What is rubella?

Rubella, also known as German measles, is an infectious disease caused by a virus. The virus is spread
through droplets of moisture from the nose or throat of someone who is infected.

Rubella can be caught from face-to-face contact with someone who has the disease or even by being in
the same room.

Rubella causes a red rash and a high temperature.

For most people it is a mild disease, but it can have serious consequences forpregnant women.

Rubella used to be common in children, but since the introduction of a vaccination programme in the
1980s, the disease has been almost entirely eradicated.

Rubella remains a notifiable disease under the Public Health (Infectious Diseases) Regulations 1988. This
means that any doctor who diagnoses the infection must, by law, inform the local authority. This is to
identify the source of the rubella infection and stop it spreading.

Symptoms of rubella

The main symptom of rubella is a rash that is a distinctive red-pink colour. It starts as spots, which can be
itchy, before spreading from behind the ears to the head and neck and then other parts of the upper body.
The rash usually lasts for up to a week.

Other main symptoms are swollen lymph glands around the ears and back of the head, a high temperature
of 38C or more and cold-like symptoms.
Other less common symptoms in adults are arthritis and arthralgia ( pain in a jointcaused by
inflammation).

In rare cases rubella can lead to serious complications. In one in 6,000 cases it can lead to inflammation
of the brain; in one in 3,000 cases it can affect bloodclotting.

The incubation period for rubella is 14 to 21 days, with most people developing a rash between 14 and 17
days after exposure.

In most cases rubella is a mild condition, but if you suspect you have the disease you should contact your
doctor to have it confirmed. Phone the surgery, rather than visit, in case there are pregnant women in the
waiting room.

Rubella can be diagnosed with a blood test.

Stay away from work and keep a child off school until you have consulted a doctor.

Why can rubella be dangerous if you are pregnant?

Most pregnant women will have immunity to rubella from having the MMR vaccine during childhood.
The number of rubella immune women is so high that routine rubella screening during pregnancy was
stopped in England in April 2016.

However, if a pregnant woman who does not have immunity contracts the virus, she can pass it on to her
unborn child.

The virus can cause a number of birth defects known as congenital rubella syndrome (CRS). Defects
include mental handicap, cataract, deafness, heartabnormalities and slower than normal foetal growth.
Rubella, also known as German measles or three-day measles,[5] is an infection caused by the rubella
virus.[3] This disease is often mild with half of people not realizing that they are infected.[6][1] A rash may
start around two weeks after exposure and last for three days.[1] It usually starts on the face and spreads to
the rest of the body.[1] The rash is sometimes itchy and is not as bright as that of measles.[1] Swollen
lymph nodes are common and may last a few weeks.[1] A fever, sore throat, and fatigue may also
occur.[1][2] In adults joint pain is common.[1] Complications may include bleeding problems, testicular
swelling, and inflammation of nerves.[1] Infection during early pregnancy may result in a child born
with congenital rubella syndrome (CRS) or miscarriage.[3] Symptoms of CRS include problems with the
eyes such as cataracts, ears such as deafness, heart, and brain.[3]Problems are rare after the 20th week of
pregnancy.[3]

Rubella is usually spread through the air via coughs of people who are infected.[3][4] People are infectious
during the week before and after the appearance of the rash.[1] Babies with CRS may spread the virus for
more than a year.[1] Only humans are infected.[3] Insects do not spread the disease.[1] Once recovered,
people are immune to future infections.[3] Testing is available that can verify immunity.[3] Diagnosis is
confirmed by finding the virus in the blood, throat, or urine.[1] Testing the blood for antibodies may also
be useful.[1]

Rubella is preventable with the rubella vaccine with a single dose being more than 95% effective.[3] Often
it is given in combination with the measles vaccine and mumps vaccine, known as the MMR
vaccine.[1] When some, but less than 80% of the people are vaccinated, more women might make it to
childbearing age without developing immunity by infection or vaccination and CRS rates could
increase.[3] Once infected there is no specific treatment.[2]

