A BRIEF PRESENTATION ON RUBELLA

1. P R E S E N T E D B Y : D R . A A M I R
M O D E R A T E D B Y : D R . S H U G U F T A
RUBELLA

2. HISTORY
 Discovered in 18th century –
thought to be variant of measles
 Congenital rubella syndrome
(CRS) described by Gregg in 1941
 Rubella virus first isolated in 1962
by Parkman and Weller
 An attenuated vaccine was
developed in 1967

3. INTRODUCTION
 Generally mild disease caused by the rubella virus.
 Acute exanthematous viral infection of children and adults.
 From Latin meaning “little red”
 First described as distinct clinical entity in German literature- German
measles
 Also called as three-day measles & “THIRD DISEASE”
 Because of routine vaccination against rubella since 1970 , rubella is
now rarely reported.

4. Rubella Epidemic United States, 1964-1965
 12.5 million rubella cases
 2,000 encephalitis cases
 11,250 abortions(surgical/spontaneous)
 2,100 neonatal deaths
 30,000 CRS cases
 Deaf - 11,600
 Blind - 3,580
 Mentally retarded - 1,800

5. RUBELLA VIRUS
 Rubella virus
 ssRNA Virus of the Togaviridae
Family
 Genus -Rubivirus
 One antigenic type
 Diameter => 50 – 70 nm
 Enveloped
 Spherical
 Virus carry hemagglutinin

6. GENOME

7. RESISTANCE
 Relatively unstable
 Inactivated by :
 Lipid solvents,
 Trypsin,
 Formalin,
 Ultraviolet light,
 Low pH,
 Heat, and
 Amantadine.

8. Epidemiology
 Occurs worldwide
 The virus tends to peak in countries
with temperate climates
 Common in children ages 5-10 years
old
 Human are only known reservoir.
 Host -3-10 yrs
 Source of infection – Respiratory
secretion
 Infants with CRS may shed virus for
a year or more

9. RUBELLA IN INDIA
 40-45% of women in the
childbearing age are susceptible
to Rubella.
 Over 40000 babies are born with
birth defects every year because
of Rubella infection during
pregnancy in India.

10. GENOTYPES

11.  Genotypes 1A, 1E, 1F, 2A and 2B have been isolated in China.
 Genotype 1J has only been isolated from Japan and the Philippines.
 Genotype 1E is found in Africa, the Americas, Asia and Europe.
 Genotype 1G has been isolated in Belarus, Cote d'Ivoire and Uganda.
 Genotype 1C is endemic only in Central and South America.
 Genotype 2B has been isolated in South Africa.
 Genotype 2C has been isolated in Russia

12. Modes of Transmission
1. Person to person- via
respiratory route:-
 Droplet from nose & throat
 Droplet nuclei (aerosols)
 Maintain in human population by
chain transmission.

13. 2. Acquired during pregnancy-
vertical transmission:-
 Virus can enter via the Placenta
& infect the fetus in utero
(Congenital Rubella Syndrome).

14. Communicability
 Moderately contagious
 Patients are most contagious
when the rash is erupting
 Shed virus from 7 days before
until 5-7 days after the onset of
the rash
 Infants with congenital rubella-
transmit the infection to those
who care for them

15. EPIDEMIOLOGYEPIDEMIOLOGICAL
DETERMINANTS
AGENT FACTORS
1.Agent
2.Source of infection
3.Period of
communicability
HOST FACTORS
1.Age
2.Immunity
ENVIRONMENTAL
FACTORS

16. AGENT FACTORS
1. AGENT

17. 2- Source of infection 3- Period of
communicability
 CASES
 Subclinical
 Clinical
 Congenital from infected
pregnant women to fetus.
 There is no known carrier state.
 It probably extends from a
week before symptoms to about
a week after rash appears.
 Infectivity is greatest
when the rash is erupting.
AGENT FACTORS(Contd.)

18. 1.AGE 2.IMMUNITY
 Disease of childhood 3-10 yrs
age group.
 Following widespread
immunization campaigns
persons older than 15 yrs
account for 70% cases in
developed countries
 One attack results in life long
immunity.
 Infants of immune mothers are
protected for 4-6 months.
 In India, about 40% of child
bearing age group women are
susceptible to rubella.
HOST FACTORS

19. 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

20. ENVIRONMENTAL FACTORS
 Disease usually occurs in
seasonal pattern -
late winter & early spring.
 Epidemics every 4-9 years.

21. INCUBATION PERIOD
 14 DAYS
 RANGE : 12- 23 DAYS

22. PATHOGENESIS

23. CLINICAL MANIFESTATIONS
1.ACQUIRED RUBELLA
or
POSTNATAL RUBELLA
2. CONGENITAL
RUBELLA SYNDROME

24. ACQUIRED RUBELLA
 Prodrome -Low grade fever,
malaise , anorexia
 Lymphadenopathy in second
week
 Maculopapular rash 14-17 days
after exposure
 Children have milder disease
than adults
 Many, if not most, cases of
postnatal rubella are subclinical.

