Rubella

What

Rubella is a viral illness that spreads from person to person by respiratory secretions. Rubella is usually mild and self-limiting, but exposure during pregnancy can result in fetal infection and congenital rubella syndrome.

Who

Rubella-containing vaccine is recommended for:

• children ≥12 months of age
• adolescents and adults born during or since 1966 who have not received 2 doses of rubella-containing vaccine, particularly
  • healthcare workers
  • childhood educators and carers
  • women of child-bearing age who are seronegative for rubella

How

Rubella-containing vaccine is recommended for children at 12 months of age as MMR (measles-mumps-rubella) vaccine and at 18 months of age as MMRV (measles-mumps-rubella-varicella) vaccine.

All adolescents and adults born during or since 1966 should have either:

• documented evidence of 2 doses of rubella-containing vaccine given at least 4 weeks apart and with both doses given ≥12 months of age, or
• serological evidence of immunity to measles, mumps and rubella

Why

Congenital rubella syndrome includes a range of birth defects (for example, deafness, intellectual disability, cataracts and cardiac abnormalities). World Health Organization regions have set goals for control and elimination of rubella and congenital rubella syndrome.

Rubella vaccines available in Australia

The Therapeutic Goods Administration website provides product information for each vaccine.

See also Vaccine information and Variations from product information for more details.

Dose and route

The dose of Priorix and M-M-R-II (MMR) vaccine for both children and adults is 0.5 mL given by either subcutaneous or intramuscular injection.

The dose of ProQuad and Priorix-tetra (MMRV) vaccine for children <14 years of age is 0.5 mL given by subcutaneous or intramuscular injection.¹²

MMRV vaccine is not recommended as the 1st dose of rubella-containing vaccine in children <4 years of age. This is due to a small but increased risk of fever and febrile seizures when MMRV vaccine is given as the 1st dose of rubella-containing vaccine in this age group. See Adverse events.

If MMRV vaccine is inadvertently given as dose 1 of rubella-containing vaccine, the dose does not need to be repeated (providing it was given at ≥12 months of age). The scheduled 18-month dose of MMRV should still be given at the usual time. See Table. Minimum acceptable age for the 1st dose of scheduled vaccines in infants in special circumstances in Catch-up vaccination. Advise parents and carers about the small but increased risk of fever and febrile seizures (compared with that expected after MMR vaccine).

MMRV vaccine is not recommended for use in people ≥14 years of age. No data are available on safety, immunogenicity or efficacy in this age group.

If a person ≥14 years of age is inadvertently given a dose of MMRV vaccine, this dose does not need to be repeated.
 

Co-administration with other vaccines

People can receive MMR or MMRV vaccine at the same time as other live attenuated parenteral vaccines or other inactivated vaccines,¹³ or other immunisation products (such as RSV-specific monoclonal antibody), using separate syringes and injection sites. If a person does not receive MMR or MMRV vaccine at the same time as other live attenuated parenteral vaccines, wait at least 4 weeks between vaccinations.^14,15

Measles, mumps and rubella vaccines are not available separately as an alternative to MMR vaccine. However, a monovalent varicella vaccine is available (see Varicella).

If a person receives MMR vaccine at the same time as monovalent varicella vaccine, use separate syringes and injection sites. Do not mix MMR vaccine and monovalent varicella vaccine together before injection.

Interchangeability of MMR-containing vaccines

The 2 brands of MMR vaccine are interchangeable, so the 2nd MMR vaccine dose does not have to be the same brand as the 1st.

The same principle applies to the 2 MMRV vaccines,¹³ although they are not routinely recommended in a 2-dose schedule.

Contraindications

Anaphylaxis to vaccine components

MMR and MMRV vaccines are contraindicated in people who have had:

• anaphylaxis after a previous dose of any MMR-containing vaccine
• anaphylaxis after any component of an MMR-containing vaccine 

See Anaphylaxis in Adverse events for more details about MMR vaccination for people with a known egg allergy.

Pregnant women

MMR-containing vaccines are contraindicated in pregnant women.

