Rubella
Rubella - Summary
Rubella (also known as German measles) is an infection caused by viruses of the genus Rubivirus of the family Togaviradae. It is spread through respiratory secretions.
Rubella rarely causes complications in otherwise healthy people. However, it can have serious consequences if it is contracted in early pregnancy, resulting in congenital rubella syndrome (CRS) in the child, the complications of which include: cataracts; deafness; cardiac abnormalities; microcephaly; intrauterine growth retardation; and inflammatory lesions of the brain, liver, lungs, and bone marrow.
As a result of the childhood immunization programme, rubella is now uncommon in the UK, and CRS is very rare.
Clinical features consistent with rubella include:
Rash which typically starts behind the ears, before spreading to the face and neck, and then to the trunk and extremities. The rash is non-confluent and maculopapular, resembling measles, and is transient, being present in total for 3–5 days.
Lymphadenopathy (swollen lymph nodes) which may present before the rash and may last for 2 weeks or more after the rash disappears. The suboccipital (lower part of the back of the skull), postauricular (behind the ears), and cervical (neck) lymph nodes are most often affected.
Arthritis and arthralgia (inflammation and pain of the joints) which tends to affect the fingers, wrists, and knees. It appears during or just after the rash, is usually mild, and usually resolves within a month.
Non-specific symptoms such as malaise, low-grade fever, headache, sore throat, rhinorrhoea (nasal discharge), and conjunctivitis.
Rubella is unlikely in people who have been fully immunized and in people who have previously had rubella. Other causes of rash (such as parvovirus B19, measles, scarlet fever) are more likely.
Rubella is a notifiable disease. The local Health Protection Unit should be notified immediately if there is clinical suspicion of rubella.
Rubella is usually a mild, self-limiting condition. The rash and fever will typically resolve within 5 days, although swollen lymph glands may take a week or more to improve.
Rest and adequate fluids are advised.
Paracetamol or ibuprofen can be given for symptomatic relief.
People with rubella should stay off school or work, and avoid contact with pregnant women where possible, for 6 days after the initial development of the rash.
Anyone who has been in contact with confirmed or suspected rubella should be advised to seek medical advice if the develop symptoms.
Pregnant women with confirmed rubella who are at a gestational age 20 weeks or less should be referred urgently to an obstetrician for risk-assessment and counselling. After 20 weeks gestational age there is minimal risk to the child.
Pregnant women who have been in contact with rubella should have the diagnosis confirmed or excluded by the local Health Protection Unit.
Have I got the right topic?
This CKS topic covers the management of suspected rubella, and the management of people who have been in contact with someone with rubella. It includes the management of pregnant women. This CKS topic does not cover the management of congenital rubella syndrome.
This CKS topic also does not cover the prevention of rubella with the combined measles, mumps, and rubella vaccine. This is covered in a separate CKS topic on Immunizations - childhood.
There is a separate CKS topic on Measles.
The target audience for this CKS topic is healthcare professionals working within the NHS in the UK, and providing first contact or primary health care.
How up-to-date is this topic?
How up-to-date is this topic?
Changes
February 2013 — minor update. The 2013 QIPP options for local implementation have been added to this topic [NICE, 2013].
October 2012 — minor update. The 2012 QIPP options for local implementation have been added to this topic [NPC, 2012].
July 2011 — minor update. More exact paracetamol dosing for children has been introduced by the Medicines and Healthcare products Regulatory Agency [MHRA, 2011]. Prescriptions have been updated to reflect the revised dosing. Issued in July 2011.
August 2010 — minor update. Children (and adults) are now advised to stay away from school or work for 6 days after the onset of the rash [HPA, 2010]. Issued in August 2010.
March 2010 — minor update. Advice for people with suspected rubella to avoid contact with pregnant women corrected. Issued in March 2010.
August to December 2009 — this is a new CKS topic. The evidence-base has been reviewed in detail, and recommendations are clearly justified and transparently linked to the supporting evidence.
Update
New evidence
Evidence-based guidelines
Guidelines published since the last revision of this topic:
HPA (2010) Guidance on infection control in schools and other childcare settings. Health Protection Agency. www.hpa.org.uk [Free Full-text]
HTAs (Health Technology Assessments)
No new HTAs since 1 September 2009.
Economic appraisals
No new economic appraisals relevant to England since 1 September 2009.
Systematic reviews and meta-analyses
No new systematic review or meta-analysis since 1 September 2009.
Primary evidence
No new randomized controlled trials published in the major journals since 1 September 2009.
New policies
No new national policies or guidelines since 1 September 2009.
New safety alerts
No new safety alerts since 1 September 2009.
Changes in product availability
No changes in product availability since 1 September 2009.
Goals and outcome measures
Goals
To determine the likelihood of the person having rubella
To notify the Health Protection Unit (HPU) of all cases of suspected rubella and confirm rubella through laboratory testing, when required
To give people with rubella (or their carers) self-care advice
To encourage uptake of the combined measles, mumps, and rubella (MMR) vaccine, where appropriate
In pregnant women, to:
Investigate unexplained rubella-like rash
Investigate susceptible women who have been in contact with a person with a rubella-like rash
Appropriately refer cases of confirmed rubella for specialist management
QIPP - options for local implementation
QIPP - options for local implementation
Non-steroidal anti-inflammatory drugs (NSAIDs)
Review the appropriateness of NSAID prescribing widely and on a routine basis, especially in people who are at higher risk of both gastrointestinal (GI) and cardiovascular (CV) morbidity and mortality (e.g. older patients).
If initiating an NSAID is obligatory, use ibuprofen (1200 mg per day or less) or naproxen (1000 mg per day or less).
Review patients currently prescribed NSAIDs. If continued use is necessary, consider changing to ibuprofen (1200 mg per day or less) or naproxen (1000 mg per day or less).
Review and, where appropriate, revise prescribing of etoricoxib to ensure it is in line with MHRA advice and the NICE clinical guideline on osteoarthritis [CSM, 2005; NICE, 2008b].
