Rubella

Definition

Rubella is a highly contagious viral disease, spread through contact with discharges from the nose and throat of an infected person. A person infected with the rubella virus is contagious for about seven days before any symptoms appear and continues to spread the disease for about four days after the appearance of symptoms. Rubella has an incubation period of 12–23 days.

Description

Rubella is also called German measles or the three-day measles. This disease was once a common childhood illness, but its occurrence has been drastically reduced since vaccine against rubella became available in 1969. In the three decades following the introduction of the vaccine, reported rubella cases dropped 99.6%. Only 229 cases of rubella were reported in the United States in 1996. A recent study indicates, however, that the age group pattern of rubella is shifting. As of 2002, the number of cases reported in people aged 15 years or younger is dropping, while the number of cases in people between 25 and 45 is rising.

People of any age who have not been vaccinated or previously caught the disease can become infected. Having rubella once or being immunized against rubella normally gives lifetime immunity. This is why vaccination is so effective in reducing the number of rubella cases. The United States had a public health goal of eliminating all rubella within its borders by the year 2000; however, this goal was not attained because of new strains of the rubella virus entering the country from the Caribbean and Central America. The availability of molecular typing indicates that three separate strains of the virus caused localized outbreaks that were quickly contained. As of 2002, cases of rubella in the United States are more common among Hispanics than among Caucasians, Native Americans, or African Americans.

Women of childbearing age who do not have immunity against rubella should be the most concerned about infection. Rubella infection during the first three months of pregnancy can cause a woman to miscarry or cause the baby to be born with severe birth defects, including mental retardation and sensory impairments. In addition, recent studies indicate that infants exposed to rubella in utero (in the womb) are at increased risk of developing schizophrenia as adults.

Although it has been practically eradicated in the United States, rubella is still common in less developed countries because of poor immunization penetration, creating a risk to susceptible travelers. Some countries have chosen to target rubella vaccination to females only. As a result, outbreaks among foreign-born males have occurred on cruise ships and at summer camps in the United States. The United Kingdom is considering targeting immigrants of either sex from underdeveloped countries for rubella immunization following several cases of babies born with congenital rubella syndrome.

Causes & symptoms

Rubella is caused by the rubella virus (Rubivirus ). Symptoms are generally mild, and complications are rare in anyone who is not pregnant.

The first visible sign of rubella is a fine red rash that begins on the face and rapidly moves downward to cover the whole body within 24 hours. The rash lasts about three days, which is why rubella is sometimes called the three-day measles. A low fever and swollen glands, especially in the head (around the ears) and neck, often accompany the rash. Joint pain and sometimes joint swelling can occur, more often in women. It is quite common to get rubella and not show any symptoms (subclinical infection).

Symptoms disappear within three to four days, except for joint pain, which may linger for a week or two. Most people recover fully with no complications. Although rubella causes only mild symptoms of low fever, swollen glands, joint pain, and a fine red rash in most children and adults, it can have severe complications for women in their first trimester of pregnancy. Babies may be miscarried or stillborn and a high percentage are born with birth defects. Birth defects are reported to occur in 50% of women who contract the disease during the first month of pregnancy, 20% of those who contract it in the second month, and 10% of those who contract it in the third month. The most common birth defects resulting from congenital rubella infection are eye defects, such as cataracts, glaucoma , and blindness, deafness, congenital heart defects, and mental retardation. Taken together, these conditions are called congenital rubella syndrome (CRS). The risk of birth defects drops after the first trimester, and by the fifth month, there are rarely any complications.

Diagnosis

The rash caused by the rubella virus and the accompanying symptoms are so similar to other viral infections that it is impossible for a physician to make a confirmed diagnosis on visual examination alone. The only sure way to confirm a case of rubella is by checking for antibodies with a blood test or in a laboratory culture.

When the body is infected with the rubella virus, it produces both immunoglobulin G (IgG) and immunoglobulin

M (IgM) antibodies to fight the infection. Once IgG exists, it persists for a lifetime, but the special IgM antibody usually wanes over six months. A blood test can be used either to confirm a recent infection (IgG and IgM) or determine whether a person has immunity to rubella (IgG only). The lack of antibodies indicates that a person is susceptible to rubella.

All pregnant women should be tested for rubella early in pregnancy, whether or not they have a history of vaccination. If the woman lacks immunity, she is counseled to avoid anyone with the disease and to be vaccinated after giving birth.

Treatment

Rather than vaccinating a healthy child against rubella, some alternative practitioners recommend allowing the child to contract the disease naturally at the age of five or six years, since the immunity conferred by contracting the disease naturally lasts a lifetime. It is, however, difficult for a child to contract rubella naturally when everyone around him or her has been vaccinated.