Vaccinated women should avoid pregnancy for 28 days after vaccination.⁹ This is due to the theoretical risk of transmitting the rubella component of the vaccine to a susceptible fetus. However, there are no reports of vaccine-induced congenital rubella syndrome.¹⁶

Active surveillance in the United States, the United Kingdom and Germany indicates that no cases of vaccine-induced congenital rubella syndrome occurred among more than 500 women who were inadvertently given rubella vaccine during pregnancy, and whose pregnancies continued.¹⁷ 

In an Iranian study performed after mass vaccination with a measles-rubella vaccine, 117 susceptible women were inadvertently vaccinated while pregnant or became pregnant within 3 months after vaccination. There were no abnormalities related to congenital rubella syndrome among the infants born to these women.¹⁸ 

Based on this evidence, the vaccine is not considered to be teratogenic. Women do not need to consider ending a pregnancy after inadvertent vaccination.^16,19

See also Vaccination for women who are planning pregnancy, pregnant or breastfeeding.

Breastfeeding women can receive MMR vaccines. The rubella vaccine virus may be secreted in human breast milk, and rare cases of transmission of vaccine virus through breast milk have been reported. However, symptoms in the newborn have been absent or mild.^20-22 Post-partum vaccination of women who are not immune to rubella does not need to be delayed because of breastfeeding.

There is no risk to pregnant women from contact with people who have recently been vaccinated. The vaccine viruses is not transmitted from vaccinated people to susceptible contacts.¹⁶

See also Vaccination for women who are planning pregnancy, pregnant or breastfeeding and Table. Vaccines that are contraindicated in pregnancy: live attenuated vaccines for more details.

People who are severely immunocompromised 

MMR-containing vaccines contain live attenuated viruses and are contraindicated in people who are severely immunocompromised, as a result of a primary/secondary medical condition(s), or receiving certain immunosuppressive therapies (e.g. B-cell depleting biological therapy). See Table. Types of medical conditions and immunosuppressive therapy and associated levels of immunocompromise in Vaccination for people who are immunocompromised.

However, MMR vaccine may be considered for certain types of immunodeficiencies, well-controlled immunocompromising conditions or after a specific period following the completion of immunosuppressive therapies (see Precautions).

Precautions

Vaccination after receiving immunoglobulin or a blood product

A recent blood transfusion with washed red blood cells is not a contraindication to MMR or MMRV vaccines.

People who have received an immunoglobulin-containing blood product should wait 3–11 months before receiving a rubella-containing vaccine. This is because the immunoglobulin may impair the expected immune response to the vaccine.^15,23

The interval between receiving the blood product and the vaccine depends on the amount of immunoglobulin in each product.¹⁵ See Table. Recommended intervals between immunoglobulins or blood products, and measles-mumps-rubella, measles-mumps-rubella-varicella or varicella vaccination and Vaccination for people who have recently received normal human immunoglobulin and other blood products.

People may receive MMR vaccine at the same time as anti-D immunoglobulin, but at different injection sites. They can also receive MMR vaccine at any time after anti-D immunoglobulin. Anti-D immunoglobulin does not interfere with the antibody response to the vaccine. 

Immunoglobulin or blood product administration after vaccination

People who have received a rubella-containing vaccine should not receive immunoglobulin-containing products for 3 weeks after vaccination, unless the benefits of receiving the blood product outweigh the benefits of vaccination. If the person receives an immunoglobulin-containing product within 3 weeks after a rubella-containing vaccine, the vaccinated person should be either:

• revaccinated later at the appropriate time, as indicated in Table. Recommended intervals between immunoglobulins or blood products, and measles-mumps-rubella, measles-mumps-rubella-varicella or varicella vaccination, or
• tested for immunity 6 months later and then revaccinated if seronegative

People may receive anti-D immunoglobulin at any time after receiving MMR vaccine.

People who are mildly or moderately immunocompromised

Vaccination with MMR vaccines can be considered for people who are not severely immunocompromised based on a risk-benefit assessment, taking into account the level of immunocompromise or consult a specialist if needed.

See Table. Types of medical conditions and immunosuppressive therapy and associated levels of immunocompromise in Vaccination for people who are immunocompromised.

