Pediatric Rubella in Emergency Medicine 

Updated: May 03, 2017
Author: Pamela L Dyne, MD; Chief Editor: Kirsten A Bechtel, MD 

Overview

Background

Rubella is now rare because of widespread compliance with childhood immunization programs. The disease is usually a benign and inconsequential viral illness unless exposure occurs in utero.

Congenital rubella syndrome is associated with clinically significant congenital malformations.[1] The live-attenuated virus vaccine has decreased the incidence of rubella significantly, thereby decreasing congenital disease. See the image below.

Image in a 4-year-old girl with a 4-day history of Image in a 4-year-old girl with a 4-day history of low-grade fever, symptoms of an upper respiratory tract infection, and rash. Courtesy of Pamela L. Dyne, MD.

Pathophysiology

The causative organism is a single-stranded RNA togavirus that is transmitted by means of respiratory droplets. The virus replicates in the nasopharynx and regional lymph nodes, resulting in viremia. The virus then may spread to the skin, CNS, synovial fluid, and transplacentally to a developing fetus.

Epidemiology

Frequency

United States

Before the rubella vaccination became available in 1969, epidemics occurred every 6-9 years and pandemics every 10-20 years. In 1977-1981, 20,395 cases of rubella were reported in the United States. According to Statistical Handbook on Infectious Disease regarding historical trends of rubella in the United States, the incidence has significantly decreased since that time.[2] In 1990, 1124 cases of rubella occurred, and, in 1999, only 267 occurred. In the last decade, the rate has been less than 10 cases of congenital rubella syndrome per year. These cases mostly affected mothers born outside of the United States in Latin American countries with lower vaccination rates.

In 2004, the Centers for Disease Control and Prevention (CDC) reported that, since 2001, fewer than 25 cases of rubella have occurred each year in the United States.[3] The CDC estimates 95% vaccination coverage among school-aged children and 91% immunity in the population.[3]

During the 1990s resistance to the MMR vaccine developed. An earlier (since discontinued) version in the United Kingdom was associated with aseptic meningitis. As a result of this, vaccination rates in the United Kingdom fell from an earlier level of 92% to 79% in 1998; they have since rebounded.[4] Moreover, a correlation between autism and MMR use was later postulated. Subsequent epidemiologic studies have shown no significant association between the vaccine and either condition. Inadequate vaccination rates have led to an ongoing outbreak in Austria.[5]

A recent case control study, presuming it to be a random variation, found a correlation between early rubella vaccination (before age 10) and later development of multiple sclerosis.[6] Another recent study shows that immigrant women in Canada had surprisingly low vaccination rates; this highlights the risk of epidemics in areas with significant immigrant populations.[7] Vaccination rates remain very high in the United States; should this change in the future, the frequency of rubella could change dramatically.

From 2000 to 2012, rising numbers of WHO member states began using rubella-containing vaccines (RCVs) in their immunization program and began reporting rubella and congenital rubella syndrome (CRS) surveillance data. As of December 2012, 132 (68%) WHO member states had introduced RCV, a 33% increase from 99 member states in 2000. Some 43% of infants had received a RCV dose in 2012, a 96% increase from the 22% of infants who had been vaccinated against rubella in 2000. A total of 94,030 rubella cases were reported to WHO in 2012 from 174 member states, an 86% decrease from the 670,894 cases reported in 2000 from 102 member states.[8, 9]

International

The rubella vaccination is given to only about half the world's population. Congenital rubella syndrome remains a major problem in some areas. In Russia, for instance, congenital rubella syndrome causes 15% of all birth defects.

Mortality/Morbidity

Infection in healthy children or young adults is generally self-limited and without sequelae.

  • The most common complications are arthropathies of the fingers, wrists, and knees that can persist for a year or more.

  • Thrombocytopenia with purpura and hemorrhage is a rare complication of rubella.

  • Congenital rubella syndrome is associated with malformations of multiple organ systems including the CNS and cardiac, ocular, and skeletal systems. Infants with congenital rubella syndrome who survive into adulthood may be plagued by autoimmune disorders and dysgammaglobulinemia.

