Rubella, commonly known as German measles, is a disease caused by the rubella virus. The name "rubella" is
derived from Latin, meaning little red.
Rubella is also known as German measles because the disease was first described
by German physicians in the mid-eighteenth century. This disease is often mild
and attacks often pass unnoticed. The disease can last one to three days.
Children recover more quickly than adults. Infection of the mother by Rubella
virus during pregnancy can be serious; if the mother is infected within the
first 20 weeks of pregnancy, the child may be born with congenital rubella
syndrome
(CRS), which entails a range of serious incurable illnesses. Spontaneous
abortion occurs in up to 20% of cases.
Rubella is a common childhood infection usually with minimal
systemic upset although transient arthropathy may occur in adults. Serious
complications are very rare. Apart from the effects of transplacental infection
on the developing fetus, rubella is a relatively trivial infection.
Acquired (i.e. not congenital) rubella is transmitted via
airborne droplet emission from the upper respiratory tract of active cases (can
be passed along by the breath of people sick from Rubella). The virus may also
be present in the urine, feces and on the skin. There is no carrier state: the
reservoir exists entirely in active human cases. The disease has an incubation period of 2 to 3 weeks.[2] In most people the virus is rapidly
eliminated. However, it may persist for some months post partum in infants
surviving the CRS. These children are a significant source of infection to
other infants and, more importantly, to pregnant female contacts.
The name rubella
is sometimes confused with rubeola,
an alternative name for measles in English-speaking countries; the
diseases are unrelated. In some other European languages, like Spanish, rubella and rubeola are synonyms, and rubeola
is not an alternative name for measles.
Signs and symptoms
After an incubation period of 14–21 days, German measles
causes symptoms that are similar to the flu. The primary symptom of rubella
virus infection is the appearance of a rash (exanthem) on the face which
spreads to the trunk and limbs and usually fades after three days (that is why
it is often referred to as three-day measles). The facial rash usually clears
as it spreads to other parts of the body. Other symptoms include low grade
fever, swollen glands (sub occipital & posterior cervical lymphadenopathy),
joint pains, headache and conjunctivitis. The swollen glands or lymph nodes can persist for up
to a week and the fever rarely rises above
38 oC (100.4 oF). The rash of German measles is typically
pink or light red. The rash causes itching and often lasts for about three
days. The rash disappears after a few days with no staining or peeling of the
skin. When the rash clears up, the skin might shed in very small flakes where
the rash covered it. Forchheimer's sign occurs in 20% of cases, and is
characterized by small, red papules on the area of the soft palate.
Rubella can affect anyone of any age and is generally a mild
disease, rare in infants or those over the age of 40. The older the person is
the more severe the symptoms are likely to be. Up to two-thirds of older girls
or women experience joint pain or arthritic type symptoms with rubella. The
virus is contracted through the respiratory tract and has an incubation period
of 2 to 3 weeks. During this incubation period, the patient is contagious
typically for about one week before he develops a rash and for about one week
thereafter.
Congenital rubella syndrome
Rubella can cause congenital rubella
syndrome
in the newly born. The syndrome (CRS) follows intrauterine infection by the
Rubella virus and comprises cardiac, cerebral, ophthalmic and auditory defects.
It may also cause prematurity, low
birth weight, and neonatal thrombocytopenia, anaemia and hepatitis. The risk of
major defects or organogenesis is highest for infection in the first trimester. CRS is the main
reason a vaccine for rubella was developed. Many mothers who contract rubella
within the first critical trimester either have a miscarriage or a still born
baby. If the baby survives the infection, it can be born with severe heart
disorders (Patent ductus
arteriosus being the most common), blindness, deafness, or other life
threatening organ disorders. The skin manifestations are called "blueberry
muffin lesions". For these reasons, Rubella is included on the TORCH complex of perinatal
infections.
Cause
The disease is caused by Rubella virus, a togavirus that is enveloped and has a
single-stranded RNA genome. The virus is transmitted by the respiratory route
and replicates in the nasopharynx and lymph nodes. The virus is found in the blood 5 to
7 days after infection and spreads throughout the body. The virus has teratogenic properties and is
capable of crossing the placenta and infecting the fetus where it stops cells
from developing or destroys them.
