of the vaccine was tested in addition to the subcutaneous administration, but it was less effective.
Clinical studies of intranasal vaccine are also cited here and here. Apparently, the subcutaneous vaccine administration was chosen in the end, because nasal vaccine required more virus, and because subcutaneous vaccine is easier to administer.
Rubella vaccines: past, present and future.
First attenuated rubella vaccine, HPV77.DE5, appeared in 1961. It was called this way because it was attenuated by 77 consecutive passages in green monkey kidney cells, and then 5 times in duck embryo fibroblasts. Duck fibroblasts were added, because it was believed that avian embryos carry less extraneous viruses and other infections than monkey kidneys. This vaccine was widely used in the US and in Europe in the 1970s, and the first MMR vaccine (MMR1) contained this strain. MMR-II, licensed in 1988 (in UK), is used today.
Another strain of rubella virus, HPV77.DK12 was attenuated by 12 passages in dog kidney cells, instead of duck fibroblasts. This vaccine was licensed in 1969, but its production was discontinued a few years later due to high incidence of adverse reactions (severe arthritis in children, lasting up to three years).
RA27/3 strain caused arthropathy (joint damage) for over 18 months in 5% of women, joint pain in 42%, and rash in 25%. One study showed that joint pains were less likely to occur in those vaccinated 6-24 days after the start of menstruation, while a different study showed that they occurred most often in those who got vaccinated during the first 7 days after the start of menstruation. The authors recommend vaccinating in the last 7 days of the cycle.
Few studies on the role of cellular immunity in rubella have been conducted. Transformation of lymphocytes was lower after the vaccine than after the disease exposure.
Rubella revaccination is not particularly effective. Revaccinating people with low level of antibodies resulted in only a slight increase in antibodies level, and in 28% there was no increase at all.
Safety, immunogenicity and immediate pain of intramuscular versus subcutaneous administration of a measles-mumps-rubella-varicella vaccine to children aged 11-21 months.
Eur J Pediatr
Unlike inactivated vaccines, MMR and MMRV need to be administered subcutaneously, and not intramuscularly. However, since few people know how to administer subcutaneous injections, this study examined what would happen if MMRV was administered intramuscularly, and concluded that it was also possible. Well, at least during the first 42 days after the injection everything was fine.
Viral infections during pregnancy.
Am J Reprod Immunol
There are plenty of other viruses and bacteria, besides rubella, that increase the risk of birth defects and spontaneous abortion, if contracted during pregnancy. For example, herpes, varicella, cytomegalovirus, hepatitis, influenza, parvovirus B19, syphilis, listeria, toxoplasma, chlamydia, trichomonas, etc. There is no vaccine against most of them, so few people are afraid of them.
Rubella in Europe.
In 1984, the WHO Regional Office for Europe decided to eliminate rubella by the year 2000 (as well as measles, polio, neonatal tetanus and diphtheria).
After the introduction of MMR vaccine in Poland, Finland and other countries, the incidence of rubella has shifted from children to teenagers and adults.
There are three vaccination strategies:
1) One dose of MMR vaccine at the age of 15 months for all children (USA);
2) One dose of rubella vaccine only for girls at the age of 10-14 years, who had not been exposed to the disease (UK);
3) Two doses of MMR vaccine at the ages of 18 months and 12 years for all children (Sweden).
Selective vaccination strategy (as in UK), although did decrease the incidence of rubella in pregnant women, still left 3% of women unprotected. Therefore, WHO decided to eradicate rubella completely, by vaccinating all infants.
Mathematical models predict that if the initial coverage is less than 60-70%, it will cause an increase in the number of rubella susceptible adults.
Increase in congenital rubella occurrence after immunization in Greece: retrospective review and systematic review.
Rubella vaccination in Greece began in 1975, but the vaccination coverage was below 50%. This led to a consistent increase in the number of pregnant women susceptible to rubella. As a result, there was a rubella epidemic in Greece in 1993, and in 6-7 months an epidemic of 25 cases of congenital rubella followed, the largest such epidemic in the country’s history. Prior to this, congenital rubella syndrome was very rare in Greece.
Moreover, adults also started to get sick with rubella. Before vaccination began, the average age of rubella patients was 7 years, but in 1993 the average age was already 17 years. Although the total number of rubella cases was smaller in 1993 than in 1983, the number of cases in people aged 15 or more, increased.
Evolution of surveillance of measles, mumps, and rubella in England and Wales: providing the platform for evidence-based vaccination policy.
Among other things here, there is a graph of the number of rubella susceptible women of childrearing age in England from 1985 to 1998, which shows no significant change. Solid line represents nulliparous women, and the dotted line is for parous women.
