Rubella

eMedicine2|derm|259
MeshID = D012409

Rubella, commonly known as German measles, is a disease caused by Rubella virus. The name is derived from the Latin, meaning "little red". Rubella is also known as German measles because the disease was first described by German physicians in the mid-eighteenth century. This disease is often mild and attacks often pass unnoticed. The disease can last one to five days. Children recover more quickly than adults. Infection of the mother by Rubella virus during pregnancy can be serious; if the mother is infected within the first 20 weeks of pregnancy, the child may be born with congenital rubella syndrome (CRS), which entails a range of serious incurable illnesses. Spontaneous abortion occurs in up to 20% of cases.cite journal
author=Siegel M, Fuerst HT, Guinee VF
title=Rubella epidemicity and embryopathy. Results of a long-term prospective study
journal=Am. J. Dis. Child.
volume=121
issue=6
pages=469–73
year=1971
pmid=5581012
doi=]

Rubella is a common childhood infection usually with minimal systemic upset although transient arthropathy may occur in adults. Serious complications are very rare. Apart from the effects of transplacental infection on the developing foetus, rubella is a relatively trivial infection.

Acquired, (i.e. not congenital), rubella is transmitted via airborne droplet emission from the upper respiratory tract of active cases. The virus may also be present in the urine, faeces and on the skin. There is no carrier state: the reservoir exists entirely in active human cases. The disease has an incubation period of 2 to 3 weeks.cite journal
author=Richardson M, Elliman D, Maguire H, Simpson J, Nicoll A
title=Evidence base of incubation periods, periods of infectiousness and exclusion policies for the control of communicable diseases in schools and preschools
journal=Pediatr. Infect. Dis. J.
volume=20
issue=4
pages=380–91
year=2001
pmid=11332662
url=http://meta.wkhealth.com/pt/pt-core/template-journal/lwwgateway/media/landingpage.htm?issn=0891-3668&volume=20&issue=4&spage=380
doi=10.1097/00006454-200104000-00004]

In most people the virus is rapidly eliminated. However, it may persist for some months post partum in infants surviving the CRS. These children are a significant source of infection to other infants and, more importantly, to pregnant female contacts.

igns and Symptoms

After an incubation period of 14-21 days, 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. Other symptoms include low grade fever, swollen glands (post cervical lymphadenopathy), joint pains, headache, conjunctivitis.cite journal
author=Edlich RF, Winters KL, Long WB, Gubler KD
title=Rubella and congenital rubella (German measles)
journal=J Long Term Eff Med Implants
volume=15
issue=3
pages=319–28
year=2005
pmid=16022642
doi= 10.1615/JLongTermEffMedImplants.v15.i3.80] The swollen glands or lymph nodes can persist for up to a week and the fever rarely rises above 38 ^oC (100.4 ^oF). The rash disappears after a few days with no staining or peeling of the skin. Forchheimer's sign occurs in 20% of cases, and is characterized by small, red papules on the area of the soft palate.

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 one-third of older girls or women experience joint pain or arthritic type symptoms with rubella. The virus is contracted through the respiratory tract and has an incubation period of 2 to 3 weeks. During this incubation period, the carrier is contagious but may show no symptoms.

Congenital Rubella Syndrome

Rubella can cause congenital rubella syndrome in the newly born. The syndrome (CRS) follows intrauterine infection by Rubella virus and comprises cardiac, cerebral, ophthalmic and auditory defects.cite journal
author=Atreya CD, Mohan KV, Kulkarni S
title=Rubella virus and birth defects: molecular insights into the viral teratogenesis at the cellular level
journal=Birth Defects Res. Part A Clin. Mol. Teratol.
volume=70
issue=7
pages=431–7
year=2004
pmid=15259032
doi=10.1002/bdra.20045] It may also cause prematurity, low birth weight, and neonatal thrombocytopenia, anaemia 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. Many mothers who contract rubella within the first critical trimester either have a miscarriage or a still born baby. If the baby survives the infection, it can be born with severe heart disorders (PDA being the most common), blindness, deafness, or other life threatening organ disorders. The skin manifestations are called "blueberry muffin lesions." cite journal
author=De Santis M, Cavaliere AF, Straface G, Caruso A
title=Rubella infection in pregnancy
journal=Reprod. Toxicol.
volume=21
issue=4
pages=390–8
year=2006
pmid=16580940
doi=10.1016/j.reprotox.2005.01.014
url=http://linkinghub.elsevier.com/retrieve/pii/S0890-6238(05)00073-0]

