RUBELLA
Etiology
• Caused by an enveloped, single-stranded RNA virus from the Togaviridae family.
• Highly contagious; transmitted through respiratory secretions.
• First isolated in 1962.
• Endemic to humans.
• Known as German measles or 3-day measles.
Epidemiology
• Live attenuated vaccine first licensed in the U.S. in 1969.
• Pre-vaccine epidemics every 6–9 years.
• 1964 U.S. epidemic: >20,000 congenital rubella syndrome (CRS) cases and unknown
stillbirths.
• PAHO efforts to eliminate rubella in the Americas.
• Countries with high incidence due to low vaccination: epidemics common.
• Recent U.S. outbreak groups:
◦ Unvaccinated preschool children
◦ Highly vaccinated school-age children (due to vaccine failures)
• Up to 20% of U.S. college students may be susceptible.
• Routes to immunity: infection or vaccination.
• Permanent immunity usually results from infection or successful vaccination.
• Only proof of immunity: positive serologic test.
• Clinical history (even physician-verified) not acceptable for proof.
Groups Needing Rubella Immune Status Determination
• Preschool and school-age children
• Females near or at childbearing age
• Women about to marry or already married
• Pregnant women (do not vaccinate during pregnancy; vaccinate post-termination)
• Health care personnel
Rubella Vaccine Reactions
• Linked to acute arthritis in adult females.
• Weak but consistent link to chronic arthritis.
• 13–15% incidence in adult females post-vaccination.
• Lower reaction rates in males and younger populations.
Signs and Symptoms
Acquired Rubella
• Incubation: 10–21 days (12–14 typical).
• Contagious: 5–7 days before rash to ~15 days.
• Duration: 3–5 days, mild course, rare permanent effects.
• Begins with catarrhal symptoms, then lymph node involvement.
• Followed by maculopapular rash (face → neck → trunk).
• Common: mild fever (<34.4°C or 94°F), arthralgia/arthritis in older children/adults.
• Can mimic infectious mononucleosis or drug-induced rash.
Congenital Rubella Syndrome (CRS)
• High risk if infection during 1st trimester.
• Outcomes: fetal death, rubella syndrome (congenital defects).
• 10–20% of infected infants die before 18 months.
Risk by gestational age:
◦ Before 11 weeks: 90%
◦ 11–12 weeks: 33%
◦ 13–14 weeks: 11%
◦ 15–16 weeks: 24%
◦ After 16 weeks: 0%
Congenital Defects May Include:
◦ Stillbirth
◦ Encephalitis
◦ Hepatomegaly
◦ Bone defects
◦ Mental retardation
◦ Cataracts
◦ Thrombocytopenic purpura
◦ Cardiovascular defects
◦ Splenomegaly
◦ Microcephaly
◦ Low birth weight, failure to thrive
• Some congenital infections show symptoms only months/years later.
• Most develop rubella immunity but may lose antibodies by late childhood.
• Recommendation: test and vaccinate children with CRS before adolescence.
Immunologic Manifestations
Acquired Rubella
• IgM: appears after symptoms, peaks 7–10 days, gone in 4–5 weeks. Indicates recent
infection.
• IgG: rises with symptoms, remains indefinitely. Indicates past infection or immunity.
• Diagnosis: requires acute and convalescent samples (≥2 weeks apart).
• IgG ≥1:8 dilution = immunity.
• IgM also appears briefly after vaccination.
Congenital Rubella
• IgG (maternal origin) crosses placenta — not diagnostic.
• IgM does not cross placenta — its presence in neonate confirms congenital rubella.
• Test neonates up to 6 months after birth, especially if clinical evidence is delayed or
unclear.
Diagnostic Evaluation
• Screening tests: TORCH panel (Toxoplasma, Others, Rubella, CMV, Herpes).
• Diagnostic tests (IgM and IgG detection):
◦ Chemiluminescent immunoassay
◦ Immunochromatographic assay
◦ Indirect immunofluorescence assay
◦ Monoclonal antibodies to rubella virion proteins (E2, C)
Cross-Reactivity Issues:
• Rubella-specific IgM may appear in infectious mononucleosis or parvovirus.
• Pregnant women may test positive for IgM to rubella, CMV, varicella-zoster, measles.
• In such cases, diagnosis must rely on rubella-specific IgG and clinical history.
