Basics
Description
- Rubella derived from Latin, meaning "little red."
- Disease initially considered variant of measles
- Viral infection characterized by mild symptoms (often subclinical), with an erythematous rash progressing from head to toes
- Congenital rubella syndrome can be devastating.
Epidemiology
- Spread person to person via airborne transmission; worldwide infection
- Infection most contagious when rash is erupting. However, virus may be shed beginning 7 days before rash to 14 days after.
- Infants with congenital rubella syndrome may shed virus for up to 1 year.
- In temperate regions, peaks in late winter and early spring
- Infection occurs equally in following age groups: <5 years, 5-19 years, and 20-39 years.
- In prevaccine era, annual incidence of infection in the United States was ~58 per 100,000 population.
- 2004: No longer endemic in the United States.
- 2004-2011: 77 reported cases, mostly in unvaccinated individuals born overseas
- Congenital rubella syndrome
- 1964: 20,000 newborns
- 1980s: reported rarely, with <5 cases annually
- 1990-1991: ~30 cases reported annually
- 2004-2011: Total of 4 cases reported to CDC, only 1 with mother born in the United States.
General Prevention
- Prevention of congenital rubella syndrome is main objective of vaccination programs.
- Rubella vaccine
- Current strain of vaccine (RA 27/3, developed at the Wistar Institute in Philadelphia) was licensed in 1979 and has replaced all other strains.
- Given as part of MMR vaccine at 12-15 months and again at 4-6 years
- Immunity occurs in 95% of those vaccinated and is thought to be lifelong.
- Important to ensure full vaccination for preschool-aged children
- Vaccine virus is not communicable: Pregnant women and persons who are immunodeficient (except asymptomatic HIV infection) should not receive vaccine, but household contacts should.
- Isolation
- Pregnant women should avoid contact with source patient.
- Postnatal: Droplet precautions and/or school exclusion is indicated for 7 days after onset of rash.
- Congenital: Contact isolation until 1st birthday, or until 2 nasopharyngeal and urine cultures consecutively negative
Pathophysiology
- Respiratory transmission
- Replication in nasopharynx and regional lymph nodes
- Viremia 5-7 days after exposure, with spread of virus throughout body
- In congenital rubella syndrome, transplacental infection of fetus occurs during viremia.
Etiology
- Rubella virus
- Classified as a Rubivirus in the Togaviridae family
- RNA virus with single antigenic type
- First isolated in 1962 by Parkman and Weller
Diagnosis
If rubella is suspected, case should be reported to local public health authorities.
History
- In children, prodrome is not often recognized.
- In adults, a 1-5-day prodrome of low-grade fever, malaise, and cervical adenopathy may precede rash.
- Inquire about immunizations and exposures.
Physical Exam
- Rash
- Begins on face, then progresses to trunk and extremities
- Does not usually coalesce
- Lasts for 3 days
- Adenopathies, especially postauricular, posterior cervical, and suboccipital, are commonly noted along with conjunctivitis.
- Arthralgia/arthritis may be seen in adolescents and adults.
Diagnostic Tests & Interpretation
Lab
- Congenital infection
- Serologic testing should be performed on both mother and infant.
- Rubella-specific IgM in infant is highly suggestive.
- Viral isolation from throat or nasal specimen can confirm diagnosis. Blood, urine, and CSF samples may also be diagnostic.
- Diagnosis is difficult to verify after neonatal period.
- Postnatally acquired
- Rubella-specific IgM or a ≥4-fold rise in rubella-specific IgG antibodies between acute and convalescent titers is diagnostic.
Differential Diagnosis
Infections that are sometimes confused with rubella include the following:
- Modified measles
- Scarlet fever
- Roseola
- Erythema infectiosum (fifth disease, parvovirus B19 infection)
- Enteroviral infections
- Infectious mononucleosis
- Drug eruptions
Treatment
Supportive care
Ongoing Care
Prognosis
- Quite good; as many as 50% of infections are asymptomatic.
- Rubella infection in pregnant woman can be devastating for infant (see "Complications").
Complications
- Tend to occur in adults; most are uncommon.
- Arthritis or arthralgia
- Occur in 70% of adult women, lasting up to 1 month
- Usually affects small joints
- Encephalitis
- 1 in 5,000 cases
- May be associated with mortality
- Bleeding
- 1 in 3,000 cases
- Occurs in children more than in adults
- Thrombocytopenia: commonly noted
- Orchitis and neuritis: rare
- Congenital rubella syndrome
- Rubella infection in early gestation can lead to fetal death, premature delivery, and congenital defects.
- Severity of defects is worse the earlier in gestation the infection occurs.
- 85% of infants are affected if infection occurs in 1st trimester.
- Defects are rare if infection occurs after 20th week.
- Common defects of congenital rubella syndrome:
- Deafness: most common defect
- Ophthalmologic defects: cataracts, glaucoma, microphthalmia
- Cardiac defects: patent ductus arteriosus, ventricular septal defect, pulmonic stenosis, coarctation of aorta
- Neurologic defects: mental retardation, microcephaly
- Some manifestations of congenital rubella syndrome (diabetes mellitus, progressive encephalopathy) may be delayed for years.
Additional Reading
- American Academy of Pediatrics. Rubella. In: Pickering LK, Baker CJ, Kimberlin DW, et al, eds. 2012 Red Book: Report of the Committee on Infectious Diseases, 29th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2012:629-634.
- Atkinson W, et al. Epidemiology and prevention of vaccine-preventable diseases. 2nd ed. Bethesda, MD: Centers for Disease Control and Prevention; 1995.
- Centers for Disease Control and Prevention. Elimination of rubella and congenital rubella syndrome-United States, 1969-2004. MMWR Morb Mortal Wkly Rep. 2005;54(11):279-282. [View Abstract]
- Papania MJ, Wallace GS, Rota PA, et al. Elimination of endemic measles, rubella, and congenital rubella syndrome from the Western Hemisphere: the U.S. experience. JAMA Pediatr. 2014;168(2):148-155. [View Abstract]
- Retraction-Ileal-lymphoid-nodular hyperplasia, non-specific colitis, and pervasive developmental disorder in children. Lancet. 2010;375(9713):445. [View Abstract]
Codes
ICD09
- 056.9 Rubella without mention of complication
- 771.0 Congenital rubella
- 056.79 Rubella with other specified complications
- 056.71 Arthritis due to rubella
ICD10
- B06.9 Rubella without complication
- P35.0 Congenital rubella syndrome
- B06.89 Other rubella complications
- B06.82 Rubella arthritis
SNOMED
- 36653000 Rubella (disorder)
- 1857005 Congenital rubella syndrome (disorder)
- 186570004 Rubella deafness (disorder)
- 19431000 Rubella arthritis (disorder)
FAQ
- Q: Although pregnancy is a contraindication to rubella vaccination, if a pregnant woman is inadvertently vaccinated, will there be harm to the fetus?
- A: Data collected since 1979 by the CDC show no evidence of congenital rubella syndrome in 321 susceptible women who were vaccinated while pregnant. Therefore, inadvertent vaccination is not an indication for termination of pregnancy.
- Q: Is there any evidence that the MMR vaccine causes autism spectrum disorder?
- A: No. Multiple epidemiologic studies have shown no difference in the rates of autism spectrum disorder in children who received the MMR vaccine versus those who did not. The original paper that suggested a link between vaccines and autism was retracted in 2010.