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Rubella

Rubella
Literature review current through: Jan 2024.
This topic last updated: Nov 29, 2022.

INTRODUCTION — Rubella is a vaccine-preventable viral illness that most often presents as a self-limiting illness in children but can have devastating effects on the fetus when acquired during pregnancy. It was first described in the 1750s and is often referred to as “German measles” due to its characteristic rash that is similar to measles and the attention it received in German literature [1]. The epidemiology, microbiology, pathogenesis, clinical manifestations, clinical approach, diagnosis, treatment, and prevention of rubella will be reviewed here.

Issues related to rubella in pregnancy and congenital rubella syndrome are discussed separately. (See "Rubella in pregnancy" and "Congenital rubella".)

Details on vaccination are also discussed separately. (See "Measles, mumps, and rubella immunization in infants, children, and adolescents" and "Measles, mumps, and rubella immunization in adults".)

EPIDEMIOLOGY

Burden of disease — In 2004, rubella was officially declared eliminated from the United States [2]; in 2015, rubella was eliminated from the Americas [3]. The region of the Americas has sustained elimination of rubella and congenital rubella syndrome [4]. Considerable progress has occurred toward rubella elimination worldwide. By the end of 2021, 173 of 195 countries (89 percent) had introduced rubella-containing vaccines (RCV) into national childhood immunization programs, and 93 (48 percent) of countries verified eliminating transmission of rubella [4,5]. Despite this progress, rubella cases continue to occur, with 10,194 cases occurring globally in 2020 [4]. Estimated coverage of infant rubella vaccine worldwide was 70 percent in 2020 and 66 percent in 2021 [6]. Based on World Health Organization estimates, approximately 100,000 infants are born annually with congenital rubella syndrome [7].

Intermittent outbreaks of rubella may still occur in countries that have a national immunization program with good coverage if there is a substantial proportion of the population that remains susceptible [8,9]. Rubella vaccination based on sex can lead to susceptible males who acquire infection later in life and drive outbreaks of rubella. As an example, Japan introduced rubella vaccination for adolescent females in 1976 and for all children aged one to six years in 1989 [10]. Although the number of cases remained low from 2000 until 2010, the incidence of rubella subsequently increased rapidly, such that over 8500 cases were reported in the first five months of 2013 [9]. From 2012 to 2014, Japan reported over 12,000 cases with 45 cases of congenital rubella syndrome. Most of the cases were in males aged 20 to 49 years, a subset of the population that was not included in the initial rubella vaccination. While the majority of cases were reported in the Kanto area, which includes Tokyo and its surrounding prefectures, the epidemic progressively spread throughout Japan. A surge in rubella cases occurred again in 2018, with most cases reported in the Kanto region [11].

Transmission — Rubella is acquired via inhalation of infectious large particle aerosols and thus is augmented by close and prolonged contact with infected individuals. The incubation period is typically 14 to 18 days (range 12 to 23 days) [2,12,13]. Individuals with infection may shed the virus and are potentially contagious for one week before to two weeks after the rash is noted [14]. In 25 to 50 percent of adult cases, rubella infection is asymptomatic and the shedding and infectiousness of the infected individual is never recognized. Viral shedding decreases with the appearance of the rash.

Infection can also occur from mother to fetus through the placenta. This is discussed separately. (See "Rubella in pregnancy" and "Congenital rubella".)

Outbreaks — All suspected and confirmed cases of rubella should be reported to appropriate public health authorities to monitor disease activity and to document regional and global progress toward rubella elimination [5]. Prior to the development and introduction of rubella vaccine, outbreaks of rubella occurred variably every few years, peaking in the winter and early spring in temperate areas. The incidence tended to be highest among school-age children. Following vaccine implementation, the incidence of rubella declined by more than 99 percent in the United States [13].

