A Survey For Rubella Virus And Antibodies Among Pregnant Women

A Survey For Rubella Virus And Antibodies Among Pregnant Women
Abstract
Background. The aim of this study was to determine rubella virus infections and immune status among pregnant women before the introduction of rubella vaccine in Kaduna State, Nigeria. Methods. A prospective cross-sectional study was conducted on pregnant women attending antenatal clinic in three referral hospitals in Amhara Regional State, namely Dessie, Felege-Hiwot, and University of Gondar referral hospitals, from December 2015 to February 2017. The study participants were selected using a simple random sampling technique and the sample size was calculated by considering a 95% confidence interval, 4% margin of error, and 50% proportion. Data were entered into and analyzed using IBM SPSS Statistics version 20.0 (IBM Corp., Armonk, NY, USA). Results. The seroprevalence of Rubella virus was found to be high, and many (9.5%) of the pregnant women had acute rubella viruses infections at the time of data collection. Despite 79.5% of pregnant women having IgG levels >10 IU/ml and being immune to natural/wild-type rubella infection, about 11% of the women were classified as seronegative and represent the susceptible group. Conclusion. The results of the study emphasize the need for establishment of an improved and continuous surveillance network for rubella infections and CRS cases; prompt vaccination of vulnerable population and periodic evaluation of health policies to guarantee immunization.
Chapter One
1.0 Background of the Study
Rubella Virus
Rubella virus (RV) causes a benign systemic rash illness when it infects humans as a result of acute infection and causes severe birth defects if acute maternal infection occurs during the first trimester of pregnancy(Willey et al., 2011). This virus is a positive-strand RNA virus that replicates in the cytoplasm of the infected cell. Rubella virus is taxonomically unique, being the sole member of the genus Rubivirus of the familyTogaviridae (Brooks et al., 2007). The rubella virus causes “German measles,” also known as “three-day measles”(Bukbuk et al., 2002), this is usually a milder disease than red measles. Infections occur most commonly in children and the resulting natural immunity is most probably lifelong (Matthews et al., 2011). However, in pregnant women the risk of intrauterine transmission is up to 90% if infection occurs in early pregnancy (8-10 weeks gestation). As the viraemia leads to placental infection and spread of the virus, it causes a chronic infection of the foetus leading to the development of congenital rubella syndrome (CRS) (Matthews et al., 2011).Red/Hard measles or just measles is caused by Rubeola virus.
Rubella virus is an important human pathogen that causes an acute and contagious disease known as rubella, little red, 3-day measles, or German measles (Fokunang et al., 2010). Humans are the only reservoir for this virus (Mounerou et al., 2015). The virus has an incubation period of 2–3 weeks. The route of transmission is air-borne in postnatal cases and transplacental during pregnancy (Kolawole et al., 2014). The disease caused by this virus commonly occurs in childhood and is characterized by a maculopapular rash associated with a low-grade fever, lymphadenopathy, and malaise (Al-Rubai et al., 2010). It can also cause joint pains, headache, and conjunctivitis in adults (Lezan, 2015). Transient arthralgia or arthritis may also occur (Heggie and Robbins, 1969). It is also a rare cause of thrombocytopenic purpura and encephalitis (Sherman et al., 1965). However, up to 50% of rubella cases are subclinical (Horstmann et al., 1965).
Rubella infection is considered relatively benign, and in the absence of pregnancy, the infection is usually mild and self-limiting (CDC, 2001). However, during pregnancy, it has a devastating effect on the developing fetus (Adam et al., 2013, Cradock-Watson et al., 1981) and this represents a major health concern worldwide (Mirambo et al., 2015). Currently, there is no specific treatment for the virus (Olajide et al., 2015). However, its burden can be minimized through use of the live attenuated rubella vaccine (Alleman et al., 2016, Demicheli et al., 2012, WHO, 2014). The control of rubella and congenital rubella syndrome (CRS) relies on a high population level of immunity (Gilbert et al., 2017).
The World Health Organization (WHO) proposed the introduction of rubella vaccine in each country in the year 2000 (Robertson et al., 2003) and different efforts are undergoing in different WHO regions (Martínez-Quintana et al., 2015, CDC, 2010, WHO, 2008). As a result, the burden has declined, although mostly in industrialized countries (Adewumi et al., 2014). However, rubella vaccine is still not available in many developing countries (Njeru et al., 2015) and it is not included in their immunization programs (WHO, 2012). Rubella is an under-recognized public health problem (Cutts and Vynnycky, 1999, Mamvura et al., 2015). In Africa, few countries have included rubella vaccine in their national immunization programs and data on the seroprevalence of the virus are very limited (Martínez-Quintana et al., 2015).