Co-prescribe a proton pump inhibitor (PPI) with NSAIDs for people with osteoarthritis, rheumatoid arthritis, or low back pain (for people over 45 years) in accordance with NICE guidance [NICE, 2008b; NICE, 2009a; NICE, 2009b].
Take account of drug interactions when co-prescribing NSAIDs with other medicines (see Summaries of Product Characteristics). For example, co-prescribing NSAIDs with ACE inhibitors or angiotensin receptor blockers (ARBs) may pose particular risks to renal function; this combination should be especially carefully considered and regularly monitored if continued.
Background information
Definition
What is it?
Rubella (also known as German measles) is an infection caused by viruses of the genus Rubivirus of the family Togaviradae. It is spread through respiratory secretions.
Rubella is usually a mild disease, resulting in a transient rash and swollen lymph glands (lymphadenopathy). In adults, it can also occasionally cause joint inflammation and pain.
Individuals with rubella are usually infectious from 1 week before symptoms appear, to 4 days after the onset of the rash.
Once infected, most people develop life-long immunity to rubella. On rare occasions reinfection can occur, but the clinical significance of this is unknown.
Rubella can have serious consequences if it is contracted in early pregnancy, resulting in congenital rubella syndrome (CRS) in the child. Complications of CRS include: cataracts; deafness; cardiac abnormalities; microcephaly; intrauterine growth retardation; and inflammatory lesions of the brain, liver, lungs, and bone marrow.
Prevalence
How common is it?
Before the introduction of routine vaccination, rubella was endemic in the UK, and mainly affected young children (5–9 years of age). However, because the disease is only moderately infectious, about 18% of women of child-bearing age remained susceptible to infection, and there were 200–300 congenital rubella syndrome (CRS) births during non-epidemic years (and many more during epidemic years).
Immunization against rubella has greatly reduced the incidence of CRS.
Selective rubella vaccination was introduced for pre-pubertal girls and non-immune women of child-bearing age in 1970. Although this had an immediate impact, it did not interrupt the circulation of rubella, and non-immunized women remained vulnerable to infection. During the period 1971–1975, there was an annual average of 48 cases of CRS, with 742 terminations carried out due to women contracting rubella during pregnancy.
Universal rubella vaccination was introduced in 1988 through the combined measles, mumps, and rubella (MMR) vaccine of the childhood immunization programme, and the combined measles and rubella (MR) vaccine during the catch-up campaign of 1994. In 1996, a two-dose MMR regimen was implemented.
As a result of the childhood immunization programme, rubella is now uncommon in the UK, and CRS is very rare.
In 2008, there were 888 notifications of rubella, but only 16 of these (1.8%) were laboratory-confirmed as positive for rubella.
Since 2000, there have been about 10 reports of CRS, mostly in women who were born overseas and who had not been adequately immunized.
In recent years, uptake of the MMR vaccine has decreased to 80% (or less in some areas), due to unfounded fears of adverse outcomes associated with the vaccine. There is concern that this could lead to more outbreaks of rubella and CRS in the future.
Rubella remains endemic in many developing countries, and it is estimated that over 100,000 children are born worldwide with CRS each year.
[Tookey, 2004; DH, 2006; Gershon, 2006; Best, 2007; HPA, 2009b]
Complications
What are the complications?
Rubella rarely causes complications in otherwise healthy people.
Arthritis or arthralgia (joint pain) occurs in up to 60% of women (it is less common in men and children), but is rarely severe, chronic, or permanent.
Bleeding disorders (transient thrombocytopenia) have been reported in about one in 3000 people with rubella, and are more common in children.
Post-infectious encephalitis is a rare but serious complication of rubella (affecting one in 6000 people).
The main importance of rubella is the complications it can cause in pregnancy.
Rubella causes spontaneous abortion in the first trimester in about 20% of infected women.
Congenital rubella syndrome (CRS) occurs in 90% of fetuses when rubella is contracted in the 11th week (or before) of pregnancy, and 20% of fetuses when rubella is contracted in the 11th to 16th weeks of pregnancy (significant problems after this period are rare).
Permanent abnormalities include:
Heart and lung defects, for example patent ductus arteriosus, pulmonary artery stenosis, and pulmonary arterial hypoplasia.
Eye defects, including cataracts, iris hypoplasia, and retinopathy.
Central nervous system defects, such as microcephaly, and mental and psychomotor retardation.
Sensorineural deafness.
Developmental and late-onset abnormalities include:
Progressive developmental problems, eye problems, and hearing loss.
Persistent immunological problems.
Diabetes mellitus.
Progressive panencephalitis (a rare and invariably fatal illness similar to subacute sclerosing panencephalitis seen in measles).
Transient abnormalities caused by CRS include low birth weight, hepatosplenomegaly, meningoencephalitis, and thrombocytopenia with or without purpura.
Prognosis
What is the prognosis?
Rubella is usually a mild, self-limiting infection which is often asymptomatic. When present, symptoms tend to be worse in adults than in children.
The rash caused by rubella lasts for 3–5 days, and before and during this time there may be symptoms of generalized viremia (malaise, fever, nasal symptoms, and loss of appetite).
Swollen lymph nodes (lymphadenopathy) may take several weeks to resolve.
Diagnosis
Diagnosis
Diagnosis - non-pregnant
Diagnosis of rubella - non-pregnant
When to suspect rubella
When should I suspect rubella?
Confirm the clinical features are consistent with rubella (although diagnosis using clinical features alone is not possible).
Rash is usually the presenting feature of rubella. It typically starts behind the ears, before spreading to the face and neck, and then to the trunk and extremities. The rash is non-confluent and maculopapular, resembling measles, and is transient, being present in total for 3–5 days.
Lymphadenopathy (swollen lymph nodes) may present before the rash, and may last for 2 weeks or more after the rash disappears. The suboccipital (lower part of the back of the skull), postauricular (behind the ears), and cervical (neck) lymph nodes are most often affected.
Arthritis and arthralgia (inflammation and pain of the joints) occurs in up to 60% of women (less commonly in men and children), tending to affect the fingers, wrists, and knees. It appears during or just after the rash, is usually mild, and usually resolves within a month.