Benefits of vaccination — The goal of rubella vaccination is to prevent congenitally acquired rubella. We recommend at least one dose of live attenuated rubella-containing vaccine for all individuals 12 months of age or older. Available rubella vaccines are based on the RA/23 strain grown in human diploid cell cultures; in many locations, including the United States, the rubella vaccine is only available as part of the combined measles, mumps, rubella vaccine (MMR) and the MMR combined with varicella vaccine. Given the two-dose recommendations for measles and mumps, two doses of rubella vaccine are routinely recommended in the United States as MMR or measles, mumps, rubella, and varicella (MMRV), with the first dose at 12 to 15 months of age and the second dose at 4 to 6 years of age or sooner [13]. Global immunization programs often deploy a two-dose schedule of combined measles and rubella vaccine initiated at nine months of age to optimize measles vaccine coverage. Immunization of all young children is required to reduce rates of congenital rubella syndrome [15,16]. One dose of rubella vaccine produces a seroconversion rate of about 95 percent. Details on vaccination of children and adults are discussed elsewhere. (See "Measles, mumps, and rubella immunization in infants, children, and adolescents" and "Measles, mumps, and rubella immunization in adults".)

Vaccination has resulted in a precipitous fall in the number of reported rubella cases. In 1964 to 1965, over 12 million cases of rubella and 20,000 cases of congenital rubella syndrome were recorded in the United States [17]. In 1969, just before the introduction of the vaccine, the reported incidence of rubella was 58 cases per 100,000 populations. By 1983, fewer than 0.5 cases per 100,000 populations were reported (figure 1).

In 2020, rubella vaccine coverage worldwide was 70 percent, suggesting that rubella eradication is feasible [4]. From 2012 to 2019, rubella cases have declined worldwide by 48 percent [4]. An estimated rubella vaccine coverage of greater than 80 percent leads to decreased incidence of rubella in individuals of all ages, including females of childbearing age, leading to a decrease in incidence of congenital rubella syndrome [18,19].

VIROLOGY AND PATHOGENESIS — Rubella virus is the only recognized member of the family Matonaviridae, genus Rubivirus. Its genomic structure and replication process are similar to those of the alphaviruses. In contrast to the alphaviruses, however, humans are the only natural host, though two relatives of rubella virus can infect asymptomatic bats and rodents [20]. The most frequent circulating genotype worldwide is 1E (70 percent) followed by 2B (30 percent) with a wide geographic distribution [4].

Rubella virus' positive-sense, single-stranded RNA encodes three structural proteins: C, E1, and E2 [21]. These proteins are encoded as a single precursor on a 24S subgenomic mRNA and cleaved by cellular peptidases. The capsid protein, C, surrounds the RNA of the virion while the glycosylated envelope proteins, E1 and E2, form transmembrane spikes and serve as the major antigenic sites of the virus [22].

Attachment of the virus occurs at the cell surface, and cell entry likely occurs by transportation into endosomes mediated by specific cellular receptors. The cellular receptor for rubella virus has not yet been elucidated, but the virus' wide tissue tropism suggests membrane phospholipids and glycolipids may be important; myelin oligodendrocyte glycoprotein has been identified as a cellular receptor for rubella [23].

Viral replication takes place in the cytoplasm of the host cell. Virus particles assemble on intracellular membranes. The mechanism of virus release from cells remains undefined, but the cytoplasmic domain of E1 is required [21,24].

Initial replication occurs in nasopharyngeal cells followed by spread to cells within regional lymph nodes. Viremia occurs five to seven days after exposure, allowing the virus to spread throughout the body. The rash appears around the same time as the neutralizing antibodies appear, leading to the hypothesis that the rash is an immune-mediated phenomenon.

CLINICAL MANIFESTATIONS — The clinical manifestations of postnatally acquired rubella are generally mild and many cases are subclinical or asymptomatic. Illness among children tends to be milder than among adults, with fewer prodromal symptoms and complications.

In children — The clinical manifestations of postnatal rubella infection among children typically include the acute onset of a generalized maculopapular rash (can occasionally be pruritic; typically nontender) with minimal systemic symptoms [12,14,15,22,25]. Low-grade fever and lymphadenopathy may occur concurrently or one to five days prior to the appearance of the exanthem. The lymphadenopathy characteristically involves the posterior cervical, posterior auricular, and suboccipital lymph nodes, lasting for five to eight days [22].

The exanthem consists of pinpoint, pink maculopapules. The rash first appears on the face, spreads caudally to the trunk and extremities while sparing palms and soles, and becomes generalized within 24 hours (picture 1). The rash is usually evident for about three days but may last anywhere from one to eight days. Mild nonexudative conjunctivitis and small red spots on the soft palate (Forchheimer spots) also may be observed, and occasionally acute thyroiditis develops.