Increased susceptibility to infection might be inherited as
there is some indication that HLA-A1 or factors
surrounding A1 on extended haplotypes are involved in
virus infection or non-resolution of the disease.
Diagnosis
Rubella virus specific IgM antibodies are
present in people recently infected by Rubella virus but these antibodies can
persist for over a year and a positive test result needs to be interpreted with
caution. The presence of these antibodies along with, or a short time after,
the characteristic rash confirms the diagnosis.
Prevention
Further
information: MMR vaccine
Rubella infections are prevented by active immunisation programs using live,
disabled virus vaccines. Two live attenuated virus vaccines,
RA 27/3 and Cendehill strains, were effective in the prevention of adult
disease. However their use in prepubertile females did not produce a
significant fall in the overall incidence rate of CRS in the UK. Reductions
were only achieved by immunisation of all children.
The vaccine is now usually given as part of the MMR vaccine. The WHO recommends the first dose is given at 12 to 18 months of
age with a second dose at 36 months. Pregnant women are usually tested for
immunity to rubella early on. Women found to be susceptible are not vaccinated
until after the baby is born because the vaccine contains live virus.
The immunisation program has been
quite successful. Cuba declared the disease
eliminated in the 1990s, and in 2004 the Centers
for Disease Control and Prevention announced that both the congenital and
acquired forms of rubella had been eliminated from the United States.
Screening for rubella susceptibility by history of
vaccination or by serology is recommended in the United States
for all women of childbearing age at their first preconception
counseling visit to reduce incidence of congenital rubella
syndrome
(CRS). It is recommended that all susceptible non-pregnant women of
childbearing age should be offered rubella vaccination. Due to concerns about
possible teratogenicity, use of MMR vaccine is not recommended during pregnancy.
Instead, susceptible pregnant women should be vaccinated as soon as possible in
the postpartum period.
Treatment
There is no specific treatment for Rubella; however,
management is a matter of responding to symptoms to diminish discomfort.
Treatment of newly born babies is focused on management of the complications. Congenital heart
defects[citation needed] and cataracts can be corrected by direct surgery.[18] Management for ocular congenital rubella
syndrome (CRS) is similar to that for age-related macular degeneration, including
counseling, regular monitoring, and the provision of low vision devices, if
required.
Prognosis
Rubella infection of children and adults is usually mild,
self-limiting and often asymptomatic. The prognosis in children born with CRS
is poor.
Epidemiology
Rubella is a disease that occurs worldwide. The virus tends
to peak during the spring in countries with temperate climates. Before the
vaccine to rubella was introduced in 1969, widespread outbreaks usually
occurred every 6–9 years in the United States and 3–5 years in Europe, mostly
affecting children in the 5-9 year old age group. Since the
introduction of vaccine, occurrences have become rare in those countries with
high uptake rates.
Vaccination has interrupted the transmission of rubella in
the Americas: no endemic case has
been observed since February 2009. Since
the virus can always be reintroduced from other continents, the population
still need to remain vaccinated to keep the western hemisphere free of rubella.
During the epidemic in the US between 1962–1965, Rubella virus infections
during pregnancy were estimated to have caused 30,000 still births and 20,000
children to be born impaired or disabled as a result of CRS. Universal immunisation
producing a high level of herd immunity is important in the control of
epidemics of rubella.
In the UK, there remains a large population of men
susceptible to rubella who have not been vaccinated. Outbreaks of rubella
occurred amongst many young men in the UK in 1993 and in 1996 the infection was
transmitted to pregnant women, many of whom were immigrants and were
susceptible. Outbreaks still arise, usually in developing countries where the vaccine is
not as accessible.
History
Rubella was first described in the mid-eighteenth century. Friedrich Hoffmann made the first
clinical description of rubella in 1740, which was confirmed by de Bergen in
1752 and Orlow in 1758.
