Rubella

• Identification
  • Invasion phase
  • Status phase
  • Congenital rubella
    • Congenital Malformative Rubella
    • Rubella Congenital evolution
• Infectious Agent
• Incidence and prevalence
• Source
• How to transmit
• Risk groups
• Incubation period
• Infectiousness Period
• Prophylaxis
  • Vaccination
  • Aministration of Immunoglobulins
  • Birth to the infected woman
  • Breast-feeding
  • Treatment

Identification

Rubella is a contagious viral infectious disease that can be both asymptomatic and symptomatic. The rubella infection leads to very long-term immunity, most often for life (after healing).
It’s a benign infection in childhood. The risk is high in the pregnant woman because rubella can cause congenital malformations to the fetus.
Both the risk of fetal infection and the severity of embryo-fetal touch are inversely correlated with the age of pregnancy at the time of maternal infection.
In case of first maternal infection

• Before 11 weeks of pregnancy the frequency of transmission of maternal-foetal infection is about 90% and most commonly translates by severe impairment of the embryo.
• Between 11 and 18 weeks of pregnancy leads to congenital birth which often is limited to an isolated deafness.
• After 18 weeks of pregnancy the risk of congenital malformations to the fetus is very low (almost null).

In symptomatic patients, the disease has 2 stages: the invasion phase and the status phase.

Invasion phase

-Is short (1-5 days) and appears at only 25% of the patients, especially in adults. Is characterized by:

• Discomfort
• Subfebrileness,
• Discreet pain at the pharynx level,
• Sometimes joint pain,
• Increase enlargement of retro-auricular, posterior cervical and sub-occipitals ganglions. The enlargement of the ganglions may persist for about 10-14 days after the eruption has disappeared.

Status phase

-Starts with the occurrence of the rash that is inconsistent.

• It is a maculopapular eruption (reddened skin lesions); it starts on the face and occupies trunk and upper limbs within 24 hours.
• On the second day it can get a rough skin appearance on the buttocks and lower limbs
• Disappears on day 3 in the order in which it appeared

The skin eruption occurs in a single wave (compared to the situation in other eruptive diseases).

The biggest inconveninences accused are joint pains. Especially in young people and women (with a frequency of 15-20% of cases). It affects both the large joints-knees, ankles, shoulders, punches and small ones at the hand. Sometimes they still appear in the invasion phase and can persist for a long time.
There can also be associated signs and symptoms such as

• Cough
• Headache
• Conjunctivitis
• Splenomegaly (increased spleen size),
• Fever. Rarely the fever lasts more than a day after the eruption occurs.

The diagnosis of certainty is based on laboratory analyses. Clinical diagnosis is not certain. There are other diseases that can lead to similar signs and symptoms. Therefore, the diagnosis is based on a blood sample collected within 28 days of the infection onset. In the blood sample, the presence of Ig M antirubella antibodies is determined by an ELISA-type technique. There are also tests involving modern techniques of molecular biology (reserved for laboratories that have the necessary equipment; they are intended for virus detection).

Congenital rubella/Congenital rubella syndrome (SRC) – clinical manifestations in the newborn

The risk is:

• Fetal death,
• Malformative Congenital rubella and
• Evolutionary congenital rubella.
  

Malformative Congenital rubella

is detcted:

• Prior to birth (by ultrasound; the technique can allow detection of malformations of the central nervous system or of an intrauterine growth retardation),
• After birth,
• Or later (a complete balance of rubella sequelae can be done after several years of birth).

Birth generally affects:

• Auditory system,
• Visual system,
• Heart
• Central nervous system.

They are generally multiple and associated.

Ocular impairment include:

• Cataract (the most common birth, generally bilateral),
• Microophthalmia,
• Glaucoma
• Corneal opacity.

Hearing impairment consists of deafness (frequently asymmetric and rarely complete). This is about a hearing loss that interests the high frequencies.

Cardiac birth can be of many types but the most common are:

• Persistence of the arterial channel and
• Pulmonary stenosis.

Central nervous system lesions include:

• Microcephaly and
• Psychomotor retard.

Other rare malformations may be dental ones (hypoplasia, agenezia of certain teeth, micrognathia).

Congenital Rubella evolution

It refers to a generalized chronic viral infection. The virus is present both in viscera and pharynx, which makes the newborn very contagious. In this case, the newborn may be contagious for about 6 months, but infectiveness may persist even 24 months. Congenital Rubella evolution is generally associated with malformations present since birth.
The clinical picture associates at birth:

• Thrombocytopenic purpura,
• Hepatitis with Hepatoslenomegaly and jaundice,
• Lymphocytic meningitis with or without neurological signs,
• Myocarditis
• Interstitial pneumonia,
• Radiologically visible bone lesions.

Death occurs in 1 out of 5 cases.
Subsequently, neurological anomalies can also be found, a psychomotor retardation that can reveal an evolutionary rubella encephalitis.
The long-term prognosis is reserved.

The diagnosis to baby is based on:

• ELISA for the detection of antirubella IgM-type antibodies in the blood or
• Virus detection through genetic amplification techniques from pharyngeal exudate, blood, urine (e.g. PCR).

Children with congenital rubella may remain positive for antirubella IgM-type antibodies up to 6 months. In the pharyngeal or urinary samples of the childrens with congenital rubella the virus may persist until the age of 3 years.

The infectious agent

The rubella virus is an RNA virus in the Togaviridae family, genus Rubivirus.