In neonates (congenital rubella syndrome) — Morbidity resulting from rubella infection occurs primarily in congenitally acquired infections. The most frequent defect associated with congenital rubella syndrome is sensorineural hearing loss, followed by intellectual disability, congenital heart defects, and ocular defects [16,26,27]. These issues are discussed in detail separately. (See "Congenital rubella".)

In adults — Primary infection among teenagers and adults tends to be of longer duration than that among young children. Adults are more frequently symptomatic and symptoms are more frequently accompanied by a prodrome of fever and systemic complaints. The exanthem in adults is similar to that in children, as described above.

Arthralgias and arthritis occur among as many as 70 percent of teenagers and adult women but are uncommon among children and adult males [22,25]. They usually occur concurrently with the rash and may persist for a month or more. The knees, wrists, and fingers are most frequently involved. Although cases of chronic arthritis with rubella have been reported occasionally, the role of rubella virus in causing chronic forms of arthritis is uncertain [12].

Additional findings may include conjunctivitis, testalgia, and orchitis. (See "Conjunctivitis", section on 'Viral' and "Causes of scrotal pain in children and adolescents", section on 'Orchitis'.)

Complications — Complications of rubella are infrequent except in the developing fetus. Hemorrhagic complications (eg, thrombocytopenic purpura, cerebral, gastrointestinal, and intrarenal hemorrhage) are estimated to occur in approximately 1 per 3000 cases and are more frequent among children than adults [28]. Other complications are observed more frequently among teenagers and adults. Postinfectious encephalitis occurs in about 1 per 6000 rubella cases, usually within a week of the exanthem, but may occur without any rash. Although the prognosis is generally good, fatal cases have been reported [24,28]. Progressive rubella panencephalitis is a rare and devastating complication [29].

EXPECTED CLINICAL COURSE — The infection is typically self-limited and does not cause long-lasting complications except in the developing fetus. Immunoglobulin (Ig)G antibodies produced after rubella infection provide protective immunity, but reinfection can occur. Re-exposure can produce a significant rise in the pre-existing antibody titer but rarely results in detectable viremia or risk to a developing fetus. However, a few cases of fetal infection following maternal reinfection have been reported [30,31].

EVALUATION

History and physical — The possibility of postnatally acquired rubella infection should be considered clinically, especially in an outbreak setting in individuals with compatible symptoms (eg, rash, with or without fever, and posterior or suboccipital lymphadenopathy), lack of documented immunity to the virus, history of potential exposure (eg, travel to rubella-endemic countries), and lack of an alternative diagnosis. (See 'When to suspect rubella' below.)

The history, including the review of systems, and physical examination is essential to identifying risk factors or exposures. Exposure to any drugs, new creams, lotions, or detergents, or sick contacts should be reviewed. Routine laboratory tests do not differentiate rubella from other diseases, but special testing, such as a monospot test for infectious mononucleosis or a parvovirus B19 IgM assay, may help establish an alternative diagnosis.

The history should include:

Assessment of immunity to rubella – Presumption of immunity can be made if the individual was born in the United States before 1957, has written documentation of adequate vaccination with at least one dose of a live rubella virus-containing vaccine at >12 months of age, has laboratory evidence of positive rubella IgG titers, and/or has laboratory confirmation of previous infection [25]. If there is any doubt regarding immunity or reinfection in a previously immune individual is suspected, rubella IgG titers should be sent. (See 'Diagnosis' below.)

Assessment of epidemiologic risk factors for exposure to rubella – Risk factors include travel to or immigration from a rubella-endemic country (see 'Burden of disease' above), direct contact with a known or potentially infected individual (see 'Managing exposed individuals without symptoms' below), or recent travel to the location of a current/recent outbreak. Rubella is rare in most high-income countries, but outbreaks can occur even in nations with robust immunization programs.

When to suspect rubella — Suspicion of rubella infection is largely based on immune status and potential for exposure. Rubella is rare in countries with effective national immunization programs. Most cases of rubella occur in nonimmune patients who either live in or have traveled to a country with rubella endemicity or a known outbreak.

Among immune patients, rubella is not typically suspected, even in cases of exposure.

Among nonimmune patients, rubella is suspected in the presence of the following:

Acute onset of generalized maculopapular rash AND

Epidemiologic history that suggests potential exposure to rubella (eg, travel to countries of endemicity in the past two to three weeks, currently living in a country of endemicity, or contact with an individual diagnosed with rubella).

