A 25 y/o post partum female shows up for a post partum check-up about 3 months after the birth of a full term, normal baby. You notice she is not immune against rubella and has not had her rubella vaccine.  She has no other significant medical history and has no allergies.  She did receive RhoGam® right after her delivery. Can you still give her the rubella vaccine or the mumps-measles-rubella (MMR) vaccine now?

SELECT  here for discussion

Based on the latest guidance below from the CDC (Feb 2003), yes.

Live vaccines contain live, attenuated viruses. These have to replicate and immune globulins may interfere with this replication. This interference may produce a sub-optimal immune response. Some general guidelines are:

*    If the live vaccine is given first, wait at least TWO WEEKS (i.e. incubation period) until giving the immune globulin.

*    If the antibody/immune globulin is given first, a minimum of 6-12 weeks should go by before giving the live vaccine.

From CDC Pink Book on Immunizations, dtd February 2003:

“Although passively acquired antibodies can interfere with the response to rubella vaccine, the low dose of anti-Rho(D) globulin administered to postpartum women has not been demonstrated to reduce the response to the RA27/3 strain rubella vaccine. Because of the importance of rubella immunity among childbearing-age women, the postpartum vaccination of rubella-susceptible women with rubella or MMR vaccine should not be delayed because of receipt of anti-Rho(D) globulin or any other blood product during the last trimester of pregnancy or at delivery. These women should be vaccinated immediately after delivery and, if possible, tested >3 months later to ensure immunity to rubella and, if necessary, to measles.”

I’ve attached a chart (click here for the chart ) showing recommended intervals between various antibody and blood products and vaccination with live vaccines, specifically measles and varicella from this 2003 CDC publication.

From MICROmedex®:

LIVE VIRUS VACCINES

    1.    Summary: Live-virus vaccines may not replicate successfully, and antibody response could be reduced when the vaccine is administered after Rho(D) immune globulin because of the presence of antibodies in the immune globulin. Live-virus vaccines should ideally be administered at least three months after therapy with Rho(D) immune globulin. If the administration of an immune globulin preparation becomes necessary because of exposure or potential exposure to disease, live-virus vaccines can be given simultaneously with the immune globulin at a site remote from that chosen for the immune globulin. Such is the case with rubella vaccine and Rho(D) immune globulin, which should both be administered postpartum in a Rho(D) negative mother who is not vaccinated against rubella virus. Vaccine virus replication and stimulation of immunity will occur one to two weeks after vaccination. Therefore, if the interval between administration of the vaccine and immune globulin is less than 14 days, or if they were administered simultaneously, vaccination should be repeated at least three months after the immune globulin preparation was given, unless serologic testing indicates that adequate antibodies were formed (CDC, 1989; Prod Info RhoGAM™, 1995).

    2.    Adverse Effect: interference with the immune response to the live vaccine

    3.    Clinical Management: The administration of live viral vaccines should be deferred, if possible, until three months after the administration of Rho(D) immune globulin. If the live-virus vaccine was administered less than 14 days before or at the same time as the immune globulin, vaccination may need to be repeated at least three months after the immune globulin, unless serologic testing indicates that adequate antibodies were produced.

    4.    Severity: moderate

    5.    Onset: delayed

    6.    Documentation: fair

    7.    Probable Mechanism: presence of antibodies in the immune globulin

Follow-up/comments from staff Endocrinology regarding last week’s Pearl on spironolactone and acne: “You might want to mention that birth control should be advised in women of childbearing potential taking Spironolactone, since there is concern (although no data that I know of) that it could cause undervirilization of a male fetus.”

This Pearl is meant for academic and educational purposes only. This Pearl is meant to raise important points regarding the safe and cost-effective pharmacotherapy of patients. It is not meant to be the definitive reference for the treatment or prophylaxis of various diseases. Although every effort is taken to ensure this Pearl is correct and factual, errors may occur. The Pharmacoeconomic Center assumes no liability for incorrect information or harm that may occur from the use of the information included in this Pearl.