For more detailed guidance on each type of immunodeficiency, see the following tables:

• Table. Vaccination for people with inborn errors of immunity: live vaccines
• Table. Recommendations for vaccination before and after solid organ transplant
• Table. Recommendations for vaccination after haematopoietic stem cell transplant in children and adults
• Table. Recommendations for vaccination in children and adults with HIV
• Table. Recommendations for vaccination before and after completion of chemotherapy
• Table. Recommended timing of live vaccine administration for people receiving immunosuppressive therapies
• Table. Recommended timing of live vaccine administration for people receiving corticosteroids

People with inborn errors of immunity, including primary immunodeficiency

People with less severe inborn errors of immunity, including primary immunodeficiency (e.g. defects of innate immunity and complement deficiencies) can receive the MMR vaccine. Advice on vaccination of children or adults who have been diagnosed with specific immunodeficiencies, such as interferon-alpha/beta receptor subunit 1 (IFNAR1) deficiency, should be sought from their immunologist.

See Inborn errors of immunity, including primary immunodeficiency.

People receiving immunosuppressive therapies

For people receiving immunosuppressive therapy (e.g. high doses of corticosteroids, conventional immunosuppressive therapies, small molecule targeted therapies, and biological therapies), live vaccines including MMR-containing vaccines should ideally be administered at least 4 weeks before starting treatment. If this is not feasible, live vaccines should be administered after the designated waiting period once therapies are completed, with the timing varying based on the specific agent.

See Secondary (acquired) immunodeficiency due to medical therapies.

People with malignancies

In general, live vaccines are contraindicated in people with immunodeficiency due to malignancies or cancer treatments, especially in people undergoing B- or T-cell-targeting biological therapies, immunosuppressive chemotherapy or radiotherapy. However, live vaccines, including MMR vaccine may be administered in cancer patients when:

• a malignancy is in remission, and
• immune competence is demonstrated (such as lymphocyte count >1 × 109/L), and
• immunosuppressive chemotherapy, immunotherapy or radiotherapy have not been administered for at least 3 months, and
• no anti-B-cell therapies (such as rituximab) have not been administered in the past 6 months

See People with malignancies: recommendations for vaccination.

People receiving a solid organ transplant

MMR vaccine may be considered at least 1 year after solid organ transplant following a risk–benefit assessment including the level of immunocompromise.

MMRV vaccine is not recommended for people who have received a solid organ transplant because there are no data relating to the safety or efficacy of MMRV vaccine in this group.

See Solid organ transplant: recommendations for vaccination.

People receiving haematopoietic stem cell transplant (HSCT)

People undergoing HSCT can receive the MMR vaccine at least 2 years after HSCT, but only when:

• there is no evidence of chronic graft-versus-host disease, and
• immunosuppressive therapy has been discontinued for at least 3 months, and
• the person is deemed immunocompetent by their treating specialist

See Haematopoietic stem cell transplant: recommendations for vaccination.
 

People with HIV

MMR vaccine can be given to people with well-controlled HIV who are not severely immunocompromised, ie. asymptomatic children >12 months of age with an age-specific CD4+ count of ≥15%; adults with a CD4+ cell count ≥200 cells/μL. ^9,24-28

There have been no studies on the safety, immunogenicity or efficacy of combination MMRV vaccines in asymptomatic people with HIV or people with an age-specific CD4+ count of ≥15%.9,23 Therefore, it is recommended that these groups receive only MMR vaccine (and monovalent varicella vaccine — see Varicella).^26,28,29

See People with HIV: recommendations for vaccination.

Household contacts of people who are immunocompromised

Household contacts of people who are immunocompromised should ensure that they are age-appropriately vaccinated against, or are immune to, measles, mumps, rubella and varicella.

Household contacts of people who are immunocompromised can safely receive rubella-containing vaccines, because the vaccine viruses are not transmissible from vaccinated people to others.⁹  See also Close contacts of people who are immunocompromised.

If using MMRV vaccine, see Varicella for details about varicella vaccine virus transmission.

People receiving long-term aspirin or salicylate therapy

There is no need to avoid salicylates before or after receiving MMR or MMRV vaccine.

