Background
Rubella is now rare because of widespread compliance with childhood immunization programs. The disease is usually a benign and inconsequential viral illness unless exposure occurs in utero.
Congenital rubella syndrome is associated with clinically significant congenital malformations.[1] The live-attenuated virus vaccine has decreased the incidence of rubella significantly, thereby decreasing congenital disease. See the image below.
View Image | Image in a 4-year-old girl with a 4-day history of low-grade fever, symptoms of an upper respiratory tract infection, and rash. Courtesy of Pamela L. .... |
Pathophysiology
The causative organism is a single-stranded RNA togavirus that is transmitted by means of respiratory droplets. The virus replicates in the nasopharynx and regional lymph nodes, resulting in viremia. The virus then may spread to the skin, CNS, synovial fluid, and transplacentally to a developing fetus.
Epidemiology
Frequency
United States
Before the rubella vaccination became available in 1969, epidemics occurred every 6-9 years and pandemics every 10-20 years. In 1977-1981, 20,395 cases of rubella were reported in the United States. According to Statistical Handbook on Infectious Disease regarding historical trends of rubella in the United States, the incidence has significantly decreased since that time.[2] In 1990, 1124 cases of rubella occurred, and, in 1999, only 267 occurred. In the last decade, the rate has been less than 10 cases of congenital rubella syndrome per year. These cases mostly affected mothers born outside of the United States in Latin American countries with lower vaccination rates.
In 2004, the Centers for Disease Control and Prevention (CDC) reported that, since 2001, fewer than 25 cases of rubella have occurred each year in the United States.[3] The CDC estimates 95% vaccination coverage among school-aged children and 91% immunity in the population.[3]
During the 1990s resistance to the MMR vaccine developed. An earlier (since discontinued) version in the United Kingdom was associated with aseptic meningitis. As a result of this, vaccination rates in the United Kingdom fell from an earlier level of 92% to 79% in 1998; they have since rebounded.[4] Moreover, a correlation between autism and MMR use was later postulated. Subsequent epidemiologic studies have shown no significant association between the vaccine and either condition. Inadequate vaccination rates have led to an ongoing outbreak in Austria.[5]
A recent case control study, presuming it to be a random variation, found a correlation between early rubella vaccination (before age 10) and later development of multiple sclerosis.[6] Another recent study shows that immigrant women in Canada had surprisingly low vaccination rates; this highlights the risk of epidemics in areas with significant immigrant populations.[7] Vaccination rates remain very high in the United States; should this change in the future, the frequency of rubella could change dramatically.
From 2000 to 2012, rising numbers of WHO member states began using rubella-containing vaccines (RCVs) in their immunization program and began reporting rubella and congenital rubella syndrome (CRS) surveillance data. As of December 2012, 132 (68%) WHO member states had introduced RCV, a 33% increase from 99 member states in 2000. Some 43% of infants had received a RCV dose in 2012, a 96% increase from the 22% of infants who had been vaccinated against rubella in 2000. A total of 94,030 rubella cases were reported to WHO in 2012 from 174 member states, an 86% decrease from the 670,894 cases reported in 2000 from 102 member states.[8, 9]
International
The rubella vaccination is given to only about half the world's population. Congenital rubella syndrome remains a major problem in some areas. In Russia, for instance, congenital rubella syndrome causes 15% of all birth defects.
Mortality/Morbidity
Infection in healthy children or young adults is generally self-limited and without sequelae.
The most common complications are arthropathies of the fingers, wrists, and knees that can persist for a year or more.
Thrombocytopenia with purpura and hemorrhage is a rare complication of rubella.
Congenital rubella syndrome is associated with malformations of multiple organ systems including the CNS and cardiac, ocular, and skeletal systems. Infants with congenital rubella syndrome who survive into adulthood may be plagued by autoimmune disorders and dysgammaglobulinemia.
Damage to the fetus is most likely when maternal infection occurs during the first 2 months of pregnancy, although there is risk associated with infection up to 5 months.
Race
See the list below:
The highest risk is among members of racial or ethnic groups who are unvaccinated and who may be exposed to persons traveling from areas where rubella vaccination is not routine.
Recent outbreaks have occurred among persons of Hispanic ethnicity. Consequently, Hispanic persons and persons from countries without rubella vaccination programs should be considered susceptible to rubella unless they have documentation of vaccination or serologic evidence of immunity.
Sex
Rubella affects men and women equally.
Age
Before vaccination, the peak incidence occurred in children aged 5-14 years. However, at present, most cases occur in teenagers or young adults.
Causes
Rubella is caused by a single-stranded RNA togavirus.
Emergency Department Care
No antiviral therapy for rubella is available. Treatment is supportive.
Medication Summary
The goals of pharmacotherapy are to reduce morbidity and prevent complications.
Acetaminophen (Tylenol)
Clinical Context:
Reduces fever by direct action on the hypothalamic heat-regulating centers, which increases dissipation of body heat by vasodilation and sweating.
Ibuprofen (Motrin, Advil)
Clinical Context:
NSAID that inhibits cyclooxygenase, inhibiting formation of prostaglandins.
Class Summary
These agents may be used to decrease fever.
Diphenhydramine (Benadryl)
Clinical Context:
Competitive antagonist of histamine at the H1 receptor prevents histamine response in sensory nerve endings and blood vessels. More effective in preventing histamine response than reversing it.
Class Summary
May be used to control itching.
Author
Pamela L Dyne, MD, Professor of Clinical Medicine/Emergency Medicine, University of California, Los Angeles, David Geffen School of Medicine; Attending Physician, Department of Emergency Medicine, Olive View-UCLA Medical Center
Disclosure: Nothing to disclose.
Coauthor(s)
Peter Bloomfield, MD, MPH, Clinical Instructor, Department of Emergency Medicine, Olive View-UCLA Medical Center
Disclosure: Nothing to disclose.
Specialty Editors
Mary L Windle, PharmD, Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference
Disclosure: Nothing to disclose.
Grace M Young, MD, Associate Professor, Department of Pediatrics, University of Maryland Medical Center
Disclosure: Nothing to disclose.
Chief Editor
Kirsten A Bechtel, MD, Associate Professor of Pediatrics, Section of Pediatric Emergency Medicine, Yale University School of Medicine; Co-Director, Injury Free Coalition for Kids, Yale-New Haven Children's Hospital
Disclosure: Nothing to disclose.
Additional Contributors
Garry Wilkes, MBBS, FACEM, Director of Clinical Training (Simulation), Fiona Stanley Hospital; Clinical Associate Professor, University of Western Australia; Adjunct Associate Professor, Edith Cowan University, Western Australia
Disclosure: Nothing to disclose.
Acknowledgements
The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous author, Kelli N McCartan, MD, to the development and writing of this article.
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