Women, Children s and Sexual Health Division Maternity Services. MMR / Rubella Vaccine for Postnatal Woman

Transcription

1 Women, Children s and Sexual Health Division Maternity Services Guideline: MMR - Rubella Vaccination for Postnatal Woman 1. Introduction Rubella vaccine is usually given in childhood along with the measles and mumps vaccines as a part of the MMR vaccine. Before the introduction of this vaccine there were around 43 cases each year of Congenital Rubella Syndrome. Recently this has reduced to an average of less than two cases per year. The purpose of the guideline is to offer rubella vaccination to all postnatal women known to be non-immune at this hospital, to reduce the risk of congenital abnormalities in the future. This guideline is intended to be for the use of midwives and obstetricians and applies to both the home and hospital setting, regardless of type of birth. 2. Aims and objectives All women will be offered screening for rubella immunity during pregnancy. On no account should any pregnant woman be vaccinated Women who are found to be not immune to rubella should be advised to avoid contact with anyone thought to be infectious. Following delivery, women who are not rubella immune must be offered rubella vaccination. This should be prescribed and administered prior to discharge. 3. Definitions Rubella is an infectious viral disease associated with a rash, which in adults can also cause joint pain and arthritis. It has an incubation period of days. Individuals suffering from rubella are infectious from one week before the onset of rash until four days afterwards. Most women of childbearing age are immune to rubella because either they have been vaccinated prior to pregnancy or they had the illness during childhood. However, in recent years a fall in the uptake of MMR (mumps, measles and rubella) vaccination in children has raised concerns about a possible increase in cases Although rubella is a mild disease, it can have devastating effects on the fetus if a woman contracts it early in her pregnancy. The risk is of congenital rubella syndrome, a condition resulting in profound birth defects such as; Cataracts and other eye defects Deafness Cardiac abnormalities Microcephaly Retardation of intra-uterine growth Inflammatory lesions of brain, liver, lungs and bone marrow. (DH 2006) Page 1 of 10

2 4. Incidence The greatest risk is from infection in the first 8-10 weeks of pregnancy, with 90% of cases resulting in severe birth defects. At weeks fetal damage occurs in 50% of cases and at 17 weeks this reduces considerably. After this stage, birth defects rarely result from maternal rubella infection (MacLean, RCOG 2001, DH 2006) 5. Rubella Vaccine, MMR is a vaccine consisting of a mixture of live attenuated measles, mumps and rubella virus. A single dose of this vaccine confers around % protection to rubella virus but a lower level of protection against measles and mumps and thus the current recommendation is for two separate doses of MMR to be given to those found to be nonimmune. 6. Recommendations for Practice/Administration (see Appendix Three for practice points) Post-natal prophylaxis with MMR vaccine is recommended for all postnatal women known to be non-immune to rubella Non-immunity is reported as IgG not detected Appendix One In most cases non-immunity is identified in the antenatal period. In this case the women should be informed of the result and provided with appropriate information and offered postnatal MMR vaccination, thus ensuring immunity in future pregnancies The MMR vaccine must be prescribed on a medication chart by an obstetrician and written consent gained prior to administration, Appendix Two A stock of six MMR vaccines will be kept in the fridge on the postnatal ward and two delivery suite ready for administration when required. The dose to be administered to confer adequate immunity to all three elements of MMR is two doses of 0.5ml of MMR vaccine, at least one month apart. The vaccine should be given immediately prior to discharge as an intramuscular or subcutaneous injection. The vaccine should be administered into the deltoid muscle in the upper arm (as best practice) or anterior-lateral thigh. Individuals with a bleeding disorder should be given the injection by deep subcutaneous injection to reduce the risk of bleeding. It must be clearly documented in the woman s handheld records that the immunisation process has been commenced in the postnatal care plan and discharge details. Lactating women of normal full term infants can receive MMR vaccination during lactation Women requiring the MMR vaccination, who plan to transfer from the Lexden ward to either Harwich or Clacton midwife led units should be vaccinated prior to transfer. Page 2 of 10