Ayurvedic practitioners recommend making the patient comfortable and giving the patient ginger or clove tea to hasten the progress of the disease. Traditional Chinese medicine uses a similar approach. Believing that inducing the skin rash associated with rubella hastens the progress of the disease, traditional Chinese practitioners prescribe herbs such as peppermint (Mentha piperita ) and chai hu (Bupleurum chinense ). Cicada is often prescribed as well. Western herbal remedies may be used to alleviate rubella symptoms. Distilled witch hazel (Hamamelis virginiana ) helps calm the itching associated with the skin rash and an eyewash made from a filtered diffusion of eyebright (Euphrasia officinalis ) can relieve eye discomfort. Antiviral western herbal or Chinese remedies can be used to assist the immune system in establishing equilibrium during the healing process. Depending on the patient's symptoms, among the remedies a homeopath may prescribe are Belladonna, Pulsatilla, or Phytolacca. These can be used with or with out bilberry .

Allopathic treatment

There is no drug treatment for rubella. Bed rest, fluids, and acetaminophen or Motrin for pain and temperatures over 102°F (38.9°C) are usually all that is necessary.

Babies born with suspected CRS are isolated and cared for only by people who are sure they are immune to rubella. Congenital heart defects are treated with surgery.

Expected results

Complications from rubella infection are rare in children, pregnant women past the fifth month of pregnancy, and other adults.

Prevention

Vaccination is the best way to prevent rubella and is normally required by law for children entering school. Rubella vaccine is usually given in conjunction with measles and mumps vaccines in a shot referred to as MMR (mumps, measles, and rubella). Children receive one dose of MMR vaccine at 12–15 months and another dose at four to six years. The MMR vaccine has aroused some controversy since early 2000 because of media reports that it increases the risk of wheezing and lower respiratory tract disorders in young children. A recent study of vaccine safety has concluded, however, that there is no connection between the MMR vaccine and a reported rise in the incidence of wheezing in children.

Pregnant women should not be vaccinated; women who are not pregnant should avoid conceiving for at least three months following vaccination. To date, however, accidental rubella vaccinations during pregnancy have not clearly been associated with the same risk as the natural infection itself. Women may be vaccinated while they are breast-feeding. People whose immune systems are compromised, either by the use of such drugs as steroids or by disease, should discuss possible complications with their doctor before being vaccinated.

Resources

BOOKS

Cooper, Louis Z. "Rubella." In Rudolph's Pediatrics, 21st ed., edited by M. M. Rudolph, J. I. E. Hoffman, and C. D. Rudolph. Stamford, CT: McGraw-Hill, 2002.

Gershon, Anne. "Rubella (German Measles)." In Harrison's Principles of Internal Medicine, 15th ed., edited by Anthony S. Fauci. New York: McGraw-Hill, 2001.

PERIODICALS

Brown, A. S., and E. S. Susser. "In Utero Infection and Adult Schizophrenia." Mental Retardation and Developmental Disabilities Research and Review 8 (January 2002): 51–7.

Carvill, S., and G. Marston. "People with Intellectual Disability, Sensory Impairments and Behaviour Disorder: A Case Series." Journal of Intellectual Disability Research 46 (March 2002): 264–72.

Case Definitions for Infectious Conditions under Public Health Surveillance. Morbidity and Mortality Weekly Report 46 (1997): 30.

Dixon, B. "Triple Vaccine Fears Mask Media Efforts at Balance." Current Biology 12 (March 5, 2002): R151-R152.

Mullooly, J. P., J. Pearson, L. Drew, et al. "Wheezing Lower Respiratory Disease and Vaccination of Full-Term Infants." Pharmacoepidemiology and Drug Safety 11 (January-February 2002): 21–30.

Reef, S. E., T. K. Frey, K. Theall, et al. "The Changing Epidemiology of Rubella in the 1990s: On the Verge of Elimination and New Challenges for Control and Prevention." Journal of the American Medical Association 287 (January 23, 2002): 464–72.

Sheridan E., C. Aitken, D. Jeffries, et al. "Congenital Rubella Syndrome: A Risk in Immigrant Populations." Lancet 359 (February 23, 2002): 674–675.

ORGANIZATIONS

March of Dimes Resource Center. 1275 Mamaroneck Avenue, White Plains, NY 10605. (888) 663-4637. <http://www.modimes.org>.

National Organization of Rare Disorders. 55 Kenosia Avenue PO Box 1968 Danbury, CT 06813-1968. (800) 999-6673. [email protected]. <http://www.rarediseases.org>.

Kathleen Wright

Rebecca J. Frey, PhD

Rubella

Introduction

Disease History, Characteristics, and Transmission

Scope and Distribution

Treatment and Prevention

Impacts and Issues

BIBLIOGRAPHY

Introduction

The word rubella comes from the Latin word for “little red” and refers to the characteristic rash that accompanies the disease. It was first described in the early nineteenth century, when it was thought to be a type of either scarlet fever or measles. German doctors then decided that rubella was a disease in its own right— which is why it is sometimes called German measles.

People of any age can contract rubella, and there were many epidemics in the first half of the twentieth century. Rubella only poses a real risk to the developing fetus. Infection during the first three months of pregnancy can cause the child to be born with congenital rubella syndrome, which may be accompanied by deafness, mental retardation, and blindness. Vaccination has greatly reduced the rate of rubella in the United States, and it is especially important that women of child-bearing age are protected from the disease.