Rubella vaccine was introduced in England in the 1970s for girls of the 11-13 years age group, and the MMR vaccine was introduced in 1988.
Global seroprevalence of rubella among pregnant and childbearing age women: a meta-analysis.
Eur J Public Health
In 2012, the WHO decided to eradicate rubella by 2020.
Since rubella, as well as the congenital rubella syndrome, is very difficult to diagnose, the true incidence could be 10-50 times higher.
The authors conducted a meta-analysis of 122 studies of rubella susceptibility among pregnant and childbearing age women. ~11% of women in Africa did not have rubella antibodies, 10% in the Americas, 7% in the Middle East, 7.6% in Europe, 19% in Southeast Asia and 9% in the Far East. Overall, 9.5% of pregnant women and 9.5% of childbearing age women around the world did not have rubella antibodies, while the WHO’s goal for rubella susceptibility is 5% or lower.
In 2011 not a single country in Africa vaccinated against rubella, but most countries of the Americas already did vaccinate in 2008, as did all European countries.
To increase vaccination coverage among teenagers and adults, the US federal government spends $4 billion each year.
Immunogenicity of the second dose of measles-mumps-rubella (MMR) vaccine and implications for serosurveillance.
2-4 years after receiving the first vaccine, 19.5% of children had measles antibodies below protective level, 23.4% of children had mumps antibodies below protective level, and 4.6% of children had rubella antibodies below protective level.
41% of children did not have protection against at least one of the diseases, which means that a second dose of the vaccine is needed. Similar results were obtained in other studies in the UK and in Canada.
Second dose of the MMR vaccine causes an increase in the levels of measles and rubella antibodies, but 2-3 years later they decrease back to the pre-vaccination levels. Similar results were recorded in other studies in Finland and in other counties.
The authors conclude that the level of antibodies in the blood correlates poorly with the level of protection against the disease.
Epidemiology of measles, mumps and rubella in Italy.
In the 70s to 90s Italy, the incidence of rubella in children decreased, but increased significantly in teenagers and adults.
The incidence of mumps significantly decreased in children under 14 years of age, but remained almost the same among adults. It could be because the Rubini strain was used in Italy, which turned out to be very ineffective. This strain was replaced in 2001.
The number of rubella cases among children increased in the 80s, and then decreased again. Among the teenagers and adults, the number of cases increased significantly in the 80s, and remained high in the following years.
59% of children in the 2-4 years age group had measles and rubella antibodies, but only 32% had antibodies against all three infections. Among the 14-year-olds, only 46% had antibodies against all three diseases. Among those of the age 20 years and older, 6.1% had no measles antibodies, 11.7% had no mumps antibodies, and 8.8% of those 15 years old and over had no rubella antibodies.
The incidence of rubella has not changed over the last decades, despite the fact that rubella vaccination for girls was introduced in Italy in the 1970s. On the contrary, insufficient vaccination coverage, which does not eradicate the disease, as in the case of measles, causes a shift of the disease incidence to adults, which is much more dangerous in the case of rubella due to the risk of infection during pregnancy.
The authors conclude that the WHO’s goal of measles, mumps and rubella eradication has not been achieved, and that insufficient vaccination in Italy only caused an increase in number of adults susceptible to measles and rubella, and had no effect on mumps.
Humoral immunity in congenital rubella.
Clin Exp Immunol
There is no obvious relationship between the number of antibodies and the elimination of the virus in patients with congenital rubella syndrome.
Congenital rubella infection after previous immunity of the mother.
Eur J Pediatr
Vaccination of the mother does not always protect the child from congenital rubella syndrome. A case of the mother who had been vaccinated 7 years prior to pregnancy, and whose antibodies level was confirmed as protective 3 years prior to pregnancy, and who still got infected with rubella during pregnancy, is cited here.
Here are some more similar cases: , , , , , , , , , , , , , , , .
Does Rubella Cause Autism: A 2015 Reappraisal?
Front Hum Neurosci
In the 1990s outbreak of congenital rubella syndrome in California, 43% of mothers had been vaccinated.
An Italian study showed that 9.8% of women contracted rubella within 5 years of vaccination.
5-10 times more antibodies are formed after the disease exposure than after the vaccination.
In a study of 190 soldiers during an epidemic, 80% of those vaccinated got infected. Of those previously exposed to rubella, only 3.4% got re-infected. Of those unvaccinated and never exposed, 100% got infected. Those re-infected showed no symptoms. Only a third of those infected for the first time showed symptoms.