3 The MMR vaccine should not be given to pregnant women The information leaflet accompanying the vaccine (from the supplier) should be consulted prior to giving the vaccination. This will ensure correct administration of the vaccine and that contraindications are known to the person who is administering the vaccine. Staff are also able to refer to BNF (British National Formulary) available in clinical areas. However, in general: The vaccine should not be given to anyone with a acute severe febrile condition The vaccine must not be given to anyone allergic to neomycin The MMR vaccine is not recommended for women with severe immunosuppression. The MMR vaccine can be given to HIV positive women with or without moderate immuno-suppression. (DH Green Book 2006) If a woman has received blood products such as whole blood, packed red cells and intravenous immunoglobulin, vaccination should be deferred for 3 months, this information should be given to the woman and documented on the discharge summary to inform her General Practitioner. (DH Green Book 2006) Women who have experienced anaphylaxis after egg ingestion should be vaccinated with extreme caution, with adequate treatment for anaphylaxis on hand should such a reaction occur 6.1 Adverse Reactions Severe allergic reactions are rare (<1, 10,000) but may consist of sudden wheeziness, chest pain or tightness, swelling of the eyelids, face, lips, mouth or tongue or generalised urticaria. Mild reactions such as fever, sore throat, rash and joint pain can occur following vaccination. Symptoms usually begin one to three weeks after immunisation and are transient. For anaphylaxis algorithm see appendix Four 7. Consent and Documentation Written consent must be obtained and documented in the woman s handheld healthcare records prior to administration. Appendix Two All parts of the consent form should be completed: copies are available on Lexden ward, the completed form should then be photocopied 3 times. The original form should then be retained in the women s health records; One copy sent to the GP along with the other discharge summary letter. One copy issued to the woman with a full explanation and then placed in the discharge envelope Page 3 of 10

4 When the MMR vaccine is given, this must be clearly recorded in the woman s handheld healthcare records and the prescription chart should be signed with the batch number of the MMR vaccine, with the correct date, time, dosage and route of administration The Administration of vaccine should also be communicated clearly in both the postnatal care plan and discharge details (where a copy of the consent form should be placed) along with the need for the second dose of MMR vaccine to be administered via GP s surgery. Equally, if a woman declines the vaccination this should also be recorded clearly in her handheld healthcare records and on the discharge summary. 8. Advice to women following Vaccination The patient information leaflet (PIL) from the MMR vaccine should be given to the woman. A woman who is breastfeeding can be safely vaccinated Pregnancy should be avoided for at least one month following vaccination, with the use of adequate contraception. The vaccine is not transmitted from vaccinated individuals to susceptible contacts. Therefore there is no risk to pregnant women contact with recently immunised individuals. There is no known risk or adverse effect, associated with receiving of the MMR vaccine in women already immune to measles and mumps as these women will already have antibodies to these two viruses A second dose of MMR vaccine is recommended at least one month following the first, this would usually be administered via the GP. Immunity to rubella should be confirmed by a blood test eight weeks following the second vaccination via the GP. 9. Staffing and Training Registered Nurses and Midwives must be currently registered with the Nursing and Midwifery Council (NMC); they will practise according to the standard laid down by the NMC. A copy of this guideline will be available in hard copy in all areas and on the Trust intranet site. The Practice Development Midwife at Colchester General Hospital will be available for training sessions for all midwives requiring updates in performing deltoid injections. 10. Infection Prevention All staff should follow Trust guidelines on infection control by ensuring that they effectively decontaminate their hands before and after each procedure. Page 4 of 10

