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Rubella

Queensland Health Guidelines for Public Health Units

Revision History

VersionDateChanges
1.0 November 2010 Full revision of guideline
2.0 June 2015 Full revision of guideline
3.0 June 2019 Case definitions revision

Infectious Agent

  • Rubella virus is a togavirus of the genus Rubivirus.

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Notification Criteria - Rubella

Reporting

Both confirmed cases and probable cases should be notified.

Confirmed case

A confirmed case requires laboratory definitive evidence only.

Laboratory definitive evidence

Isolation of rubella virus

OR

Detection of rubella virus by nucleic acid testing

OR

IgG seroconversion or a significant increase in antibody level or a fourfold or greater rise in titre to rubella virus in the absence of recent rubella vaccination. The results must be established by the testing of paired sera in parallel.

OR

Detection of rubella-specific IgM, in the absence of recent rubella vaccination*. (Note that in pregnant women, the result needs to be confirmed in a reference laboratory**).

Probable case

A probable case requires:

Clinical evidence

AND

Laboratory suggestive evidence OR epidemiological evidence.

Clinical Evidence

A generalised maculopapular rash

AND

fever

AND

arthralgia/arthritis OR lymphadenopathy OR conjunctivitis.

Epidemiological evidence

An epidemiological link is established when there is:

contact between two people involving a plausible mode of transmission at a time when:

a) one of them is likely to be infectious (about 1 week before to at least 4 days after appearance of rash)

AND

b) the other has an illness that starts within 14 to 23 (usually 14 to 17) days after this contact

AND

at least one case in the chain of epidemiologically linked cases (which may involve many cases) is laboratory confirmed.

Laboratory suggestive evidence

In a pregnant patient, detection of rubella-specific IgM that has not been confirmed in a reference laboratory, in the absence of recent rubella vaccination.**

*see also Laboratory Aspects section.

**The need for confirmation in a reference laboratory is part of the national case definition. In Queensland, Pathology Queensland, QML and S&N all use EIA for rubella IgM. Each of these is considered a valid IgM result without need for testing in another lab. However, consideration should be given to the likelihood of false positive IgM, particularly in a pregnant woman. Please refer to the Laboratory Aspects section for more details.

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Notification Criteria - Congenital Rubella Infection

Congenital rubella infection is reported based on relevant evidence from a live or stillborn infant, miscarriage or pregnancy termination. Congenital rubella syndrome is reported as a subset of congenital rubella infection.

Reporting

Both confirmed cases and probable cases should be notified.

Confirmed case

A confirmed case requires laboratory definitive evidence (fetal).

OR

Laboratory definitive evidence (infant) AND epidemiological evidence.

Laboratory definitive evidence

Fetal

Isolation or detection of rubella virus from an appropriate clinical sample (i.e. fetal blood or tissue, amniotic fluid, chorionic villus sample) by culture or nucleic acid testing.

Infant

Isolation or detection of rubella virus from an appropriate clinical sample in an infant, by culture or nucleic acid testing.

OR

Detection of rubella-specific IgM antibody in the serum of the infant.

Epidemiological evidence

The mother has confirmed rubella infection during pregnancy (see definition for Rubella – non-congenital).

Probable case

A probable case requires:

Epidemiological evidence (1st trimester infection).

OR

Epidemiological evidence (2nd and 3rd trimester infection) AND laboratory suggestive evidence (infant).

Laboratory suggestive evidence

Infant

High / rising rubella-specific IgG level in first year of life.

Notification Criteria - Congenital Rubella Syndrome

Reporting

Both confirmed cases and probable cases should be reported.

Confirmed case

A confirmed case requires laboratory definitive vidence (fetal or infant), as described above AND clinical evidence.

Clinical evidence

A live or still born infant with ANY of the following compatible defects:

  • Cataracts
  • Congenital glaucoma
  • Congenital heart disease
  • Hearing defects
  • Microcephaly
  • Pigmentary retinopathy
  • Development delay
  • Purpura
  • Hepatosplenomegaly
  • Meninigoencephalitis
  • Radioluscent bone disease
  • Other defect not better explained by an alternative diagnosis.

Probable case

A probable case requires laboratory suggestive evidence (infant) OR epidemiological evidence, as described above.

AND clinical evidence

Clinical evidence

(as for confirmed CRS case).

