Rubella in Europe

Global seroprevalence of rubella among pregnant and childbearing age women: a meta-analysis

Background

We conducted a meta-analysis of articles published between January 2000 and July 2016 with the aim of defining the proportion of rubella seronegative women of childbearing age (WCBA), providing the best information available on the seroprevalence of rubella in this population. We selected articles published in the time period between 2000 and 2016. The pooled prevalence of rubella seronegative women was calculated by a fixed effect model and a random effect model, according to the heterogeneity among studies. Studies were sub-grouped by population type (pregnant women and WCBA with no mention of ongoing pregnancy) and by geographic area [World Health Organization (WHO) region]. Sensitivity analysis was performed to assess the stability of results. We found important differences in rubella seronegativity prevalence estimates by WHO Region. About 88% of the studies conducted on pregnant women reported a seronegativity rate >5%. The pooled rubella seronegativity prevalence was 9.3%. When considering population groups, we obtained a seronegativity pooled estimate of 9.4% for pregnant women and of 9.5% for WCBA with no mention of ongoing pregnancy. This meta-analysis shows that the proportion of WCBA who are susceptible to rubella is still high. The figures are worrisome, taking into account that the WHO set at 5% the rubella susceptibility threshold for WCBA.

Rubella Seroprevalence and real-time PCR detection of RUBV among Congolese pregnant women

Background

Rubella is an acute infectious disease caused by Rubella virus (RUBV). RUBV remains an important pathogen worldwide, causing approximately 100 000 cases of congenital rubella syndrome (CRS) every year; and the most severe consequence of rubella is teratogenicity. The aim of this study was to estimate the prevalence of RUBV IgG antibodies and determine RUBV genotypes in Congolese pregnant women in Kongo central province, Democratic Republic of Congo (DRC).

Methods

This was a prospective cross-sectional study that consisted of a laboratory analysis of blood samples from 78 pregnant women to check for the presence of RUBV IgG antibodies, and also determine RUBV genotypes in seropositive samples (using primers targeting RUBV nucleoprotein), with the use of serological and molecular methods, respectively. Participants were pregnant women attending antenatal care clinics (ANC) at two health zones of Kisantu town in DRC. They were followed-up from the first to third trimester. Those who were negative for RUBV antibodies at the initial assay (first trimester) were tested in the second and, eventually, the third trimester.

Results

An overall rubella seroprevalence of 58.97% was observed, whereas RUBV nucleoprotein was detected in 60% of randomly selected 30 blood samples among the 46 RUBV seropositive pregnant women. Five (27.77%) of positive samples were positive for both RUBV genotypes (RV8633/9112 and RV8945/9577), whereas 11 (61.11%) of them were positive for RV8633/9112 and two (11.11%) were positive for RV8945/9577 only. Regarding rubella clinical signs and complications, two subjects (2.56%) presented with fever, whereas five pregnant women (6.41%) had experienced abortion. None (0%) of the participants has been vaccinated against RUBV.

Conclusions

Findings from this study suggest that RUBV is prevalent in Congolese pregnant women. Further research is required to elucidate the molecular epidemiology of RUBV in order to design a rational rubella surveillance and control program in DRC.

Is birth cohort 1985/9-1990/8 a susceptibility window for congenital rubella syndrome in Taiwan?

OBJECTIVE

The worldwide prevalence of congenital rubella syndrome has drastically decreased after the uptake of vaccine to prevent the infection. However, outbreaks have occurred in some countries due to their own vaccination policies, and this phenomenon has not yet been investigated in Taiwan. Our study aims to fill this gap.

MATERIALS AND METHODS

We constructed an analytical database containing 10,824 pregnant women at the Taipei City Hospital, Taipei, Taiwan from January 2004 to July 2012. They were categorized into five birth cohorts according to the different vaccination programs in Taiwan: those born before 1971; those born between September 1971 and August 1976; between September 1976 and August 1979; between September 1979 and August 1985; and between September 1985 and August 1990. Differences of the seronegative rate and titers were compared using the Chi-square and Kruskal-Wallis tests among the five cohorts.

