* - Congenital rubella syndrome in the first 16 weeks of pregnancy causes intrauterine growth restriction (sometimes termed intrauterine growth retardation), intracranial calcifications, microcephaly, cataracts, sensorineural defects, cardiac defects, hepatosplenomegaly, osteitis, or miscarriage.
GENERAL MEASURES
β’ Postnatal rubella - mild and self-limited. Treat for symptomatic relief.
β’ Congenital rubella - supportive, unless neurologic or hemorrhagic complications develop
ACTIVITY
β’ For postnatal rubella - contact isolation for 7 days after onset of rash, bedrest is not necessary
β’ Contact isolation of congenitally infected infants for one year, unless nasopharyngeal and urine cultures after 3 months of age are negative for rubella virus
DIET No special diet
PATIENT EDUCATION
β’ Make every effort to avoid exposing infected patient to pregnant women
DRUG(S) OF CHOICE Acetaminophen for fever every 4 hours if needed - 10-15 mg/kg/dose
PATIENT MONITORING
. Persons immune to rubella via natural infection or vaccine may be reinfected when re-exposed. This
infection is usually asymptomatic and detectable only by serologic means.
. In congenital rubella, it is extremely important to detect auditory and visual impairment early, so that adequate
education and counseling can begin. Two-thirds of internationally adopted children entering the U.S. have no written records of overseas immunizations
PREVENTION/AVOIDANCE
. Rubella vaccine
. A 2-dose schedule in combination with measles and mumps (MMR) is recommended for those born after
1956. The fi rst dose is recommended at age 12-15 months; the second dose is recommended either at
4-6 years of age or at 11-12 years of age. Children with HIV should receive MMR vaccine at 12 months of age if no contraindications exist.
. Recommended for susceptible individuals in the following groups: Prepubertal boys and girls, premarital
or postpartum women, college students, day care personnel, health care workers, military personnel
. It is contraindicated in: Pregnancy, immunodeficiency or immunocompromised state (except HIV), receipt
within the last 3 months of immunoglobulin (Ig) or blood, severe febrile illness, or hypersensitivity to vaccine components
. Persons who receive rubella vaccine do not transmit rubella to others, although the virus can be isolated
from the pharynx
. During outbreaks of rubella, serologic screening before vaccination is not recommended, because rapid vaccination is necessary to stop the spread of the disease
. In 1997 Finland became the first country to be free of rubella; the result of an effective vaccination program
. In 2005 the USA labeled rubella as no longer a health threat. All known cases reported since 2004 have
been infected outside of the USA and transported in . Strong evidence exists against the hypothesis that
MMR vaccination causes autism
. An investigational vaccine against measles, mumps, rubella and varicella (MMRV) shows similar efficacy to the currently licensed MMR vaccine. The two-dose response rate for rubella is 94.8% for MMRV vs. 92.8% for MMR.
POSSIBLE COMPLICATIONS
. Postnatal rubella
. Postinfectious encephalitis (1/5,000 cases)
. Thrombocytopenic purpura (1/3,000 cases)
. Testicular pain
. Mild hepatitis
. Congenital rubella
. Spontaneous abortion
. Stillbirth
. Premature delivery
. Progressive rubella panencephalitis
. Endocrine disturbances (diabetes, thyrotoxicosis, hypothyroidism)
. Rubella vaccine
. Lymphadenopathy
. Fever
. Rash
. Arthritis/arthralgia (older girls, women)
. Polyneuropathy
. Idiopathic thrombocytopenic purpura (ITP)
EXPECTED COURSE/PROGNOSIS
. Postnatal rubella
. Fever, 1-2 days
. Rash, 3 days
. Coryza, 5 days
. Lymphadenopathy, 1 week
. Arthralgia (when present), 2 weeks
. Complete and full recovery without sequelae is the rule
. Congenital rubella
. Varied and unpredictable spectrum of consequences, ranging from stillbirth to completely normal infancy
and childhood
. Disease characterized by chronic infection; infants may remain contagious for months after birth
. Detectable levels of hemagglutination-inhibiting antibody (IgG) persist for years, then may decline. By age 5, 20% have no detectable antibody.
. Overall mortality 10%; greatest during fi rst 6 months
. 70% of those with encephalitis develop residual neuromotor defects, including an autistic syndrome
. Prognosis is excellent when only minor defects are present
PREGNANCY
β’ Women vaccinated against rubella are advised not to become pregnant for at least 1 month. The Vaccine type virus can cross the placenta. However, no case of congenital rubella has occurred after inadvertent
vaccination
β’ If a pregnant woman is exposed to rubella (native disease, not vaccine associated), obtain an antibody titer. Presence of antibody implies immunity and no risk. If antibody is not detectable, obtain a second titer in 3 weeks. If antibody is present in the second specimen, infection has occurred. If antibody is again negative, obtain a third titer in 3 more weeks (6 weeks after exposure). At this time, a negative test means that infection has not occurred; a positive test means that infection did occur, and the fetus is at risk for congenital
rubella.
β’ Human immunoglobulin (gamma globulin) in prophylaxis of rubella during pregnancy does not prevent rubella
or the congenital rubella syndrome in a predictable or reliable fashion
β’ A reliable PCR-based method of detecting viral RNA may allow much more rapid prenatal diagnosis of
rubella virus infection. Routine use is not yet available.