Cause

The disease is caused by Rubella virus, a togavirus that is enveloped and has a single-stranded RNA genome.cite journal
author=Frey TK
title=Molecular biology of rubella virus
journal=Adv. Virus Res.
volume=44
issue=
pages=69–160
year=1994
pmid=7817880
doi=] 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. It is capable of crossing the placenta and infecting the fetus where it stops cells from developing or destroys them.cite journal
author=Edlich RF, Winters KL, Long WB, Gubler KD
title=Rubella and congenital rubella (German measles)
journal=J Long Term Eff Med Implants
volume=15
issue=3
pages=319–28
year=2005
pmid=16022642
doi= 10.1615/JLongTermEffMedImplants.v15.i3.80]

Increased susceptibility to infection might be inherited as there is some indication that HLA-A1 or factors surrounding A1 on extended haplotypes are be involved in virus infection or non-resolution of the disease.cite journal |author=Forrest JM, Turnbull FM, Sholler GF, "et al" |title=Gregg's congenital rubella patients 60 years later |journal=Med. J. Aust. |volume=177 |issue=11-12 |pages=664–7 |year=2002 |pmid=12463994 |doi= |url=http://www.mja.com.au/public/issues/177_11_021202/for10634_fm.html] cite journal |author=Honeyman MC, Dorman DC, Menser MA, Forrest JM, Guinan JJ, Clark P |title=HL-A antigens in congenital rubella and the role of antigens 1 and 8 in the epidemiology of natural rubella |journal=Tissue Antigens |volume=5 |issue=1 |pages=12–8 |year=1975 |month=February |pmid=1138435 |doi= |url=]

Diagnosis of acquired rubella

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.cite journal
author=Best JM
title=Rubella
journal=Semin Fetal Neonatal Med
volume=12
issue=3
pages=182–92
year=2007
pmid=17337363
doi=10.1016/j.siny.2007.01.017
url=http://linkinghub.elsevier.com/retrieve/pii/S1744-165X(07)00018-2] The presence of these antibodies along with, or a short time after, the characteristic rash confirms the diagnosis.cite journal
author=Stegmann BJ, Carey JC
title=TORCH Infections. Toxoplasmosis, Other (syphilis, varicella-zoster, parvovirus B19), Rubella, Cytomegalovirus (CMV), and Herpes infections
journal=Curr Women's Health Rep
volume=2
issue=4
pages=253–8
year=2002
pmid=12150751
doi=]

Prevention

Rubella infections are prevented by active immunisation programs using live, disabled 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 prepubertile 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.

The vaccine is now given as part of the MMR vaccine. The WHO recommends the first dose is 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.cite journal
author=Watson JC, Hadler SC, Dykewicz CA, Reef S, Phillips L
title=Measles, mumps, and rubella--vaccine use and strategies for elimination of measles, rubella, and congenital rubella syndrome and control of mumps: recommendations of the Advisory Committee on Immunization Practices (ACIP)
journal=MMWR Recomm Rep
volume=47
issue=RR-8
pages=1–57
year=1998
pmid=9639369
doi=]