RESULTS

The seronegative rates for the five cohorts were 15.00%, 4.07%, 2.88%, 4.21%, and 10.98%, respectively, and were statistically significant different (p < 0.001). The first and fifth cohorts were higher than the average of seronegativity (5%). The mean of log transformed titers were 3.69 IU/mL, 4.22 IU/mL, 4.22 IU/mL, 4.05 IU/mL, and 3.44 IU/mL, which were statistically significant different (p<0.001). Our study also found that the equivocal rates (7.58%) were the highest in the cohort born between September 1985 and August 1990, among those who had been vaccinated. Our study showed that women younger than 27 years had a lower geometric mean titer of antibody titer than the average (60.60 IU/mL).

CONCLUSION

The previous vaccination policy in Taiwan has created a susceptibility window for rubella and congenital rubella syndrome over the past decades. We recommend having the antibody test before pregnancy for women born between September 1985 and August 1990, and implement a catch-up vaccine for those who were either seronegative or equivocal to prevent reinfection during their childbearing period.

Application of Oral Fluid Assays in Support of Mumps, Rubella and Varicella Control Programs

Detection of specific viral antibody or nucleic acid produced by infection or immunization, using oral fluid samples, offers increased potential for wider population uptake compared to blood sampling. This methodology is well established for the control of HIV and measles infections, but can also be applied to the control of other vaccine preventable infections, and this review describes the application of oral fluid assays in support of mumps, rubella and varicella national immunization programs. In England and Wales individuals with suspected mumps or rubella, based on clinical presentation, can have an oral fluid swab sample taken for case confirmation. Universal varicella immunization of children has led to a drastic reduction of chickenpox in those countries where it is used; however, in England and Wales such a policy has not been instigated. Consequently, in England and Wales most children have had chickenpox by age 10 years; however, small, but significant, numbers of adults remain susceptible. Targeted varicella zoster virus (VZV) immunization of susceptible adolescents offers the potential to reduce the pool of susceptible adults and oral fluid determination of VZV immunity in adolescents is a potential means of identifying susceptible individuals in need of VZV vaccination. The main application of oral fluid testing is in those circumstances where blood sampling is deemed not necessary, or is undesirable, and when the documented sensitivity and specificity of the oral fluid assay methodology to be used is considered sufficient for the purpose intended.

Serological makers of rubella infection in Africa in the pre vaccination era: a systematic review

BACKGROUND

Rubella infections in susceptible women during early pregnancy often results in congenital rubella syndrome (CRS). World Health Organisation (WHO) recommends that countries without vaccination programmes to assess the burden of rubella infection and CRS. However; in many African countries there is limited data on epidemiology of rubella infection and CRS. This review was undertaken to assess the serological markers and genotypes of rubella virus on the African continent in order to ascertain the gap for future research.

FINDINGS

A systematic search of original literatures from different electronic databases using search terms such as 'rubella' plus individual African countries such as 'Tanzania', 'Kenya', 'Nigeria' etc. and different populations such as 'children', 'pregnant women' etc. in different combinations was performed. Articles from countries with rubella vaccination programmes, outbreak data and case reports were excluded. Data were entered in a Microsoft Excel sheet and analyzed. A total of 44 articles from 17 African countries published between 2002 and 2014 were retrieved; of which 36 were eligible and included in this review. Of all population tested, the natural immunity of rubella was found to range from 52.9 to 97.9 %. In these countries, the prevalence of susceptible pregnant women ranged from 2.1 to 47.1 %. Rubella natural immunity was significantly higher among pregnant women than in general population (P < 0.001). Acute rubella infection was observed to be as low as 0.3 % among pregnant women to 45.1 % among children. All studies did not ascertain the age-specific prevalence, thus it was difficult to calculate the rate of infection with increase in age. Only two articles were found to report on rubella genotypes. Of 15 strains genotyped; three rubella virus genotypes were found to circulate in four African countries.

CONCLUSION

Despite variations in serological assays, the seroprevalence of IgG rubella antibodies in Africa is high with a substantial number of women of childbearing age being susceptible to rubella infection. Standardized sero-epidemiological data in various age groups as well as CRS data are important to implement cost-effective vaccination campaigns and control strategies.

Fuchs' Uveitis Syndrome: No Longer a Syndrome?

PURPOSE

Rubella virus (RV) has a central role in the etiopathogenesis of Fuchs' uveitis syndrome (FUS). We aim to offer new insights by comprehensive analysis of recent laboratory and epidemiologic data.

METHODS

We conducted a literature search for laboratory data and papers on etiopathogenesis.