5 All staff should ensure that they follow Trust guidelines on infection control when carrying out procedures 11. Monitoring compliance The risk management team will review all Datix and complaints. Any immediate training or educational issues relating to lack of compliance with this guideline will be addressed on a one to one basis. All incidents and trends analysis will be reviewed at the Maternity Risk Management Group meeting. 12. References British National Formulary Measles, Mumps and Rubella vaccine (MMR). Centre for Disease Control and Prevention (CDC) (2005) A detailed review of the epidemiology, pathogenesis, clinical features and management of rubella. Department of Health (1998) Immunisation against infectious diseases. Chapter 22, pp140. HMSO Department of Health (2003) Screening for infectious diseases in pregnancy; standards to support the UK antenatal screening programme. DoH August 2003 London Department of Health (2006) The Green Book. DoH Donalson L, Mullally S, Smith J and House R (2003) Protecting women against rubella: the switch from rubella vaccine to MMR. Joint chief medical, nursing and pharmaceutical officers circular, September 2003 DoH. MacLean AB, et al (2001) Infection and Pregnancy, RCOG Press London. National Institute of Clinical Excellence (2006) Routine postnatal care of women and their babies. NICE Clinical guideline 37. NICE, London/ WHO (2003) Vaccines, immunizations and biologicals. April Page 5 of 10

6 Dymphna Sexton-Bradshaw Associate Director of Women & Children's/ Head of Midwifery Women & Children s Division... Professor Khaled Consultant Obstetrician Screening Lead Anne Regan Lead Pharmacist Version Author Date Circulation Comments One Jenny Collins Matron for Postnatal & Community Supervisor of Midwives With Acknowledgements to the contribution from Derwent Valley & Mid-Essex maternity units. Tracy Baxter Antenatal and Newborn Screening Midwife 2012 Supervisors of midwives Thinking of getting pregnant Rubella Lea Page 6 of 10

7 Appendix One Results from Pathology as shown on screen / printed Rubella IgG: Detected Explanation; (Results Interpretation for Rubella Antibodies) (If result equals Detected patient is immune,) (unless there has been a recent contact with rubella). (If result equals NOT detected patient is not immune and rubella) (vaccination post partum is recommended.) Page 7 of 10

8 Appendix Two Consent for Postnatal MMR Vaccination Woman s Details Surname: First Name: Hospital No: NHS Number: D.O.B.: Address: Consultant: G.P. Name and address and courier no; 1. Have the reasons for MMR vaccination been explained? Yes 2. Is the woman aware of any side effects? Yes 3. Has the woman been informed of the need to avoid pregnancy for 1 month following vaccination? Yes 4. Is the woman aware that she should have a second dose of MMR from her GP at least one month after this initial dose and a blood test to confirm immunity, approximately eight weeks following the second vaccination? Yes 5. Has a copy of the Patient information leaflet been given to the woman? Yes 6. Has a copy of this form been attached to the GP discharge letter Yes Woman s Signature Batch number Dose given Given by Checked by Route Date Time Page 8 of 10

9 Please photocopy this completed form: retain the original in the woman s healthcare records, one copy attached to the GP discharge letter and second copy in the woman s discharge envelope. MMR VACCINE PRACTICE POINTS Appendix Three The MMR vaccine must be prescribed on a medication chart by an obstetrician & written consent gained prior to administration Appendix Two The vaccine should not be given to anyone with an acute febrile condition. The vaccine must not be given to anyone allergic to neomycin The MMR vaccine is not recommended for women with severe immunosuppression The MMR vaccine can be given to HIV positive with or without moderate immuno-suppression If a women has received blood products (such as whole blood, packed red cells & intravenous immunoglobulin), vaccination should be deferred for 3 months; this information should be given to the women & documented on the discharge summary to inform her GP Women who have had Anti-D this vaccine can be given but should be in the opposite arm The vaccine is not transmitted from vaccinated individuals to susceptible contacts. Therefore there is no risk to pregnant women contact with recently immunised individuals. For women transferring to the coastal Midwife-led units, for postnatal care, the vaccine can be administered prior to them leaving Colchester For women delivering in the Midwife led units, Vaccine should be administered prior to discharge. Women who have experienced anaphylaxis after egg ingestion should be vaccinated with extreme caution, with adequate treatment for anaphylaxis on hand should such a reaction occur Page 9 of 10

10 Anaphylaxis algorithm Appendix Four Anaphylactic Algorithum Page 10 of 10