Rubella secondary prevention
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Michael Maddaleni, B.S., Aravind Kuchkuntla, M.B.B.S[2]
Overview
Rubella is a very controlled disease due to the fact that there is a successful vaccination against it. Therefore, many secondary education techniques would be employed in case of an outbreak. According to the situation of the potential patient involved, the secondary prevention technique will differ accordingly. One of the most serious situations is with a pregnant woman. The reason this situation is so severe is due to the fact of the severity of congenital rubella syndrome.
Secondary Prevention
Pregnant women
During an outbreak, the following steps should be taken to evaluate and follow up with pregnant women who had contact with a person with confirmed, probable, or suspected rubella:
- Use documented serologic test results to verify immunity. If unavailable, conduct rubella IgG and IgM antibody testing regardless of symptom history. Pregnant women who are exposed to rubella and who do not have documented proof of immunity should be tested for rubella-specific IgM antibodies to identify recent infection. Because 20%--50% of rubella cases are asymptomatic, this testing policy is crucial to assess the possibility of risk to the fetus. Another way to identify recent infection is to detect a significant rise in paired IgG serum. A single positive IgG test indicates rubella immunity, but does not give information regarding the timing of the infection. However, a significant rise in IgG antibody (determined by testing paired sera) or positive IgM antibody test indicates recent infection.
- Recommend restricting activities to avoid exposure while waiting for serologic test results. During this time, pregnant women should be excluded from activities (e.g., work or school) that present the possibility of exposure to persons with confirmed or suspected cases of rubella. Pregnant women found to be susceptible to rubella should avoid these settings for 6 weeks (two incubation periods) after the onset of symptoms of rubella in the last patient for whom rubella cannot be ruled out.
- Evaluate exposed pregnant women with positive IgG titers and negative IgM to determine if they acquired immunity before pregnancy or infection during pregnancy. Women without previously documented immunity who were exposed during pregnancy and >6 weeks before IgM testing could test negative for IgM antibodies, which are normally not detectable >6 weeks after infection. Thus, a negative rubella IgM antibody assay does not rule out infection during pregnancy. The dates of the pregnancy, possible exposures, test(s), and history of rash illness should be considered in assessing the possibility of risk to the fetus.
- Evaluate pregnant women with confirmed rubella to assess risk to the fetus. Rubella infection during the first 3 months of pregnancy is associated with the greatest risk for congenital rubella syndrome, and up to 90% of infants born to mothers infected during the first 11 weeks of gestation will develop congenital rubella syndrome. Infection late in the first half of pregnancy is more likely to result in hearing impairment and less likely to be associated with other defects. Although not likely to result in CRS, rubella infection late in pregnancy can result in congenital rubella infection only.
- Pregnant women with negative IgG and negative IgM on first testing should be retested in 10--14 days; the first specimen should be reanalyzed along with the second specimen. A significant rise in IgG or positive IgM indicates recent infection. If a susceptible pregnant woman continues to be directly exposed to rubella, repeat tests of paired sera in 10-14 days to determine if infection occurs, then every 3--4 weeks if exposure continues. Testing can be performed earlier if pregnancy outcome might be influenced. Evaluate the infant on delivery for signs of congenital rubella syndrome, and vaccinate the mother postpartum.
- Recommend restricting activities for susceptible women (i.e., those without detectable IgG and IgM antibodies), obtain follow-up serologic testing, and vaccinate after delivery. Susceptible pregnant women should be excluded from activities (e.g., work or school) that present the possibility of exposure to persons with confirmed or suspected cases of rubella. Pregnant women found to be susceptible should avoid these settings for 6 weeks (two incubation periods) after the onset of symptoms of rubella in the last patient for whom rubella cannot be ruled out. Household contacts or other ongoing contacts without documented rubella immunity should be vaccinated.
- Evaluate asymptomatic, exposed pregnant women with documented history of previous rubella immunity. Women with documentation of previous rubella immunity who are exposed to rubella during pregnancy should consult their physicians. After discussing the potential for reinfection, physicians might recommend acute- and convalescent-phase IgG antibody testing or an IgM antibody test to document whether reinfection has occurred. However, the potential for false-positive IgM tests exists, and the potential risks and benefits of testing should be considered.
- Counsel pregnant women with documentation of previous immunity to seek medical attention promptly if rubella-like symptoms appear. Any pregnant woman with documented immunity and rubella-like symptoms should be immediately evaluated by a physician to diagnose the symptoms and ensure the health of the mother and fetus.