Dermatologic Manifestations of Rubella Follow-up
- Author: Peter C Lombardo, MD; Chief Editor: Dirk M Elston, MD more...
While rubella usually has a mild clinical course, the sequel of congenital rubella syndrome can be devastating. The main defense against congenital rubella syndrome is a comprehensive vaccination plan nationally and internationally.
In 2003, an increase occurred in cases of rubella in England and Wales that was the direct result of a decrease in the vaccination rate, because of perceived adverse effects of the MMR vaccination, namely autism. A population-based study in Denmark involving more than a half million children showed no significant increase in autism in children who had received the MMR vaccination compared with those who were not vaccinated. These results have been confirmed by other studies.
The idea that the MMR vaccine causes autism is a misconception that must be overcome. Because of the lack of valid evidence, the Federal "vaccine court" now rejects claims that the MMR vaccine causes autism. Parents must be cautioned that by not vaccinating their children because of this misconception, they may be exposing them and others to the very real complication of congenital rubella syndrome. Physicians, who are usually the primary source of correct information for their patients, must work with these parents to understand and attempt to minimize these fears.
The Measles and Rubella Initiative Strategic Plan 2010-2020, which is indorsed by the WHO, the CDC and other global health organizations, models its plan to eliminate these viral diseases globally based on the experience in the Americas, where endemic rubella is now eliminated. The mainstay of this strategy is to achieve and maintain high levels of population immunity by providing high vaccination coverage with two doses of measles- and rubella-containing vaccines. One obstacle to achieving this goal is the increase in vaccine refusals for "personal belief" in the United States, resulting in geographic clusters of refusals and the possibility of outbreaks. This increases the risk of infection for those who refuse vaccination and for those who are not candidates for it because of age, immunosuppression, or some other contraindication. Fortunately, some states are now passing legislation that removes personal belief as a reason not to be vaccinated.
The live rubella vaccine is an RA27/3 strain grown in human diploid cell cultures. The live rubella vaccine is usually given with the measles and mumps vaccine (ie, MMR vaccine) at age 12-15 months and again at school entry at age 4-6 years. The MMR vaccine can now be combined with the varicella vaccine (ie, MMRV vaccine) as one injection for ease of administration.
The Centers for Disease Control and Prevention have issued the following recommendation for 2009 :
One or more doses of MMR vaccine should be given to adults who were born during or after 1957 unless they have a medical contraindication, documentation of one or more doses, history of measles diagnosed by a healthcare provider, or laboratory evidence of immunity.
A second dose of MMR is recommended for adults recently exposed in an outbreak setting, previously vaccinated with a killed measles vaccine, or vaccinated with an unknown type of measles vaccine during 1963-1967.
Second doses should also be given to students in postsecondary educational institutions, who work in a healthcare facility, or who plan international travel.
Women of childbearing age, regardless of birth year, should be assessed for rubella immunity and counseled concerning congenital rubella syndrome. Women without immunity should receive the MMR vaccine upon completion or termination of pregnancy and before discharge from the healthcare facility.
A few contraindications to vaccination should be noted, as follows:
Pregnant women should not be vaccinated; however, vaccination of her household contacts is not contraindicated because no evidence indicates that the virus would spread to her even though the vaccinee may shed the virus for 1-4 weeks.
Patients receiving hyperimmune globulin should avoid vaccination 2 weeks before and 3 months after its administration. If hyperimmune globulin is given, the patient should be tested for immunity at least 8 weeks following vaccination.
Patients who are seriously ill should not be vaccinated; however, fever in itself is not a contraindication.
Patients with severe altered immunity should not be vaccinated. Patients on immunosuppressive therapy should not be vaccinated for 3 months. Patients with HIV disease may be vaccinated if they are not severely immunocompromised.
Adverse reactions to vaccination include rash, fever, and/or lymphadenopathy developing 5-12 days later in 5-15% of children. Joint pain is rare but is more prevalent in women and is usually less severe than that seen in the naturally occurring disease. Rarely, transient peripheral neuritis symptoms have been reported.
The combined MMRV vaccine (ProQuad) has been shown to be associated with an increased risk of febrile seizures occurring 5-12 days following vaccination, at a rate of 1 in 2300-2600 in children aged 12-23 months compared with a separate MMR vaccine and a varicella vaccine administered simultaneously.[16, 17] As a result, the CDC Advisory Committee on Immunization Practices (ACIP) recommends that separate MMR and varicella vaccines be used for the first dose, although providers or parents may opt to use the combined MMRV for the first dose after counseling regarding this risk. MMRV is preferred for the second dose (at any age) or the first dose if given at age 48 months or older.
Data from postlicensure studies do not suggest that children aged 4-6 years who received the second dose of MMRV vaccine had an increased risk for febrile seizures after vaccination compared with children of the same age who received the MMR vaccine and varicella vaccine administered as separate injections at the same visit.
Complications are rare with rubella in healthy infants and adults. Rarely, encephalitis or peripheral neuritis may occur; however, recovery is usually complete without sequelae. Thrombocytopenia usually resolves within a month, but it may result in purpura, epistaxis, and intestinal bleeding.
Congenital rubella syndrome is the most severe and important complication of rubella and occurs in the fetus of a pregnant woman without immunity to the virus. Of infants infected in the first trimester, 50% are affected, and the severity depends on how early the infection occurs. Note the following:
The most common abnormalities are ophthalmologic in nature (eg, cataracts, retinopathy).
Cardiac abnormalities (eg, patent ductus arteriosus, pulmonary stenosis) may be seen.
Auditory involvement may be present as sensorineural deafness.
Neurologic disorders (eg, meningoencephalitis, mental retardation with behavioral disorders) may occur.
If infection occurs after organ development, a variable picture may be seen, with hepatitis, splenomegaly, pneumonitis, myocarditis, and/or osteomyelitis.
If the bone marrow is affected, thrombocytopenia with purpura and petechiae occur. Bizarre purple macules and papules, which represent persistent dermal (extramedullary) hematopoiesis, are seen in the skin. This appearance is known as blueberry muffin baby. Note the image below.
An infant who is affected may continue to shed the virus for up to 1 year. At least 85% of infants who are affected shed the virus at 1 month, and 1-3% do so at 1 year. Therefore, these individuals should be considered contagious for at least 1 year and should be considered an exposure threat to nonimmune pregnant women, unless nasopharyngeal or urine culture results are repeatedly negative.
No adequate treatment is available for pregnant women exposed to rubella. Immunoglobulin is not recommended unless termination of the pregnancy is not an option because cases of congenital rubella syndrome have occurred in infants born to mothers who received immunoglobulin shortly after exposure.
The prognosis is usually excellent, with the exception of congenital rubella syndrome.
Now that endemic rubella is eliminated in the Americas, the threat of rubella epidemics and subsequent congenital rubella syndrome would be from cases of rubella that enter the United States from other areas of the world and infect the unvaccinated clusters in this country. Therefore, the Measles and Rubella Initiative calls for monitoring the disease using effective surveillance, developing and maintaining outbreak preparedness, communicating and engaging to build public confidence and demand for immunization, and continuing research to improve cost-effective vaccinations and diagnostic tools.
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