Rubella is a common infection in many areas of the world.[2] Each year about 100,000 cases of congenital
rubella syndrome occur.[3] Rates of disease have decreased in many areas as a result of
vaccination.[6][2] There are ongoing efforts to eliminate the disease globally.[3] In April 2015 the World
Health Organization declared the Americas free of rubella transmission.[7][8] The name "rubella" is from
Latin and means little red.[1] It was first described as a separate disease by German physicians in 1814
resulting in the name "German measles."[1]

Signs and symptoms[edit]

Young boy displaying the characteristic maculopapular rash of rubella[9]

Generalized rash on the abdomen due to rubella

Rubella has symptoms that are similar to those of flu. However, 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 and posterior cervical lymphadenopathy), joint pains, headache,
and conjunctivitis.[10]

The swollen glands or lymph nodes can persist for up to a week and the fever rarely rises above 38 °C
(100.4 °F). 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.[11]

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 60% of older girls or
women experience joint pain or arthritic type symptoms with rubella.[12]
In children rubella normally causes symptoms which last two days and include:[13]

 Rash beginning on the face which spreads to the rest of the body.

 Low fever of less than 38.3 °C (101 °F).

 Posterior cervical lymphadenopathy.[14]

In older children and adults additional symptoms may be present including:[13]

 Swollen glands

 Coryza (cold-like symptoms)

 Aching joints (especially in young women)

Rare problems can occur including the following:

 Brain inflammation

 Ear infection [15]

Coryza in rubella may convert to pneumonia, either direct viral pneumonia or secondary bacterial
pneumonia, and bronchitis (either viral bronchitis or secondary bacterial bronchitis).[16]

Congenital rubella syndrome[edit]

Main article: Congenital rubella syndrome

Cataracts due to congenital rubella syndrome

Rubella can cause congenital rubella syndrome in the newborn. The syndrome (CRS) follows intrauterine
infection by the rubella virus and comprises cardiac, cerebral, ophthalmic and auditory defects.[17] It may
also cause prematurity, low birth weight, and neonatal thrombocytopenia, anemia 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.[18]
Many mothers who contract rubella within the first critical trimester either have a miscarriage or a
stillborn baby. If the fetus 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".[18] For these reasons, rubella is included on
the TORCH complex of perinatal infections.

About 100,000 cases of this condition occur each year.[3]

Cause[edit]

Main article: Rubella virus

Transmission electron micrograph of rubella viruses

The disease is caused by rubella virus, a togavirus that is enveloped and has a single-stranded RNA
genome.[19] 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.[10] During this incubation period, the patient is contagious
typically for about one week before he/she develops a rash and for about one week thereafter.

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.[20] [21]

Diagnosis[edit]

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.[22] The presence of these antibodies along with, or a short time after, the characteristic rash
confirms the diagnosis.[23]

Prevention[edit]

Further information: MMR vaccine

Rubella infections are prevented by active immunisation programs using live attenuated 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 prepubertal 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.[24]

The vaccine is now usually given as part of the MMR vaccine. The WHO recommends the first dose be
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.[25]

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.[26][27]

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).[28] It is recommended that all susceptible non-pregnant
women of childbearing age should be offered rubella vaccination.[28] Due to concerns about possible
teratogenicity, use of MMR vaccine is not recommended during pregnancy.[28] Instead, susceptible
pregnant women should be vaccinated as soon as possible in the postpartum period.[28]

Treatment[edit]

There is no specific treatment for rubella; however, management is a matter of responding to symptoms to
diminish discomfort. Treatment of newborn babies is focused on management of the
complications. Congenital heart defects[citation needed] and cataracts can be corrected by direct surgery.[29]

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.[30]

Prognosis[edit]

Rubella infection of children and adults is usually mild, self-limiting and often asymptomatic. The
prognosis in children born with CRS is poor.[31]