Disease History, Characteristics, and Transmission

The rubella virus belongs to the togavirus family and is a single-stranded RNA virus—that is, its genetic material is RNA, not DNA. It only naturally infects humans although other animals can be infected in experimental conditions. The incubation period of rubella virus is around 14 days, and infections are most common in late winter and early spring.

Most people with rubella infection have no, or only mild, symptoms. A rash, which is sometimes the only symptom, appears around 14–17 days after exposure to the virus. This rash is fainter than a measles rash and consists of tiny red spots. The rubella rash typically begins on the face and then spreads down the trunk to the rest of the body. Sometimes the rash is preceded by fever and swollen glands, while tiny red spots may appear on the soft palate. Generally the rash clears up in 3–4 days.

Adults are more prone to complications and more severe symptoms of rubella than children. Arthritis in the fingers, wrists, and knees affects 70% of adult females with rubella. Encephalitis (inflammation of the brain) is a rare complication, affecting one in 6,000 rubella cases, and clinical studies have suggested a mortality rate varying between zero and 50%.

Congenital rubella syndrome (CRS) occurs among babies born to a mother who was infected with the virus during early pregnancy. Rubella can affect all the organs of a developing fetus. Deafness is the most common symptom, but cataract and other visual defects, and neurological abnormalities may also occur. The problems may not appear until the child is two to four years old. Other complications arising from CRS include diabetes and autism. Maternal infections occurring after 20 weeks of pregnancy are far less likely to lead to CRS.

Rubella is transmitted by the respiratory route— through coughs and sneezes. It is only moderately contagious. People without symptoms may still be infectious. Those with symptoms are at their most infectious when the rash appears.

WORDS TO KNOW

MEASLES: Measles is an infectious disease caused by a virus of the paramyxovirus group. It infects only man and the infection results in life-long immunity to the disease. It is one of several exanthematous (rash-producing) diseases of childhood, the others being rubella (German measles), chickenpox, and the now rare scarlet fever. The disease is particularly common in both pre-school and young school children.

MMR VACCINE: MMR (measles, mumps, rubella) vaccine is a vaccine that is given to protect someone from measles, mumps, and rubella. The vaccine is made up of viruses that cause the three diseases. The viruses are incapable of causing the diseases but can still stimulate the immune system.

NOTIFIABLE DISEASE: A disease that the law requires must be reported to health officials when diagnosed; also called a reportable disease.

RIBONUCLEIC ACID (RNA): Any of a group of nucleic acids that carry out several important tasks in the synthesis of proteins. Unlike DNA (deoxyribonucleic acid), it has only a single strand. Nucleic acids are complex molecules that contain a cell's genetic information and the instructions for carrying out cellular processes. In eukaryotic cells, the two nucleic acids, ribonucleic acid (RNA) and deoxyribonucleic acid (DNA), work together to direct protein synthesis. Although it is DNA (deoxyribonucleic acid) that contains the instructions for directing the synthesis of specific structural and enzymatic proteins, several types of RNA actually carry out the processes required to produce these proteins. These include messenger RNA (mRNA), ribosomal RNA (rRNA), and transfer RNA (tRNA). Further processing of the various RNAs is carried out by another type of RNA called small nuclear RNA (snRNA). The structure of RNA is very similar to that of DNA, however, instead of the base thymine, RNA co

TOGAVIRUS: Togavirus are a type of virus. Rubella is caused by a type of togavirus.

Scope and Distribution

Rubella has been known since the nineteenth century and was long thought to be a trivial disease. Then, in 1941, the Australian ophthalmologist Norman Gregg reported a worrying trend—78 cases of severe cataracts among newborns, all of which could be traced back to rubella infection among the mothers in early pregnancy. Later, other problems such as heart defects, deafness, and mental retardation were noted in such babies. CRS is now diagnosed in around 85% of babies who have been exposed to rubella in the womb.

Epidemics of rubella were the norm every 7–10 years throughout the first half of the twentieth century and were always followed by an increase in the number of cases of CRS. The last major epidemic in the United States was in 1964 when there were 20,000 resulting cases of CRS and many deaths of babies in the womb.

Rubella and CRS became notifiable diseases in the United States in 1966 and a peak of 57,686 cases was noted in 1969, the year in which a vaccine was first introduced. Since then, cases have fallen to around 0.5 per 100,000 of the population, although there have been outbreaks in California, in 1990, and among the Amish people of Pennsylvania, in 1991. Following these outbreaks, California reported 25 new cases of CRS, Pennsylvania reported 33. The National Congenital Rubella Registry, which is managed by the National Immunization Program, carries out the national surveillance of CRS.

In 2004, the Centers for Disease Control and Prevention declared that rubella was no longer endemic in the United States. Cases that do occur tend to be among Hispanic people who have been born in the Caribbean or in Latin America.