In addition, fever (temperature >37.2°C or 99.0°F), lymphadenopathy, arthralgias, arthritis, and/or conjunctivitis may also be seen and increase suspicion for rubella.

Management of exposed patients without clinical manifestations of rubella infection is discussed below. (See 'Managing exposed individuals without symptoms' below.)

Clinical suspicion of congenital rubella syndrome or rubella in pregnant persons is discussed separately. (See "Congenital rubella" and "Rubella in pregnancy".)

DIAGNOSIS — Diagnostic testing should be obtained for any individual suspected of having rubella. We suggest rubella-specific IgM serology by enzyme immunoassay as the initial diagnostic test due to its availability and low cost [13]. Specific IgM antibody can be detected as early as four days after the onset of rash and is usually detectable after primary infection for six to eight weeks or longer [32]. If ordered within three days of rash onset, IgM may be negative and requires repeat testing in two to four weeks. In some cases, IgG avidity assays requested from a Centers for Disease Control and Prevention (CDC) reference laboratory may be beneficial to differentiate recent rubella infection (low avidity) from past infection or reinfection (high avidity) [13].

Occasionally, false-positive IgM can occur due to cross-reactivity with rheumatoid factor, parvovirus IgM, or heterophile antibodies [13]. Real-time reverse transcriptase-polymerase chain reaction (RT-PCR) is an alternative diagnostic modality that avoids the problem of cross-reactivity and can be detected from a throat swab, nasal swab, or urine specimen. However, RT-PCR is most valuable in the first three days of onset of rash [22]. RT-PCR is generally available through commercial laboratories.

Alternatively, rubella infection and reinfection can be demonstrated by a fourfold rise in rubella IgG antibody concentrations between acute and convalescent sera spaced at least two weeks apart [28].

Viral culture requires specialized cell culture methods and is seldom employed for diagnosis of postnatally acquired rubella.

Diagnosis of prenatal and congenital rubella is discussed elsewhere. (See "Rubella in pregnancy", section on 'Diagnosis' and "Congenital rubella", section on 'Diagnosis'.)

DIFFERENTIAL DIAGNOSIS — The differential diagnosis of rubella includes infectious and noninfectious causes such as other viral illnesses, skin diseases, and drug reactions that cause a similar-looking rash (generalized maculopapular rash with sparing of palms and soles). Rubella generally can be distinguished from other causes of a similar-looking rash based on its pattern of presentation. The typical rubella rash begins on the face and spreads downward to involve the trunk and extremities over the next 24 hours; it typically disappears by the end of the third day. Although the measles rash can present in a similar fashion, it typically presents along with coryza or conjunctivitis, both of which are rarely seen with rubella.

Other infections that should be considered based on their similar-looking rashes include scarlet fever, parvovirus B19, roseola (human herpes virus 6 and 7-associated disease), rash-associated enteroviral infections, infectious mononucleosis, and toxoplasmosis. These illnesses can often be differentiated from rubella based on epidemiologic exposure history and presence of other symptoms (eg, pharyngitis, conjunctivitis).

Certain skin diseases and drug reactions may also present with a similar-appearing rash but rarely demonstrate the same pattern of spread. (See "Fever and rash in the immunocompetent patient".)

TREATMENT AND MANAGEMENT — There is no available specific antiviral therapy for rubella. Treatment consists of supportive care. Supportive therapy includes antipyretics, oral fluids, and symptomatic control of the rash and arthralgias/arthritis, if present. Symptomatic management of rash and joint symptoms are discussed separately. (See "Exanthematous (maculopapular) drug eruption", section on 'Symptomatic treatment'.)

All confirmed cases of rubella should be reported to the local public health department.

PREVENTION AND CONTROL

Isolation of infected individuals — Individuals infected with postnatal rubella should remain in isolation with droplet precautions for seven days after the onset of the rash [13,25,33]. Only individuals who are known to be immune to rubella (see 'History and physical' above) should care for infected individuals while they are in isolation.

Managing exposed individuals without symptoms — Individuals exposed to rubella should be assessed for immunity to the virus. Exposure is defined as any direct contact with an infected individual seven days before and after rash onset. All women of childbearing age in contact with infected individuals should have their pregnancy status determined.

