In 2017, the Ministry of Health and Family Welfare (MoHFW) introduced the MR Campaign to immunise children under the age of 15 against measles and rubella, which plagues around 2 million children globally each year. Two years down the road, even with significant traction having been achieved with the campaign, the government still continues to face a challenge in the form of Congenital Rubella Syndrome (CRS) which plagues as many as 40,000 newborns in India each year.
“Congenital rubella syndrome is a condition wherein children are born with birth defects as a result of exposure to the rubella virus while in the womb,” explains senior gyanaecological-oncologist Dr Jaishree Gajraj, who runs Mangai Health Clinic in Chennai.
While rubella is generally considered a mild infection, which manifests with symptoms similar to that of a common cold, the problem occurs when the infected individual happens to be a pregnant woman. According to the Center for Disease Control and Prevention (CDC), there is a 90% chance of the virus being transmitted from an infected mother to an unborn child, resulting in CRS. The MR campaign was introduced to immunise children and adults against measles and rubella and to reduce the burden of CRS. When done effectively, up to 95% vaccination coverage is ensured among the target group in the community, as per the World Health Organisation(WHO).
“The best thing to be done is to ensure that all adolescent women are immunised against the virus. Ideally, any woman planning for a family should be given the vaccine as part of counseling for family planning,” adds Dr Jaishree. She also notes that it would be effective to subject young girls and women to a screening test to detect for the presence of antibodies against the virus.
The problem is two-fold according to Dr Jaishree. First, there are a group of girls who do not get vaccinated at all. At a later age, should they contract the virus when pregnant, this may result in the unborn child being affected with CRS. However, in some instances, those who have received the vaccine will still need to undergo screening at a later age, as there is a lack of antibodies against the virus in their system. "So even though they have received the vaccination, there is no trace of the antibodies in their system. If they become pregnant and are exposed to rubella, the baby could develop CRS," she states.
While the vaccine is given to children at the ages of 10 and 16 months and a final dose at 5 years of age, women who are planning to have children should ideally take the vaccine 3 months prior to trying to conceive.
How CRS presents in children
CRS in children can manifest as one of a number of birth defects, with many children afflicted with multiple issues.
“Most of these children present with cardiac problems, which is when pediatricians will begin to probe into the prenatal history of the mother and her immunisation history as well,” explains Dr Vikas Satwik, Consultant Neonatologist and Pediatrician at Motherhood Hospital in Bengaluru.
“We also notice that many of these children present with visual impairments, namely congenital cataracts, hearing defects and overall developmental delays,” he adds.
Several studies have noted that most instances of congenital blindness are the result of CRS. One of the most controversial of these studies was published in the British Medical Journal (BMJ) and specifically stated that half of the cataracts seen in children in South India were largely due to preventable causes, namely CRS.
Once doctors suspect that a child may have CRS, further work up is accordingly done. Pediatricians then refer the child to a specialist as needed. Ophthalmologists will be able to determine the extent of visual disturbances by examining the eyes. Following this, surgery may be advised depending on the severity of the child’s condition.
Next otorhinolaryngologists (ENT specialists) are involved in assessing the extent of the child’s hearing loss. After various tests are done, the doctor will then determine whether it will be effective to perform a cochlear implant to help restore hearing.
If a child has a heart defect, this is monitored and treated symptomatically and with medication until it can be operated upon.
“The best thing we can do is to screen the children whose mothers give a history of fever in the first three months (first trimester) of pregnancy. This is when organ formation of the baby occurs and the virus can really affect a child’s development in-utero,” notes Dr Jaishree. She further adds that it would be ideal for all mothers to undergo antibody titer test to determine if they’re susceptible to contracting the virus. “If someone is found to be non-immune to Rubella, then we must give them the vaccine.”
Since the vaccine given is a live attenuated vaccine, in theory a woman getting the vaccine could pass on the virus to an unborn child. To avoid this, doctors advise contraception for at least a month after she receives the vaccine.