25. Sign & Symptoms
RASH
 Primary symptom- appearance of a
rash (exanthema)on the face
 Spreads to the trunk and limbs
 Usually fades after three days with no
staining or peeling of the skin.
 The skin manifestations are called
"blueberry muffin lesions."

26. LYMPH NODE-
 Tender Lymphadenopathy
 Posterior auricular lymph nodes
 Posterior cervical nodes
 Sub occipital lymph nodes
 Persist for up to a week.

27. TEMPERATURE-Fever rarely rises above 38 C (100.4F)

28. Pathognomonic Sign
Forchheimer’s Spot
 Fleeting enanthema
 Pinpoint or larger
petechiae that usually
occur on the soft palate
in 20% of patients
 Similar spots can be
seen in measles and
scarlet fever.
 Not diagnostic

29. Complications
 May produce transient
Arthritis or Arthalgia, particular
in women.
 Serious complications are-
 Thrombocytopenia
 Purpura
 Encephalitis

30. Main Clinical Events During Pregnancy
 The clinical events occurring in the
neonatal age is more important and
divided into two major groups-

31. Congenital Rubella Syndrome(CRS)
 Occurs during the first trimester of
pregnancy.
 Affects the development of the fetus.
 May lead to several birth defects.
 Infection may affect all organs.
 May lead to fetal death or premature delivery.
 Severity of damage to fetus depends
gestational age.
 Infants: virus is isolated from urine and feces.

32. Clinical Manifestations

33. Classical Triad of Congenital Rubella
HEARING LOSS CARDIAC DEFECTS

34.  Rubella syndrome retinopathy
is also called as:
SALT & PEPPER RETINOPATHY

35. CRS Manifestations
Transient
• Low birth weight,
• Hepatosplenomegaly,
• Thrombocytopenic
purpura,
• Bone lesions,
• Meningoencephalitis,
• Hepatitis,
• Haemolytic anemia,
• Pneumonitis,
• Lymphadenopathy
Permanent
• Sensory-neural deafness,
• Heart Defects (PDA,VSD)
• Eye Defects (retinopathy,
cataract, microopthalmia
glaucoma, severe myopia)
• Other Defects
(Microcephaly, diabetes
mellitus, dermatoglyptic
abnormalities)
Developmental
• Sensory-neural deafness,
• Mental retardation,
• Diabetes Mellitus,
• Thyroid disorder

36. Rubella infection – At various trimesters
 First 2 months of gestation-65% to 85% chance of being affected,
 multiple congenital defects or
 spontaneous abortion, or
 Both
 Rubella during the third month-30% to 35% chance of developing a
single defect
 Fourth month -10% risk for a single congenital defect
 Fetal damage (deafness alone) -rubella occurs up to the 20th week of
gestation

38. DIAGNOSIS OF ACQUIRED RUBELLA
 Clinical Diagnosis is unreliable
 Many viral infections mimic Rubella
 Specific diagnosis of infection with-
1. Isolation of virus from clinical specimen( nasopharynx, urine etc)
2. Evidence of seroconversion
#.Significant rise in IgG by any standard serologic assay
(enzyme immunoassay)
#.Positive serologic test for IgM Rubella antibody

39. 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

40.  Using cell cultured in shell vial -antigens can be detected by Immuno-
fluorescence methods

41. Culturing the Virus
 The virus can be cultured and
adopted to continuous cell
lines
 Rabbit kidney cells (RK
13 )
 Vero cells
 Identified by characteristic
Cytopathic effect on cell
cultures.

42. Serology In Rubella
 Hemagglutination inhibition
test for Rubella is of Diagnostic
significance
 ELISA tests are greater Importance,
 Passive latex agglutination test,
 and Radial hemolysis test
 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.

43. Diagnosis of Acute Rubella in Mother
 Fourfold rise in IgG titer between acute and
convalescent serum specimens
Obtained within 7 to 10 days after onset of rash
Repeated 2 to 3 weeks later
 Presence of rubella specific IgM
 Positive rubella culture
Can be isolated from nasal, blood, throat, urine, or cerebrospinal fluid
Generally isolated from pharynx 1 week before to 2 weeks after rash.

44. Algorithm for Serologic Evaluation

45. Diagnosis in Infant
 Isolation of rubella virus
Most frequently isolated from nasopharyngeal secretions
Can be cultured from blood, urine, CSF, lens tissue, amniotic fluid.
 Serial rubella-specific IgG levels at 3, 6, and 12 months
 Rubella-specific IgG antibodies that persist at higher concentration or longer
duration than expected from passive transfer of maternal antibody
 Maternal rubella antibody- half-life= 1 month, should decrease by 4 to 8 fold
by 3 months of age and should disappear by 6 to 12 months
 Can delay diagnosis

46.  Presence of rubella-specific hemagglutination inhibition(HAI) after
nine months of age.
 Demonstration of rubella-specific IgM antibodies
 Demonstration of Rubella antibodies of IgM in a new born is diagnostic value.
 Most useful in infants younger than 2 months, but may persist for up to 12
months
 RT-PCR results may be positive before the appearance of rubella IgM
antibodies