Individual with immunity – These individuals are assumed to be protected against rubella and no further action is necessary. Evaluation of immunity is discussed elsewhere. (See 'History and physical' above.)

Individual without immunity – Nonimmune persons should be isolated from infected patients for seven days after onset of the rash. In cases of an outbreak, nonimmune persons should be excluded from the outbreak setting (eg, school) until 23 days after the onset of rash in the last reported case associated with the outbreak [25,33]. Additionally, any exposed person without documented immunity to rubella should receive rubella vaccination except in situations when it is contraindicated (eg, pregnancy, immunosuppressed individual). Administration of the vaccine after exposure has not been shown to prevent illness, but it will protect these individuals in the future. Immunization during the incubation period is not associated with an increased risk of adverse effects [15].

Postexposure prophylaxis with immune globulin following rubella exposure is not recommended. Although a meta-analysis of 11 trials including children and adults suggested that various doses of immune globulin could decrease rates of symptomatic rubella following exposure, there was significant heterogeneity across studies, with several suggesting no effect. Furthermore, most of the studies were very small, and in one of the largest studies, neither exposure nor the outcome of rubella were clearly defined [34]. Additionally, in exposed pregnant persons, failures to prevent congenital rubella have been reported with the use of immune globulin [15].

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

Basics topic (see "Patient education: Rubella (The Basics)")

SUMMARY AND RECOMMENDATIONS

Introduction

Rubella (German measles) is a viral illness that most often presents as a self-limiting illness in children but can have devastating effects on the fetus when acquired during pregnancy. Vaccination against rubella is highly effective. (See 'Introduction' above and 'Benefits of vaccination' above.)

Rubella is acquired through the inhalation of large particle aerosols of infectious secretions with initial infection of nasopharyngeal cells and subsequent viremia and spread to other body sites. Infected individuals may shed virus and are potentially contagious for one week before to two weeks after onset of rash. (See 'Virology and pathogenesis' above.)

Clinical presentation

Rubella is typically characterized by rash, fever, and lymphadenopathy, although subclinical or asymptomatic infection is common. The rash is usually an erythematous, discrete maculopapular exanthem that begins on the face and spreads caudally; palms and soles are spared. It usually lasts for three to eight days. (See 'Clinical manifestations' above.)

Rubella infection during pregnancy can lead to fetal death, premature delivery, and a myriad of congenital abnormalities. The most common manifestations of congenital rubella syndrome are hearing loss, developmental delay, growth retardation, and cardiac and ophthalmic defects. (See "Rubella in pregnancy" and "Congenital rubella".)

Evaluation and diagnosis

Rubella should be suspected in a nonimmune individual who shows symptoms or signs consistent with rubella infection (eg, rash, fever) and has been in contact with an infected person, currently lives in an endemic country, or has traveled to an endemic country in the past two to three weeks. (See 'Burden of disease' above and 'When to suspect rubella' above.)

We suggest rubella-specific immunoglobulin (Ig)M serology as the initial diagnostic test due to its availability and low cost. Real-time reverse transcriptase-polymerase chain reaction is an alternative diagnostic modality that can be detected from a throat swab, nasal swab, or urine specimen when false-negative or false-positive IgM results are of concern. (See 'Diagnosis' above.)

Differential diagnosis includes scarlet fever, parvovirus B19, roseola (human herpes virus 6 and 7-associated disease), rash-associated enteroviral infections, infectious mononucleosis, measles, toxoplasmosis, as well as noninfectious skin diseases and drug reactions. (See 'Differential diagnosis' above.)

Management

Management of infected individuals consists of supportive care. No specific therapy exists for rubella. (See 'Treatment and management' above.)

Individuals with postnatal rubella should remain in isolation for seven days after the onset of the rash. Hospitalized or institutionalized patients should be placed on droplet precautions and only individuals who are known to be immune to rubella virus should care for infected individuals. (See 'Isolation of infected individuals' above.)

For individuals exposed to rubella, management depends on immune status. No precautions are necessary if the person is immune. For nonimmune individuals, isolation from infected individuals is recommended for seven days after onset of rash in the infected individual. In cases of an outbreak, avoidance of the outbreak setting is recommended for 23 days after the onset of rash in the last reported case. (See 'Managing exposed individuals without symptoms' above.)

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References

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