Rubella occurs around the world and it can affect people of any age. However, only around 10% of cases occur in people over 40 years old. In recent years, adults between 15 and 39 have accounted for about half of all cases, so rubella is no longer considered to be a childhood disease.

IN CONTEXT: SCIENTIFIC, POLITICAL, AND ETHICAL ISSUES

With regard to a potential connection between the measles, mumps, and rubella Vaccine (MMR Vaccine) and autism, scientists at the National Immunization Program (NIP) at Centers for Disease Control and Prevention (CDC) state that “the weight of currently available scientific evidence does not support the hypothesis that MMR vaccine causes autism. CDC recognizes there is considerable public interest in this issue, and therefore supports additional research regarding this hypothesis. CDC is committed to maintaining the safest, most effective vaccine supply in history.”

As of May 2007 the CDC further states that, “there is no convincing evidence that vaccines such as MMR cause long term health effects. On the other hand, we do know that people will become ill and some will die from the diseases this vaccine prevents. Measles outbreaks have recently occurred in the UK and Germany following an increase in the number of parents who chose not to have their children vaccinated with the MMR vaccine. Discontinuing a vaccine program based on unproven theories would not be in anyone's best interest. Isolated reports about these vaccines causing longterm health problems may sound alarming at first. However, careful review of the science reveals that these reports are isolated and not confirmed by scientifically sound research. Detailed medical reviews of health effects reported after receipt of vaccines have often proven to be unrelated to vaccines, but rather have been related to other health factors. Because these vaccines are recommended widely to protect the health of the public, research on any serious hypotheses about their safety are important to pursue. Several studies are underway to investigate still unproven theories about vaccinations and severe side effects.”

SOURCE: Centers for Disease Control and Prevention, National Immunization Program

Treatment and Prevention

There is no treatment for rubella infection. The first live vaccines were introduced in 1969 and were replaced by an improved version in 1979. Rubella vaccine is now given in combination with mumps and measles as the MMR vaccine. It is recommended that a child be vaccinated with MMR between the age of 12 and 15 months, and he or she should receive another dose before school entry. Women of childbearing age should be checked for their immunity to rubella, or offered vaccination, if they do not already have evidence of having received the vaccine earlier. This can be done as part of regular gynecologic care, that is, at the family planning clinic, at a sexual health clinic, or in the doctor's office.

The rubella vaccine is very safe and confers lifelong immunity. Any adverse effects from MMR are likely due to the measles component, not the rubella component. However, there is a small theoretical risk that an unborn child could be affected by rubella vaccine, so it is not recommended for pregnant women, or for women who might become pregnant within four weeks of receiving the vaccine.

Impacts and Issues

Despite mass vaccination efforts, there are still an average of five to six cases of CRS per year in the United States. The numbers are tiny, in comparison to the size of the population. Yet each case represents a family tragedy and is costly in terms of health care for the child involved. In the United States, it is estimated that the lifetime health care costs for a person with CRS are more than $200,000. The mothers of most of the babies born with CRS in the United States were themselves born in countries where rubella vaccine was not readily available. Therefore, such vulnerable women should be targeted for rubella vaccination before they become pregnant. In addition, vaccination with MMR ought to be made universally available to reduce the burden of CRS worldwide.

See AlsoMeasles (Rubeola); Mumps; Scarlet Fever.

BIBLIOGRAPHY

Books

Wilson, Walter R., and Merle A. Sande. Current Diagnosis & Treatment in Infectious Diseases. New York: McGraw Hill, 2001.

Web Sites

Centers for Disease Control and Prevention Pink Book. “Rubella.” <http://www.cdc.gov/nip/publications/pink/rubella.pdf> (accessed April 23, 2007).

Susan Aldridge

Rubella (German Measles)

What Is Rubella?

How Common Is Rubella?

Is Rubella Contagious?

What Happens When Someone Has Rubella?

How Can Rubella Be Prevented?

Resources

Rubella (roo-BEH-luh) is a viral illness that causes a rash. Many people know the disease by its other common name, German measles.

KEYWORDS

for searching the Internet and other reference sources

Congenital rubella syndrome

German measles

MMR

Vaccination

What Is Rubella?

Rubella is caused by the virus of the same name. The word “rubella” comes from the Latin word for “little red,” which originally described the infection’s telltale rash. It also is known by the names German measles and three-day measles, because of its short duration.

Rubella infection usually is not serious. Most people have mild symptoms and a faint rash. However, if a woman develops rubella during the early stages of her pregnancy, it can cause miscarriage*, premature delivery*, and multiple birth defects, known as congenital (kon-JEH-nih-tul) rubella syndrome (CRS). Babies born with CRS may have cataracts* and other eye problems, microcephaly*, mental retardation, deafness, heart defects, enlarged liver or spleen, and other problems.

*miscarriage

is the ending of a pregnancy through the death of the embryo or fetus before birth.

*premature delivery

is when a baby is born before it has reached full term.

*cataracts

(KAH-tuh-rakts) are areas of cloudiness of the lens of the eye that can interfere with vision.