People taking long-term salicylate therapy (aspirin) can receive MMRV vaccine if needed. The benefit is likely to outweigh any possible risk of Reye syndrome after vaccination with a varicella-containing vaccine (see Varicella).

People with a history of thrombocytopenia

Thrombocytopenia is a rare adverse event associated with MMR vaccination (see Adverse events).^31-33

In children who have had an episode(s) of idiopathic thrombocytopenia purpura (ITP), the risk of vaccine-associated thrombocytopenia after a dose of MMR vaccine is uncertain.^9,33 However, a systematic review concluded that MMR vaccination, either a 1st or 2nd dose, did not lead to a recurrence of ITP.³⁴ In children due for their 2nd dose, serological testing can be used to determine whether the child needs the extra dose of MMR or MMRV vaccine.

Personal or close family history of seizures or convulsions

Children with a personal or close family history of seizures or convulsions can receive MMR or MMRV vaccine.

Ensure that the parents or carers understand that the child may develop a fever 6–14 days after vaccination.⁹ Advise parents or carers about how to manage the fever with paracetamol or ibuprofen and other measures (see Adverse events following immunisation in After vaccination).

MMRV vaccines are only recommended for use as the 2nd dose of rubella-containing vaccine. This is because the risk of fever and febrile convulsions is higher if children receive MMRV vaccine as their 1st dose. See Recommendations and Adverse events.

Tuberculin skin testing after MMR vaccination

The measles virus inhibits the response to tuberculin. Tuberculin-positive people may become tuberculin-negative for 4–6 weeks after measles infection, and measles-containing vaccines have a similar effect.^9,36 Because of this, a tuberculin skin test (TST; Mantoux) may be unreliable for at least 4–6 weeks in people who have received MMR vaccine.

There are no studies on if and how MMR or MMRV vaccination affects the results of interferon-gamma release assays used for testing for M. tuberculosis infection.³⁷

Adverse events after receiving a rubella-containing vaccine are generally mild and well tolerated.⁸ Adverse events are much less common after the 2nd dose of MMR or MMRV vaccine than after the 1st dose.

A history of rubella is not a contraindication to vaccination. People who are already immune to rubella have no increased risk of side effects from vaccination.^8,9

Fever and febrile convulsions

MMR vaccines

People who receive MMR vaccine may develop a fever between 7–10 days (range 5–12 days) after vaccination. This can last 2–3 days. The fever may be associated with malaise and/or a non-infectious rash. Up to 15% of young children receiving MMR vaccine develop a high fever (>39.4°C).^9,38

An increased risk of febrile seizures of about 1 case per 3000–4000 doses occurs during the same time period.⁹

This time frame coincides with the period of peak measles vaccine virus replication.

Inform vaccine recipients, or their parents or carers, about:

• possible symptoms occurring 5–12 days after vaccination
• how to manage the symptoms, including using paracetamol or ibuprofen for fever

See Adverse events following immunisation in After vaccination.

MMRV vaccines

In clinical trials, people who received MMRV vaccine had higher rates of fever than people who received MMR vaccine and monovalent varicella vaccine at the same time but at separate sites.^39-42 Rates of fever were highest in young children who received MMRV vaccine as their 1st dose.

Post-marketing studies in the United States identified an approximately 2-fold increased risk of fever and febrile convulsions 7–10 days⁴³ (or 5–12 days)⁴⁴ after vaccination in children who received MMRV vaccine as a 1st dose. MMRV recipients were compared with recipients of separate MMR and varicella vaccines. MMRV vaccination resulted in 1 additional febrile seizure for every 2300 doses compared with separate MMR and varicella vaccination.⁴³ Children in these studies were mostly 12–23 months of age.

In the United States, post-marketing studies did not find an increase in fever or febrile convulsions after children received the 2nd dose of ProQuad (MMRV) vaccine. However, most 2nd-dose recipients were aged 4–6 years, an age at which the incidence of febrile convulsions is low.⁴⁵ This side effect profile is expected to be similar in children who receive Priorix-tetra.

