Rubella, also known as German measles, is a contagious viral illness caused by the rubella virus. It is most common in children between 5-10 years of age. The virus is transmitted through respiratory droplets. Common symptoms include a rash and tender lymph nodes. If a woman is infected during pregnancy, especially in the first trimester, it can cause congenital rubella syndrome in the fetus, resulting in defects like deafness, heart problems, and intellectual disabilities. Diagnosis involves isolating the virus or detecting antibodies in blood tests. Vaccination is the best way to prevent rubella infection and its complications.

1. Rubella
Presented By- Dr. Kunal
Guided By- Dr. Abhay Mudey

2. HISTORY - RUBELLA
 Discovered in 18th century -
thought to be variant of measles
 The Teratogenic property of the
infection was documented by an
Australian ophthalmologist
Norman McAlister Gregg, in 1941
 The virus was isolated in 1962
04/04/20152

3. Introduction
 From Latin meaning "little red"
 An attenuated vaccine was
developed in 1967
 First described as distinct
clinical entity in German
literature
04/04/20153

4. Rubella Virus
 Togavirus
 RNA virus
 One antigenic type
 Rapidly inactivated by chemical agents, low pH,
heat and ultraviolet light
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5. EPIDEMIOLOGICAL
DETERMINANTS
04/04/20155
Agent
factors
Host
factors
Environmental
factors

6. AGENT FACTORS
A- Agent
 Causative agent: Rubella virus
 ssRNA Virus of the
Togaviridae Family
 genus Rubivirus
 One antigenic type
 Diameter 50 – 70 nm
 Enveloped Spherical
 Virus carry hemagglutinin
 Virus multiply in the cytoplasm of infected cell.
 Highly sensitive to heat, extremes of pH & uv light.
 At 4°C, virus is relatively stable for 24 hours. 04/04/20156

7. AGENT FACTORS cont.
B- Source of infection
 CASES
 Subclinical
 Clinical
 Congenital from infected
pregnant women to fetus.
 There is no known carrier
state.
C- Period of
communicability
 It probably extends from
a week before symptoms
to about a week after
rash appears.
 Infectivity is greatest
when the rash is
erupting.
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8. HOST FACTORS
A- Age
 Disease of childhood
3-10 yrs age group.
 Following widespread
immunization
campaigns persons
older than 15 yrs
account for 70% cases
in developed
countries.
B- Immunity
 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.
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9. Immunity - Rubella
 Antibodies appear in
serum as rash fades and
antibody titres raise
 Rapid raise in 1 – 3 weeks
 Rash in association with
detection of IgM indicates
recent infection.
 IgG antibodies persist for
life
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10. ENVIRONMENTAL
FACTORS
Disease usually
occurs in seasonal
pattern, during the
late winter & spring.
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11. Mode of Transmission
Person to person- via
respiratory route:-
 Droplet from nose & throat
 Droplet nuclei (aerosols)
 Maintain in human population
by chain transmission.
Acquired during pregnancy- vertical
transmission:-
 Virus can enter via the Placenta & infect the
foetus in utero (Congenital Rubella Syndrome).
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12. Incubation period
Between 14-21 days
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13. Rubella Pathogenesis
 Respiratory transmission of virus
[Spread by respiratory droplets]
 Replication in nasopharynx and
regional lymph nodes
 Viremia 5-7 days after exposure
with spread to tissues
 Placenta and fetus infected during
viremia
04/04/201513

14. Pathogenesis Continued……
Rubella Virus Developed in the nasopharynx
Respiratory
Tract
Skin Lymph
Nodes
Joints
Placenta or
Fetus
• Cough
• Minor
sore
throat
• Rashes
• Lesions
• Mild
arthralgia
• arthritis
• Placentitis
• Fetal
Damage
• Lymphadenopathy 04/04/201514

15. Rubella virus
Transmitted
via
respiratory
droplets
Infects cells in
the upper
respiratory
tract
Infects cells in
the upper
respiratory
tract
Virus
multiplies
Extends in the
regional
lymph nodes
Virus replicates in
the nasopharynx
Infection is
established in
the skin and
other tissues
including the
respiratory tract
Pathophysiology
Forchheimer’s
Spot may
develop
Rashes
develops,
cough etc.
Virus can be
found in the
skin, blood and
respiratory tract
04/04/201515

16. Vaccination
and proper
interventions
Recent
infection
With german
measles
vaccine
Virus
culture/
blood test
Diagnosis:
doctor
suspects
whether
patient has
measles
German Measles left
untreated, it may cause
complications: Rubella
Arthritis, Encephalitis,
Purpura bronchitis,
abscesses in the ears and
pneumonia 04/04/201516