*microcephaly

(my-kro-SEH-fah-lee) is the condition of having an abnormally small head, which typically results from having an underdeveloped or malformed brain.

How Common Is Rubella?

In the United States, the disease was widespread before the current rubella vaccine was introduced. A rubella epidemic* in 1964 and 1965 spawned an estimated 12.5 million cases and 20,000 cases of CRS, according to the U.S. Centers for Disease Control and Prevention (CDC). In 1969, the year the vaccine became available, 57,686 cases of rubella were reported to the CDC. Since then, the number of U.S. cases each year has dropped steadily. The CDC reports that most cases of rubella since the mid-1990s have been seen in young Latino adults who did not receive the vaccine as children. In 2001, there were only 19 cases of rubella reported in the United States, versus 1,400 a decade earlier. The CDC credits global immunization efforts, particularly in Latin America, for the decline.

*epidemic

(eh-pih-DEH-mik) is an outbreak of disease, especially infectious disease, in which the number of cases suddenly becomes far greater than usual. Usually epidemics are outbreaks of diseases in specific regions, whereas worldwide epidemics are called pandemics.

Is Rubella Contagious?

The illness is contagious and spreads through contact with tiny drops of fluid from the mouth and nose of someone who is infected. The drops

leave the mouth and nose when the person sneezes, coughs, or talks. Then other people may inhale the drops, or the drops may land on something that other people touch. Once people get the drops on their hands, they can infect themselves by touching their mouth or nose. The virus enters through the mucous membranes* there and takes hold in the body. Pregnant women also can pass the infection to the fetus* in the womb.

*mucous membranes

are the moist linings of the mouth, nose, eyes, and throat.

*fetus

(FEE-tus) is the term for an unborn human after it is an embryo, from 9 weeks after fertilization until childbirth.

What Happens When Someone Has Rubella?

Signs and symptoms

Symptoms of the illness are often mild, particularly in children. In fact, between one third and one half of all cases may not even be identified as rubella because the symptoms go unnoticed or cannot be distinguished from those of a common, mild respiratory illness such as a cold.

Children with rubella usually develop a distinctive rash. It starts on the face as pink or light red spots and then spreads downward on the body. The rash is fainter than a measles rash, usually does not itch, and lasts from 1 to 3 days. Older children and adults may have symptoms of a viral illness before the rash appears, including swollen lymph nodes* (particularly in the area behind the ears and in the back of the neck), mild fever, runny nose, and conjunctivitis*. Adults also may experience joint and muscle pain and stiffness along with their other symptoms.

*lymph

(LIMF) nodes are small, bean-shaped masses of tissue that contain immune system cells that fight harmful microorganisms. Lymph nodes may swell during infections.

*conjunctivitis

(kon-jung-tih-VY-tis), often called “pinkeye,” is an inflammation of the thin membrane that lines the inside of the eyelids and covers the surface of the eyeball. Conjunctivitis can be caused by viruses, bacteria, allergies, chemical irritation, and other conditions or diseases that cause inflammation.

Making the diagnosis

If a patient is suspected of having rubella, the doctor can confirm the diagnosis by taking samples of fluid from the mouth or nose with a swab. Samples of blood and, rarely, cerebrospinal fluid*

*cerebrospinal

(seh-ree-bro-SPY-nuhl) fluid is the fluid that surrounds the brain and spinal cord.

may be collected as well. All of these will be examined for signs of the virus. The blood sample also may be tested for antibodies* to the virus.

*antibodies

(AN-tih-bah-deez) are protein molecules produced by the body’s immune system to help fight specific infections caused by microorganisms, such as bacteria and viruses.

Treatment

There is no treatment for the disease, and it is generally so mild that specific treatment is unnecessary. Over-the-counter medication such as acetaminophen (uh-see-teh-MIH-noh-fen) can lower a fever and ease pain in the muscles and joints. Infants born with CRS will be treated for any defects they may have developed.

Recovery

Most patients recover completely in 1 to 2 weeks, and in many patients the disease runs its course in as little as 3 days.

Complications tend to occur more often in adults than in children. Temporary arthritis*, which can last up to a month, is common in adults who have rubella. Other, rare complications include inflammation of the brain (encephalitis, en-seh-fuh-LYE-tis), inflammation of nerves (neuritis, nuh-RYE-tis), and abnormal bleeding. If the infection occurs in a pregnant woman, it can lead to miscarriage, premature delivery, or congenital rubella syndrome.

*arthritis

(ar-THRY-tis) refers to any of several disorders characterized by inflammation of the joints.

How Can Rubella Be Prevented?

Vaccination is the best way to prevent rubella infection. The vaccine for rubella is given as part of a combined vaccination for measles*, mumps*, and rubella called MMR. Children receive the MMR vaccine in two doses, usually at age 15 months and 5 years, before entering kindergarten. Doctors recommend that women who are old enough to have children be tested for immunity* to rubella, and if the woman is not immune to the virus, she should be vaccinated.

*measles

(ME-zuls) is a viral respiratory infection that is best known for the rash of large, flat, red blotches that appear on the arms, face, neck, and body.