In 1814, George de Maton first suggested that it be
considered a disease distinct from both measles and scarlet fever. All these physicians were German, and
the disease was known as Rötheln (contemporary German Röteln), hence the common name of "German measles".Henry
Veale, an English Royal Artillery surgeon, described an outbreak in India. He
coined the name "rubella" (from the Latin, meaning "little
red") in 1866.
It was formally recognised as an individual entity in 1881,
at the International Congress of Medicine in London. In 1914, Alfred Fabian Hess theorised that
rubella was caused by a virus, based on work with monkeys. In 1938, Hiro and
Tosaka confirmed this by passing the disease to children using filtered nasal
washings from acute cases.
In 1940, there was a widespread epidemic of rubella in
Australia. Subsequently, ophthalmologist Norman McAllister Gregg found 78 cases of congenital cataracts
in infants and 68 of them were born to mothers who had caught rubella in early
pregnancy. Gregg published an account, Congenital
Cataract Following German Measles in the Mother, in 1941. He described a
variety of problems now known as congenital rubella
syndrome
(CRS) and noticed that the earlier the mother was infected, the worse the
damage was. The virus was isolated in tissue culture in 1962 by two separate
groups led by physicians Parkman and Weller.
There was a pandemic of rubella between 1962 and 1965,
starting in Europe and spreading to the United States. In the years 1964-65,
the United States had an estimated 12.5 million rubella cases. This led to
11,000 miscarriages or therapeutic abortions and 20,000 cases of congenital
rubella syndrome. Of these, 2,100 died as neonates, 12,000 were deaf, 3,580
were blind and 1,800 were mentally retarded. In New York alone, CRS affected 1%
of all births
In 1969 a live attenuated virus vaccine was licensed. In the
early 1970s, a triple vaccine containing attenuated measles, mumps and rubella
(MMR) viruses was introduced.
Rubella Outbreak --- Arkansas, 1999
Rubella is a viral disease that usually presents as a mild
febrile rash illness in adults and children; however, 20%--50% of infected
persons are asymptomatic. Rubella can have severe adverse effects on the
fetuses of pregnant women who contract the disease during the first trimester
of pregnancy, causing a wide range of congenital defects known as congenital
rubella syndrome (CRS). The primary objective of the rubella vaccination
program is to prevent intrauterine rubella infection. The primary strategies
for rubella control in the United States are universal childhood vaccination,
prenatal screening of pregnant women for rubella immunity, and vaccinating
rubella-susceptible women postpartum. After the licensure of rubella vaccine in
1969, the incidence of rubella and CRS decreased 99% by 1997. However,
outbreaks continue to occur. During September 7--October 26, 1999, a total of
12 cases of rubella were confirmed in three Arkansas counties. This report
describes this outbreak, which prompted reimplementation of routine rubella
control and prevention measures. These included prenatal screening for rubella
immunity and postnatal vaccination of rubella-susceptible women and the
initiation of prevention and control activities in foreign-born populations
that are less likely to be vaccinated.
On September 7, a pregnant woman aged 23 years presented to
a public health clinic in Fort Smith, Sebastian County, Arkansas, with rash and
fever. The woman was from Mexico and had lived in Arkansas for 1 year before
onset of illness. She later delivered a stillborn infant with pathologic
findings compatible with intrauterine rubella infection. The index patient was
a household contact of a Mexican aged 20 years who also was confirmed as
infected with rubella by EIA testing. Both patients worked in a poultry
processing plant in Fort Smith.
Outbreak investigators interviewed household and workplace
contacts, suspected patients, and potentially exposed pregnant women and tested
them for rubella IgG and IgM antibodies. An additional 10 cases were confirmed
by laboratory testing in this and two other counties. A definitive laboratory
diagnosis or epidemiologic link could not be established for an additional 14
patients (seven meeting the case definition for suspected and seven for
probable rubella). Among the 12 confirmed cases, the median age was 23 years
(range: 18--34 years); 10 (83%) were Hispanic, nine (75%) were foreign-born,
and six (50%) were women. All six female patients were pregnant, and one became
infected during the first trimester of pregnancy. Ten (83%) patients worked in
poultry processing plants; the index patient and seven others worked at the
same plant in Fort Smith. Nine of these 10 patients were Hispanic and were
foreign-born (Mexico and El Salvador).