Rare adverse events

Anaphylaxis

Anaphylaxis after receiving an MMR vaccine is very rare (1.8–14.4 per million doses).⁹

Although no cases of anaphylaxis were reported in MMRV vaccine clinical trials, the incidence is likely to be similar to that of MMR vaccine.

Anaphylaxis after vaccination is probably due to anaphylactic sensitivity to gelatin or neomycin, not an egg allergy. Measles and mumps (not rubella or varicella) vaccine viruses are grown in chick embryo tissue cultures, but measles- and mumps-containing vaccines have negligible amounts of egg ovalbumin. See Variations from product information and Vaccination for people who have had an adverse event following immunisation.

People with an egg allergy can safely receive an MMR or MMRV vaccine.^31,46,47 Skin testing is not needed before vaccination.³¹

Thrombocytopenia

Thrombocytopenia has been very rarely associated with the rubella or measles component of MMR vaccine. It is usually self-limiting and occurs in 3–5 per 100,000 doses of MMR vaccine.^31-33 This is considerably less frequent than after natural measles, mumps and rubella infections.³³

Any association with MMRV vaccine is expected to be similar.

Encephalopathy

It is uncertain whether people can develop encephalopathy after MMR vaccination. If they do, it is at least 1000 times less frequent than encephalopathy as a complication from natural infection.³⁸

Lymphadenopathy, arthralgia and parotitis

Other rare adverse events attributed to MMR vaccine include:⁹

• transient lymphadenopathy
• arthralgia
• parotitis (see Mumps)

Some studies have reported arthralgia as an adverse event among people receiving rubella vaccine. However, other studies report similar rates between those receiving vaccine and placebo.⁸ A 2011 Institute of Medicine report concluded that there is inadequate evidence to accept or reject a causal relationship between MMR vaccine and chronic arthralgia or arthritis.⁴⁸

Conditions not linked to MMR vaccination

MMR vaccine is not associated with:

• autism
• autistic spectrum disorder
• inflammatory bowel disease

No credible scientific evidence supports a link between MMR and these conditions. Most proponents of the link have retracted this claim.^49,50 There is a substantial body of evidence to refute these claims.^51-54

Rubella is caused by an enveloped togavirus from the genus Rubivirus. The rubella virus has an RNA genome.

The rubella virus is relatively unstable. It is inactivated by:¹⁶

• lipid solvents
• trypsin
• formalin
• extremes of heat and pH
• light 

Pathogenesis

The incubation period for rubella is 14–21 days. 

Transmission

Rubella spreads from person to person by respiratory secretions, possibly including aerosol transmission.^16,55 People are infectious from 7 days before the rash appears (see Symptoms of rubella) until 7 days after. People with rubella are most infectious while the rash is erupting.^56,57

Rubella virus can reinfect people who already have natural or vaccine-induced antibodies to rubella.⁸

Symptoms of rubella

Rubella is generally a mild and self-limiting disease.^16,55 It can cause:

• a transient, generalised, erythematous, maculopapular rash
• lymphadenopathy involving the post-auricular and suboccipital glands

Clinical diagnosis is unreliable because the symptoms are often fleeting and other viruses can cause similar symptoms. In particular, the rash is not unique to rubella, and it may be absent.^16,55 

Up to 50% of rubella virus infections are subclinical or asymptomatic.¹⁶ This means that a history of rubella can only be confirmed by serological evidence of previous infection.¹⁶ 

Complications of rubella

Rubella occasionally causes arthritis and arthralgia. People may experience other complications, such as neurologic disorders and thrombocytopenia, but these are rare.⁸ 

Congenital rubella syndrome

Rubella infection in pregnancy can result in fetal infection, causing congenital rubella syndrome (CRS) in many cases. 

