Rubella is the third part of the combined measles, mumps and rubella (MMR) vaccine.
The word “rubella” is derived from Latin and means “little red”. It was first described by German doctors in the mid-1700s and can appear similar to measles, especially the red rash. Rubella is often called German measles or 3-day measles, although it is not measles.
Rubella is similar in name and symptoms to rubeola (measles) and roseola (a common childhood rash for which there is no vaccine), but the three viruses are not related.
When weighing the risks and benefits of vaccinating our children against rubella we had to look at the risk of the MMR vaccination as a whole, since it is not possible to get separate measles, mumps and rubella shots in the U.S. at this time. However, our choice to decline for our children would have been the same even if a separate shot were available, for the following reasons.
1. Rubella is an extremely mild disease.
Rubella is asymptomatic (does not cause symptoms) up to 50% of the time. If symptoms do appear, they are usually mild and can include a rash (which usually lasts about three days), low-grade fever, and upper respiratory symptoms.
Complications are rare and occur more often in adults than in children. Complications can include joint pain, encephalitis (1 in 6,000 reported cases with a complete recovery rate of 80%), hemorrhage manifestations such as thrombocytopenic purpura, orchitis (inflammation of the testicles), neuritis (inflammation of one or more nerves) and a rare syndrome called progressive panencephalitis (PRP) which can develop months or years after the initial rubella infection. Only 20 cases of PRP have ever been reported (the first reported case was in 1974), all in males between the ages of 8 and 21 years old, most of whom were infected with rubella while in the womb.
There is a condition caused by rubella that is very serious, called congenital rubella syndrome (CRS).
What is CRS?
Congenital rubella syndrome (CRS) is a condition that occurs when a woman is infected with rubella during her pregnancy and her baby is also infected in the womb. CRS can lead to miscarriage or preterm labor and can cause birth defects in the infant.
The risk is highest in the first trimester. If the woman is infected with rubella in her third trimester, the baby’s risk of defects drops and the risks are thought to be the same as in a normal, uncomplicated pregnancy.
Deafness is the most common birth defect seen in babies born with CRS. Other birth defects can include eye defects, cardiac defects, and neurological abnormalities. Children born with CRS also have a higher incidence of autism and diabetes mellitus in toddlerhood.
2. Complications from rubella virus can also occur from MMR vaccination.
CRS is specific to pregnant women and will be examined in further detail later on in this post. Because the MMR vaccine is most frequently given to children and is not recommended for pregnant women, this section examines complications that can occur in children and non-pregnant adults.
Complications that can occur from rubella infection can also occur following the MMR vaccination, including joint paint, encephalitis, hemorrhagic disorders such as immune thrombocytopenic purpura, orchitis, and neuritis.
When comparing the risks of the vaccine compared to the disease, one must also take into account the risk of the MMR vaccine as a whole, which also includes the measles and mumps components, as the three cannot be separated in the U.S.
A list of complications following the MMR vaccine can be viewed in the package insert.
3. The vaccine is not necessary for children.
In the first section of this post, we talked about congenital rubella syndrome (CRS). CRS occurs when a pregnant woman is infected with rubella and passes the virus to her unborn child.
To quote the CDC (United States Centers for Disease Control and Prevention):
Prevention of CRS (congenital rubella syndrome) is the main objective of rubella vaccination programs in the United States.
In other words, the reason why our babies are vaccinated against rubella is because it is thought that this will protect pregnant women from catching rubella.
Rubella is a childhood disease, so it could be assumed that if a pregnant woman catches rubella she likely caught it from a child. But a 1981 study of rubella noted:
Furthermore, one of the assumptions of the American immunization program is questionable; this program had concentrated on young children because they were considered the major source of infection for pregnant women. However, half of the babies with rubella syndrome are first babies, whose mothers may have had little contact with young children.
In 1977, an outbreak of rubella occurred in Hawaii in women 20-24 years old with the school-aged children nearly completely unaffected. The study noted:
The occurrence of this epidemic confirms the changing epidemiology of rubella with respect to age distribution and supports the view that vaccination of young children may not be sufficient to protect adult women from exposure to rubella, especially in areas where a high proportion of adults remain susceptible.
Before the vaccine nearly all children had rubella in childhood, at which age it is almost always a mild and uncomplicated disease. Immunity from rubella virus lasts a lifetime and most women were immune by the time they were old enough to become pregnant. But immunity from the rubella vaccine wears off before most these girls are old enough to have a baby, even with two doses on the childhood vaccine schedule.
The CDC says:
Although a second dose of vaccine may increase antibody titers in some persons who responded to the first dose, available data indicate that these increased antibody titers are not sustained.
