Little Red

By on October 6, 2013

Perhaps you saw the shocking headlines: “CDC Issues Level 2 Travel Alert for Japan”. Radiation? Earthquakes? Tainted sushi? No, it’s rubella (little red, in Latin), which has recently made a roaring comeback in Japan.

Although now relatively rare in developed nations, roughly 100,000 cases per year are reported worldwide. Also known as German measles, it is a viral illness transmitted from person to person through respiratory secretions. Roughly 14 days after being infected, a person may develop cold like symptoms, followed by a diffuse rash of fine, red spots, typically starting on the head and spreading downward. The disease is usually mild, and although there is no specific treatment, it is self-limited. In addition, up to 50% of people infected may never develop symptoms. Adults generally fare worse and may suffer high fevers and develop a temporary arthritis. Serious complications are rare, but include encephalitis (inflammation of the brain) and gastrointestinal or other bleeding.
Many nations have all but eliminated the disease through vaccination programs, usually using the MMR (measles-mumps-rubella) vaccine. Only four cases were reported in the United States in 2011, while in Japan more than 13,000 cases have been reported thus far this year. Of the 13,000 cases, roughly 10,000 were in adult males, many of who were susceptible due to a gap in government vaccination programs for this age group. The outbreak appears to be fading at this time, due in part to immunization programs and heightened public awareness.
So, why all the fuss about a self-limited and relatively mild disease? The answer is Congenital Rubella Syndrome or “CRS”. Contracting rubella during pregnancy can adversely affect the developing fetus and may lead to CRS, which is a constellation of congenital defects that can affect all organ systems, leading to deafness, ocular abnormalities, heart defects, and mental retardation. The main purpose of preventing rubella is to prevent CRS. As of this writing, there have been 16 reported cases of CRS in Japan since October 2012 and this number is expected to rise as infants conceived during the outbreak are delivered. Infection within the first 20 weeks of pregnancy is more likely to result in CRS. Spontaneous abortion, fetal death, and premature delivery are other possible effects of rubella infection during pregnancy.
The key to preventing CRS is immunization of not only the potential mothers, but also the community as a whole. Most nations use the MMR vaccine, while either the MR (measles-rubella) or rubella-only vaccines are generally utilized in Japan. A single dose will confer immunity in most adults, but as these are “live” vaccines with weakened but live viral elements, vaccination during pregnancy is not recommended, and avoiding pregnancy for 1 to 3 months after vaccination is advisable due to the theoretical risk of vaccine-induced CRS.
Determining whether one needs the vaccine can be a bit tricky. Those who have had two doses of rubella containing vaccine after one year of age are generally considered immune. A prior history of rubella may not always be reliable and is not considered adequate by itself as proof of immunity. Doing a blood test to measure antibody levels can be helpful. “HI titers” are usually measured in Japan and titers greater than 1:64 are felt to indicate adequate protection, although there is no level that insures 100% protection. If in doubt, vaccination is recommended, as the benefits are felt to outweigh any potential harms, even in an individual possibly already immune. If you are planning to get pregnant, vaccination or confirmation of immunity should be completed prior to getting pregnant.
Due to the recent outbreak, many municipal governments are currently subsidizing rubella immunizations for adults, while some have also begun subsidizing antibody tests; details should be available at your local health department. Two doses of the MR vaccine are currently part of the standard childhood vaccination schedule in Japan and should provide long lasting immunity to measles and rubella.
Although the current outbreak seems to be waning, all susceptible people older than one year of age should consider vaccination to protect themselves and the babies-to-be in their communities.

Additional information
The National Health Insurance (Kokumin Kenko Hoken) does not cover most vaccinations and rubella is no exception to this. Since the outbreak, many (but not all) local municipal governments have begun a subsidy program for adults needing rubella vaccine. Most pay a portion of the fee (typically up to 5,000 yen) for women desiring vaccination, while men may be eligible only if their wife is currently pregnant. The criteria and monetary amount of the subsidies vary considerably depending on the region, so one would need to check with their local ward/municipal office. Some municipalities may require obtaining a voucher prior to vaccination, some only require completing a simple form at the time of vaccination, while others may reimburse you after vaccination with presentation of a receipt.

As National Health does not cover these costs, the fees would be the same for those that do not have National Health Insurance.  In persons that are not eligible for the above-mentioned subsidies, Primary Care Tokyo’s fee is 5,000 yen for the rubella vaccine and 9,000 yen for the MR (measles-rubella) vaccine. If the visit is for vaccination only, there are no additional fees aside from the 5% consumption tax.

At this time the rubella-only vaccine is in very short supply nationally, so most clinics, Primary Care Tokyo included, are using the MR vaccine instead.

About Dr. Joe Kurosu

Joe Kurosu, M.D., is director of Primary Care Tokyo, a solo practice in Shimokitazawa, Tokyo. He is an American graduate of Yale Medical School and licensed in Japan and the United States. His clinic provides a range of primary care services for the pediatric and adult patient, including immunizations, check-ups, acute & chronic disease management, and minor surgical procedures. Dr. Kurosu has experience in caring for both the expatriate and local communities in Japanese or English. Japanese National Health Insurance is accepted. 
Tel 03-5432-7177.