Up to 90% of infants born to women who had rubella infection in the 1st trimester of pregnancy have abnormalities (often multiple) that are characteristic of CRS.^8,58,59 

The risk of damage declines to 10–20% by 16 weeks gestation. After this stage of pregnancy, fetal damage is rare, but has been reported when mothers were infected up to 20 weeks gestation.⁸ 

The characteristics of CRS include:⁸

• intellectual disabilities
• cataracts
• deafness
• cardiac abnormalities
• intrauterine growth retardation
• inflammatory lesions of the brain, liver, lungs and bone marrow 

CRS can include any combination of these defects. Deafness and pigmentary retinopathy commonly occur alone if infection occurs after the first 8 weeks of pregnancy. Some infected infants may appear normal at birth, but defects, especially sensorineural deafness, may be detected later.⁶⁰ 

Occasionally, some infants have been born with CRS after their mother was reinfected during pregnancy. However, fetal damage is very rare in pregnant women who have detectable antibodies.^9,19,58,61

Rubella in Australia

Endemic rubella is well controlled in Australia.⁶² The incidence of rubella has fallen rapidly since rubella vaccine was registered in 1970. Notifications of rubella have been low since the National Measles Control Campaign in late 1998 resulted in high vaccine coverage, which has been maintained.⁶³

Since 2003, rubella notifications in Australia have been less than 0.3 per 100,000 population. In 2014, the notification rate was 0.1 per 100,000 population (17 notifications).⁶⁴

From 2008 to 2012, the age distribution of cases shifted, with comparatively more cases seen in adult age groups, particularly the 20–29 years age group.⁶⁵ Males >30 years of age are more likely to be notified with rubella than older females,⁶⁵ and demonstrate lower seroprotection than females in population-based serosurveys.⁶⁶ This is because males were not included in the school-based rubella vaccination program between 1971 and 1993.⁶⁷ For this reason, all adult males, as well as females, who do not have a documented history of receiving 2 doses of MMR vaccine should receive rubella-containing vaccine (see Recommendations). Vaccination will both protect the individual and prevent transmission in the community.

Mass vaccination campaigns starting in the 1970s have successfully reduced the incidence of congenital rubella syndrome (CRS) since 1977.^2,3,10 Between 2004 and 2014, 5 confirmed cases of CRS were reported in Australia, all in children whose mothers were born overseas.^64,68 

A study in 2000 showed that about 2.5% of women of child-bearing age in Australia were seronegative for rubella.⁴ However, susceptibility was higher among certain groups of women, particularly overseas-born women (see Women of child-bearing age in Recommendations).⁴

Global elimination of rubella and congenital rubella syndrome

Several World Health Organization (WHO) regions have set goals to eliminate rubella and CRS. The Pan American Health Organization has declared elimination in its region.⁶⁹

The WHO Western Pacific Region (WPRO) has set goals for increased rubella and CRS control efforts. As of 2016, all WPRO Member States have introduced rubella vaccination into their national immunisation programs.⁷⁰ As with measles, achieving rubella and CRS elimination will need strong immunisation and surveillance efforts. This includes identifying rubella virus genotypes to confirm the absence of an endemic strain.⁷¹

Monovalent rubella vaccine is not available in Australia. People receive rubella vaccine as either MMR or MMRV vaccine.

Immunogenicity

A single dose of rubella-containing vaccine produces an antibody response in more than 95% of vaccine recipients.¹⁹ But antibody levels are lower than in people who have had natural infection.^8,9

A 2nd vaccine dose aims to confer immunity in those who fail to seroconvert to the 1st dose.

Clinical trials of MMR vaccine compared with MMRV vaccine were mainly done in children 12 months to 6 years of age. MMRV vaccines produce similar rates of seroconversion to all 4 vaccine components as MMR and monovalent varicella vaccines given at the same time at separate injection sites.^39-42

Vaccine effectiveness

Outbreaks of rubella in populations that are vaccinated against rubella are rare. A 1981 study from an outbreak at a United States university showed vaccine effectiveness against clinical rubella of 97%.⁷² Another study among Italian military recruits showed vaccine effectiveness of 94.5% after rubella vaccination.⁷³

Duration of immunity

Vaccine-induced antibodies persist for at least 16 years in the absence of endemic disease.^9,74,75 Protection against clinical rubella appears to be long term in those who seroconvert.^8,19

Transport according to National vaccine storage guidelines: Strive for 5.⁷⁶ Store at +2°C to +8°C. Do not freeze. Protect from light.

Both MMR and MMRV vaccines must be reconstituted. Add the entire contents of the diluent container to the vial containing the pellet. Shake until the pellet completely dissolves.