Non-specific symptoms tend to affect adults more than children (and in adults are sometimes prodromal), and are significantly less troublesome than seen with measles. They include malaise, low-grade fever, headache, sore throat, rhinorrhoea (nasal discharge), and conjunctivitis.
Assess the likelihood of rubella by considering:
Immunization history
Rubella is unlikely in people who have been fully immunized (that is, they have received two doses of the combined measles, mumps, and rubella [MMR] vaccine or equivalent).
People who were born in a country where rubella vaccine is not routinely administered are most at risk from rubella.
History of rubella
Rubella is unlikely in people who have previously had rubella (although reinfection can occur).
History of contact with someone with rubella within the last 3 weeks
Significant contact is considered as being in the same room for 15 minutes or more, or face-to-face contact.
Recent outbreaks
Consider contacting the Health Protection Unit (HPU) to find out if there are any localized outbreaks of rubella.
It is not possible to accurately diagnose rubella through immunization history and clinical features alone. If, after considering other causes, rubella is still considered likely, notify the local HPU, who may advise confirmation through laboratory investigation.
Basis for recommendation
Basis for recommendation
Clinical features of rubella
The clinical features of rubella are described in the textbook Principles and practice of infectious diseases [Gershon, 2006], in guidelines from the Department of Health [DH, 2006] and the Health Protection Agency [HPA, 2008], and in narrative reviews [Banatvala and Brown, 2004; Best, 2007].
Immunization status and likelihood of correct diagnosis
Most people develop life-long immunity after an episode of rubella (either acquired naturally or though immunization). However, for reasons that are not fully understood, some people can experience a significant immunological response to rubella on subsequent exposure, although this rarely results in symptomatic infection [Gershon, 2006].
Immunization with one dose of the combined measles, mumps, and rubella (MMR) vaccine confers 95–100% protection against rubella. An additional dose, as indicated by the childhood immunization programme, provides close to full protection [DH, 2006].
Serological studies indicate that until recently, 97–98% of children and adults were immune to rubella [HPA, 2007]. However, it is feared that immunity in the population may have decreased due to low uptake of the MMR vaccine [Chief Medical Officer et al, 2008].
Differential diagnosis
What else may cause a rubella-like rash?
Other causes for the rash are much more likely in people who have previously had rubella or been fully immunized (that is, the person has received two doses of combined measles, mumps, and rubella [MMR] or equivalent vaccine).
Parvovirus B19 is difficult to differentiate clinically from rubella.
Parvovirus B19 is the virus that causes erythema infectiosum (also known as fifth disease or slapped cheek syndrome, particularly common in children). It is a self-limiting illness which, in addition to a bright red rash on the cheeks, may cause a red, lacy rash on the rest of the body.
In adults, parvovirus can cause rash, fever, and joint inflammation that can be indistinguishable from rubella.
Parvovirus B19 can have harmful effects on the fetus, and pregnant women with a rubella-like rash should also be tested for parvovirus B19 infection (see Suspected rubella in pregnancy).
Measles causes a characteristic erythematous and maculopapular rash with a similar distribution to rubella. However, both the rash and accompanying symptoms of viremia (malaise, fever, loss of appetite, cough, rhinorrhoea, and conjunctivitis) tend to be more severe than in rubella, particularly in children. See the CKS topic on Measles.
Other causes of rash which may look similar to rubella include:
Streptococcal infection (scarlet fever).
Herpesvirus type 6 (roseola infantum), enterovirus, and adenovirus.
Tropical viruses, including alphaviruses and flaviviruses (for example Dengue fever) — should be considered if the person has recently been to the tropics.
Brucellosis, cytomegalovirus, HIV, mononucleosis reaction with amoxicillin, Kawasaki disease, syphilis, toxoplasmosis, and reaction to anti-epileptic drugs — may all cause rash accompanied with lymphadenopathy (swollen lymph nodes).
Adverse drug reactions, echovirus, coxsackievirus, infectious hepatitis, and rat bite fever (Spirillum minus) — although these cause a rash they are not usually associated with lymphadenopathy.
Basis for recommendation
Basis for recommendation
Information on the differential diagnosis is based on expert opinion from narrative reviews of rubella [Banatvala and Brown, 2004; Gershon, 2006; Best, 2007].
An observational study examined the cause of illness in 195 children from England presenting with a measles-like rash [Ramsay et al, 2002]. The investigators found:
None of the children had measles or rubella.
No cause could be identified in most of the children (52%).
Parvovirus B19 was the most common single cause of rash that could be identified (17%).
Streptococcus was the only bacterial cause identified (Group A accounted for 15% and Group C 3%).
Less common pathogens that were identified included human herpesvirus type 6 (6%), enterovirus (5%), and adenovirus (4%).
Diagnosis - pregnant
Diagnosis of rubella - pregnancy
When to suspect rubella
When should I suspect rubella in a pregnant woman?
It is essential to have a low threshold of suspicion of rubella in women in early pregnancy. Rubella should be excluded even when other causes (such as measles, enterovirus, infectious mononucleosis, and streptococcal infection) are considered to be more likely.
Women who have not spent their childhood years in the UK may be at increased risk of rubella.
Confirm the rash is consistent with rubella. The rash:
Typically starts behind the ears, before spreading to the face and neck, and then to the trunk and extremities.
Is non-confluent and maculopapular, resembling measles, and is transient, being present in total for 3–5 days.
May be atypical in dark-skinned women.
Other clinical features that are consistent with rubella include:
Lymphadenopathy (swollen lymph nodes) may present before the rash, and may last for 2 weeks or more after the rash disappears. The suboccipital (lower part of the back of the skull), postauricular (behind the ears), and cervical (neck) lymph nodes are most often affected.
Arthritis and arthralgia (inflammation and pain of the joints) occurs in up to 60% of women, tending to affect the fingers, wrists and knees. It appears during or just after the rash, is usually mild, and usually resolves within a month.
Non-specific symptoms (which may appear as a prodrome) are significantly less troublesome than seen with measles. They include malaise, low-grade fever, headache, sore throat, rhinorrhoea (nasal discharge), and conjunctivitis.
