For Healthcare Professionals

Clinical Overview

Clinical Features

Rubella is a viral illness that can lead to complications and death. It is characterized by a mild, maculopapular rash along with lymphadenopathy, and a slight fever. The rash usually starts on the face, becomes generalized within 24 hours, and lasts a median of 3 days; it occurs in 50% to 80% of infected people, Lymphadenopathy, which may precede rash, often involves posterior auricular or suboccipital lymph nodes, can be generalized, and lasts between 5 and 8 days. About 25% to 50% of infections are asymptomatic.

Clinical diagnosis of rubella virus is unreliable and should not be considered in assessing immune status. Up to half of all infections may be subclinical or unapparent. Many rubella infections are not recognized because the rash resembles many other rash illnesses.

The Virus

Rubella virus is an enveloped, positive-stranded RNA virus classified as a Rubivirus in the Togaviridae family.

Background

Before the rubella vaccine was licensed in the United States in 1969, rubella was a common disease that occurred primarily among young children. Epidemics occurred every 6 to 9 years, with the highest number of cases during the spring.

Rubella was declared eliminated (the absence of endemic transmission for 12 months or more) from the United States in 2004. However, it is still commonly transmitted in many parts of the world. As a result, less than 10 cases (primarily import-related) have been reported annually in the United States since elimination was declared. Rubella incidence in the United States has decreased by more than 99% from the pre-vaccine era.

Because rubella continues to circulate in other parts of the world, an estimated 100,000 infants are born with congenital rubella syndrome (CRS) annually worldwide.

Complications

Arthralgia or arthritis may occur in up to 70% of adult women with rubella. Rare complications include thrombocytopenic purpura and encephalitis.

When rubella infection occurs during pregnancy, especially during the first trimester, serious consequences can result. These include miscarriages, fetal deaths/stillbirths, and severe birth defects known as CRS. The most common congenital defects are cataracts, heart defects, and hearing impairment.

Transmission

Rubella is transmitted primarily through direct or droplet contact from nasopharyngeal secretions. Humans are the only natural hosts. In temperate climates, infections usually occur during late winter and early spring.

The average incubation period of rubella virus is 17 days, with a range of 12 to 23 days. People infected with rubella are most contagious when the rash is erupting, but they can be contagious from 7 days before to 7 days after the rash appears.

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Diagnosis and Treatment

Healthcare providers should

• consider rubella in unvaccinated patients with febrile rash illness and other rubella symptoms, especially if the person recently traveled internationally or was exposed to a person with febrile rash illness
• promptly isolate people suspected to have rubella and report them to the local health department
• collect throat (best source), nasal, or urine specimens for viral detection by polymerase chain reaction (PCR) testing and molecular typing, and blood for serologic testing.

See information on laboratory testing here.

There is no specific antiviral therapy for rubella infection.

Evidence of Immunity

Acceptable presumptive evidence of immunity against rubella includes at least one of the following:

• written documentation of vaccination with one dose of live rubella virus-containing vaccine administered on or after the first birthday,
• laboratory evidence of immunity,
• laboratory confirmation of rubella disease, or
• birth before 1957

Healthcare providers should not accept verbal reports of vaccination without written documentation as presumptive evidence of immunity. For additional details about evidence of immunity criteria, see Table 3 in Prevention of Measles, Rubella, Congenital Rubella Syndrome, and Mumps, 2013: Summary Recommendations of the Advisory Committee on Immunization Practices (ACIP).

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Vaccination

Rubella can be prevented with rubella-containing vaccine, which is primarily administered as the combination measles-mumps-rubella (MMR) vaccine. The combination measles-mumps-rubella-varicella (MMRV) vaccine can be used for children aged 12 months through 12 years for protection against measles, mumps, rubella and varicella. Single-antigen rubella vaccine is not available.

One dose of MMR vaccine is about 97% effective at preventing rubella if exposed to the virus.

Vaccine Recommendations

Children

CDC recommends routine childhood immunization for MMR vaccine starting with the first dose at 12 through 15 months of age, and the second dose at 4 through 6 years of age or at least 28 days following the first dose.

Adults

Adults born during or after 1957 should receive at least one dose of rubella-containing vaccine. These people include students attending colleges or other post high school educational institutions, healthcare personnel, international travelers, and non-pregnant women of childbearing age. Healthcare providers should routinely assess women of childbearing age for evidence of immunity (see section above) and vaccinate those who lack acceptable evidence of immunity and who are not pregnant. Pregnant women who do not have evidence of immunity should be vaccinated immediately after giving birth.

For more information, see rubella vaccination recommendations.

Some people should not get MMR vaccine. For information about contraindications, see who should NOT get vaccinated with MMR vaccine.

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Isolation

Patients with rubella should be isolated for 7 days after they develop rash. In settings where pregnant women may be exposed, outbreak control measures should begin as soon as rubella is suspected and should not be postponed until laboratory confirmation of cases.

People at risk who cannot readily provide acceptable evidence of rubella immunity should be considered susceptible and should be vaccinated. People without evidence of immunity who are exempt from rubella vaccination for medical, religious, or other reasons should be excluded from affected institutions in the outbreak area until 23 days after the onset of rash in the last case of rubella. Unvaccinated people who receive MMR vaccine as part of rubella outbreak control may immediately return to school provided all people without documentation of rubella immunity have been excluded.

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