Use reconstituted Priorix (MMR), M-M-R II (MMR) and Priorix-tetra (MMRV) vaccines as soon as practicable. If reconstituted vaccine must be stored, hold at +2°C to +8°C for no more than 8 hours.

Use reconstituted ProQuad (MMRV) vaccine immediately. If it must be stored, hold at:

• +2°C to +8°C for no more than 2.5 hours, or
• +20°C to +25°C for no more than 1 hour.

Notifying rubella

Rubella is a notifiable disease in all states and territories in Australia.

State and territory public health authorities can provide advice about the public health management of rubella, including management of cases and their contacts.

Managing rubella cases

Rubella-containing vaccine does not protect people if they receive it after they have been exposed to rubella.⁹ However, if the exposure did not result in infection, the vaccine will protect the person against future infection.

People with confirmed rubella should not go to school or work, and should avoid contact with women of child-bearing age for at least 7 days after onset of the rash.^56,57,77,78

Managing suspected rubella contacts

Identify all contacts of people with suspected rubella infection, especially those who are pregnant (see NHIG as prophylaxis below).

Exposed healthcare workers without proof of immunity should not go to work beginning 7 days after exposure to rubella and continuing until either 23 days after last exposure or for at least 7 days after onset of rash if rubella is confirmed or probable or until fully recovered, whichever is longer.⁷⁸

Contacts >12 months of age without proof of immunity should receive 1 dose of MMR vaccine (or MMRV vaccine, if appropriate). However, this will not prevent rubella disease if the person has already been exposed.

If the contact refuses vaccination, they should avoid further contact with the case until at least 7 days after onset of the case’s rash.

Seronegative women of child-bearing age should receive rubella vaccine and be tested for seroconversion 6 to 8 weeks after vaccination (see Recommendations).

NHIG as prophylaxis

Using normal human immunoglobulin (NHIG) as post-exposure prophylaxis in non-immune pregnant contacts may reduce the risk of rubella infection to the non-immune adult. In such cases, give NHIG (0.5mL up to 160kg; and 1mL >160kg) given intramuscularly within 5 days of rubella exposure.^8,78 Serological follow-up of NHIG recipients is essential, and should continue for up to 2 months.

Some evidence suggests that, in outbreak situations, pre-exposure NHIG may be effective in preventing infection in women who are likely to be pregnant. It may be used in such women with low antibody titres in high-risk occupations.⁷⁹

People with egg allergy

The product information for Priorix, M-M-R II and Priorix-tetra states that people with a history of anaphylactic or anaphylactoid reactions to egg should not receive these vaccines.

The Australian Technical Advisory Group on Immunisation (ATAGI) recommends that these people can receive Priorix, M-M-R II, Priorix-tetra or ProQuad.⁹

Women planning pregnancy

The product information for M-M-R II and ProQuad recommends that women of child-bearing age should avoid pregnancy for 1 month after vaccination.

ATAGI recommends that these women should avoid pregnancy for 28 days after vaccination,⁹ as for Priorix and Priorix-tetra.

People taking salicylates

The product information for ProQuad and Priorix-tetra states that people should avoid taking salicylates for 6 weeks after vaccination. This is because Reye syndrome has been reported after using salicylates during natural varicella infection.

ATAGI recommends that non-immune people on long-term salicylate therapy can receive varicella-containing vaccines, because the benefit is likely to outweigh any possible risk of Reye syndrome after vaccination.

Recommended ages for MMR vaccines

The product information for M-M-R II and Priorix states vaccine is for use in children ≥12 months of age.

ATAGI recommends that children ≥9 months can receive both MMR vaccines in certain circumstances, including travel and during outbreaks.

Recommended ages for MMRV vaccines

The product information for ProQuad states that this vaccine is for use in children 12 months to 12 years of age. The product information for Priorix-tetra states that children ≥9 months of age can receive this vaccine. 

ATAGI recommends that children up to 14 years of age can receive both MMRV vaccines. ATAGI also recommends that MMRV vaccine should not be used routinely as the 1st dose of MMR-containing vaccine in children aged <4 years. 

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