RESULTS

Aqueous humour samples of FUS patients show immunoreactivity to RV, in a specific and sensitive manner. Identification of RV genome confirm intraocular infection in a subset of FUS patients. Epidemiologic findings further support causality. The clinical spectrum of RV-associated uveitis is similar but not identical to FUS. FUS eyes exhibit a predominance of CD8 + T cells, high IFN-? and IL-10 levels.

CONCLUSIONS

RV is the leading cause of FUS. Cytokine-based findings mirror a viral etiology and chronic low-grade inflammation. RV-associated FUS represents a common pathway of intraocular RV inoculation after congenital or acquired infection. Other causes, including HSV and CMV, may lead to FUS.

Effects of campaign for postpartum vaccination on seronegative rate against rubella among Japanese women

BACKGROUND

Japan experienced two rubella outbreaks in the past decade (2004 and 2012-2013), resulting in 10 and 20 infants with congenital rubella syndrome (CRS), respectively. This study was performed to determine whether the seronegative rate was lower in multiparous women than in primiparous women in Japan.

METHODS

Hemagglutination inhibition (HI) test results during pregnancy were analyzed retrospectively in 11048 primiparous and 9315 multiparous women who gave birth at six hospitals in northern Japan in the 5-year study period (January 2008 through December 2012). Women with HI titer <  1:8 were defined as susceptible to rubella.

RESULTS

The seronegative rate was significantly lower in multiparous than primiparous women aged 30 - 31 years (2.3% [22/967] vs. 4.5% [66/1454], P  =  0.0036), 36 - 37 years (3.4% [55/1601] vs. 5.7% [79/1389], P  =  0.0030), and overall women (3.8% [350/9315] aged 34.7  ±  5.2 vs. 5.4% [597/11048] for 33.2  ±  5.9, P  <  0.001). The susceptible fraction size did not differ largely according to hospital, ranging from 3.5% to 6.3%. Those for each year did not change markedly; 4.5% [150/3369], 5.2% [221/4268], 4.4% [195/4412], 4.6% [186/4056], and 4.6% [195/4258] for 2008, 2009, 2010, 2011, and 2012, respectively. Those for teenagers were consistently high: 22.7% [5/22], 20.7% [6/29], 20.6% [7/34], 13.0% [3/23], and 23.5% [4/17] for 2008, 2009, 2010, 2011, and 2012, respectively.

CONCLUSIONS

The seronegative rate was significantly lower in multiparous than primiparous women. However, Japanese rubella vaccination programs were insufficient to eliminate CRS.

Congenital rubella syndrome: progress and future challenges

Since 1941, when Gregg first described the triad of deafness, cataracts and cardiac disease as the classical clinical manifestations of congenital rubella syndrome (CRS), strong efforts have been implemented around the world to achieve effective preventive strategies. In Costa Rica, vaccination against rubella started in 1972 and in 1986, the combined measles, mumps and rubella vaccine was introduced in the national schedule among 1-year-old children. This vaccination strategy shifted the susceptibility to other groups at child-bearing age. To protect this age group, in 2001 Costa Rica implemented a successful national immunization campaign targeting both men and women aged 15-39 years, followed by postpartum vaccination of women who were pregnant when the campaign was implemented. The epidemiological surveillance system of rubella and CRS cases was strengthened and it was integrated with the investigation and notification system of febrile eruptive diseases. We describe the Costa Rican experience, which has led to similar actions in other countries in Latin America. Challenges and strategies in the elimination of rubella and CRS are also discussed.

Comparison of rubella seroepidemiology in 17 countries: progress towards international disease control targets

OBJECTIVE

To standardize serological surveillance to compare rubella susceptibility in Australia and 16 European countries, and measure progress towards international disease-control targets.

METHODS

Between 1996 and 2004, representative serum banks were established in 17 countries by collecting residual sera or community sampling. Serum banks were tested in each country and assay results were standardized. With a questionnaire, we collected information on current and past rubella vaccination programmes in each country. The percentage of seronegative (< 4 IU/ml) children (2-14 years of age) was used to evaluate rubella susceptibility, and countries were classified by seronegativity as group I (< 5%), group II (5-10%) or group III (> 10%). The proportion of women of childbearing age without rubella protection (< or = 10 IU/ml) was calculated and compared with WHO targets of < 5%.