Vaccines for measles, mumps and rubella in children.
Cochrane Database Syst Rev
In a Cochrane systematic review, the authors conclude that there is not a single study proving the clinical effectiveness of rubella vaccine.
Dangers of vaccine refusal near the herd immunity threshold: a modelling study.
Lancet Infect Dis
Since due to vaccination childhood infections have shifted to adulthood, measles has become 4 times more dangerous, chickenpox - 2 times more dangerous, and rubella - 5 times more dangerous.
Anaphylaxis following single component measles and rubella immunization.
Arch Dis Child
Safety of the MMR vaccine was discussed in detail in measles and mumps sections. Here are some more studies, focused more on rubella:
The risk of anaphylactic shock due to vaccination is 1.89 in 10,000 cases for measles vaccine and 2.24 in 10,000 cases for rubella vaccine. The authors believe that these figures are underestimated, since the exact number of administered vaccines is unknown, and that the actual figures may be 3-5 times higher.
The risk of anaphylactic shock due to MMR vaccine was estimated as 1.4 in 100,000 cases in 2004. However, in 2003 the risk of anaphylactic shock due to all the vaccines was estimated at 0.65 in a million.
Is RA27/3 rubella immunization a cause of chronic fatigue?
RA27/3 strain vaccine was introduced in 1979. Within three years, medical literature began to feature a new disease – chronic fatigue syndrome, which was first attributed to the Epstein-Barr virus.
Majority of people suffering from the chronic fatigue syndrome were adult women who started showing symptoms after receiving the rubella vaccine.
Patients with this syndrome have elevated levels of antibodies for many viruses.
The more rubella antibodies were found in a patient, the more severe the chronic fatigue symptoms were.
Chronic arthritis after rubella vaccination.
Clin Infect Dis
Report of the special committee of the Institute of Medicine, which met for 20 months and concluded that the RA27/3 strain causes chronic arthritis in women.
Here is another report that links rubella vaccine to acute arthritis.
A one year followup of chronic arthritis following rubella and hepatitis B vaccination based on the analysis of the Vaccine Adverse Events Reporting System (VAERS) database.
Clin Exp Rheumatol
VAERS analysis. Rubella vaccine is associated with a 32-59 times increase in the risk of chronic arthritis, and hepatitis B vaccine is associated with a 5.1-9 times increase in the risk of chronic arthritis.
Antibodies directed against rubella virus induce demyelination in aggregating rat brain cell cultures.
J Neurosci Res
Rubella antibodies induce demyelination of brain cells in rats through molecular mimicry.
Since MMR is contraindicated for pregnant women (and 1-3 months prior to conception), CDC recommends pregnant women who do not have rubella antibodies to get vaccinated right after giving birth.
However, CDC does not recommend taking a pregnancy test before getting the rubella vaccine.
Effect of immunization against rubella on lactation products, I. Development and characterization of specific immunologic reactivity in breast milk.
J Infect Dis
69% of women vaccinated against rubella after childbirth had the virus secreted in their breast milk. 87.5% of those who received RA27/3 strain had the virus in breast milk.
Effect of immunization against rubella on lactation products, II. Maternal-neonatal interactions.
J Infect Dis
56% of breastfed infants, whose mothers got vaccinated against rubella after childbirth, contracted rubella.
Postpartum rubella immunization: association with the development of prolonged arthritis, neurological sequelae, and chronic rubella viremia.
J Infect Dis
Six women got vaccinated against rubella after childbirth. All of them developed acute arthritis, and then chronic arthritis, which lasted for 2-7 years after vaccination. Three women had neurological consequences (carpal tunnel syndrome, paresthesiae, blurred vision, etc). Five of them had the virus in their blood up to 6 years after vaccination. One of the women had the virus in her breast milk 9 months after vaccination. Two out of four breastfed infants had the virus in their blood.
Postpartum live virus vaccination: lessons from veterinary medicine.
Out of 62 mothers that received rubella or MMR vaccine after childbirth, 47 had at least one child diagnosed with ASD and 10 more had children with suspected ASD or developmental delays.
It is known that rubella virus from vaccine is secreted in breast milk, but it is unknown whether measles and mumps viruses are secreted as well.
In veterinary medicine, many vaccines are not recommended after delivery and during lactation (one of them being canine distemper vaccine).
Canine distemper is often lethal, and when it is not, it causes neurological damage. Canine distemper virus is similar to the measles virus. Measles vaccine also protects dogs from distemper, and these two viruses are usually combined into one vaccine.