*mumps

is a contagious viral infection that causes inflammation and swelling in the glands of the mouth that produce saliva.

*immunity

(ih-MYOON-uh-tee) is the condition of being protected against an infectious disease. Immunity often develops after a germ is introduced to the body. One type of immunity occurs when the body makes special protein molecules called antibodies to fight the disease-causing germ. The next time that germ enters the body, the antibodies quickly attack it, usually preventing the germ from causing disease.

See also

Congenital Infections

Conjunctivitis

Encephalitis

Vaccination (Immunization)

Resources

Organization

U.S. Centers for Disease Control and Prevention (CDC), 1600 Clifton Road, Atlanta, GA 30333. The CDC is the U.S. government authority for information about infectious and other diseases. It provides information about rubella at its website.

Telephone 800-311-3435 http://www.cdc.gov

Website

KidsHealth.org. KidsHealth is a website created by the medical experts of the Nemours Foundation and is devoted to issues of children’s health. It contains articles on a variety of health topics, including rubella.

http://www.KidsHealth.org

Rubella

Definition

Rubella is a highly contagious viral disease, spread through contact with discharges from the nose and throat of an infected person. Although rubella causes only mild symptoms of low fever, swollen glands, joint pain, and a fine red rash in most children and adults, it can have severe complications for women in their first trimester of pregnancy. These complications include severe birth defects or death of the fetus.

Description

Rubella is also called German measles or three-day measles. This disease was once a common childhood illness, but its occurrence has been drastically reduced since vaccine against rubella became available in 1969. In the 20 years following the introduction of the vaccine, reported rubella cases dropped 99.6%. Only 229 cases of rubella were reported in the United States in 1996.

Rubella is spread through contact with fluid droplets expelled from the nose or throat of an infected person. A person infected with the rubella virus is contagious for about seven days before any symptoms appear and continues to be able to spread the disease for about four days after the appearance of symptoms. Rubella has an incubation period of 12-23 days.

Although rubella is generally considered a childhood illness, people of any age who have not been vaccinated or previously caught the disease can become infected. Having rubella once or being immunized against rubella normally gives lifetime immunity. This is why vaccination is so effective in reducing the number of rubella cases.

Women of childbearing age who do not have immunity against rubella should be the most concerned about getting the disease. Rubella infection during the first three months of pregnancy can cause a woman to miscarry or cause her baby to be born with birth defects. Although it has been practically eradicated in the United States, rubella is still common in less developed countries because of poor immunization penetration, creating a risk to susceptible travelers. Some countries have chosen to target rubella vaccination to females only and outbreaks in foreign-born males have occurred on cruise ships and at U.S. summer camps.

Causes and symptoms

Rubella is caused by the rubella virus (Rubivirus ). Symptoms are generally mild, and complications are rare in anyone who is not pregnant.

The first visible sign of rubella is a fine red rash that begins on the face and rapidly moves downward to cover the whole body within 24 hours. The rash lasts about three days, which is why rubella is sometimes called the three-day measles. A low fever and swollen glands, especially in the head (around the ears) and neck, often accompany the rash. Joint pain and some-times joint swelling can occur, more often in women. It is quite common to get rubella and not show any symptoms (subclinical infection).

Symptoms disappear within three to four days, except for joint pain, which may linger for a week or two. Most people recover fully with no complications. However, severe complications may arise in the unborn children of women who get rubella during the first three months of their pregnancy. These babies may be miscarried or stillborn. A high percentage are born with birth defects. Birth defects are reported to occur in 50% of women who contract the disease during the first month of pregnancy, 20% of those who contract it in the second month, and 10% of those who contract it in the third month.

The most common birth defects resulting from congenital rubella infection are eye defects such as cataracts, glaucoma, and blindness; deafness; congenital heart defects; and mental retardation. Taken together, these conditions are called congenital rubella syndrome (CRS). The risk of birth defects drops after the first trimester, and by the 20th week, there are rarely any complications.

Diagnosis

The rash caused by the rubella virus and the accompanying symptoms are so similar to other viral infections that it is impossible for a physician to make a confirmed diagnosis on visual examination alone. The only sure way to confirm a case of rubella is by isolating the virus with a blood test or in a laboratory culture.

A blood test is done to check for rubella antibodies. When the body is infected with the rubella virus, it produces both immunoglobulin G (IgG) and immunoglobulin M (IgM) antibodies to fight the infection. Once IgG exists, it persists for a lifetime, but the special IgM antibody usually wanes over six months. A blood test can be used either to confirm a recent infection (IgG and IgM) or determine whether a person has immunity to rubella (IgG only). The lack of antibodies indicates that a person is susceptible to rubella.

All pregnant women should be tested for rubella early in pregnancy, whether or not they have a history of vaccination. If the woman lacks immunity, she is counseled to avoid anyone with the disease and to be vaccinated after giving birth.

Treatment

There is no drug treatment for rubella. Bed rest, fluids, and acetaminophen for pain and temperatures over 102°F (38.9°C) are usually all that is necessary.

