Rubella

oPatientPlus articles are written by UK doctors and are based on research evidence, UK and European Guidelines. They are designed for health professionals to use, so you may find the language more technical than the condition leaflets.

Synonym: German measles

This disease is notifiable in the UK, see NOIDs article for more detail.

Rubella is a viral infection once seen mainly in spring and early summer. Epidemics occur every 6 to 9 years in populations with no vaccination programme.[1] Before introduction of vaccination it was endemic in virtually all countries.

It is now quite rare in developed nations since the introduction of immunisation (see separate article Measles, Mumps and Rubella (MMR) Vaccination). The vaccine is safe and vaccination is a very successful health intervention.

In the absence of mass vaccination, approximately 10-20% of women reaching child-bearing age are susceptible to rubella.

  • An RNA virus (genus Rubivirus, family Togaviridae) with man as the only known host:
    • There is only one major antigenic type.
    • It is transmitted as airborne droplets between close contacts (unlike most togaviruses which are arthropod-borne).
    • The incubation period is 14-21 days with patients being infectious for up to seven days before and four days after symptoms appear.
    • Infectivity is greatest just before and on the day of symptoms appearing.
  • Its major complication of maternal infection in early pregnancy is congenital rubella syndrome (CRS) - see separate article Congenital Rubella Syndrome:
    • This causes a wide variety of malformations affecting the cardiac, ocular, central nervous and skeletal systems when a pregnant mother is infected.
    • This is still a problem in many developing countries.

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  • Since 1991, only around one third of congenital rubella syndrome (CRS) infants have been born to UK-born women who acquired the infection in the UK.
  • In 2011, there was only one confirmed case of rubella in England and Wales.[2]
  • It should be remembered that rubella remains endemic in many developing countries, and that over 100,000 children worldwide every year are born with CRS.
  • Symptoms:
    • Prodromal phase of lassitude, low-grade fever, headache, mild conjunctivitis and anorexia with rhinorrhoea very similar to a cold. The prodrome may be absent in children and tends to be more noticeable in adults.
    • The rash then develops (it may be absent, especially in young children) - initially, pink discrete macules that coalesce, starting behind the ears and on the face, spreading to the trunk and then the extremities.
    • Cervical, suboccipital, and postauricular lymphadenopathy are characteristic and may precede the rash.
    • Constitutional symptoms are usually mild (can be more prominent in adults).
    • In older patients, arthralgia is common.
  • Signs:
    • There may be petechiae on the soft palate (Forchheimer's sign), but this is not diagnostic for rubella.
    • The rash is shown in close-up, but it should be remembered that clinical diagnosis is unreliable.
    • The rash usually develops 14-17 days after exposure to the virus.
RUBELLA

Clinical diagnosis is unreliable since symptoms are often fleeting and mimicked by other viruses. In particular, the rash is not diagnostic.

  • Detection of specific IgM in saliva samples is both sensitive and specific.
    • Rubella-specific IgM implies primary infection.
    • A rise in IgG titre over two weeks usually occurs.
    • The rubella virus can potentially be isolated from a throat culture during the acute phase of illness, but this technique is not a practical way to establish the diagnosis.[3]
  • FBC may show a low WBC count with an increased proportion of lymphocytes and thrombocytopenia (usually resolves in a month).
  • There is no specific treatment.
  • Keep the child away from school for seven days after the rash appears.
  • Use antipyretics for fever - avoid aspirin in children due to the danger of Reye's syndrome.
  • Ask about any contact with pregnant women.
  • Where suspected infection occurs in a pregnant woman, it should be confirmed by investigation, in liaison with a virologist, and counselling should be given about the dangers to the fetus. Management requires referral and expert support.
  • Complications occur rarely.
  • Rubella encephalopathy may occur about six days after the rash (usually there is full recovery in a few days without sequelae).
  • Arthritis and arthralgia can occur in adults.
  • Thrombocytopenia occurs in around 1 in 3,000 cases.
  • Guillain-Barré syndrome/neuritis.
  • Panencephalitis.
  • The advice is that children should be excluded from school for 5-7 days after onset of the rash.[4] This is not an effective preventative measure, as the infection is most contagious before appearance of the rash.
  • Vaccination via MMR in the second year of life plus a preschool booster, with antenatal screening for rubella susceptibility.
  • Where non-immunity to rubella is discovered during pregnancy, immunisation after delivery offers protection for future pregnancies.
  • The vaccine has been proven to be safe, immunogenic and effective.[5]
  • The overall decline in rubella incidence and increase in the number of countries conducting rubella surveillance through a mandatory notification system are notable achievements toward the goal of rubella elimination in Europe.[6]

See separate Congenital Rubella Syndrome article.

Further reading & references

  1. General Information on Rubella (German Measles), Health Protection Agency
  2. Rubella notifications (confirmed cases), England and Wales, 1995-2011, Health Protection Agency
  3. Dyne PL et al, Pediatrics, Rubella, Medscape, Sep 2009
  4. Guidelines on Rubella (German Measles), Health Protection Agency (2009)
  5. Davidkin I, Kontio M, Paunio M, et al; MMR vaccination and disease elimination: the Finnish experience. Expert Rev Vaccines. 2010 Sep;9(9):1045-53.
  6. Muscat M, Zimmerman L, Bacci S, et al; Toward rubella elimination in Europe: An epidemiological assessment. Vaccine. 2011 Dec 14.

Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. EMIS has used all reasonable care in compiling the information but make no warranty as to its accuracy. Consult a doctor or other health care professional for diagnosis and treatment of medical conditions. For details see our conditions.

Original Author:
Dr Richard Draper
Current Version:
Peer Reviewer:
Dr John Cox
Last Checked:
20/02/2012
Document ID:
2741 (v24)
© EMIS