FINDINGS

Only Romania had no rubella immunization programme at the time of the survey; the remaining countries had a two-dose childhood schedule using the measles, mumps and rubella (MMR) vaccine. The percentage of susceptible children defined five countries as group I, seven as group II and four as group III. Women of childbearing age without rubella protection were < 5% in only five countries.

CONCLUSION

Despite the low reported incidence in many countries, strengthening the coverage of the routine two-dose of MMR vaccine among children is needed, especially in group III countries. Catch-up campaigns in older age groups and selective targeting of older females are needed in many countries to ensure necessary levels of protective immunity among women of childbearing age.

Congenital rubella syndrome in Iran

BACKGROUND

Congenital rubella syndrome (CRS) can be prevented with appropriate vaccination programs. The prevalence rates of rubella and CRS in Iran are unknown; therefore, the risk of exposure in pregnant women is not clear. The prevalence of CRS in the pre-vaccine period can be estimated by evaluating the proportion of children in the population with sensorineural hearing loss attributable to rubella.

METHODS

This was a case-control study to estimate prevalence of CRS in Tehran (Iran) by evaluating the proportion of children with sensorineural hearing loss attributable to rubella. The study used rubella antibody titer as an indicator, and compared the prevalence of rubella antibody between children with and without sensorineural hearing loss. Using these findings, the proportion of cases of sensorineural hearing loss attributable to rubella was estimated.

RESULTS

A total of 225 children aged 1 to 4 years were entered into the study (113 cases and 112 controls). There was a significant difference between cases and controls with regard to rubella antibody seropositivity (19.5% vs. 8.9%, respectively, odds ratio = 2.47, 95% CI = 1.04-5.97). The proportion of sensorineural hearing loss cases attributable to rubella was found to be 12%, corresponding to a CRS prevalence of 0.2/1000.

CONCLUSION

The prevalence of CRS was approximately 0.2/1000 before rubella vaccination in Iran, Moreover; the results suggest that implementation of appropriate rubella vaccination programs could potentially prevent about 12% of cases of sensorineural hearing loss in Iranian children. This data could potentially be used as baseline data, which in conjunction with an appropriate method, to establish a surveillance system for rubella vaccination in Iran. An appropriate surveillance system is needed, because the introduction of a rubella vaccine without epidemiological data and an adequate monitoring program could result in the shifting of rubella cases to higher ages, and increasing the incidence of CRS.

Viruses and inflammatory bowel disease: is there evidence for a causal association?

There has been a resurgent interest in potential microbial etiologies of inflammatory bowel disease (IBD). Over the past decade there have been both epidemiological and tissue studies exploring the potential role of paramyxoviruses in IBD, particularly Crohn's disease. This article will review the evidence and hence plausibility of a causal association between these viruses and IBD.

Evaluation of rubella screening in pregnant women

BACKGROUND

The rationale for rubella vaccination in the general population and for screening for rubella in pregnant women is the prevention of congenital rubella syndrome. The objective of this study was to evaluate the effectiveness of the prenatal rubella screening program in Quebec.

METHODS

A historical cross-sectional study was designed. Sixteen hospitals with obstetric services were randomly selected, 8 from among the 35 "large" hospitals in the province (500 or more live births/year) and 8 from among the 50 "small" hospitals (fewer than 500 live births/year). A total of 2551 women were randomly selected from all mothers of infants born between Apr. 1, 1993, and Mar. 31, 1994, by means of stratified 2-stage sampling. The proportions of women screened and vaccinated were ascertained from information obtained from the hospital chart, the physician's office and the patient.

RESULTS

The overall (adjusted) screening rate was 94.0%. The rates were significantly different between large and small hospitals (94.4% v. 89.6%). Five large hospitals and one small hospital had rates above 95.0%. The likelihood of not having been screened was statistically significantly higher for women who had been pregnant previously than for women pregnant for the first time (4.8% v. 1.4%; p < 0.001). Of the 200 women who were seronegative at the time of screening (8.4%), 79 had been vaccinated postpartum, had a positive serological result on subsequent testing or did not require vaccination, and 59 had not been vaccinated postpartum; for 62, subsequent vaccination status was unknown.

INTERPRETATION

Continued improvement in screening practices is needed, especially in small hospitals. Because vaccination rates are unacceptably low, it is crucial that steps be taken to address this issue.