In other words, if the second dose of rubella vaccine boosts immunity at all, it is only a temporary boost.
Yet we continue to give two doses of the rubella vaccine to young children (aged 12-15 months and again between 4-6 years of age) against a disease that is not dangerous at a young age, with a vaccine that likely wears off by the time these children are old enough to become pregnant.
4. The efficacy of the rubella vaccine drops after 6 months and wears off almost completely after 12 years.
Right when our daughters are of the age when pregnancy becomes possible, their protection against rubella drops.
A vaccine is considered effective when the body produces antibodies in response to it. High antibody levels mean that person is presumably protected from getting that disease.
But antibody levels from vaccination can vary. Some people make no noticeable antibodies after vaccination which means that they are not protected from the disease. Some people have low levels which means they most likely could still catch the disease. Others have medium to high antibody levels which means they are more likely to be protected against the disease.
Antibodies from most diseases usually last a lifetime. For example, it is incredibly rare for someone to catch measles, mumps or rubella more than once.
In contrast, antibodies created by vaccines often wane quickly. This is why booster vaccinations are recommended. Booster shots are supposed to give antibody levels a “boost” in case the levels have dropped and are too low to protect against disease.
However, these booster vaccinations do not always work like they are intended to.
A study published in 2009 in The Journal of Infectious Diseases examined rubella antibodies in kindergarten-aged children and middle-school aged children.
All of the children in the study had already been vaccinated with one dose of MMR vaccine. Four years following the first dose of MMR vaccine, nearly 10% of the children had no immunity to rubella- they would be able to catch rubella if exposed and pass it on to others. In the middle-school-aged group, this number was nearly 25% of children. Almost 60% of the kindergarten children and 52% of the middle-school children had the lowest detectable titer (antibody levels), meaning they had barely any protection at all and could likely catch rubella and pass it to others.
A second dose of MMR vaccine was given and rubella antibody levels were checked again. There was a spike in the level of antibodies for all of the children and then the levels started to drop again 6 months after vaccination. The lower the levels, the more likely it was that the children could catch the disease and spread it to others.
When the kindergarten-aged children were checked 12 years following the second MMR vaccine (when they were about 17 years old), 10% of the children had no antibodies against rubella at all- they could likely catch full-blown rubella and pass it to others. For the middle-school group (now in their 20s), more than 20% had no protection against rubella.
Twelve years after vaccination, overall protection levels had dropped at least 50%, and those who had no protection before the second dose again had little to no protection against rubella.
Based on the evidence in this study, we see that some people respond well to two doses of rubella vaccine and some don’t respond at all. Most people are somewhere in the middle, which means they may become infected (possibly without showing any symptoms) and can likely still spread disease to others.
The World Health Organization states that the threshold for herd immunity for rubella is 80% to 90%. This means that 80-90% of the population needs to be immune to rubella for herd immunity to work.
Only about 30% of those vaccinated with a second dose of MMR responded well and maintained immunity against rubella for a long period of time (over 12 years).
Interestingly, if you examine the graph above between the 10 and 12 year marks in the kindergarten group, there is actually an increase in antibody levels.
The study addresses this as well:
However, surveillance for rubella may be difficult in a highly vaccinated population. Secondary vaccine failure tends to manifest as subclinical infection or illness without a rash.
This means that even if a person has received two doses of MMR vaccine and has produced antibodies against rubella, these antibodies can wane and the person may still get sick with rubella (and be contagious) with mild or no symptoms.
It goes on to say:
In our study, we detected a number of 4-fold increases in antibody titers not attributable to vaccination, suggesting that exposures to wild rubella may have occurred, despite the lack of reported rubella disease in the study population or its geographical area.
Rubella is reported as being almost completely wiped out in the U.S. due to vaccination. However, we don’t actually know how many cases of rubella there are in the U.S. each year. 50% of all cases show no symptoms. If only mild symptoms such as a fever or rash were present (as is normal with rubella), a doctor would have no reason to do blood tests to diagnose which virus the child has; a rubella infection with the usual mild symptoms could be easily mistaken for “roseola”, a common childhood rash for which there is no vaccine.
5. The vaccine does not necessarily protect against rubella or CRS during pregnancy.
The 2009 study that we looked at in detail above states:
A substantial number of case reports have documented the occurrence of rubella infection and CRS in infants born to women with apparent secondary vaccine failure. Thus, the possibility of rubella susceptibility among those whose titers have waned cannot be ruled out.