The immunization 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. [cite journal |author=Dayan GH, Castillo-Solórzano C, Nava M, "et al" |title=Efforts at rubella elimination in the United States: the impact of hemispheric rubella control |journal=Clin. Infect. Dis. |volume=43 Suppl 3 |issue= |pages=S158–63 |year=2006 |pmid=16998776 |doi=10.1086/505949] [cite journal |author= |title=Elimination of rubella and congenital rubella syndrome--United States, 1969-2004 |url= http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5411a5.htm|journal=MMWR Morb. Mortal. Wkly. Rep. |volume=54 |issue=11 |pages=279–82 |year=2005 |pmid=15788995 |doi=]

Treatment

There is no specific treatment for Rubella; management is a matter of responding to symptoms to diminish discomfort. Treatment of newly born babies is focused on management of the complications. Congenital heart defectsFact|date=January 2008 and cataracts can be corrected by surgery.cite journal
author=Khandekar R, Sudhan A, Jain BK, Shrivastav K, Sachan R
title=Pediatric cataract and surgery outcomes in Central India: a hospital based study
journal=Indian J Med Sci
volume=61
issue=1
pages=15–22
year=2007
pmid=17197734
doi=
url=http://www.indianjmedsci.org/article.asp?issn=0019-5359;year=2007;volume=61;issue=1;spage=15;epage=22;aulast=Khandekar] Management for ocular CRS is similar to that for age-related macular degeneration, including counseling, regular monitoring, and the provision of low vision devices, if required.cite journal
author=Weisinger HS, Pesudovs K
title=Optical complications in congenital rubella syndrome
journal=Optometry
volume=73
issue=7
pages=418–24
year=2002
pmid=12365660
doi=]

Prognosis

Rubella infection of children and adults is usually mild, self-limiting and often asymptomatic. The prognosis in children born with CRS is poor.cite journal
author=Freij BJ, South MA, Sever JL
title=Maternal rubella and the congenital rubella syndrome
journal=Clin Perinatol
volume=15
issue=2
pages=247–57
year=1988
pmid=3288422
doi=]

Epidemiology

Rubella is a disease that occurs worldwide. The virus tends to peak during the spring in countries with temperate climates. Before the vaccine to 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.cite journal
author=Reef SE, Frey TK, Theall K, "et al"
title=The changing epidemiology of rubella in the 1990s: on the verge of elimination and new challenges for control and prevention
journal=JAMA
volume=287
issue=4
pages=464–72
year=2002
pmid=11798368

doi=10.1001/jama.287.4.464
url=http://jama.ama-assn.org/cgi/pmidlookup?view=long&pmid=11798368] Since the introduction of vaccine, occurrences have become rare in those countries with high uptake rates. However, 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.cite journal
author=Reef S
title=Rubella mass campaigns
journal=Curr. Top. Microbiol. Immunol.
volume=304
issue=
pages=221–9
year=2006
pmid=16989272
doi=]

During the epidemic in the US between 1962-1965, Rubella virus infections during pregnancy were estimated to have caused 30,000 still births and 20,000 children to be born impaired or disabled as a result of CRS.cite journal
author=Plotkin SA
title=Rubella eradication
journal=Vaccine
volume=19
issue=25-26
pages=3311–9
year=2001
pmid=11348695
doi=
url=http://linkinghub.elsevier.com/retrieve/pii/S0264410X01000731] [Cooper, L.Z. Congenital Rubella in the United States. 1975 In: Krugman, S Gershon, A (eds), Symposium on Infections Of the Fetus and Newborn Infant. New York, Alan R. Liss Inc.,p.1.] Universal immunisation producing a high level of herd immunity is important in the control of epidemics of rubella.cite journal
author=Danovaro-Holliday MC, LeBaron CW, Allensworth C, "et al"
title=A large rubella outbreak with spread from the workplace to the community
journal=JAMA
volume=284
issue=21
pages=2733–9
year=2000
pmid=11105178

doi=10.1001/jama.284.21.2733
url=http://jama.ama-assn.org/cgi/pmidlookup?view=long&pmid=11105178]