Babies born with suspected CRS are isolated and cared for only by people who are sure they are immune to rubella. Congenital heart defects are treated with surgery.

Alternative treatment

Rather than vaccinating a healthy child against rubella, many alternative practitioners recommend allowing the child to contract the disease naturally at the age of five or six years, since the immunity conferred by contracting the disease naturally lasts a lifetime. It is, however, difficult for a child to contract rubella naturally when everyone around him or her has been vaccinated.

Ayurvedic practitioners recommend making the patient comfortable and giving the patient ginger or clove tea to hasten the progress of the disease. Traditional Chinese medicine uses a similar approach. Believing that inducing the skin rash associated with rubella hastens the progress of the disease, traditional Chinese practitioners prescribe herbs such as peppermint (Mentha piperita ) and chai-hu (Bupleurum chinense). Cicada is often prescribed as well. Western herbal remedies may be used to alleviate rubella symptoms. Distilled witch hazel (Hamamelis virginiana ) helps calm the itching associated with the skin rash and an eyewash made from a filtered diffusion of eyebright (Euphrasia officinalis ) can relieve eye discomfort. Antiviral western herbal or Chinese remedies can be used to assist the immune system in establishing equilibrium during the healing process. Depending on the patient's symptoms, among the remedies a homeopath may prescribe are Belladonna,Pulsatilla, or Phytolacca.

Prognosis

Complications from rubella infection are rare in children, pregnant women past the 20th week of pregnancy, and other adults. For women in the first trimester of pregnancy, there is a high likelihood of the child being born with one or more birth defect. Unborn children exposed to rubella early in pregnancy are also more likely to be miscarried, stillborn, or have a low birthweight. Although the symptoms of rubella pass quickly for the mother, the consequences to the unborn child can last a lifetime.

Prevention

Vaccination is the best way to prevent rubella and is normally required by law for children entering school. Rubella vaccine is usually given in conjunction with measles and mumps vaccines in a shot referred to as MMR (mumps, measles, and rubella). Children receive one dose of MMR vaccine at 12-15 months and another dose at four to six years.

Pregnant women should not be vaccinated, and women who are not pregnant should avoid conceiving for at least three months following vaccination. To date, however, accidental rubella vaccinations during pregnancy have not clearly been associated with the same risk as the natural infection itself. Women may be vaccinated while they are breastfeeding. People whose immune systems are compromised, either by the use of drugs such as steroids or by disease, should discuss possible complications with their doctor before being vaccinated.

Resources

ORGANIZATIONS

March of Dimes Birth Defects Foundation. 1275 Mamaroneck Ave., White Plains, NY 10605. (914) 428-7100. [email protected]. 〈http://www.modimes.org〉.

National Organization for Rare Disorders. P.O. Box 8923, New Fairfield, CT 06812-8923. (800) 999-6673. 〈http://www.rarediseases.org〉.

KEY TERMS

Incubation period— The time it takes for a person to become sick after being exposed to a disease.

Trimester— The first third or 13 weeks of pregnancy.

Rubella

Definition

Rubella, also called German measles or three-day measles, is a highly contagious viral disease that in most children and adults causes mild symptoms of low fever , swollen glands, joint pain , and a fine red rash. Although rubella causes only mild symptoms in child and adult sufferers, the infection can have severe complications for the fetus of a woman who becomes infected with the virus during the first trimester of pregnancy. These complications include severe birth defects or death of the fetus.

Description

Rubella is spread through contact with fluid droplets expelled from the nose or throat of an infected person. A person infected with the rubella virus is contagious for about seven days before any symptoms appear and continues to be able to spread the disease for about four days after the appearance of symptoms. Rubella has an incubation period of 12 to 23 days.

Although rubella is generally considered a childhood illness, people of any age who have not been vaccinated or previously caught the disease can become infected. Having rubella once or being immunized against rubella normally gives lifetime immunity. For this reason vaccination is highly effective in reducing the number of rubella cases.

Women of childbearing age who do not have immunity against rubella should be particularly concerned about getting the disease. Rubella infection during the first three months of pregnancy can cause a woman to miscarry or cause her baby to be born with birth defects. Although it has been practically eradicated in the United States, rubella is still common in less developed countries because of poor immunization penetration, creating a risk to susceptible travelers. Some countries have chosen to target rubella vaccination to females only and outbreaks in foreign-born males have occurred on cruise ships and at U.S. summer camps.

Demographics

Although rubella was once a common childhood illness, its occurrence has been drastically reduced since vaccine against it became available in 1969. According to statistics for 1964–1965, prior to routine rubella immunization in the United States, there were 2,100 newborn deaths and 11,250 miscarriages attributed to rubella infection of pregnant women. In addition, about 20,000 infants were born with birth defects attributable to rubella infection in utero. Of these babies, 11,600 were born deaf; 3,580 were born blind; and 1,800 suffered severe developmental delay . In the 20 years following the introduction of the vaccine, reported rubella cases dropped 99.6 percent. In 2000, there were only 152 reported cases of rubella infection and seven reported cases of congenital rubella.