Use of a microquantity enzyme immunoassay in a large-scale study of measles, mumps and rubella immunity in Italy

The seroprevalence of antibodies to measles, mumps, and rubella viruses (MMR) was determined in 1498 subjects in Catania, Italy, ranging in age from 1 month to 25 years. The study population was divided into seven age groups and screened by enzyme immunoassay using microquantities (10 microl) of whole blood collected by fingerprick on filter paper discs. The results showed that seroconversion for measles (87.6%) and mumps (73.2%) occurred between 6 and 10 years of age. The seroprevalence of antibodies to rubella virus increased slowly through the age groups, reaching the highest rate (93.3%) between 16 and 20 years of age. Passively transmitted maternal antibodies to mumps and rubella were absent in babies between 5 and 8 months of age, and a few cases positive for measles antibodies were found among babies 6 and 7 months of age. The enzyme immunoassay was demonstrated to be suitable for low-cost large-scale screening for MMR immunity. The rate of vaccine failure was also evaluated and found to be 9.5% for the measles virus, 12.9% for the mumps virus and 0.0% for the rubella virus.

Control of rubella and congenital rubella syndrome (CRS) in developing countries, Part 1: Burden of disease from CRS

Congenital rubella syndrome (CRS) can lead to deafness, heart disease, and cataracts, and a variety of other permanent manifestations. In developing countries, the burden of CRS has been assessed as follows: by surveillance of CRS; by surveillance of acquired rubella; by age-stratified serosurveys; and by serosurveys documenting the rubella susceptibility of women of childbearing age. During rubella outbreaks, rates of CRS per 1000 live births were at least 1.7 in Israel, 1.7 in Jamaica, 0.7 in Oman, 2.2 in Panama, 1.5 in Singapore, 0.9 in Sri Lanka, and 0.6 in Trinidad and Tobago. These rates are similar to those reported from industrialized countries during the pre-vaccine era. Special studies of CRS have been reported from all WHO regions. Rubella surveillance data show that epidemics occur every 4-7 years, similar to the situation in Europe during the pre-vaccination era. In developing countries, the estimated average age at infection varies from 2-3 years to 8 years. For 45 developing countries we identified serosurveys of women of childbearing age that had enrolled > or = 100 individuals. The proportion of women who remained susceptible to rubella (e.g. seronegative) was < 10% in 13 countries. 10-24% in 20 countries, and > or = 25% in 12 countries. Discussed are methods to improve the surveillance of rubella and CRS in developing countries.

Rubella infection during pregnancy in the 1985-86 epidemic: follow-up after seven years

The study covered 310 pregnant women from southern Poland who were exposed to rubella during the 1985-86 epidemic, none of whom had been vaccinated against rubella. Rubella specific antibodies were detected by hemagglutination-inhibition (HI) tests, and IgM antibodies by enzyme immunoassay (ELISA) (Organon Teknika). Clinical symptoms according to anamnesis were recorded. The consequences of serologically confirmed maternal rubella on the course of pregnancy and on fetal outcome were evaluated. IgM antibodies could be examined in only 10 newborns at delivery or in the first days of life. After seven years, follow-up studies of children born to infected mothers were done. The mental development of 14 of these children was evaluated with Terman-Merrill test. Among 310 women examined during pregnancy, rubella infection was confirmed serologically in 46 cases (14.8%). All but 3 of those had clinical symptoms. The course of pregnancy was observed in 36 of the infected mothers. Only 5 women (22.7%) who had the infection in the first trimester of pregnancy delivered a healthy child. The rate of complications in pregnancy among women infected in the second trimester was lower, and 8 (66.7%) bore healthy children. All the children born to mothers infected in the third trimester were healthy. Eight of the 10 newborns examined at delivery were IgM positive. Of 29 children congenital rubella syndrome (CRS) was confirmed in 5 cases, CRS compatible or CRS possible in 7 and 3 had congenital infection only confirmed serologically (IgM-positive) without defects or symptoms. Seventeen (58.6%) children were found healthy including the 3 who had congenital infection only. The mental development of 14 children at age 7 was assessed; 10 cases (72%) fell within rank II 130-85, and 4 (28%) were of borderline intelligence. The study indicates that congenital rubella is still a serious problem in Poland. Immunization was introduced only in 1988-89, for 13-year-old girls. Women of child-bearing age should be screened for rubella antibodies and those susceptible to rubella infection should be vaccinated.