Pregnant women with a rubella-like rash require further investigation regardless of previous immunization history, previous screening results, history of contact with a person with rubella, or presence of local outbreaks.
Basis for recommendation
Basis for recommendation
The clinical features of rubella are described in the textbook Principles and practice of infectious diseases [Gershon, 2006], in guidelines from the Department of Health [DH, 2006] and the Health Protection Agency [HPA, 2008], and in narrative reviews [Banatvala and Brown, 2004; Best, 2007].
Women born overseas:
Special consideration should be given to pregnant women who were born overseas; they may not have had the same childhood exposure to rubella, or may have been brought up in a country without an adequate vaccination programme [Morgan-Capner et al, 2002].
Since 1991 in the UK, two thirds of cases of congenital rubella syndrome were born to mothers who were themselves born overseas, and half of these women acquired the infection while overseas [DH, 2006].
Differential diagnosis
What else may cause a rubella-like rash in a pregnant woman?
Rubella-like rash in pregnant women always requires further investigation. However, other causes are much more likely if the woman:
Has previously had laboratory-confirmed rubella, or has been fully immunized (that is, she has received two doses of combined measles, mumps, and rubella [MMR] vaccine).
Has tested positive for rubella antibodies during antenatal screening.
Consider the following causes of rash:
Parvovirus B19 is difficult to differentiate clinically from rubella.
In adults, parvovirus B19 can cause rash, fever, and joint inflammation that can be indistinguishable from rubella.
Parvovirus B19 can have harmful effects on the fetus, and all pregnant women with a rubella-like rash should also be tested for parvovirus B19 infection, unless they are known to be immune to parvovirus B19 (see Suspected rubella in pregnancy).
Measles causes a characteristic erythematous and maculopapular rash with a similar distribution to rubella. However, both the rash and accompanying symptoms of viremia (malaise, fever, loss of appetite, cough, rhinorrhoea, and conjunctivitis) tend to be more severe than in rubella. See the CKS topic on Measles.
Other causes of rash which may look similar to rubella:
Streptococcal infection (scarlet fever).
Herpesvirus type 6 (roseola infantum), enterovirus, and adenovirus.
Tropical viruses, including alphaviruses and flaviviruses (for example Dengue fever) — should be considered if the woman has recently been to the tropics.
Brucellosis, cytomegalovirus, HIV, mononucleosis (reaction with ampicillin), Kawasaki disease, syphilis, toxoplasmosis, and reaction to anti-epileptic drugs — may all cause rash accompanied with lymphadenopathy (swollen lymph nodes).
Adverse drug reactions, echovirus, coxsackievirus, infectious hepatitis, and rat bite fever (Spirillum minus) — although these cause a rash they are not usually associated with lymphadenopathy.
Basis for recommendation
Basis for recommendation
Information on the differential diagnosis is based on expert opinion from narrative reviews [Banatvala and Brown, 2004; Gershon, 2006; Best, 2007].
Another cause of symptoms should be suspected because clinically-diagnosed rubella is rarely subsequently confirmed to be rubella through laboratory analysis. For example, in 2008 there were 888 notifications of rubella, but only 16 of these (1.8%) were confirmed as laboratory-positive rubella [HPA, 2009b].
Management
Management
Scenario: Non-pregnant - suspected rubella or possible exposure: covers the management of people (children, men, and women who are not pregnant) with suspected rubella, or who have been in contact with a person who has confirmed or suspected rubella.
Scenario: Pregnant - suspected/confirmed rubella or possible exposure: covers the management of pregnant women who have suspected rubella, or who have been in contact with a person who has confirmed or suspected rubella.
Scenario: Non-pregnant - suspected rubella or possible exposure
Scenario: Non-pregnant - suspected rubella or possible exposure
Notification and confirmation
How should I notify and confirm infection with rubella?
Rubella is a notifiable disease.
Contact the local Health Protection Unit (HPU) immediately if there is clinical suspicion of rubella, and enquire about the need for a testing kit (and the testing schedule).
Usually, an immediate oral fluid sample will be required for serological and/or polymerase chain reaction (PCR) testing.
If the initial serological test proves positive, further testing (using the same sample) may be carried out for confirmatory and genotyping purposes.
Virus reference department
Virus reference department
The Virus Reference Department of the Health Protection Agency (HPA) is the national reference laboratory for diagnostic tests for rubella in the UK.
For more information, see www.hpa.org.uk, or telephone 020 8327 6017.
Basis for recommendation
Basis for recommendation
This recommendation is based on advice from the Health Protection Agency [HPA, 2007; HPA, 2009a].
Laboratory confirmation of rubella in non-pregnant people is necessary for surveillance purposes rather than management of the individual (which it does not usually directly affect).
Currently, in the UK, assays of rubella-specific immunoglobulins (IgG and IgM) from oral fluid samples are used first-line to diagnose rubella. For early samples (that is, samples collected within 7 days of the rash appearing) that have tested negative for rubella (IgM and IgG negative), polymerase chain reaction (PCR) may be carried out to detect the presence of rubella RNA [Brown, Personal Communication, 2009].
Management of suspected rubella
How should I manage a person who has suspected rubella?
Advise the person (or their carer) that rubella is usually a mild, self-limiting condition. The rash and fever will typically resolve within 5 days, although swollen lymph glands may take a week or more to improve.
Advise the person to:
Rest, drink adequate fluids, and take paracetamol or ibuprofen for symptomatic relief (aspirin should be avoided in children younger than 16 years of age).
Stay off school or work, and avoid contact with pregnant women where possible, for 6 days after the initial development of the rash.
Specific follow up of people with rubella is not necessary (results of tests can be relayed by phone). However, when the person has recovered from the acute symptoms, encourage them to get up-to-date with their vaccinations, if applicable (see the CKS topic on Immunizations - childhood).
People who are immunocompromised and have suspected rubella do not require specialist management as they are not at increased risk.
Basis for recommendation
Basis for recommendation
These recommendations are based on advice from the Department of Health and the Health Protection Agency (HPA) [DH, 2006; HPA, 2008].
Prognosis and interventions
The natural history of rubella is described in the textbook Principles and practice of infectious diseases [Gershon, 2006]. Rubella is a mild, self-limiting illness, and serious complications are rare.