Causes and symptoms

Rubella is caused by the rubella virus (Rubivirus ). Symptoms are generally mild, and complications are rare in anyone who is not pregnant.

The first visible sign of rubella is a fine red rash that begins on the face and rapidly moves downward to cover the whole body within 24 hours. The rash lasts about three days, which is why rubella is sometimes called the three-day measles. A low fever and swollen glands, especially in the head (around the ears) and neck, often accompany the rash. Joint pain and sometimes joint swelling can occur, more often in women. It is quite common to get rubella and not show any symptoms (subclinical infection).

Symptoms disappear within three to four days, except for joint pain, which may linger for a week or two. Most people recover fully with no complications. However, severe complications may arise in the unborn children of women who get rubella during the first three months of their pregnancy. These babies may be miscarried or stillborn. A high percentage is born with birth defects. Birth defects are reported to occur in 50 percent of women who contract the disease during the first month of pregnancy, 20 percent of those who contract it in the second month, and 10 percent of those who contract it in the third month.

The most common birth defects resulting from congenital rubella infection are eye defects such as cataracts, glaucoma, and blindness; deafness; congenital heart defects; and mental retardation . Taken together, these conditions are called congenital rubella syndrome (CRS). The risk of birth defects drops after the first trimester, and by the twentieth week, there are rarely any complications.

Diagnosis

The rash caused by the rubella virus and the accompanying symptoms are so similar to other viral infections that it is impossible for a physician to make a confirmed diagnosis on visual examination alone. The only sure way to confirm a case of rubella is by isolating the virus with a blood test or in a laboratory culture.

A blood test is done to check for rubella antibodies. When the body is infected with the rubella virus, it produces both immunoglobulin G (IgG) and immunoglobulin M (IgM) antibodies to fight the infection. Once IgG exists, it persists for a lifetime, but the special IgM antibody usually wanes over six months. A blood test can be used either to confirm a recent infection (IgG and IgM) or determine whether a person has immunity to rubella (IgG only). The lack of antibodies indicates that a person is susceptible to rubella.

All pregnant women should be tested for rubella early in pregnancy, whether they have a history of vaccination. If the woman lacks immunity, she is counseled to avoid anyone with the disease and to be vaccinated after giving birth.

Treatment

There is no drug treatment for rubella. Bed rest, fluids, and acetaminophen for pain and temperatures over 102°F (38.9°C) are usually all that is necessary.

Babies born with suspected CRS are isolated and cared for only by people who are sure they are immune to rubella. Congenital heart defects are treated with surgery.

Prognosis

Complications from rubella infection are rare in children, pregnant women past the twentieth week of pregnancy, and other adults. For women in the first trimester of pregnancy, there is a high likelihood of the child being born with one or more birth defect. Unborn children exposed to rubella early in pregnancy are also more likely to be miscarried, stillborn, or have a low birth weight. Although the symptoms of rubella pass quickly for the mother, the consequences to the unborn child can last a lifetime.

Prevention

Vaccination is the best way to prevent rubella and is normally required by law for children entering school. Rubella vaccine is usually given in conjunction with measles and mumps vaccines in a shot referred to as MMR (mumps, measles, and rubella). Children receive one dose of MMR vaccine at 12 to 15 months and another dose at four to six years.

Pregnant women should not be vaccinated, and women who are not pregnant should avoid conceiving for at least three months following vaccination. As of 2004, however, accidental rubella vaccinations during pregnancy had not clearly been associated with the same risk as the natural infection itself. Women may be vaccinated while they are breastfeeding. People whose immune systems are compromised, either by the use of drugs such as steroids or by disease, should discuss possible complications with their doctor before being vaccinated.

KEY TERMS

Incubation period —The time period between exposure to an infectious agent, such as a virus or bacteria, and the appearance of symptoms of illness. Also called the latent period.

Trimester —The one of three periods of about 13 weeks each into which a pregnancy is divided.

Parental concerns

While rubella infection in an older child or adult is rarely complicated, the risks of not immunizing a child against rubella are highest in the unborn. Congenital rubella is a serious, life-changing condition, and adherence to immunization recommendations is crucial to the public health.

Resources

BOOKS

Maldonado, Yvonne A. "Rubella Virus." In Principles and Practice of Pediatric Infectious Diseases, 2nd ed. Edited by Sarah S. Long et al. St. Louis, MO: Elsevier, 2003.

Thompson, George H. "The Neck." In Nelson Textbook of Pediatrics. Edited by Richard E. Behrman et al. Philadelphia: Saunders, 2004.

ORGANIZATIONS

March of Dimes Birth Defects Foundation. 1275 Mamaroneck Ave., White Plains, NY 10605. Web site: <www.modimes.org>.

National Organization for Rare Disorders. PO Box 8923, New Fairfield, CT 06812-8923. Web site: <www.rarediseases.org>.

Tish Davidson, A.M. Rosalyn Carson-DeWitt, MD