Use of PCR for prenatal and postnatal diagnosis of congenital rubella

A reverse transcription-nested PCR assay (RT-PCR) was evaluated for diagnosis of congenitally acquired rubella in utero and during infancy. RT-PCR was compared with virus isolation for retrospective detection of rubella virus in placental and fetal tissues obtained after termination of pregnancy following primary rubella or rubella virus reinfection. Concordant results were obtained for 85% of samples; rubella virus RNA was detected by RT-PCR alone in four samples, and rubella virus was detected by isolation alone in two samples. Samples were also obtained for prenatal diagnosis of congenital infection; rubella virus RNA was detected in three of seven chorionic villus samples and one of three amniotic fluid samples by RT-PCR, while rubella virus was isolated in only one chorionic villus sample. To demonstrate that the RNA extracted from chorionic villus samples contained amplifiable RNA, a nested RT-PCR was used to detect keratin mRNA. Rubella virus was detected in placenta in two cases in which the fetus was uninfected, and there was no evidence of rubella virus in the placenta from one case in which the fetus was infected. Thus, detection of rubella virus in chorionic villus samples by RT-PCR may not always correctly predict fetal rubella virus infection. RT-PCR was successfully used for the diagnosis of congenitally acquired rubella in infancy. Rubella virus RNA was detected in cyropreserved or formalin-fixed lens aspirates obtained from infants in India with serologically confirmed congenital rubella but not in samples from controls with inherited cataract.

PCR for detection of rubella virus RNA in clinical samples

A reverse transcription nested PCR (RT-PCR) assay for the detection of rubella virus RNA using primers from the E1 open reading frame was established. This assay was found to be sensitive (detecting approximately two synthetic RNA copies and RNA extracted from 0.1 50% tissue culture infective dose of rubella virus) and specific; five wild-type rubella strains and four vaccine strains were detected, and no nonspecific amplification of 16 other RNA viruses or RNAs from seven cell types occurred. Rubella virus RNA was detected in 12 pharyngeal swabs from patients with serologically confirmed rubella; these RT-PCR results were in complete agreement with virus isolation. Analysis of products of conception obtained after confirmed primary maternal rubella infection by RT-PCR gave 92% agreement (12 of 13 samples) with virus isolation. No false-positive results were obtained. The potential use of this assay for prenatal diagnosis of congenital rubella infection and for investigating aspects of the pathogenesis of chronic disease is discussed.

Prevalence of rubella antibodies in a non-immunized urban population, São Paulo, Brazil. The Division of Immunization, CVE

The prevalence of rubella antibodies was evaluated through a random seroepidemiological survey in 1400 blood samples of 2-14 year old children and in 329 samples of umbilical cord serum. Rubella IgG antibodies were detected by ELISA, and the sera were collected in 1987, five years before the mass vaccination campaign with measles-mumps-rubella vaccine carried out in the city of São Paulo in 1992. A significant increase in prevalence of rubella infection was observed after 6 years of age, and 77% of the individuals aged from 15 to 19 years had detectable rubella antibodies. However, the seroprevalence rose to 90.5% (171/189) in cord serum samples from children whose mothers were 20 to 29 years old, and reached 95.6% in newborns of mothers who were 30 to 34 years old, indicating that a large number of women are infected during childbearing years. This study confirms that rubella infection represents an important Public Health problem in São Paulo city. The data on the seroprevalence of rubella antibodies before the mass vaccination campaign reflects the baseline immunological status of this population before any intervention and should be used to design an adequate vaccination strategy and to assess the seroepidemiological impact of this intervention.

Molecular biology of rubella virus

This chapter summarizes the present medical significance of rubella virus. Rubella virus infection is systemic in nature and the accompanying symptoms are generally benign, the most pronounced being a mild rash of short duration. The most common complication of rubella virus infection is transient joint involvement such as polyarthralgia and arthritis. The primary health impact of rubella virus is that it is a teratogenic agent. The vaccination strategy is aimed at elimination of rubella and includes both universal vaccination of infants at 15 months of age with the trivalent measles, mumps, rubella (MMR) vaccine and specific targeting with the rubella vaccine of seronegative women planning pregnancy and seronegative adults who could come in contact with women of childbearing age, although it is recommended that any individual over the age of 12 months without evidence of natural infection or vaccination be vaccinated. Medically, the current challenge posed by rubella virus is to achieve complete vaccination coverage to prevent resurgences.