Notification Procedure

Pathology laboratories

To notify on microbiological or serological confirmation of rubella or congenital rubella syndrome, by usual means.

Laboratory aspects

IgM is produced early after vaccination, reaching a peak at 1 month and lasting approximately 1 month more, but may persist for longer at low levels. In acute infection, IgM usually becomes detectable shortly after the rash onset, peaks approximately 7 days after rash onset and remains detectable for 4–12 weeks.

Because rubella incidence in Australia is low, a high proportion of IgM-positive tests will likely be false positive. False-positive serum rubella IgM tests may occur due to the presence of rheumatoid factors (indicating rheumatologic disease) or cross-reacting IgM, or infection with other viruses.

Testing repeat samples in parallel and detection of wild-type rubella virus by PCR can be used to resolve uncertainties in the serologic evaluation of suspected cases. The best specimens for PCR detection are throat or nasopharyngeal swab or urine. Blood can be used, but has not been validated.

Particular care should be taken when rubella IgM is detected in a pregnant woman with no history of illness or contact with a rubella-like illness. Although this is not recommended, many pregnant women with no known exposure to rubella are tested for rubella IgM as part of their antenatal care. If rubella test results are IgM-positive for persons who have no or low risk of exposure to rubella, additional laboratory evaluation should be conducted. Laboratory evaluation is similar to that described in the IgM-positive section of Appendix 1 - Serologic evaluation of pregnant women exposed to rubella.

Reporting to NOCS

Rubella
Both confirmed and probable cases should be notified.

Confirmed case
A confirmed case requires laboratory definitive evidence only.

Probable case
A probable case requires clinical evidence AND either laboratory suggestive evidence OR epidemiological evidence.

Congenital rubella syndrome
Both confirmed and probable cases should be notified.

Confirmed case
A confirmed case requires laboratory definitive evidence AND clinical evidence.

Probable case
A probable case requires laboratory suggestive evidence (either maternal or infant) AND clinical evidence.

Objectives of Surveillance

  1. To monitor the epidemiology of rubella and congenital rubella syndrome in Queensland to inform public health initiatives.
  2. To identify cases and outbreaks of rubella to enable appropriate public health responses.

Public Health Significance and Occurrence

Because Rubella is usually a mild disease with non-specific symptoms it is often difficult to diagnose clinically. However, Rubella is of public health significance because infection during pregnancy can cause miscarriage (up to 20% of cases in the first 8 weeks of gestation), foetal death and congenital anomalies.

Congenital rubella syndrome occurs in up to 90% of infants born to women who acquire rubella during the first trimester of pregnancy. The risk of a single congenital defect falls to approximately 10–20% by the 16th week and defects are rare when the maternal infection occurs after the 20th week of gestation. The most common congenital defects are cataracts, heart defects and hearing impairment.

The incidence of congenital rubella infection has decreased markedly since the schoolgirl vaccination program was initiated in Australia in the early 1970s. Australia has the opportunity to eliminate endemic rubella with rates of reported disease less than one case per 100,000 population since 2002.

Clinical Features

Rubella
Rubella is a mild febrile viral disease with a diffuse, punctate and maculopapular rash. Clinically, this is usually indistinguishable from febrile rash illness due to measles, dengue, parvovirus B19, human herpesvirus 6, coxsackie virus, echovirus, adenovirus or scarlet fever. The rash occurs in 50%–80% of rubella infected persons.

Children usually present few or no constitutional symptoms, but adults may experience a 1–5 day prodrome of low grade fever, headache, malaise, mild coryza, and conjunctivitis. Post-auricular, occipital and posterior cervical lymphadenopathy is the most characteristic clinical feature, and precedes the rash by 5–10 days. Many cases (up to 50%) are subclinical.

Complications of rubella are not common, but they generally occur more often in adults than in children.

Arthralgia or arthritis may occur in up to 70% of adult women who contract rubella, but is rare in children and adult males. Fingers, wrists, and knees are often affected. Joint symptoms tend to occur about the same time or shortly after appearance of the rash and may last for up to 1 month; chronic arthritis is rare.

Encephalitis occurs in one in 6,000 cases, more frequently in adults (especially in females) than in children. Mortality estimates vary from 0 to 50%.