Secondary vaccine failure occurs when antibody levels wane over time, as shown above. Case reports of infants born with CRS in fully vaccinated women show that those whose antibody levels have fallen are susceptible to rubella infection.
Another study published in the year 2000 states:
Reviewing the last 10 years of literature, we were unable to define a cutoff level of antirubella antibodies considered protective in case of renewed contact with the wild virus during pregnancy. In eight of 16 cases of CRS after reinfection the maternal specific antirubella IgG was at least 15 IU/mL (equivalent to a hemagglutinin inhibition [HIA] assay IgG titer of 1:16) at the start of pregnancy, and even serum levels as high as 25 IU/mL seem to be not high enough for fetal protection.
Even if a mother is vaccinated and still shows antibody levels enough that should be high enough to protect from infection, she could still contract the virus and pass it on to her baby during the pregnancy. Studies have not shown at what level antibodies are high enough to protect against rubella infection.
6. The biggest danger to a fetus infected with rubella during pregnancy is likely elective abortion.
On the CDC’s landing page for parents (titled “Rubella, Make Sure Your Child Gets Vaccinated”), the CDC says:
From 1963 to 1965, a rubella epidemic swept throughout the world. In the United States alone, about 11,000 babies died and 20,000 babies developed birth defects from rubella.
The wording here would lead parents to think that 11,000 babies died as a direct result of becoming infected with rubella from miscarriage or stillbirth.
What the CDC fails to mention on their informational landing page for parents is that the 11,000 babies who died following rubella infection of the mother includes a number of babies who were surgically aborted (elective abortion).
As we will see from other studies, it is likely that 50%-75% or more of these 11,000 deaths were caused by elective abortions.
Several sources piece together a picture of just how many women elect to get abortions when rubella infection is suspected during the first half of pregnancy:
- The United Kingdom is one of the few countries that tracks rubella-related elective abortions. The Public Health Wales website notes the ratio of elective abortions to CRS cases as 10 to 1, meaning for every 70 babies infected with rubella during pregnancy and born with CRS, another 700 babies would be aborted.
A study published in The Lancet in October 1982 noted that out of 1,000 women in the study who were infected with rubella during their pregnancy, “pregnancy continued in 40%”. The study doesn’t separate abortions from the spontaneous losses in the 60% of the women for which pregnancy did not continue.
In a rubella outbreak in Hawaii in 1977, 11 out of 12 women infected with rubella during their pregnancy chose to abort their babies. The one woman who went on to give birth had a completely healthy baby.
A review of Danish pregnant women (1975-1984), by M. Mitsch, published in the Danish Medical Bulletin in March 1987 was one of the largest studies done in pregnant women with rubella. Of those women, 623 chose to abort their pregnancy (46.3%). Of the 559 women who continued the study, 6.97% of them had miscarriages or stillbirths (39 babies total). That leaves 520 women who gave birth. Of those babies, 111 were infected with rubella (21.34%). Only 7 babies of the 111 (6.3%) had serious malformations. Total, 513 babies were born healthy (91.77%).
One disturbing thing about this high rate of abortions is that many of these women never had laboratory-confirmed rubella at all. Rubella was suspected based on symptoms but not necessarily always confirmed.
For example, in the study of the outbreak in Hawaii mentioned above, only five of the 12 women (41.7% of them) had laboratory-confirmed rubella (including the one woman who did not abort and went on to have a healthy baby). One woman “had laboratory results inconsistent with rubella as evidenced by absence of rubella antibody seven days after rash onset”, which means she likely did not have rubella at all. The other 6 women had unavailable or non-confirming laboratory results.
As recently as 2011, a hospital in Vietnam had 103 patients who chose to abort their babies following suspected rubella infection. However, a study done on the babies’ umbilical cord blood later found that only 17 of these babies would’ve been infected with rubella if they were born. That means that doctors who recommended abortion due to rubella were correct only 16.5% of the time. One doctor said he was “sad” but “poor diagnostics techniques left doctors with little choice”.
These diagnostic techniques would’ve been similar in the 1960s-1980s, when abortions as a result of rubella outbreaks were usually recommended by doctors. The only way to know for sure if a baby would be born with rubella infection was to wait and see, or abort the baby and test the umbilical cord blood for antibodies. If cord blood was positive for rubella, this did not necessarily mean that the baby would’ve been born with defects.
According to the CDC, up to 85% of infants infected with rubella in the first trimester of pregnancy will be found to be affected if followed after birth. They don’t specify if this means that 85% of those infants will have birth defects or if 85% of them will simply have evidence of rubella infection (such as antibodies in their blood that show they had a previous infection) but based on other sources it is likely the latter. Rubella infection in the baby did not always mean there would be defects or something wrong with the baby.