There are no specific interventions required for acute rubella. There are no rubella-specific immunoglobulins available, and Human Normal Immunoglobulin (HNIG) is only indicated in exceptional cases for pregnant women [HPA, 2009c].
Self-care advice
Adequate fluid intake should be maintained to replace fluid loss, although there have been no controlled trials that have shown the benefit of this [Guppy et al, 2005].
Paracetamol and ibuprofen are recommended for the symptomatic relief of rubella on the basis that they reduce fever and headache [Eccles, 2006]. Aspirin should be avoided as it has a less favourable adverse effect profile. It is contraindicated in children younger than 16 years of age, because of the risk of Reye's syndrome [BNF for Children, 2009].
Guidance from the HPA states that children with suspected rubella should be kept away from school or nursery for 6 days after the development of the rash [HPA, 2010], and this can be reasonably extrapolated to adults. As rubella remains infectious for about 6 days after the onset of rash, CKS recommends it is also prudent for the affected person to avoid contact with pregnant women during this time period.
Management of possible exposure to rubella
How should I manage a person who has been in contact with confirmed or suspected rubella?
Contact is defined as being in the same room as an infected person for 15 minutes or more, or face-to-face contact.
Advise the person (or their carer) to seek medical advice only if they develop symptoms. If symptoms suggestive of rubella develop, the local Health Protection Unit should be notified and laboratory confirmation may be required.
Basis for recommendation
Basis for recommendation
The definition of 'significant contact' is based on research on varicella (chicken pox) transmission. However, as varicella is significantly more infectious than rubella, this is likely to be a conservative definition [Morgan-Capner et al, 2002].
Rubella is a mild, self-limiting illness, and serious complications are rare in people who are not pregnant, including immunocompromised people [Best, 2007]. Active management or follow up of people who may have been in contact with rubella is not necessary.
Rubella is infectious for about 7 days before symptoms develop [Gershon, 2006]. Therefore CKS recommends that, where practical, susceptible people who could have been in contact with the virus during this period should avoid contact with pregnant women.
Referral or admission
When should a person with suspected rubella be referred or admitted?
Consider admitting people who develop a serious complication of rubella.
Haemorrhagic complications (caused by thrombocytopenia) can rarely cause bleeding into vital areas (for example the eyes or brain). They are more common in children.
Encephalitis is a rare but serious complication that is more common in adults.
Basis for recommendation
Basis for recommendation
Complications of rubella are rare in non-pregnant people but are potentially serious [Gershon, 2006].
Haemorrhagic disorders are estimated to affect one in 3000 people. Case reports have described bleeding into vital organs such as the eye, brain, or kidney.
Encephalitis occurred in one in 5000 people in a previous epidemic, and has an estimated mortality rate of 20–50%.
Scenario: Pregnant - suspected/confirmed rubella or possible exposure
Scenario: Pregnant - suspected/confirmed rubella or possible exposure
Suspected rubella in pregnancy
How should I manage suspected rubella in a pregnant woman?
If rubella infection is considered possible, notify the local Health Protection Unit (HPU) immediately.
Contact with the HPU should be made irrespective of previous testing or immunization status to rubella. The HPU will advise on rubella screening and the time frame involved.
Pregnancies which are of less than 16 weeks' gestation are at greatest risk from rubella exposure. However, women at any stage of pregnancy who have suspected rubella require investigation.
Rubella is a notifiable infection.
It is likely the HPU will request blood samples and initiate simultaneous investigation for possible rubella and parvovirus B19 infection.
Provide the HPU with full information regarding the woman's details, to enable accurate diagnosis.
Arrange with the HPU who will supply the test results and arrange further management in pregnancy if rubella is confirmed.
If rubella is considered highly likely, or if the initial test is suggestive of recent rubella infection, a second blood test will probably be required.
Provide the woman with information prior to testing for rubella and parvovirus B19, explaining that:
Rubella is now extremely rare in the UK, and tests are routine and are likely to confirm absence of the infection.
Testing for rubella and parvovirus B19 will initially only involve testing of blood samples. More invasive tests, such as amniocentesis, are rarely needed.
There is no effective treatment for rubella in pregnancy if the infection is confirmed.
Give the woman self-care advice. Advise her to:
Avoid contact with other pregnant women for 15 days after the start of the rash.
Rest, drink adequate fluids, and take paracetamol for symptomatic relief (ibuprofen can be taken as a second-line option in the first and second trimesters).
Stay off work for 5 days after the initial development of the rash.
Information required for laboratory requests
Information required for laboratory requests
The Health Protection Unit (HPU) should be provided with the following information to enable the test results to be reported with the correct interpretation.
Full demographic details of the woman.
Gestation stage of pregnancy (date of last menstrual period).
Date of onset, clinical features, and type and distribution of rash.
History of rubella, and any other antibody testing or rubella vaccine administration (including dates and places).
Any known contacts with individuals suffering from a rash illness, and dates of contact.
Basis for recommendation
Basis for recommendation
These recommendations are based on guidelines from the Health Protection Agency (HPA) [Morgan-Capner et al, 2002; HPA, 2007].
Screening regardless of immunization status
Most women in the UK receive antenatal screening for rubella antibodies in the early stages of pregnancy [DH, 2003; NICE, 2008a]. However, further screening is recommended in pregnant women with a rubella-like rash regardless of the results of previous testing or immunization status. This is because of the possibility of laboratory or documentation error, failed immunization, symptomatic rubella reinfection, or parvovirus B19 infection [Morgan-Capner et al, 2002].
Screening of women in early pregnancy
Because of the potential for serious complications of rubella infection contracted in early pregnancy, the HPA considers it is important to establish the diagnosis of rubella with great certainty [HPA, 2007; HPA, 2009a].
Although solitary immunoglobulin M (IgM) assays have a high specificity, the low prevalence of rubella in the UK means that the predictive value of an IgM assay alone is now relatively low. Therefore, all positive samples in pregnancy should be confirmed by requesting a second serum sample.