Statement of Problem
Although Nigeria has planned to introduce the rubella vaccine (WHO, 2015), it is currently not included in the national immunization program (Getahun et al., 2016). There are only a few reports on rubella in the country (Cutts et al., 2000a, Gebreselassie and Almaz, 1985), with most containing very old information (Gebreselassie and Almaz, 1985, Sandow et al., 1982) or reporting on suspected cases of measles among children (Mitiku et al., 2011, Getahun et al., 2016, Shiferaw et al., 2016). There is only one recently published report on rubella among pregnant women (Tamirat et al., 2017) and one case report on CRS (Mekonnen, 2017) in the country. All of these indicate that there is scarcity of data and that the magnitude of rubella and its consequences is largely unknown. Hence, the aim of this study was to determine rubella virus infections and immune status among pregnant women before the introduction of rubella vaccine in Kaduna State, Nigeria.
Research Objectives
Rubella Virus (RV) causes a mild disease, but maternal infection early in pregnancy often leads to birth defects known as congenital rubella syndrome (CRS). Rubella remains poorly controlled in Africa despite being a vaccine preventable disease. The aim of this study was to determine the survey for rubella virus and antibodies among pregnant women in Kaduna State Nigeria. The study was carried out on pregnant women attending ante-natal clinic in three different senatorial districts in Kaduna State.
Chapter Five
Conclusions and Recommendations
Summary
When a comparison was made of the possible risk factors and rubella IgM positivity, the pregnant women who had frequent exposure to children in their daily activities had 2.8 times the IgM positivity of those who had no daily exposure. This can be explained by the fact that rubella infection is more common in childhood (Junaid et al., 2011) and children might harbor and spread the infection to susceptible pregnant women. Similarly, the pregnant women from Dessie Referral Hospital had 2.8 times the IgM positivity rate of pregnant women from University of Gondar Referral Hospital. This indicates that there may be epidemiological differences in the circulation of rubella virus within the country. In addition, there may also have been differences in temperature and humidity between the study sites at the time of data collection. These differences might have contributed to the differences in active transmission of rubella virus in the study areas.
Although maternal immunity is protective against intrauterine rubella infection (Aboudy et al., 1997), around 11% (95% CI 8.7–13.7%) of the study participants had IgG levels 10 IU/ml; these women were classified as seronegative and represent the susceptible group. A similar finding has also been reported in previous studies (Yadav et al., 1995; Pooja and Piyush, 2012; Oyinloye et al., 2013). In developing countries, about 10–25% of women have been reported to be seronegative (Cutts et al., 2000b; Gavin et al., 2015), and countries with high rates of susceptibility to rubella virus among women of child-bearing age might be at risk of CRS (Lambert et al., 2015). The susceptibility rate of 10% among adult women could result in outbreaks of CRS (WHO, 2011b). Therefore, attention must be paid to the susceptible group of women in this study in order to reduce the risk of CRS in their future pregnancies.
Limitations of the Study
Due to the lack facilities, it was not possible to use advanced laboratory techniques like RT-PCR for the diagnosis of rubella. Furthermore, due to the nature of the study (cross-sectional study) and reagent constraints, it was not possible to obtain convalescent sera from each rubella IgM-positive/IgG-negative study participant. Since the study was conducted only in the selected referral hospitals of Amhara Regional State, Ethiopia, a large-scale community-based study might be important. However, as there is scarcity of data about rubella among pregnant women in the country, the information provided by this study might serve as a baseline for the study area and increase awareness for health decision-makers and collaborators in the country so that the long- term health consequences can be reconsidered.
Conclusions
The seroprevalence of rubella virus was found to be high, and many (9.5%) of the pregnant women had acute rubella virus infections at the time of data collection. This implies that the virus is endemic in the study areas. Despite 79.5% of pregnant women having IgG levels >10 IU/ml and being immune to natural/wild- type rubella virus infections, about 11% of the pregnant women were found to be non-immune and represent the susceptible group. These pregnant women may be at risk of developing rubella-associated congenital anomalies in their future pregnancies. Hence, the screening of women of child-bearing age before conception, introduction of rubella vaccination, and a strong surveillance system might be important to reduce rubella- associated health complications in the country.
Recommendations
In conclusion, results of the study emphasize the need for establishment of an improved and continuous surveillance network for rubella infection and CRS cases; prompt vaccination of vulnerable population and periodic evaluation of health policies to guarantee immunization. Thus, to facilitate prompt elimination of rubella we recommend the establishment of health policy that promotes:
- Free vaccination programmes for children and adults of childbearing age
- Evaluation of available vaccines to ascertain their potency prior recommendation for vaccination
- Review of antibody response in randomly selected individuals post vaccination, and
- Rubella virus and CRS surveillance.


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