Incidence and prevalence

The epidemiology of rubella was modified by generalization of vaccination. A monovalent (anti-Rubella) vaccine was originally used. After 1970, the trivalent vaccine ROR/MMR (Measles-mumps-rubella/Measles-Mumps-Rubella) was also in use. Before the introduction of vaccination the disease evolves in the form of relatively frequent cyclical epidemics.
Extensive epidemics occurred every 20-30 years. In the course of these epidemics was possible to be observed and analyzed cases of congenital malformations in newborns from infected mothers with rubella during pregnancy. Thus, information on congenital rubella was accumulated (e.g. in the epidemics of 1964-1965 in the US and 1978 in the UK).
It is estimated that annually, 110,000 children are affected by Congenital rubella syndrome (CRS). Between 2002-2003 Romania faced a rubella epidemic totaling 115,000 cases (incidence of 531 cases in 100,000 inhabitants). There were suspected 150 cases of congenital rubella and seven were confirmed. In 2011-2012 Romania faced a new rubella epidemic that affected over 20,000 people.

Source

The natural reservoir is the man.
The sources of sickness are represented by:

• Patients with an asymptomatic form of disease (about 50% of total infected persons), or
• Patients with symptomatic disease;
• Newborns with congenital rubella.
  

Method of transmission

The mode of transmission is direct, aerogenic. The patients eliminate the virus through saliva drops. Another route of transmission is the transplacental pathway (congenital rubella).
Rubella is less contagious than measles or influenza. Close contact is required for the virus to be transmitted.

Risk groups

Children and medical staff, education staff and nursery / children’s homes.

Incubation period

It’s variable. It lasts between 14-21 days.

Infectiousness Period

It’s limited. It starts 3-7 days before the eruption and stops 5-7 days after the eruption has disappeared. Newborns with congenital rubella excrete the virus for about 6-12 months, thus being highly contagious for those with whom they come in contact. In congenital rubella evolution the newborn can be contagious even 24 months.

Prophylaxis

Vaccination is the only possible method of prevention. It protects women at the age of procreation and thus decreases the risk of touching embryofoetal as long as vaccination has been taken before pregnancy.
The vaccine currently in use in our country is the combined anti-measles vaccine-mumps-rubella, ROR/MMR. Includes the anti-rubella vaccine-a live attenuated vaccine. Do not administer when the woman is already pregnant due to the risk of foetal damage. It is recommended to avoid pregnancy within a month post-vaccination.
Children should be vaccinated with:

• The first dose of the vaccine between 12-15 months of life and then with
• The second dose at the begining of the school around the age of 5 years.

About 5-10% of children are not fully immunized after the first administration of the vaccine. As such, the second dose is also required, in which approximately 1% of children remain partially immunized.
The vaccination program for children reduces the virus reservoir and thus avoids the infection of pregnant women. The vaccine also protects women who want to become pregnant and who have not yet gone through the disease. In this case the vaccine should be administered before the first pregnancy or immediately after birth for future pregnancies.
If the woman who wishes to become pregnant is serologically tested for the detection of rubella anti-virus antibodies and testing shows the presence of antibodies, confirming that she has immunity (already passed through the disease), the vaccine is no longer necessary.
If the woman who wishes to become pregnant has not gone through the disease it is recommended to carry out serological checks up to 20 weeks of pregnancy. From this age of pregnancy upwords, the risk of fetus damage is very low.

Problems occur when:

• Pregnant woman comes into contact with a person suspected of having rubella– in this case the primary objective is to investigate the receptivity by blood collection to test IgG and IgM specific  antibodies. The test will be repeated after about 14-18 days, towards the end of the incubation period. The assessment of antibody titer will be made in dynamic. In absence of a rubella evoked  clinical context, the presence of specific IgM antibodies should be interpreted and announced with caution, in order not to be a false positive result. In this case it is necessary to carry out complementary techniques, such as the measurement of the avidity of IgG antibodies during the first trimester of pregnancy.
• Notice the occurrence of a suspicious rash in the pregnant woman.

Diagnosis of maternal infection can only be serological.

In case of seroconversion:

• The appearance of IgM antibodies during pregnancy, although initially did not exist, in an earlier test
  Or
• The presence of IgM-type antibodies in the disease-evoking clinical context,
  = > The diagnosis of fetal infection is done by amniocentesis and by the identification of the viral RNA in the amniotic fluid. It is preferable that this investigation be done after 20 weeks of pregnancy.
  

Vaccination

Although the anti-rubella vaccine has been in place since 1969, it has become accessible to underdeveloped countries since the 1990s.

In Romania, in May 2004, the routine vaccination of anti-rubella (ROR/MMR) was introduced in children aged 12-15 months, and in 2003 teenage girls born in the years 1987-1988 anti-rubella were vaccinated. According to the national immunization programme, the ROR vaccine is given in two doses, the first dose of all children aged 12-15 months followed by the second dose to 5 years.
Antirubella vaccination, the only means of effective prevention, should be applied not only to children but also to women of childbearing age at least one month before being pregnant or immediately after childbirth (if they are likely to make rubella during a subsequent pregancy). This can be done after serological testing. Particular attention should be paid to women who, due to the professional category they belong to, are at risk of getting into contact with rubella patients: medical staff, education staff and nursery / children’s homes.

Vaccination during pregnancy is contraindicated!

Administration of Immunoglobulins against rubella

Within 72 hours of the infectant contact, can be administered 20 ml intramuscularly. Symptomatology may improve, but maternal-fetal transmission is not prevented. There are documented cases of children birth with congenital rubella despite the administration of immunoglobulins.

Birth to the woman infected with the rubella virus

There are no special recommendations.

Breast-feeding

There are no special recommendations.

Treatment

No treatment for fetal infection with the rubella virus has been identified so far. In this situation the doctor will assess (preferably in an interdisciplinary team) a possible medical interruption of pregnancy, on a case-by-case basis. The evaluation will take place in the case of a proven infection during 12-18 weeks of pregnancy in the presence of ultrasound anomalies, or in the case of primoinfection before 11 weeks of pregnancy.