Depending on individual circumstances, the diagnosis of rubella may involve immunoglobulin testing over several days or weeks. For instance, it may be necessary to establish rising titres or seroconversion of rubella specific IgG, or to test for rubella IgG avidity (low avidity is a marker of primary infection). In addition, detection of rubella RNA using polymerase chain reaction (PCR) may also be required.
Using a combination of techniques, it is possible to establish when rubella was contracted, or to rule out antibody responses caused by recent vaccination or reinfection (this has important implications for the prognosis) [Best, 2007].
Screening of pregnant women in later gestation
Although complications of rubella infection are greatly reduced if the infection is acquired after 16 weeks' gestation, investigation is recommended after this period [Morgan-Capner et al, 2002] because:
Specific diagnosis will aid management of contacts (including in healthcare situations, such as clinics and antenatal centres).
Immunoglobulin assays may provide information on the date of infection in relation to the gestational age. Additionally, the gestational age may be wrong.
The mother can be reassured that a diagnosis has been reached or excluded, and the diagnosis may be helpful for future management (for example postnatal administration of combined measles, mumps, and rubella [MMR] vaccine).
Rubella and parvovirus B19
It is not possible to differentiate between rubella and parvovirus B19 on clinical grounds, as both can present with a similar rash, fever, and joint inflammation [Best, 2007].
It is important to diagnose parvovirus B19 in pregnant women in the first trimester as there is a 30% risk of transplacental infection, with a 5–9% risk of fetal loss. There is also a risk of hydrops fetalis, and regular ultrasound monitoring (and possible intrauterine fetal infusion) is recommended for those babies at risk [HPA, 2007].
Information and self-care advice
The recommendations for providing the woman with information on diagnostic tests and screening are in line with the minimum standards recommended by the HPA [Morgan-Capner et al, 2002].
Self-care advice
Adequate fluid intake should be maintained to replace fluid loss, although there have been no controlled trials that have shown the benefit of this [Guppy et al, 2005].
Paracetamol and ibuprofen are recommended for the symptomatic relief of rubella on the basis they reduce fever and headache [Eccles, 2006]. However, ibuprofen is not recommended in pregnant women in the third trimester (30 weeks onwards) because of the risk of causing premature closure of the ductus arteriosus, or decreasing amniotic fluid [NTIS, 2004; Schaefer et al, 2007].
Guidance from the HPA states that children with suspected rubella should be kept away from school or nursery for 5 days after the development of the rash [HPA, 2006], and this can be reasonably extrapolated to adults. However, as rubella can remain infectious for up to 15 days after symptoms develop [Gershon, 2006], CKS recommends it is prudent for the affected person to avoid contact with pregnant women during this time period.
Possible exposure to rubella in pregnancy
How should I manage a pregnant woman who has been in possible contact with rubella?
Determine whether the woman has had contact with a possible case of rubella.
Significant contact means being in the same room for 15 minutes or more, or face-to-face contact, within the previous 3 weeks.
However, if the pregnant woman is known to be susceptible to rubella, contact for less than 15 minutes should be considered a possible exposure.
Determine if the woman fulfils the criteria for immunity to rubella (that is, she has at least two previous rubella antibody screening test results that have detected antibodies, or she has received at least two documented doses of rubella vaccine, or she has received a documented dose of rubella vaccine and has a previous rubella antibody screening test result which has detected antibodies).
If the woman does not have immunity to rubella, contact the local Health Protection Unit (HPU) immediately.
It is likely the HPU will request blood samples and initiate simultaneous investigation for possible rubella and parvovirus B19 infection.
Provide the HPU with full information regarding the woman's details to enable accurate diagnosis.
Arrange with the HPU who will supply the test results and arrange further management in pregnancy if rubella is confirmed.
If the woman does have immunity to rubella, the HPU must still be contacted because investigation for parvovirus B19 may be required.
Provide the woman with information prior to testing for rubella and parvovirus B19, explaining that:
Rubella is now extremely rare in the UK, and tests are routine and are likely to confirm absence of the infection.
Testing for rubella and parvovirus B19 will initially only involve testing of blood samples. More invasive tests, such as amniocentesis, are rarely needed.
There is no effective treatment for rubella in pregnancy if the infection is confirmed.
Information required for laboratory requests
Information required for laboratory requests
The Health Protection Unit (HPU) should be provided with the following information to enable test results to be reported with the correct interpretation.
Full demographic details of the woman.
Gestation stage of pregnancy (date of last menstrual period).
History of rubella, and any other antibody testing or rubella vaccine administration (including dates and places).
Any known contacts with individuals suffering from a rash illness, and dates of contact.
Basis for recommendation
Basis for recommendation
These recommendations are based on guidelines from the Health Protection Agency (HPA) [Morgan-Capner et al, 2002; HPA, 2004].
Investigation of contacts who are pregnant
Screening for rubella is recommended for all pregnant women who are not considered to be immune. This is because:
Rubella has an incubation period of about 3 weeks before the characteristic rash becomes apparent. Early diagnosis is beneficial as treatment options may be limited to termination of pregnancy [Best, 2007].
Asymptomatic infection, or reinfection, may occur [Gershon, 2006], although the prognosis of these conditions is not fully understood [Best, 2007].
Significant contact
The definition of significant contact is based on research on varicella (chickenpox) transmission. As varicella is significantly more infectious than rubella, this is likely to be a conservative definition, although in reality household exposure (for example with an infected child) is probably the most important source of infection in pregnancy [Morgan-Capner et al, 2002].
As rubella in pregnancy has serious implications, less than 15 minutes of exposure should be considered as a risk in women who are in early pregnancy and who are susceptible to rubella [Brown, Personal Communication, 2009].
Criteria for immunity
Most women in the UK receive antenatal screening for rubella antibodies in the early stages of pregnancy [DH, 2003; NICE, 2008a], and most will have received two doses of rubella vaccine through the combined measles, mumps, and rubella (MMR) vaccine of the childhood immunization programme [DH, 2006]. The likelihood of contracting rubella following two positive antibody tests or MMR vaccines is considered to be vanishingly small [Morgan-Capner et al, 2002].
