History - RubellaThe Teratogenicproperty of theinfection wasdocumented byan AustralianophthalmologistNorman McAlisterGregg, in 1941 Dr.T.V.Rao MD 2
Introduction• 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, Friedrich Hoffmann, in the mid-eighteenth century. Dr.T.V.Rao MD 3
What is Rubella Rubella (German measles) is a disease caused by the rubella virus. Rubella is usually a mild illness. Most people who have had rubella or the vaccine are protected against the virus for the rest of their lives. Because of routine vaccination against rubella since 1970 , rubella is now rarely reported. Dr.T.V.Rao MD 4
Rubella ( German Measles ) Rubella is also called as 3 day Measles or German Measles. Family – Togaviridae Genus - Rubivirus In general belong to Togavirus group
Rubella Virus Rubella virus are ss – RNA virus Diameter 50 – 70 nm Enveloped Spherical Virus carry hem agglutinin Virus multiply in the cytoplasm of infected cell.
Prevailing Genotypes Dr.T.V.Rao MD 7
Cause and Transmission• The disease is caused by Rubella virus, a toga virus that is enveloped and has a single- stranded RNA genome, 60-70nm diameter.• 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. Dr.T.V.Rao MD 8
Acquired Rubella• Acquired rubella is transmitted via airborne droplet emission from the upper respiratory tract of active cases.• The virus may also be present in the urine, feces and on the skin. Dr.T.V.Rao MD 9
Signs and Symptoms• After an incubation period of 14-21 days, the primary symptom of rubella virus infection is the appearance of a rash (exanthema) on the face which spreads to the trunk and limbs and usually fades after three days.• The skin manifestations are called "blueberry muffin lesions." Dr.T.V.Rao MD 10
Main Clinical EventsThe clinical events occurring in the neonatal age is more important and divided into two major groups 1 Post Natal Rubella 2 Congenital Rubella Dr.T.V.Rao MD 11
Features of Rubella Infection• The rash disappears after a few days with no staining or peeling of the skin.• Other symptoms include low grade fever, swollen glands (post cervical lymphadenopathy), joint pains, headache, conjunctivitis.• The swollen glands or lymph nodes can persist for up to a week and the fever rarely rises above 38 oC (100.4 oF). Dr.T.V.Rao MD 12
How Adults acquire 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, feces 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. Dr.T.V.Rao MD 13
Clinical findings Malaise Low grade fever Morbilliform rash Rash starts on Face Extremities Rarely lasts more than 5 days No features of the rash give clues to definitive diagnosis of Rubella.
Systemic events of Rubella Infection Dr.T.V.Rao MD 15
Rubella during Pregnancy • "Rubella infection in pregnant women during the first three months of pregnancy may result in the baby being born with birth defects or congenital rubella syndrome Dr.T.V.Rao MD 16
Post natal Rubella Occurs in Neonates and Childhood Adult infection occurs through mucosa of the upper respiratory tract spread to cervical lymph nodes Viremia develops after 7 – 9 day Lasts for 13 – 15 days Leads to development of antibodies The appearance of antibodies coincides the appearance of suggestive immulogic basis for the rash In 20 – 50 % cases of primary infections are subclinical
Congenital Manifestations Dr.T.V.Rao MD 18
An Infant Presenting with Congenital Cataract Dr.T.V.Rao MD 19
Rubella Rashes When epidemics occur with similar features it is more suggestive of Rubella epidemics Other Enterovirus infections can produce similar manifestations.
Other manifestations and complications May produce transient Arthritis, in women in particular. Serious complications are Thrombocytopenia Purpura Encephalitis
Dr.T.V.Rao MD 22
Immunity - Rubella Antibodies appear in serum as rash fades and antibody titers raise Rapid raise in 1 – 3 weeks Rash in association with detection of IgM indicates recent infection. IgG antibodies persist for life
Immunity - Protects One attack of Rubella infection, protects for life Immune mothers transfer antibodies to off springs who are in turn are protected for 4 – 6 months.