47.  False Negative:- 20% of infected infants tested for rubella IgM may not
detectable titers before 1 month.
 If clinically consistent and test negative after birth, should be retested at 1
month
 False Positive-
 Rheumatoid factor,
 Viral infections (EBV, IM, parvovirus),
 Heterophile antibodies

48. TREATMENT
 Rubella is a mild self limited illness.
 No specific treatment or Antiviral treatment is indicated.

 Isolation and quarantine

 Increase fluid intake
 Encourage the patient to rest
 Good ventilation
 Encourage the patient to drink either lemon or orange juice

 Provide health teaching about Rubella (cause , immunizations)

49. Treatment For Acute Maternal Rubella Infection
 Acetaminophen for symptomatic relief
 IgG- controversial, CDC recommends limiting use of immunoglobulin
to women with known rubella exposure who decline pregnancy
termination.
 Glucocorticoids, platelet transfusion, and other supportive measures
for complications.
 Should be counseled about maternal-fetal transmission and offered
pregnancy termination, especially prior to 16 wks Gestation.
 After 20 wks. gestation- individualized management

50. Recommendations
 Do:-
 Screening at first post-
conceptual appointment, first-
trimester screening
 Don’t:-
 Routine screening of child-
bearing age women not
recommended
 Routine vaccination of all
women of childbearing age not
recommended

51. PREVENTION
 Rubella vaccine is given to
children at 15 months of age
as a part of the MMR.
 The vaccine is live and
attenuated and confers
lifelong immunity.
 Given to children 12 and 15 months
and again between 3-6 years of age

52. Prevention of Child Bearing Age Women
 Immunization of:
 Young children
 Teenage girls
 Best to prevent Congenital Rubella
Syndrome(CRS)
 Component of Rubella in MMR
protects the vaccinated

53. Vaccination of Women of Childbearing Age
 Ask if pregnant or likely to become so in next 4 weeks
 Exclude those who say “yes”
 For others
 explain theoretical risks
 vaccinate

54. VACCINES
 Vaccine Trade Name Licensure Discontinued
 HPV-77:DE5 Meruvax 1969 1979
 HPV-77:DK12 Rubelogen 1969 1979
 GMK-3:RK53 Cendevax 1969 1979
 RA 27/3* Meruvax II 1979 Still in use

55. RUBELLA VACCINE
 Composition Live virus (RA 27/3
strain)
 Efficacy 95% or more
 Duration of Immunity lifelong
 Schedule at least 1 dose
 Should be administered with measles
and mumps as MMR or with measles,
mumps and varicella as
MMRV(ProQuad)

56. CHARACTERISTICS:
 Lyophilized (freeze-dried) powder
 Reconstituted with sterile, preservative-free water
 Vaccines contains
 Small amount of human albumin
 Neomycin
 Sorbitol
 Gelatin

57. IMMUNIGENICITY &VACCINE EFFICACY
 RA 27/3 rubella vaccine
 is safe
 more immunogenic than rubella vaccines used previously
 95% or more of vaccinees aged 12 months and older develop serologic evidence
of rubella immunity after a single dose.

58. RUBELLA IMMUNITY
 Documentation of one dose of rubella-containing vaccine on or after
the first birthday
 Serologic evidence of immunity
 Birth before 1957 (except women of childbearing age)
 Birth before 1957 is not acceptable evidence of rubella immunity for
women who might become pregnant
 Only serology or documented vaccination should be accepted

59. MMR ADVERSE EFFECTS
 Rubella vaccine is very safe.
 Most adverse events reported following MMR vaccination (such as
fever and rash) are attributable to the measles component.
 Some adverse events being:
 Fever
 Rash
 Chronic arthralgias
 Chronic arthritis
 Transient peripheral neuritic complaints
 Recurrent joint symptoms
 Collagen disease

60. MMR CONTRAINDICATIONS
 History of anaphylactic reactions
to neomycin
 History of severe allergic reaction
to any component of the vaccine
 Pregnancy
 Immunosuppression
• Moderate or severe acute illness
• Recent blood product
• Personal or family
(i.e., sibling or parent) history of
seizures of any etiology (MMRV
only)

61. Rubella Vaccination in INDIA
 MR vaccine was introduced in
National Immunization Schedule
in 2017
 Phased introduction, at present in
five states namely
 Karnataka,
 Tamil Nadu,
 Goa,
 Lakshadweep and
 Pondicherry. (As of Feb’ 2017)
 First dose at 9-12months(until
5yrs)
 Booster -16-24months

62. Strategies to Decrease Rubella and CRS
 Vaccination of Susceptible Post pubertal Females
 Vaccinate susceptible adolescents and young adults of childbearing age
 Emphasizing immunization for college students
 Vaccinating women postpartum and post abortion
 Vaccination can be carried out at:
 Family planning clinics,
 Sexually transmitted disease (STD) clinics,
 As part of routine gynecologic care

63.  Hospital Rubella Programs
 Vaccinating susceptible hospital personnel
 Both male and female
 e.g., volunteers, trainees, nurses, physicians
 Ideally, all hospital employees should be immune.