Rubella and parvovirus B19
It is not possible to differentiate between rubella and parvovirus B19 on clinical grounds, as both can present with a similar rash, fever, and joint inflammation [Best, 2007]. Therefore, if a pregnant woman has been in contact with a person with possible rubella, parvovirus also needs to be considered.
It is important to diagnose parvovirus B19 in pregnant women in the first trimester.
There is a 30% risk of transplacental infection, with a 5–9% risk of fetal loss following infection in the second trimester. There is also a risk of hydrops fetalis, and regular ultrasound monitoring (and possible intrauterine fetal infusion) is recommended for those babies at risk [HPA, 2007].
Maternal asymptomatic infection with parvovirus B19 is at least as likely to infect and damage the fetus as symptomatic infection [Morgan-Capner et al, 2002].
Information about testing
The recommendations for providing the woman with information on diagnostic tests and screening are in line with the minimum standards recommended by the HPA [Morgan-Capner et al, 2002].
Confirmed rubella in pregnancy
How should I manage a pregnant woman with confirmed rubella?
Refer urgently to an obstetrician for risk-assessment and counselling if the woman has confirmed rubella and is 20 weeks or less pregnant.
The risk to the fetus is dependent on the stage of pregnancy.
Before 8–10 weeks' gestation there is a 90% risk of congenital rubella syndrome (CRS), and a high likelihood of multiple defects.
Between 11–16 weeks' gestation there is a 10–20% risk of CRS, with single defects being most common.
Between 16–20 weeks' gestation there is only a low chance of deafness occurring.
There are no effective treatments to prevent CRS. Human Normal Immunoglobulin (HNIG) is only recommended in exceptional circumstances.
Further diagnostic tests may be indicated (for example amniocentesis or fetal blood sampling).
Reassure the woman if she has confirmed rubella and is at a confirmed gestational age of 20 weeks or more that there is minimal risk to the child (if there is any doubt about the gestational age, seek specialist advice).
Basis for recommendation
Basis for recommendation
Information on the likelihood of congenital rubella syndrome (CRS) is based on guidelines from the Department of Health [DH, 2006] and observational data described in narrative reviews [Gershon, 2006; Best, 2007].
CKS recommends urgent referral of all mothers of children with the potential of CRS to an obstetrician, as they cannot be managed effectively in primary care. However, management options in secondary care are limited.
Termination of the pregnancy may be recommended where multiple defects are likely (due to infection early in pregnancy) [Morgan-Capner et al, 2002].
Human Normal Immunoglobulin (HNIG) is only used exceptionally where termination of the pregnancy is not an option. There is no evidence to support the effectiveness of HNIG in the management of rubella or for the prevention of CRS [DH, 2006].
In some instances, further investigation may be necessary (for example in cases of reinfection, where the risk to the fetus is poorly quantified). However, invasive procedures such as amniocentesis or fetal blood sampling carry a risk of adverse outcomes [Morgan-Capner et al, 2002].
Referral or admission
When should a pregnant woman with suspected rubella be referred or admitted?
Refer urgently to an obstetrician those pregnant women with confirmed rubella who are at 20 weeks' gestation or less.
Consider admitting pregnant women who develop a serious complication of rubella (very rare).
Haemorrhagic complications (caused by thrombocytopenia) can rarely cause bleeding into vital areas (for example the eyes or brain).
Encephalitis is a rare but serious complication.
Basis for recommendation
Basis for recommendation
Congenital rubella syndrome (CRS) is possible before 20 weeks of gestation, and very probable (and likely to be severe) in the first 10 weeks. It is associated with several serious complications affecting the fetus. The pregnant woman requires urgent referral for counselling and risk-assessment [Morgan-Capner et al, 2002].
Complications of rubella are rare in non-pregnant people but are potentially serious [Gershon, 2006].
Haemorrhagic disorders are estimated to affect one in 3000 people. Case reports have described bleeding into vital organs such as the eye, brain, or kidney.
Encephalitis occurred in one in 5000 people in a previous epidemic, and has an estimated mortality rate of 20–50%.
Evidence
Evidence
Supporting evidence
There is no supporting evidence section for this CKS topic because interventions for rubella have not been subject to investigation by controlled trials.
For information on the evidence available for the effectiveness of the combined measles, mumps, and rubella (MMR) vaccine, see the Supporting evidence section on Vaccines for rubella in the CKS topic on Immunizations - childhood.
Search strategy
Scope of search
A literature search was conducted for guidelines, systematic reviews and randomized controlled trials on primary care management of Rubella, with additional searches in the following area:
Exposure in pregnant women
Search dates
Medline and Embase: January 1970 – September 2009
Key search terms
Various combinations of searches were carried out. The terms listed below are the core search terms that were used for Medline and these were adapted for other databases. Further details are available on request.
exp Rubella, exp Rubella virus, exp Rubella Syndrome, Congenital/, german measles.tw.
Table 1. Key to search terms.| Search commands | Explanation |
|---|---|
| / | indicates a MeSH subject heading with all subheadings selected |
| .tw | indicates a search for a term in the title or abstract |
| exp | indicates that the MeSH subject heading was exploded to include the narrower, more specific terms beneath it in the MeSH tree |
| $ | indicates that the search term was truncated (e.g. wart$ searches for wart and warts) |
Topic specific literature search sources
Sources of guidelines
National Institute for Health and Clinical Excellence (NICE)
Scottish Intercollegiate Guidelines Network (SIGN)
Royal College of General Practitioners
National Guidelines Clearinghouse
Institute for Clinical Systems Improvement
Guidelines International Network
NHS Evidence - National Library of Guidelines
National Health and Medical Research Council (Australia)
Royal Australian College of General Practitioners
National Resource for Infection Control
NHS Scotland National Patient Pathways
Agency for Healthcare Research and Quality
UK Ambulance Service Clinical Practice Guidelines
RefHELP NHS Lothian Referral Guidelines
Medline (with guideline filter)
British Columbia Medical Association
University of Michigan Medical School
Michigan Quality Improvement Consortium
Sources of systematic reviews and meta-analyses
Systematic reviews
Protocols
Database of Abstracts of Reviews of Effects
Medline (with systematic review filter)
EMBASE (with systematic review filter)
Sources of health technology assessments and economic appraisals
NIHR Health Technology Assessment programme
NHS Economic Evaluations
Health Technology Assessments
Canadian Agency for Drugs and Technologies in Health
International Network of Agencies for Health Technology Assessment
Sources of randomized controlled trials
Central Register of Controlled Trials
Medline (with randomized controlled trial filter)
EMBASE (with randomized controlled trial filter)
Sources of evidence based reviews and evidence summaries
DynaMed
Central Services Agency COMPASS Therapeutic Notes
Sources of national policy
Health Management Information Consortium (HMIC)
References
Banatvala, J.E. and Brown, D.W. (2004) Rubella. Lancet 363(9415), 1127-1137. [Abstract]
Best, J.M. (2007) Rubella. Seminars in Fetal & Neonatal Medicine 12(3), 182-192. [Abstract]
BNF for Children (2009) British National Formulary for children. London: British Medical Association and the Royal Pharmaceutical Society of Great Britain.