Culturing the Virus The virus can be cultured and adopted to continuous cell lines Rabbit kidney cells (RK 13 ) and Vero cells
Diagnosis of Rubella in AdultsClinicalDiagnosis is unreliableMany viral infections mimic RubellaSpecific diagnosis of infection with 1 Isolation of virus 2 Evidence of seroconversion Dr.T.V.Rao MD 26
Isolation and Identification of virus Nasopharyngeal or throat swabs taken 6 days prior or after appearance of rash is a good source of Rubella virus Using cell cultured in shell vial antigens can be detected by Immunofluresecentet methods
Serology In Rubella Hemagglutination inhibition test for Rubella is of Diagnostic significance ELISA tests are greater importance A raise in Antibody titers must be demonstrated between two serum samples taken at least 10 days apart. Or Detection of Rubella specific IgM must be detected in a single specimen.
Epidemiology Rubella is world wide in distribution Occurs round the year, Epidemics occur every 20 – 25 years Infection is transmitted by respiratory route The use of Rubella vaccine has now eliminated both epidemic and endemic Rubella in USA and several developed countries Dr.T.V.Rao MD 29
Treatment and PreventionRubella is a mild self limited illness.No specific treatment or Antiviral treatment is indicated.However Laboratory proved and clinically missed Rubella in the Ist 3-4 months of pregnancy is associated with fatal infections. Dr.T.V.Rao MD 30
Congenital Rubella• Since the virus can cross the placenta, it can cause Congenital Rubella Syndrome in the newly born.• Congenital infection may be mild and asymptomatic or severe, causing cataracts, glaucoma, deafness, heart abnormalities, mental retardation or death. Dr.T.V.Rao MD 31
Congenital Rubella Syndrome Maternal Viremia with Rubella infection during pregnancy may result in infection of placenta and fetes. The growth rate of fetal cells are reduced. Results in fewer number of cells after the birth. Lead to deranged and hypo plastic organ development. Results in structural damage and abnormalities Dr.T.V.Rao MD 32
Rubella infection – At various trimesters Isttrimester infections lead to abnormalities in 85 % of cases. and greater damage to organs 2nd trimester infections lead to defects in 16 % > 20 weeks of pregnancy fetal defects are uncommon However Rubella infection can also lead to fetal deaths, and spontaneous abortion. The intrauterine infections lead to viral excretion in various secretion in new-born upto 12-18 months. Dr.T.V.Rao MD 33
Clinical Findings ( Congenital Rubella Syndrome )May be transient effects in infants.Permanent manifestations may be apparent at birth, become recognized during the first year.Developmental abnormalities appear during childhood and adolescents. Dr.T.V.Rao MD 34
Rubella Epidemic• The largest rubella epidemic in the United States occurred in 1964-1965, and resulted in the birth of an estimated 30,000 infants with congenital rubella syndrome. As many as 85% of pregnant women with clinical rubella delivered babies with congenital rubella. The highest percentage of congenital rubella occurred when the pregnant mothers had rubella during the first trimester Dr.T.V.Rao MD 35
Classical Triad of Rubella Classical Triad Cataract Cardiac abnormalities DeafnessOther manifestationsGrowth retardationRashHepatosplenomegalyJaundiceMeningoencephalitisCNS defects lead to moderate to profound mental retardation
Other Neurological manifestations Problems in balance Motor skills in preschool children altered. A rare complication of Pan encephalitis can occur in second decade with Congenital rubella syndrome may progress to death.
Diagnosis of Congenital Rubella Syndrome Demonstration of Rubella antibodies of IgM in a new born is diagnostic value. As IgM group do not cross the placenta and they are produce in the infected fetus,
Prevention and Treatment• Rubella vaccine is given to children at 15 months of age as a part of the MMR (measles-mumps-rubella) immunization.• The vaccine is live and attenuated and confers lifelong immunity.• There is no specific treatment for Rubella; management is a matter of responding to symptoms to diminish discomfort. Dr.T.V.Rao MD 39
Treatment, Prevention, Control No specific treatment is available CRS can be prevented by effective immunization of the young children and teenage girls, remain the best option to prevent Congenital Rubella Syndrome. The component of Rubella in MMR vaccine protects the vaccinated
MMR Vaccine The MMR vaccine is a mixture of three live attenuated viruses, administered via injection for immunization against measles, mumps and rubella. It is generally administered to children around the age of one year, with a second dose before starting school (i.e. age 4/5). The second dose is not a booster; it is a dose to produce immunity in the small number of persons (2-5%) who fail to develop measles immunity after the first dose In the United States, the vaccine was licensed in 1963 and the second dose was introduced in the mid 1990s. It is widely used in all National, Universal Immunization programmes Dr.T.V.Rao MD 41
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