Hemorrhagic manifestations occur in approximately one per 3,000 cases, occurring more often in children than in adults. These manifestations may be secondary to low platelets and vascular damage, with thrombocytopenic purpura being the most common manifestation. Gastrointestinal, cerebral, or intracranial haemorrhage may occur. Effects may last from days to months, and most patients recover.

Additional complications include orchitis, neuritis, and a rare late syndrome of progressive panencephalitis.

Congenital Rubella Syndrome (CRS)
Rubella is important because it can produce a constellation of anomalies in the developing foetus. Congenital rubella syndrome is an illness resulting from embryonic / foetal rubella virus infection.

CRS occurs in up to 90% of infants born to women who are infected with rubella in the first 10 weeks of pregnancy. Infection early in pregnancy conveys the greatest risk of intrauterine death, spontaneous abortion and congenital malformations of major organ systems. The risk of defects declines when maternal infection occurs after the 12th week of pregnancy and defects are rare when maternal infection occurs after the 20th week.

The specific signs and symptoms of congenital rubella syndrome may be classified as temporal e.g. low birth weight; permanent e.g. deafness; and developmental e.g. myopia. Common manifestations include: cataracts, microphthalmia, congenital glaucoma, microcephaly, meningoencephalitis, developmental delay, patent ductus arteriosus, atrial or ventricular septal defects, purpura, hepatosplenomegaly, jaundice, and radiolucent bone disease. Moderate and severe CRS is usually recognisable at birth. Mild CRS with only slight cardiac involvement or hearing impairment may not be detected for months or even years after birth. Diabetes mellitus in late childhood has been observed 50 times more frequently in children with CRS than without it.

Reservoirs

Humans are the only known reservoir.

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Mode of Transmission

Droplet spread and direct contact with nasopharyngeal secretions of people infected with rubella virus.

Rubella vaccine virus is not generally transmitted from vaccinated persons to susceptible contacts. The vaccine virus is secreted in breast milk, and rare cases of transmission of vaccine virus through breast milk have been reported. However, symptoms in the newborn have been mild or absent and post-partum vaccination of women need not be delayed because of breastfeeding.

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Incubation Period

From 14–17 days with a range of 14–21 days.

Period of Communicability

Rubella is highly communicable. The period of communicability is approximately one week before and at least 4 days after the onset of rash. People with rubella are most infectious when the rash is erupting.

Infants with congenital rubella syndrome shed virus in their pharyngeal secretions and urine for up to 1 year after birth and can therefore transmit the virus to susceptible people caring for them.

Susceptibility and Resistance

Immunity is usually permanent after natural infection and thought to be lifelong after immunisation. Ninety-five percent of people seroconvert after 1 dose of rubella-containing vaccine. However, rubella reinfection can occur in individuals who have both natural and vaccine-induced immunity.

Re-infection is not associated with a lack of neutralising antibodies, and viraemia is rare. In some studies, reinfection leads only to an IgG booster response, without IgM, whereas in others the appearance of IgM suggests significant viral replication. Clinical rubella has been documented during reinfection of vaccinated and naturally immune individuals. Occasional cases of congenital rubella syndrome after reinfection in pregnancy have been reported. The risk of foetal transmission is probably less than 5% in the first trimester (compared to at least 80% in primary infection).

Infants born to immune mothers are ordinarily protected for 6–9 months, depending on the quantity of maternal antibodies acquired transplacentally.

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Management

Cases

Investigation
In consultation with the attending medical practitioner, ensure laboratory confirmation and all relevant clinical and demographic information are obtained. Ascertain vaccination status with respect to rubella.

Laboratory confirmation is recommended for all sporadic cases of rubella and all suspected cases of congenital rubella syndrome.

Restriction
As per the current NHMRC recommendations, exclude rubella cases from school/institution/work until 4 days after onset of rash or until fully recovered, whichever is longer. Avoid contact with women of child bearing age and pregnant women.

In hospitals, as per current Queensland Health infection control guidelines, patients with suspected or proven rubella should be managed with contact and droplet precautions until 7 days after onset of rash or until fully recovered, whichever is longer. Contact isolation precautions should be applied to infants less than 12 months of age with CRS unless urine and pharyngeal cultures are negative for rubella virus.

Infants with congenital rubella syndrome should be excluded from childcare and avoid contact with pregnant women for the first 12 months of life unless urine and pharyngeal specimens are negative for rubella virus either by culture or by NAT after three months of age.

