RUBELLA

Dr.T.V.Rao MD

History - Rubella
The Teratogenic property of the infection was documented by an Australian ophthalmologist
Norman McAlister Gregg, in 1941
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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.
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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.
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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

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Cause and Transmission

The disease is caused by Rubella virus, a toga virus that is enveloped and has a singlestranded 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.
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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.

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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."
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Main Clinical Events

The

clinical events occurring in the neonatal age is more important and divided into two major groups 1 Post Natal Rubella
2 Congenital Rubella
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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).
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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.
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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

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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
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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

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An Infant Presenting with Congenital Cataract

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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

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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 Adults

Clinical

Diagnosis is unreliable Many viral infections mimic Rubella Specific diagnosis of infection with 1 Isolation of virus 2 Evidence of seroconversion
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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
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Treatment and Prevention

Rubella

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.
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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.
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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
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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 new-born upto 12-18 months.
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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.
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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
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Classical Triad of Rubella

Cataract Cardiac abnormalities Deafness

Classical Triad

Other manifestations Growth retardation Rash Hepatosplenomegaly Jaundice Meningoencephalitis CNS 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.
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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 Dr.T.V.Rao MD 41 programmes

 Programme Created by Dr.T.V.Rao MD for Medical and Paramedical Students in the Developing World Email doctortvrao@gmail.com

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