Screening of pregnant women for rubella immunity was not
part of routine prenatal care in Arkansas' public health clinics when this
outbreak occurred. Because the index patient and other potential patients
exposed persons in the clinic waiting room, and because the proportion of
rubella-susceptible pregnant women attending the clinic was unknown, a
serosusceptibility survey was conducted at the clinic during September
23--October 29. A questionnaire was administered to and serum specimens were
taken from 155 women consecutively attending the clinic and tested for rubella
IgG and IgM. Of the 155 women tested, 79 (51%) were Hispanic, 64 (41%) were
white, five were black (3%), three (2%) were Asian, and four (3%) were of
unknown race/ethnicity. Seventy-three (47%) women were foreign-born; 72 (99%)
were born in Central America and Mexico. The median age was 23 years (range:
15--43 years). Of the 155 women, 46 (32%) reported a history of rubella
vaccination, 25 (17%) had not been vaccinated, 74 (51%) did not know their
rubella vaccination status, and no data were available for the remaining 10
(6%). In comparison with the relatively low number of women with a
self-reported history of rubella vaccination, 134 (86%) women had positive test
results for rubella IgG, 14 (9%) had negative test results, and seven (5%) had
equivocal or missing test results. No association was found between
IgG-positivity and nationality or history of vaccination. Of the 21 women who
had equivocal or negative results, 11 (52%) reported a previous delivery in the
United States, and 19 (90%) missed at least one opportunity for rubella
vaccination.
The findings in this report highlight the absence of
routine, recommended prevention and control efforts in the state and the
emergence of Hispanic, foreign-born persons as the main reservoirs of rubella
virus in the United States. Prenatal screening followed by postpartum
vaccination against rubella is essential for the control and elimination of
CRS. Although recommended by the American College of Obstetricians and
Gynecologists and the Advisory Committee on Immunization Practices , prenatal
screening for rubella was discontinued in Arkansas public health clinics during
the early 1980s because of fiscal constraints. In the absence of routine prenatal
screening for rubella antibodies, the immune status of pregnant women
potentially exposed to rubella virus was unknown. In the United States,
prenatal screening and postpartum vaccination might prevent an estimated 50% of
all CRS cases.
Based on supplementary data reported through the national
notifiable diseases surveillance system in the United States, rubella primarily
affects foreign-born Hispanic adults. Among rubella patients with known
ethnicity in the United States, the proportion of Hispanics increased from 19%
in 1992 to 79% in 1998, compared with 83% of patients in this outbreak. In the
affected plant in Fort Smith, a large proportion of the workforce was Hispanic,
and many of these were born and raised abroad. In Latin America, many countries
have only recently introduced rubella into their routine childhood vaccination
programs. For immigrants entering the United States, vaccination efforts focus
on preschool-aged children and students; adults are not routinely screened or
vaccinated. To eliminate rubella and CRS in the United States, further control
efforts are needed to identify and vaccinate clusters of rubella-susceptible
adults and to ensure nationwide prenatal rubella screening and postpartum
vaccination of rubella-susceptible women.
As a result of this outbreak, the Arkansas Department of
Health (ADH), in collaboration with employers, implemented additional control
efforts that focused on workplace vaccination. ADH implemented a
measles-mumps-rubella (MMR) vaccine screening policy at a local employment
agency that supplied temporary help for the poultry processing companies.
Potential employees were required to show proof of a previous MMR vaccination
or receive MMR vaccine before employment. In addition, ADH recommended that
employers of large numbers of foreign-born persons provide vaccine at the plant
site and offered clinics to any industry that employed large numbers of
foreign-born persons in Arkansas.
ADH has reimplemented routine screening for rubella immunity
in all maternity and family planning clinics. Susceptible ADH maternity
patients are identified routinely and offered MMR vaccine postpartum, and
family planning patients are offered MMR vaccine immediately with appropriate
counseling. These measures have resulted in substantial increases in rubella
seropositivity rates for pregnant women in ADH clinics. Control efforts such as
these in conjunction with proven routine measures are necessary to eliminate
indigenous rubella and CRS in the United States.
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