Rubella and Congenital Rubella Syndrome

Rubella is also known as "German measles," as German doctors in 1814 were the first to discover that it was actually a different disease from measles.

It took another 100 years for experts to discover that rubella was caused by a virus, and it wasn't until 1941 that it was no longer thought of as a mild childhood disease. That was when rubella became linked with congenital rubella syndrome (CRS).

Symptoms

In general, rubella does cause very mild symptoms in most children. About 14 days after being exposed to someone else with rubella, children who aren't immune may develop a maculopapular (small spots) rash that starts on their face and then progresses down to their feet.

The rash of rubella has some characteristic features that help to distinguish it from a measles rash, including that the rash is fainter and the spots don't join together like they do with measles. Also, children with rubella generally don't have a high fever.

The rash lasts about three days. It may be more noticeable after your child gets overheated, especially after a hot bath or shower.

Although rubella is only considered to be moderately contagious, children are most contagious when they have a rash. They spread the virus via respiratory droplets and secretions.

Swollen lymph nodes may appear up to a week before the rash appears and can linger for several weeks.

As with many viral infections, adults with rubella can have more severe symptoms, including low-grade fever, malaise (not feeling well), and swollen lymph nodes. In rare cases, individuals may develop joint pain in the wrists, fingers, and knees (with or without swelling).

Complications

While rubella is typically a very mild disease, on rare occasions it can cause dangerous complications, especially in adults.

Rubella complications can include low platelet counts and vascular damage leading to brain, gastrointestinal, and kidney bleeding. Around 1 in 6,000 people develop life-threatening encephalitis (swelling in the brain). Neuritis (inflammation of nerves in hands and feet) and orchitis (swelling in testicles) are also possible.

Tragically, rubella complications are far from rare when a woman becomes infected early in her pregnancy, leading to congenital rubella syndrome. As the rubella virus can infect all of the organs of a developing baby, complications can include:

• Bone alterations
• Congenital heart disease
• Deafness
• Developmental delays
• Fetal death
• Intrauterine growth retardation
• Liver and spleen enlargement
• Microcephaly (in which a baby's head is smaller than expected)
• Premature delivery
• Vision abnormalities (cataracts, glaucoma, retinopathy, and microphthalmia)

Children with congenital rubella syndrome are also more at risk for diabetes mellitus, autism, and progressive panencephalitis (a neurodegenerative disorder that can present years after the initial infection).

Treatments

There is no specific treatment or cure for rubella infections.

Outbreaks

One of the biggest outbreaks of rubella and CRS in the United States occurred from 1964 to 1965 and resulted in:

• 12.5 million rubella virus infections
• 20,000 infants born with CRS
• 2,100 neonatal deaths

This outbreak was not limited to the United States. It was a pandemic that had begun in Europe the previous year.

As expected, cases of rubella and CRS quickly fell as the first vaccine was licensed in 1969. The rubella vaccine was later combined with the vaccines for mumps and measles in 1971 when the MMR vaccine was introduced.

By 1986, there were only 55 cases of rubella in the United States.

Coinciding with measles outbreaks, there were a number of rubella outbreaks in 1990 to 91, leading to at least 2,526 cases of rubella and 58 cases of CRS.

A booster dose of MMR and rising vaccination levels helped to decrease rubella cases once again. While we don't see big outbreaks anymore, it is important to note that rubella isn't totally gone in the United States:

• 2013: 9 cases of rubella and 1 case of CRS
• 2015: 5 cases of rubella and 1 case of CRS
• 2017: 7 cases of rubella and 5 cases of CRS

As with other vaccine-preventable diseases, rubella and congenital rubella syndrome are also still big problems around the world.

Rubella and congenital rubella syndrome are still problems in some developed countries too. In 2004 and 2005, an unvaccinated religious community in the Netherlands developed a rubella outbreak with 387 cases. The outbreak spread to an affiliated religious community in Canada, causing at least 309 cases of rubella. Across both communities, there were 14 cases of CRS and 2 fetal deaths.

There have also been large outbreaks in:

• Japan: In 2012 and 2013, a nationwide outbreak led to over 7,500 rubella cases and at least 10 cases of CRS.
• Romania: A 2012 outbreak caused nearly 21,000 cases of rubella.
• Poland: A 2013 outbreak caused over 38,500 cases of rubella.

Although rubella is a vaccine-preventable disease, these cases continue to occur among mostly unvaccinated people. And as we repeatedly see, this can lead to an increase in neonatal deaths and cases of CRS.

What You Need to Know About Rubella

Other interesting facts about rubella include that:

• An ophthalmologist in Australia in 1941, Dr. Norman Gregg, first linked the rubella virus with congenital birth conditions.
• The incubation period (before symptoms appear) of rubella can range from 12 to 23 days.
• Up to half of people with rubella don't have any symptoms or any obvious symptoms, although they can still be contagious to others.
• People with rubella may shed the virus, and be contagious, for up to 7 days before and after the rash starts.
• Antibody tests can determine if someone has rubella or if they are immune after vaccination.
• A single dose of MMR vaccine is about 95% protective against rubella.
• In 2004, rubella and CRS were eliminated in the United States. Since 2004, there have been fewer than 10 rubella cases and one CRS case per year.

The elimination of rubella and congenital rubella syndrome in the United States has been a great vaccination success story. But rubella has not been completely eradicated across the globe, so infection is still possible. Evidence shows that every rubella case in the U.S. since 2012 has been contracted while the individual was outside the country. Vaccination is still incredibly important.