Counselling
The case should be advised of the nature of the infection and its mode of transmission. If other vaccinations are incomplete, recommend catch up once recovered.

Pregnant cases

If the patient is pregnant, obtain information regarding number of weeks of gestation at onset of illness. Refer the case promptly to their obstetrician/clinician for counselling regarding the risks of intrauterine rubella infection and appropriate follow-up. If possible, follow up with the referring clinician for pregnancy outcome.

Contacts

Contact tracing
Yes

Definition
Anyone who is likely to have been exposed to the nose or throat secretions of a person with rubella during their infectious period. Although rubella transmission is usually associated with repeated exposure, transmission has been documented after a single exposure.

Investigation
Prioritise investigation based on the probability of transmission. First priority should be people who share a household with the case, people who attend the same class at school or childcare as the case and people who are work or social contacts of the case. Particular effort should be made to identify all pregnant women who might have been exposed and ensure they are reviewed by their clinician and serologically tested for rubella.

Except for pregnant women and women who are planning a pregnancy, adequate proof of immunity to rubella includes:

a)  written documentation of receipt of two doses of a rubella-containing vaccine administered on or after the first birthday
b)  laboratory evidence of immunity
c)  birth before 1966.

Pregnant women and women who are planning a pregnancy should be serologically tested.

Any contact who does not have adequate proof of immunity is a susceptible contact.

Management

Non-pregnant contacts

All susceptible non-pregnant contacts aged 12 months and older should be offered a single dose of MMR vaccine, provided there are no contraindications to the vaccine. This will not prevent disease if the contact is already infected. Women who are planning a pregnancy should be advised not to become pregnant for 28 days after receiving the vaccine.

Recommend that all susceptible people avoid contact with the case for at least 4 days after the onset of rash.

Pregnant contacts

Refer pregnant contacts to their clinicians for serologic evaluation of rubella-specific IgM and IgG antibodies (see Appendix) and counselling regarding the risks for intrauterine rubella infection. If the woman has an IgG antibody titre below the protective level, or is IgG negative, and remains asymptomatic, a second blood specimen should be collected 28 days after the exposure and tested in parallel with the first to detect subclinical infection. If the woman develops symptoms, specimens for rubella PCR and blood for rubella and other viral serology should be collected and tested as soon as possible to confirm diagnosis of rubella and exclude other relevant viral illnesses.

Susceptible pregnant contacts should avoid further contact with the case and with close contacts of the case for 6 weeks (two incubation periods) after the onset of symptoms of rubella in the last case.

Surveillance for CRS should be implemented when confirmed or probable rubella cases are documented in a setting where pregnant women might have been exposed.

Post-exposure prophylaxis for susceptible pregnant contacts with immunoglobulin

Post-exposure prophylaxis with NHIG (20 mls by deep IM injection in divided doses) within 72 hours of rubella exposure might reduce – but will not eliminate – the risk for rubella. Experimental studies in the 1960s confirmed the efficacy of passive antibody in preventing both viremia and clinical rubella, but there were numerous failures of gamma-globulin to prevent congenital foetal abnormality in actual practice. In one study of CRS patients, up to 6% of mothers gave histories of receipt of gamma-globulin after exposure to rubella. The newer intravenous gamma-globulins do not have high concentrations of rubella antibodies, presumably because the antibodies are now the result of immunisation rather than disease, so a higher failure rate may be expected.

Susceptible pregnant contacts of confirmed rubella cases should discuss PEP with their obstetrician/clinician, including a frank discussion of risks and possible benefits. Serological follow up of recipients is essential. IgM should be done once every 2 weeks for 2 months after last contact with the case to establish whether delayed or subclinical infection occurs.

Administration of NHIG
NHIG is available from the Red Cross Blood Bank. The PHU is responsible for notifying the obstetrician/treating clinician on the process for accessing NHIG for their patient if required. (See the following webpage for order form and contact details for CSL:  http://www.blood.gov.au/NHIg (current as at 13 April 2015).

NHIG should be given by deep IM injection, using an appropriately sized needle. The NHIG should be introduced slowly into the muscle, to reduce pain. This product must not be administered intravenously because of possible severe adverse events, and hence an attempt to draw back on the syringe after IM insertion of the needle should be made in order to ensure that the needle is not in a small vessel. A special product for IV use (NHIG [intravenous]) has been developed for patients requiring large doses of immunoglobulin.