Brown, K. (2009) Personal communication. Consultant Medical Virologist, Virus Reference Department at the Health Protection Agency: London.
Chief Medical Officer, Chief Nursing Officer and Chief Pharmaceutical Officer (2008) The MMR catch-up programme. ...www.dh.gov.uk [Free Full-text]
CSM (2005) Updated advice on the safety of selective COX-2 inhibitors. ..Committee on Safety of Medicines.www.mhra.gov.uk [Free Full-text]
DH (2003) Screening for infectious diseases in pregnancy. Standards to support the UK antenatal screening programme. ..Department of Health.www.dh.gov.uk [Free Full-text]
DH (2006) Immunisation against infectious disease - "The Green Book". Chapter 28 - Rubella. ..Department of Health.www.dh.gov.uk [Free Full-text]
Eccles, R. (2006) Efficacy and safety of over-the-counter analgesics in the treatment of common cold and flu. Journal of Clinical Pharmacy and Therapeutics 31(4), 309-319. [Abstract]
Gershon, A.A. (2006) Chapter 148: rubella virus (German measles). Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases - Online.6th edn.Elsevier.www.ppidonline.com
Guppy, M.P.B., Mickan, S.M. and Del Mar, C.B. (2005) Advising patients to increase fluid intake for treating acute respiratory infections (Cochrane Review). The Cochrane Library.Issue 4.John Wiley & Sons, Ltd.www.thecochranelibrary.com [Free Full-text]
HPA (2004) Pregnant patient in contact with rash illness. National Standard Method VSOP 33.Issue 2.Health Protection Agency.www.hpa-standardmethods.org.uk
HPA (2006) Guidance on infection control in schools and other child care settings. ..Health Protection Agency.www.hpa.org.uk [Free Full-text]
HPA (2007) Investigation of red rash. .National Standard Method QSOP 56.Health Protection Agency.www.hpa-standardmethods.org.uk
HPA (2008) General information on Rubella (German Measles). ..Health Protection Agency.www.hpa.org.uk [Free Full-text]
HPA (2009a) Virus reference department - user manual. ..Health Protection Agency.www.hpa.org.uk [Free Full-text]
HPA (2009b) Rubella notifications (confirmed cases), England and Wales, 1995 - 2009 by quarter. ..Health Protection Agency.www.hpa.org.uk [Free Full-text]
HPA (2009c) Rubella. Immunoglobulin Handbook..Health Protection Agency.www.hpa.nhs.uk [Free Full-text]
HPA (2010) Guidance on infection control in schools and other child care settings. ..Health Protection Agency.www.hpa.org.uk [Free Full-text]
MHRA (2011) Press release: more exact paracetamol dosing for children to be introduced. ..Medicines and Healthcare products Regulatory Agency.www.mhra.gov.uk [Free Full-text]
Morgan-Capner, P., Crowcroft, N.S. and PHLS Joint Working Party of the Advisory Committee of Virology and Vaccines and Immunisation (2002) Guidelines on the management of, and exposure to rash illness in pregnancy (including consideration of relevant antibody screening programmes in pregnancy). Communicable Disease and Public Health 5(1), 59-71. [Abstract] [Free Full-text]
NICE (2008a) Antenatal care: routine care for the healthy pregnant woman (NICE guideline). .Clinical guideline 62.National Institute for Health and Clinical Excellence.www.nice.org.uk [Free Full-text]
NICE (2008b) Osteoarthritis. The care and management of osteoarthritis in adults (NICE guideline). .Clinical guideline 59.National Institute for Health and Clinical Excellence.www.nice.org.uk [Free Full-text]
NICE (2009a) Rheumatoid arthritis: the management of rheumatoid arthritis (NICE guideline). .Clinical guideline 79.National Institute for Health and Clinical Excellence.www.nice.org.uk [Free Full-text]
NICE (2009b) Low back pain: early management of persistent non-specific low back pain (NICE guideline). .Clinical guideline 88.National Institute for Health and Clinical Excellence.www.nice.org.uk [Free Full-text]
NICE (2013) Key therapeutic topics - medicines management options for local implementation. ..National Institute for Health and Clinical Excellence.www.nice.org.uk [Free Full-text]
NPC (2012) Key therapeutic topics - medicines management options for local implementation. ..National Prescribing Centre.www.npc.nhs.uk [Free Full-text]
NTIS (2004) Use of ibuprofen in pregnancy. TOXBASE..National Teratology Information Service, Regional Drug and Therapeutics Centre.www.toxbase.org
Ramsay, M., Reacher, M., O'Flynn, C. et al. (2002) Causes of morbilliform rash in a highly immunised English population. Archives of Disease in Childhood 87(3), 202-206. [Abstract] [Free Full-text]
Schaefer, C., Peters, P. and Miller, R.K. (Eds.) (2007) Drugs during pregnancy and lactation: treatment options and risk assessment. 2nd edn. Oxford: Academic Press.
Tookey, P. (2004) Rubella in England, Scotland and Wales. EuroSurveillance 9(4), 21-23. [Abstract] [Free Full-text]