A case of a five-year-old female Labrador, who was vaccinated three days after she gave birth to 10 puppies, was reported. 19 days later, the puppies were diagnosed with distemper and five of them had to be put down. Canine distemper has not been observed in that region before, and most probably they contracted the disease form the mother’s vaccine, which allows for a conclusion that measles-type viruses are secreted in breast milk.
Fulminant encephalitis associated with a vaccine strain of rubella virus.
J Clin Virol
A measles and rubella vaccine was given to a healthy 31-years-old male. 10 days later he was hospitalized with a viral encephalitis diagnosis, and another 3 days later, he died. RA27/3 rubella vaccine strain was detected both on brain tissue and in cerebrospinal fluid.
Two more similar cases are described here.
Illness after measles-mumps-rubella vaccination.
After receiving MMR vaccine, 23.8% of infants had lymphadenopathy (swollen lymph nodes), 3.3% had otitis media, 4.5% had rash, and 3.3% had conjunctivitis.
An evaluation of the adverse reaction potential of the three measles-mumps-rubella combination vaccines.
Rev Panam Salud Publica
Comparison of three different MMR vaccines. Vaccines caused a 1.4-3.1 times increase in the risk of lymphadenopathy, and a 2.5-5.7 times increase in the risk of parotitis.
One of the MMR and MMRV components, as well as some other vaccines, is gelatin. Gelatin for vaccines is produced from porcine bones. This, of course, is a problem for Jews and Muslims.
Jews solve this issue very simply. Pork is prohibited for oral consumption, but Torah does not say anything about the intramuscular administration of pork. The Sages of the Talmud did not write anything against the intramuscular or subcutaneous intake of pork, and what is not prohibited is permitted.
Muslims took this issue more seriously, and held a special seminar in Kuwait in 1995, dedicated to this issue, with participation of the WHO Regional Office for the Eastern Mediterranean. They concluded that in the process of conversion, gelatin transforms from an impure substance (haram) into a pure substance (halal), and in the process of making gelatin, bones, tendons and skin of an impure animal become pure gelatin, which can even be used in food. However, not everyone agrees with this conclusion.
Prevalence of anti-gelatin IgE antibodies in people with anaphylaxis after measles-mumps rubella vaccine in the United States.
Despite the fact that MMR contains egg protein, this vaccine is not contraindicated to those allergic to eggs, since it is believed that the component that causes anaphylactic shock from MMR vaccine is gelatin.
More on this issue: , , .
Christians are not concerned over the pork in vaccines, but they are disturbed by the aborted cells. The Vatican condemns using aborted cell tissue and viruses from aborted fetuses, and encourages Catholics to lobby for the development of alternative vaccines, and to oppose in any way possible to the use of vaccines with aborted cells. Given the lack of alternatives, the Vatican allows using these vaccines, but insists that it is the duty of every Catholic to fight to change the current situation. The Vatican allows refusing vaccination, if it does not lead to any significant risks.
Vaccines originating in abortion.
Despite the fact that one’s medical career may suffer due to rejection to vaccinate, rejecting the vaccines with aborted materials is a heroic act for a Catholic.
Cinnamon as a prophylactic in measles and German measles.
Cinnamon essential oil is one of the most effective treatments for rhinitis. It is much more effective and pleasant to use than a more popular treatment of ammoniated tincture of quinine.
A few years ago, BMJ published an article where the author claimed that he had successfully used cinnamon to prevent measles. When someone in the family contracted measles, he prescribed a course of cinnamon to other children in the family, and they either did not get measles, or had very mild symptoms. I also had a similar experience.
Recently, however, I used cinnamon to prevent rubella. One of our nurses, who had been in contact with many of our children, contracted rubella. I prescribed all the children who had been in contact with her (20 children), to eat cinnamon each morning and evening for three weeks (in the amount that fits on a six-penny coin). Cinnamon was added into the food, and the children liked the new taste. None of them got sick.
Rubella, or course, is not a serious disease, and I write this to suggest using cinnamon not for rubella so much, as for preventing measles.
In 1966-1968, prior to the beginning of vaccination, 10-14 cases of congenital rubella syndrome were recorded in the US each year. In 1969-70, after vaccination began, the incidence increased to 62-67 cases each year, and remained above the initial level until the 1980s.
That is, to prevent a dozen cases, eight million children are vaccinated each year. This results in about 400 children with encephalopathy, and 400 more with anaphylactic shock (1 in every 20 thousand) each year.
1110 lethal or disability cases after MMR or MMRV vaccine have been registered with VAERS since 2000 (i.e., 50 cases per year on average). Taking into account that only 1-10% of all cases get registered with VAERS, we get 500-5,000 death or disability cases per year.