Contacts in health care settings

Any exposed health care worker who does not have adequate evidence of immunity should be excluded from duty beginning 7 days after exposure to rubella and continuing until either

a)  21 days after last exposure

OR

b)  7 days after the onset of rash if illness develops or until fully recovered, whichever is longer.

Susceptible non-pregnant health care workers should be offered MMR vaccine, although post-exposure vaccination will not prevent rubella infection following exposure.

Management of Outbreaks

  • Identify potentially susceptible groups and high risk settings to promote awareness and vaccination.
  • Alert GPs, Emergency Departments and childcare facilities to enhance surveillance and case ascertainment.
  • Exclude non-immune pregnant women from workplaces with identified transmission.
  • Alert hospital infection control practitioners so they can implement the recommendations in health care settings e.g. antenatal clinics.

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Preventive Measures

MMR vaccination is recommended for all infants at 12 months of age, and MMRV (as the second dose of rubella containing vaccine) is recommended for all infants at 18 months of age.  Women of child bearing age should be tested prior to pregnancy, if possible. All seronegative women, if not pregnant or intending to become pregnant within 28 days, should be offered free MMR vaccine. Opportunities for screening include general practice, antenatal care, and at family planning, infertility and occupational health clinics. All seronegative pregnant women should be offered free MMR vaccine post-partum. Opportunities include the post-natal ward and the 6 week postnatal visit (women should be advised not to become pregnant for 28 days after vaccination).

If born during or after 1966, and there is an absence of vaccination records or there is seronegativity on screening, all adults, and particularly male and female child care workers and staff and students in health care facilities who have contact with patients, should receive MMR vaccination.

Use epidemiologic and published data to identify groups with low vaccination coverage (e.g. some migrant groups) and enhance opportunities for vaccination.

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Summary

Prepare a report of investigation for the Communicable Diseases and Infection Management Unit, Queensland Health, on request.

References

Australian Department of Health and Ageing. 2013. The Australian Immunisation Handbook (10th ed). Australian Government: Canberra.

Bennett J Dolin R and Blaser M (2015) Mandell, Douglas and Bennett's Principles and Practice of Infectious Diseases Elsevier Saunders Philadelphia.

Begg K, Roche P, Owen R, Liu C et al. 2008.  Australia's notifiable diseases status, 2006: annual report of the national notifiable diseases surveillance system. Comm Dis Intell 32(2): 139-207.

Bouthry E, Picone O, Hamdi G, Grangeot-Keros L, Ayoubi JM, Vauloup-Fellous C. Rubella and pregnancy: diagnosis, management and outcomes. 2014. Prenatal Diagnosis 34: 1246-53.

CDC Atlanta Chapter 14 Rubella VPD Surveillance Manual 2012. Communicable Disease Control Atlanta.

CDC.2013. Measles, mumps and rubella - vaccine use and strategies for elimination of measles, rubella and congenital rubella syndrome and control of mumps: Summary recommendations of the Advisory Committee on Immunisation Practices (ACIP).  MMWR 62 (No. RR-04; 1-34).

Gao Z Wood J Burgess M et al. 2012. Models of strategies for control of rubella and congenital rubella syndrome - a 40 yr experience from Australia Vaccine 11

Heymann D. (Ed).  2015. Control of Communicable Diseases Manual (20th ed).  American Public Health Association: Washington.

Khandaker G, Zurynski Y and Jones C. 2014. Surveillance for congenital rubella in Australia since 1993: Cases reported between 2004 and 2013. Vaccine 32:50 Nov pg 6746-6751.

Ohkusa Y Sugawara T Arai S et al. Short term [prediction of the Incidence of Congenital Rubella Syndrome.Plos Currents October 30;6

Plotkin S, Orenstein W, Offit P.  2008. Vaccines (5th ed). Saunders Elsevier.

The Green Book - UK Immunisation again infectious diseases
https://www.gov.uk/government/collections/immunisation-against-infectious-disease-the-green-book accessed 17/2/15

The Pink Book - Centers for Disease Control and Prevention US
www.cdc.gov/vaccines/pubs/pinkbook/index.html accessed 17/2/15

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Appendix 1. Serologic evaluation of pregnant women exposed to rubella



Serologic evaluation of pregnant women exposed

Last updated: 25 June 2019