In Japan, a rubella outbreak from 2012-2013 saw an estimated 11,991 cases of rubella. Most cases (77%) were males. The rest of the cases, 2,754, were in females. Ten cases of CRS were reported in infants (a rate of 0.36% among the female cases).
The Wall Street Journal in 1966 talked about rubella outbreaks and elective abortions. The article says:
The risk of some damage is high. Normally, about 1% of all babies born are defective. But one study indicates that more than 33% of those mothers who contract rubella in the first three months of pregnancy will give birth to damaged children – and there is no way to be certain whether a child will be abnormal or not until it is born. Most mothers, of course, are going ahead and having their babies. In many cases, even if the baby is damaged, the damage is slight, or if it is serious, it can be repaired by an operation after birth.
The article continues:
A Los Angeles obstetrician, Dr. A. C. Mietus, notes that although rubella often leads to defective children, the majority are born normal. To legalize abortion in rubella cases, he adds, would doom more normal fetuses than abnormal ones.
Despite this, in 1973 a new recommendation was published:
Women who acquire clinical evidence of rubella within the first 16 weeks after conception should be aborted. Other susceptible women who are exposed to rubella and who show evidence of having contracted rubella infection on serial serological studies should also be aborted. The risk of fetal damage is significant if either of these conditions occurs.
So the recommendation was abortion before 16 weeks, even though The Lancet published that mothers infected with rubella between 13-16 weeks of pregnancy gave birth to healthy babies 65% of the time. (No defects were found in those infected after the 16th week of pregnancy.)
These abortions likely did prevent some cases of CRS, which as we’ve noted can be a severe and tragic illness. However, there is a possibility that many of these women were misdiagnosed and/or could’ve gone on to have healthy babies. The most common manifestation of CRS was deafness alone, and not all infected babies went on to develop CRS. Many CRS cases (such as cataracts or heart defects) were also correctable through surgery.
7. The rubella strain in the current vaccine was isolated from an aborted fetus.
This was not something our family was personally comfortable with for moral reasons as well as the presence of DNA in vaccines.
The CDC states that:
“The RA 27/3 rubella vaccine is a live attenuated virus. It was first isolated in 1965 at the Wistar Institute from a rubella-infected aborted fetus. The virus was attenuated by 25–30 passages in tissue culture, using human diploid fibroblasts.”
The human diploid fibroblasts were from a 3-month-old fetus aborted in 1962, now known as WI-38.
The MMR vaccine also uses the fetal cell line MRC-5, which was developed from a 14-week-old fetus aborted in 1966.
Dr. Stanley Plotkin and his colleagues at the Wistar Institute developed the virus strain used in the rubella vaccine. He wrote:
Source of Virus: Virus was obtained from an aborted rubella-infected human fetus. The 25 year-old mother was exposed to rubella eight weeks after the last menstrual period… The fetus was surgically aborted 17 days after the maternal illness and dissected immediately. Explants from several organs were cultured and successful cell growth was achieved from lung, skin, and kidney.
The strain is called RA 27/3 because the strain was isolated from the 27th aborted baby in the 1964 outbreak. Rubella was unable to be cultured by researches from the first 26 aborted fetuses. Although the fetuses were not aborted for the purpose of making a vaccine (they were aborted because the mother was infected with rubella), it is not clear whether or not these mothers gave consent for testing to be done on the aborted fetuses, nor whether they even knew it was being done at all.
What will we do when our daughter is old enough to have children of her own?
If the risk of rubella virus is almost entirely to the fetuses of women in their first trimester of pregnancy, what will we do when our daughter is old enough to have children of her own?
Before our children enter school, we plan to have antibody titers done, which is a simple blood test to check antibody levels for several diseases. Schools accept proof of antibodies in place of proof of vaccination (exemptions are also available in all 50 states). For example, if our child gets the chicken pox, a blood test proving that they have had the chicken pox is acceptable in place of proof of the shot.
If our daughter is negative to rubella at that time (meaning she has not had rubella and has no immunity to it), we will likely check her titers again after puberty. If her rubella titers are still negative, we will encourage her to research the current rubella vaccine, weigh the risks and benefits of the vaccine vs. the rubella virus and decide for herself whether or not she wants to get vaccinated. She will be an adult and the decision will be entirely up to her.
Meanwhile, our children are still young. The rubella vaccine is of little to no benefit to them as children, and they are too young to accept or decline the ingredients, the side effects, and all else that comes with it.
As with all vaccines; as parents we will continue to research, to speak up and to be a voice for our children.