17. 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
Immunity –life long
Occurs round the year, peak in late winter and spring season
Transmission – droplet, vertical transmission
I.P – 2-3 weeks average 18 days
Rubella is world wide in distribution
Epidemics occur every 4-9 years.
04/04/201517

18. Rubella Clinical Features
 Incubation period 14 days (range 12-23 days)
 Low grade fever
 Lymphadenopathy in
second week
 Maculopapular rash
14-17 days after exposure
04/04/201518

19. SIGNS AND SYMPTOMS
 RASH-
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 with no
staining or peeling of the skin.
 The skin manifestations are called
"blueberry muffin lesions."
04/04/201519

20. SIGNS AND SYMPTOMS
continued….
 LYMPH NODE-
 Tender lymphadenopathy
(particularly posterior
auricular and suboccipital
lymph nodes)
 persist for up to a week.
04/04/201520

21. SIGNS AND SYMPTOMS
 TEMPERATURE-Fever rarely rises above 38o C (100.4 o F)
04/04/201521

22. Other manifestations &
complications
 May produce transient
Arthritis, particular in
women.
 Serious complications
are-
 Thrombocytopenia
Purpura
 Encephalitis
04/04/201522

23. 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.
04/04/201523

24. Salt & Paper
retinopathy
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25. Systemic events of Rubella
Infection
04/04/201525

26. Main Clinical Events During
Pregnancy
The clinical events occurring in the
neonatal age is more important and
divided into two major groups-
1 Congenital Rubella
2 Post Natal Rubella
04/04/201526

27. 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.
04/04/201527

28. Rubella infection – At various
trimesters
 Ist trimester 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 newborn up to 12-18 months.
04/04/201528

29. Rubella infection & Chance of
CRS
 0–28 days before conception - 43% chance
 0–12 weeks after conception - 51% chance
 13–26 weeks after conception - 23% chance
 Infants are not generally affected if rubella is
contracted during the third trimester
04/04/201529

30. 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 immunologic basis
for the rash
 In 20 – 50 % cases of primary infections are
subclinical. 04/04/201530

31. Rubella Case Definition
Acute onset of generalized
maculopapular rash and temperature
of >37.2 C (>99 F), if measured with or
without arthritis/arthralgia or
lymphadenopathy or conjunctivitis.
04/04/201531

32. Clinical Features
Rash at birth
Deafness
Cataracts
Heart defects
Microcephaly
Mental retardation
Bone alterations
Liver and spleen damage
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33. Cataract
Hearing Defects
Sensoryneuronal
deafness
Classical
Triad
Classical Triad of
Rubella
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34. Other Abnormalities
Transient
• low birth weight, hepatosplenomegaly, thrombocytopenic purpura,bone lesions,
meningoencephalitis, hepatitis, haemolytic anemia, pneumonitis,
lymphadenopathy
Permanent
• Sensorineural deafness, Heart Defects (peripheral pulmonary
stenosis,pulmonary valvular stenosis, patent ductus arteriosus,ventricular
septal defect) Eye Defects (retinopathy, cataract, microopthalmia glaucoma,
severe myopia) Other Defects (microcephaly, diabetes mellitis, thyroid
disorders, dermatoglyptic abnormalities
Developmental
• Sensorineural deafness, Mental retardation, Diabetes Mellitus, thyroid disorder
04/04/201534

35. Risks of rubella infection during
pregnancy
Preconception minimal risk
0-12 weeks 100% risk of fetus being congenitally
infected resulting in major
congenital abnormalities.
Spontaneous abortion occurs in 20% of
cases.
13-16 weeks Deafness & retinopathy 15% cases.
After 16 weeks Normal development, slight risk of
deafness & retinopathy
04/04/201535

36. Diagnosis of Rubella in
Adults
 Clinical Diagnosis is unreliable
 Many viral infections mimic Rubella
 Specific diagnosis of infection with-
 1 Isolation of virus
 2 Evidence of seroconversion
04/04/201536

37. 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
Immunofluresecent
methods 04/04/201537

38. Culturing the Virus
 The virus can be
cultured and adopted
to continuous cell
lines
 Rabbit kidney cells (RK 13 )
and Vero cells
04/04/201538