  • Damage to the fetus is most likely when maternal infection occurs during the first 2 months of pregnancy, although there is risk associated with infection up to 5 months.

Race

See the list below:

  • The highest risk is among members of racial or ethnic groups who are unvaccinated and who may be exposed to persons traveling from areas where rubella vaccination is not routine.

  • Recent outbreaks have occurred among persons of Hispanic ethnicity. Consequently, Hispanic persons and persons from countries without rubella vaccination programs should be considered susceptible to rubella unless they have documentation of vaccination or serologic evidence of immunity.

Sex

Rubella affects men and women equally.

Age

Before vaccination, the peak incidence occurred in children aged 5-14 years. However, at present, most cases occur in teenagers or young adults.

 

Presentation

History

See the list below:

  • The incubation period of rubella is 14-23 days.

  • The prodrome is characterized by the following:

    • Malaise

    • Fever

    • Anorexia

    • Headache

    • Mild conjunctivitis

    • Rhinorrhea

  • The rash develops within 1-5 days of symptom onset, starting on the face and forehead and spreading caudally to involve the trunk and extremities.

    • The rash tends to clear in the same order as it appeared.

    • The rash may be pruritic, but it usually resolves within 3 days without residua.

Physical

See the list below:

  • Lymphadenopathy may be present, particularly in the posterior auricular, posterior cervical, and suboccipital chains.

  • The rash consists of pink macules and papules, which may become confluent, resulting in a scarlatiniform eruption.

  • Petechiae of the soft palate, known as the Forchheimer sign, may be present.

Causes

Rubella is caused by a single-stranded RNA togavirus.

 

DDx

 

Workup

Laboratory Studies

See the list below:

  • The diagnosis of rubella is clinical, though seroconversion in response to rubella antigens may confirm it.

    • Antibodies are often present shortly after the rash appears and increase in titer during the next 2-3 weeks.

    • Elevated levels of immunoglobulin M (IgM) antibodies are particularly helpful findings in newborns. IgM antibodies do not cross the placenta and indicate a recent infection acquired after birth.

  • The rubella virus can potentially be isolated from a throat culture during the acute phase of illness, but this technique is not a practical way to establish the diagnosis.

 

Treatment

Emergency Department Care

No antiviral therapy for rubella is available. Treatment is supportive.

 

Medication

Medication Summary

The goals of pharmacotherapy are to reduce morbidity and prevent complications.

Antipyretics

Class Summary

These agents may be used to decrease fever.

Acetaminophen (Tylenol)

Reduces fever by direct action on the hypothalamic heat-regulating centers, which increases dissipation of body heat by vasodilation and sweating.

Ibuprofen (Motrin, Advil)

NSAID that inhibits cyclooxygenase, inhibiting formation of prostaglandins.

Antihistamines

Class Summary

May be used to control itching.

Diphenhydramine (Benadryl)

Competitive antagonist of histamine at the H1 receptor prevents histamine response in sensory nerve endings and blood vessels. More effective in preventing histamine response than reversing it.

 

Follow-up

Further Outpatient Care

See the list below:

  • Arrange follow-up care with the patient's primary physician.

Deterrence/Prevention

See the list below:

  • As a physician, emphasizing the safety of the MMR vaccine to patients is important.[10, 11]

    • A study by Siberry et al of 428 children with perinatal HIV infection and 221 HIV-exposed but uninfected children found that only 57% of the children with perinatal HIV infection showed immunity for measles, 65% for rubella and 59% for mumps, compared to 99%, 98%, and 97% respectively in the HIV-exposed but uninfected group.[12]

Prognosis

See the list below:

  • Beyond the fetal period, rubella is generally benign and self-limiting and without complications.

  • Infants born with congenital rubella syndrome may have a variety of complications; therefore, their prognosis depends on the severity of their malformations.

Patient Education

See the list below:

  • Reinforcement of scheduled routine immunizations is imperative.

  • For excellent patient education resources, visit eMedicineHealth's Children's Health Center and Infections Center. Also, see eMedicineHealth's patient education articles Measles; Skin Rashes in Children; and Immunization Schedule, Children.