History

Rubella was first described in the mid-eighteenth century. Friedrich Hoffmann made the first clinical description of rubella in 1740,cite book |author=Ackerknecht, Erwin Heinz |title=A short history of medicine |publisher=Johns Hopkins University Press |location=Baltimore |year=1982 |pages=129 |isbn=0-8018-2726-4] which was confirmed by de Bergen in 1752 and Orlow in 1758.cite journal
author=Wesselhoeft C
title=Rubella and congenital deformities
journal=N. Engl. J. Med.
volume=240
issue=7
pages=258–61
year=1949
pmid=18109609
doi=]

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 (from the German name "Röteln"), hence the common name of "German measles". [Best, J.M., Cooray, S., Banatvala J.E. Rubella in "Topley and Wilson's Microbiology and Microbial Infections", Vol. 2, Virology, Chapter 45, p.960-92, ISBN 0 340 88562 9, 2005 ] Henry Veale, an English Royal Artillery surgeon, described an outbreak in India. He coined the name "rubella" (from the Latin, meaning "little red") in 1866.cite journal |author=Lee JY, Bowden DS |title=Rubella virus replication and links to teratogenicity |journal=Clin. Microbiol. Rev. |volume=13 |issue=4 |pages=571–87 |year=2000 |pmid=11023958 |url=http://cmr.asm.org/cgi/content/full/13/4/571 |doi=10.1128/CMR.13.4.571-587.2000] cite book
author = Atkinson W, Hamborsky J, McIntyre L, Wolfe S, eds.
year = 2007
url = http://www.cdc.gov/vaccines/pubs/pinkbook/pink-chapters.htm
title = Epidemiology and Prevention of Vaccine-Preventable Diseases. 10th ed.
chapter = Chapter 12. Rubella
chapterURL = http://www.cdc.gov/vaccines/pubs/pinkbook/downloads/rubella.pdf
publisher = Centers for Disease Control and Prevention
accessdate = 2007-07-03] cite book
year = 2006
month = April
title = Immunisation Handbook 2006
publisher = Ministry of Health, Wellington, NZ.
url = http://www.moh.govt.nz/moh.nsf/indexmh/immunisation-handbook-2006
chapter = Chapter 11 - Rubella
chapterURL = http://www.moh.govt.nz/moh.nsf/pagesmh/4617/$File/2006-11rubella.pdf
isbn=0-478-29926-5
accessdate = 2007-07-03]

It was formally recognised as an individual entity in 1881, at the International Congress of Medicine in London. [Smith, J. L. Contributions to the study of Rötheln. Trans. Int. Med. Congr. Phil. 4,14. 1881] In 1914, Alfred Fabian Hess theorised that rubella was caused by a virus, based on work with monkeys.cite journal
first = Alfred Fabian
last = Hess
year = 1914
title = German measles (rubella): an experimental study
journal = The Archives of Internal Medicine
location = Chicago
volume = 13
pages = 913–916 as cited by cite web
first = Ole Daniel
last = Enersen
url = http://www.whonamedit.com/doctor.cfm/2283.html
title = Alfred Fabian Hess
publisher = WhoNamedIt
accessdate = 2007-07-03] In 1938, Hiro and Tosaka confirmed this by passing the disease to children using filtered nasal washings from acute cases.

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. 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. The virus was isolated in tissue culture in 1962 by two separate groups led by physicians Parkman and Weller.

There was a pandemic of rubella between 1962 and 1965, starting in Europe and spreading to the United States. 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 [ J.B. Hanshaw, J.A. Dudgeon, and W.C. Marshall. Viral diseases of the fetus and newborn. W.B. Saunders Co., Philadelphia, 1985 ]

In 1969 a live attenuated virus vaccine was licensed. In the early 1970s, a triple vaccine containing attenuated measles, mumps and rubella (MMR) viruses was introduced.

ee also

* Eradication of infectious diseases
* Rubeola (measles)
* Roseola (exanthem subitum)

References

External links

* [http://www.virology-online.com/viruses/Rubella.htm Rubella] at Wong's Virology.
* [http://www.immunize.org/rubella/index.htm Immunization Action Coalition: Rubella]
*