39. Serology in Rubella
 Haemagglutination inhibition test for Rubella is of
Diagnostic significance
 ELISA tests are greater importance
 A raised Antibody Titer must be demonstrated between
two serum samples taken at least 10 days apart.
 Detection of Rubella specific IgM in a single specimen.
04/04/201539

40. 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 one week
before to two weeks after rash.
04/04/201540

41. Diagnosis in infant
 Isolation of rubella virus
 Most frequently isolated from nasopharyngeal secretions
 Can be cultured from blood, urine, CSF, lens tissue, etc.
 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
 Presence of rubella-specific haemagglutination inhibition
(HAI) after nine months of age
04/04/201541

42. Diagnosis in Infant
continued……
 Demonstration of rubella-specific IgM antibodies
 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.
 Most useful in infants younger than 2 months, but may persist
for up to 12 months
 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,
Infectious mononucleosis, parvovirus), and heterophile
antibodies 04/04/201542

43. Medical 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)
04/04/201543

44. Treatment for acute maternal
rubella infection
 Acetaminophen for symptomatic relief
 IgG –
 role is 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.
 Counseled about maternal-fetal transmission and offered
pregnancy termination, especially prior to 16 weeks
gestation.
 After 20 weeks gestation- individualized management.
04/04/201544

45. Prevention
 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.
 Given to children 12 and 15
months and again between 3-
6 years of age
04/04/201545

46. Treatment, Prevention, Control
in childbearing age women
 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
04/04/201546

47. Vaccination of Women of
Childbearing Age
 Ask if pregnant or likely to
become so in next 4 weeks
 Exclude those who say "yes
the vaccine has been already
taken"
 For others
 Explain theoretical risks
 Vaccinate
04/04/201547

48. MMR Vaccine
 The MMR vaccine is a mixture of three live
attenuated viruses, administered via injection
for immunization against measles, mumps
and rubella virus strain RA 27/3 .
 It is generally administered to children around
the age of one year, with a second dose before
starting school (i.e. age 4/5).
04/04/201548

49. MMR Vaccine
 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, the vaccine was licensed in 1963
and the second dose was introduced in
the mid 1990s. It is widely used.
 Contraindications= immunodeficiency
disorder, history of anaphylaxis to
neomycin, and pregnancy.
 Side effects: arthritis, arthralgia, rash,
adinopathy, or fever.
04/04/201549

50. Rubella Vaccines
Vaccine Trade Name
GMK-3:RK53 Cendevax
HPV-77:DK12 Rubelogen
HPV-77:DE5 Meruvax
RA 27/3* Meruvax II
04/04/201550

51. Rubella Vaccine Contined….
04/04/201551

52. Rubella Vaccine
Recommendations for Increasing
Coverage
 Continued routine vaccination of children at age
>12 months with vaccination required for school
entry
 Screen and vaccinate susceptible persons
 health care workers
 college entry
 prenatal with postpartum vaccination
 other health care visits
 workplace
04/04/201552

53. Rubella Vaccine (MMR)
Indications
 All infants >12 months of age
 Susceptible adolescents and adults without documented
evidence of rubella immunity
 Emphasis on non-pregnant women of childbearing age,
particularly those born outside the U.S.
04/04/201553

54. MMR Adverse Reactions
 Fever
 Rash
 Joint symptoms
 Thrombocytopenia
 Parotitis
 Deafness
 Encephalopathy
04/04/201554

55. MMR Vaccine
Contraindications and Precautions
 Severe allergic reaction to prior dose or
vaccine component
 Pregnancy
 Immunosuppression
 Moderate or severe acute illness
 Recent blood product
04/04/201555

56. Other Preventive Measures
Antenatal screening
 All pregnant women attending antenatal clinics are
tested for immune status against rubella.
 Non-immune women are offered rubella vaccination in
the immediate post partum period.
 Since 1968, a highly effective live attenuated vaccine has
been available with 95% efficacy
04/04/201556

57. Other Preventive Measures
Continued….
 Universal vaccination is now offered to all infants as a
part of the MMR regimen in the USA, UK and a number
of other countries.
 Some countries such as the Czech Republic, Bangladesh,
Malaysia & India continue to selectively vaccinate school
girls before they reach childbearing age.
 Both universal and selective vaccination policies will
work provided that the coverage is high enough.
04/04/201557

58. Rubella Outbreak Control
Guidelines
 Laboratory diagnosis of rubella
and CRS
 Step-by-step guidelines on
evaluation and management of
outbreak
 Rubella prevention and control
among women of childbearing
age
 Rubella and CRS surveillance
04/04/201558

59. 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
04/04/201559

60. 04/04/201560