Epidemiology[edit]

Rubella occurs worldwide. The virus tends to peak during the spring in countries with temperate climates.
Before the vaccine against 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.[32] 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.[33] Vaccination is still strongly recommended as the virus could be
reintroduced from other continents should vaccination rates in the Americas drop.[citation needed] During the
epidemic in the U.S. between 1962–1965, rubella virus infections during pregnancy were estimated to
have caused 30,000 stillbirths and 20,000 children to be born impaired or disabled as a result of
CRS.[34][35] Universal immunisation producing a high level of herd immunity is important in the control of
epidemics of rubella.[36]

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.[37]

In Japan, 15,000 cases of rubella and 43 cases of congenital rubella syndrome were reported to the
National Epidemiological Surveillance of Infectious Diseases between October 15, 2012, and March 2,
2014 during the 2012–13 rubella outbreak in Japan. They mainly occurred in men of ages 31 to 51 and
young adults aged 24–34.[38]

History[edit]

See also: Eradication of infectious diseases § Rubella

Rubella was first described in the mid-eighteenth century. Friedrich Hoffmann made the first clinical
description of rubella in 1740,[39] which was confirmed by de Bergen in 1752 and Orlow in 1758.[40]

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".[41] Henry Veale, an
English Royal Artillery surgeon, described an outbreak in India. He coined the name "rubella" (from the
Latin word, meaning "little red") in 1866.[39][42][43][44]

It was formally recognised as an individual entity in 1881, at the International Congress of Medicine in
London.[45] In 1914, Alfred Fabian Hess theorised that rubella was caused by a virus, based on work with
monkeys.[46] In 1938, Hiro and Tosaka confirmed this by passing the disease to children using filtered
nasal washings from acute cases.[43]

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.[42][43] 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. Since no vaccine was yet available, some popular magazines promoted the idea of "German
measles parties" for infected children to spread the disease to other children (especially girls) to immunize
them for life and protect them from later catching the disease when pregnant.[47] The virus was isolated in
tissue culture in 1962 by two separate groups led by physicians Parkman and Weller.[42][44]

There was a pandemic of rubella between 1962 and 1965, starting in Europe and spreading to the United
States.[44] 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.[48][49]
In 1969 a live attenuated virus vaccine was licensed.[43] In the early 1970s, a triple vaccine containing
attenuated measles, mumps and rubella (MMR) viruses was introduced.[44] By 2006, confirmed cases in
the Americas had dropped below 3000 a year. However, a 2007 outbreak in Argentina, Brazil, and Chile
pushed the cases to 13,000 that year.[7]

On January 22, 2014, the World Health Organization (WHO) and the Pan American Health
Organization declared and certified Colombia free of rubella and became the first Latin American country
to eliminate the disease within its borders.[50][51] On April 29, 2015, the Americas became the first WHO
region to officially eradicate the disease. The last non-imported cases occurred in 2009 in Argentina and
Brazil. Pan-American Health Organization director remarked "The fight against rubella has taken more
than 15 years, but it has paid off with what I believe will be one of the most important pan-American
public health achievements of the 21st Century."[52] The declaration was made after 165 million health
records and genetically confirming that all recent cases were caused by known imported strains of the
virus. Rubella is still common in some regions of the world and Susan E. Reef, team lead for rubella at
the C.D.C.’s global immunization division, who joined in the announcement, said there was no chance it
would be eradicated worldwide before 2020.[7]Rubella is the third disease to be eliminated from the
western hemisphere with vaccination after smallpox and polio.[7][8]

Etymology[edit]

The name rubella is sometimes confused with rubeola, an alternative name for measles in English-
speaking countries; the diseases are unrelated.[53][54] In some other European languages,
like Spanish, rubella and rubeola are synonyms, and rubeola is not an alternative name
for measles.[55] Thus, in Spanish, "rubeola" refers to rubella and "sarampión" refers to measles.