30 INFECTIOUS DISEASE, DISASTER PLANNING & WOUND CARE | 2019 | www.elitecme.com rubella virus acquired through vaccination cannot be transmitted to others—with the exception of breastfeeding, during which it can be passed from mother to baby (CDC, 2016-2). VACCINE EFFICACY AGAINST RUBELLA A single dose of rubella vaccine has been shown to be more than 95% effective in patients 12 months of age and older. Indicators of rubella immunity have been found for at least 15 years after receiving the vaccine; immunity is considered to be lifelong. Patients who have received the rubella vaccine have rarely become infected upon exposure to rubella. Patients with low levels of rubella antibodies are at a higher risk of developing an infection (CDC, 2016-2). Rubella-containing vaccines administered before 12 months of age should not be counted toward the completion of the vaccine schedule. All adults born after 1957 should have docu- mentation of at least one dose of rubella-con- taining vaccine. Adults born before 1957 are presumed to have immunity to rubella, but they are not guaranteed to be immune. Adults working or living in high-risk set- tings, such as health care and military person- nel, should receive at least one dose of MMR vaccine to induce rubella immunity. Since clinical diagnosis of rubella can be unreliable, it should not be considered evidence of immu- nity to rubella without laboratory confirma- tion (CDC, 2016-2). Evidence-Based Practice: Greaves et al. evaluated data obtained in a 1981 rubella outbreak in Maine to establish the effective- ness of rubella immunization. Over a period of approximately three months, a total of 83 cases of rashes that resembled those associated with rubella were reported. Of these patients, serological confirmation was obtained in 27%. Overall, 48% of the cases were recorded in the local high school and comprised approx- imately 3% of the school’s population. Based on these instances of rubella, investigators set out to calculate an attack rate in vacci- nated and un-vaccinated subjects. Analyses showed that a vaccination was effective at pre- venting rubella in 90% of cases. Investigators concluded that the rubella vaccine was highly effective in preventing rubella when admin- istered as intended. Further, they stated that their findings did not support the practice of routine re-vaccination (Greaves, et al. 1983). CONTRAINDICATIONS AND PRECAUTIONS TO RUBELLA COMPONENT OF VACCINATIONS Women who are pregnant, or who may become pregnant within four weeks, should not receive the rubella vaccine. While there is no evidence that the virus found in the rubel- la vaccine can cause damage to a fetus, best practices suggest that pregnancy should be avoided for 28 days after rubella or receiving an MMR vaccination. This recommendation may be linked to the known teratogenicity of the wild-type strain of rubella virus. This potential fetal risk has been a concern since the introduction of the vaccine. In an attempt to answer this question, the CDC maintained a registry of women vacci- nated during their pregnancies. This registry spanned a period of 18 years, 1971 to 1989, and was referred to as the Vaccine in Pregnancy (VIP) registry. According to this investigation, subclinical infections were detected serolog- ically in about one to two percent of infants born to mothers who were vaccinated. The registry recorded no instances of CRS in off- spring of the 321 susceptible, rubella-vacci- nated women who carried their pregnancies to term. Based on this low risk, a routine termi- nation of pregnancy is not indicated in cases of vaccinating pregnant women for rubella. Alternatively, individual counseling should be encouraged in order to describe the poten- tial risks of rubella vaccination in pregnant women. Due to the small theoretical risk of rubella vaccination during pregnancy, ACIP states that pregnant women should not be vac- cinated (CDC, 2016-2). ADVERSE REACTIONS TO RUBELLA COMPONENT OF VACCINATIONS The most common adverse reactions related to the rubella component of combination vaccinations include fever, swelling of the lymph nodes, arthritis, and arthralgia. These reactions are more common in adult women than in any other group. Acute arthralgia can occur in up to 25% of females receiving rubella vaccination after puberty; approx- imately 10% develop acute arthritis-like symptoms of following vaccination. If they occur, acute joint symptoms often begin one to three weeks following vaccination and last for one to 21 days. These symptoms rarely recur. Studies have not shown an associa- tion between the vaccination and chronic arthritis. Rare peripheral nerve reactions have been reported, such as tingling or pain in the arms and legs (CDC, 2016-2). MMR VACCINE According to the Public Health England (PHE), the combined MMR vaccine product is the safest and most effective means to protect people from contracting measles, mumps, and rubella (PHE, 2014). PHE’s position is founded on a number of key properties and include: • MMR allows a smaller number of injec- tions (two versus six, if the vaccines were administered individually), which decreases patient discomfort; • All available, current outcomes data is based on the combined MMR product. As a result, there are no guidelines for individual vaccine use; their use would be experimental. Although single vaccines are available in some regions, no country currently recommends the use of individual vaccines except in unique situations; • The administration of single immuni- zations would likely be accomplished over a period of time rather than all at once. This approach would leave the person susceptible to the diseases prevented by the vaccines not yet administered. In essence, this vaccination regimen would reduce the proportion of peo- ple properly immunized. The likelihood of this situation was evidenced by past experience when measles and rubella were administered separately. During this time, children con- tinued to get measles and cases of CRS were recorded. Virtual elimination of measles and CRS corresponded to the introduction of the MMR vaccine product; • Decreased compliance: Evidence suggests that the uptake rate with single vaccines is less than with the MMR vaccine product; • Potential decreased potency and increased toxicity with single products. Although sin- gle vaccines have not been fully characterized, evidence exists that suggests that some single vaccines are less effective, and are potentially less safe, than the MMR vaccine product; • Experience: MMR is the vaccine of choice in excess of 100 different countries. Through its high level of utilization, MMR is well-in- CONTINUING EDUCATION  |