How Common is Rubella in the United States?

Patient Presentation
A pediatrician received a written notice from the Department of Public Health that a newborn infant needed follow-up for failing their newborn hearing screening. The physician did not recognize the patient’s name and the infant had not been seen in the practice. When the family was contacted to arrange followup, the physician was told that the female infant had been diagnosed with congenital rubella syndrome and was seeing another physician. The parent also said that the infant had failed the followup hearing screening and was also being followed by an ophthalmologist for cataracts. Additionally the family was already receiving support services through local agencies. The physician was very surprised because he knew the rubella had been decreasing in the United States.

Discussion
Rubella (sometimes called German measles) is caused by a togavirus. The post-natally acquired infection causes erythematous macules that occur first on the face and then spreads to extremities and trunk (spreading distally). The rash fades in the same direction. Fever, posterior cervical lymphadenopathy or arthritis may also occur. The incubation period is 14-23 days and patients are contagious from 7 days before the rash until 14 days after the rash. The rash generally lasts 3 days, but the rash may be absent in 20-50% of cases.

Congenital rubella syndrome (CRS) is group of birth defects that includes:

  • Central nervous system
    • Behavior problems
    • Meningoencephalitis
    • Mental retardation
  • Congenital heart disease
    • Patent ductus arteriosus
    • Peripheral pulmonary artery stenosis
  • Ears
    • Sensorineural hearing impairment
  • Eyes
    • Blindness
    • Congenital cataract
    • Congenital glaucoma
    • Microopthalmia
    • Pigmentary retinopathy

Presentation of CRS in the neonatal period includes:

  • Bone disease, radiolucencies
  • Exantham – “blueberry muffin” caused by dermal erythropoiesis
  • Growth retardation
  • Hepatosplenomegaly
  • Pneumonitis, interstitial
  • Thrombocytosis
  • No or few clinical signs

CRS is more likely to be contracted the earlier in gestation the maternal infection occurs: 85% of fetuses develop CS if infected in the first 12 weeks of gestation, 54% in 13-16 weeks gestation, and 25% from 16-24 weeks gestation.

Rubella presents similarly to measles and therefore can be mistaken. Measles is caused by a paramyxovirus and clinically causes erythematous macules and papules that first appears on the lateral and posterior neck, and that progresses to involve the face, trunk and extremities (spreading distally). The rash fades in the same direction. Cough, coryza, Koplik spots and fever also occur. The incubation period is 8-12 days. Patients are contagious from 1-2 days before the rash until 4 days after the rash.

A review of common viral exanthams can be found here.

Learning Point
Rubella is considered non-endemic in the United States since 2010. “…[The Centers for Disease Control] defines absence of endemic transmission as the lack of existence of any continuous U.S.-acquired chain of transmission that persists for [greater than or equal to] 12 months in any defined geographic area.” This does not mean that there are no cases of rubella in the U.S.. The number of rubella cases in the U.S. has slowly but dramatically decreased after the initiation of Rubella vaccine in 1969 from 12.5 million cases in 1962-1965, to 7 and 9 cases respectively in 2003 and 2004. A similar decrease in CRS has been seen.

The demographics of rubella and CRS have changed from being endemic in the U.S. to being foreign-born. Rubella in the U.S. is most often found in persons born outside the U.S. who are unvaccinated or the vaccine status is unknown. Many of these people are from countries who have recently begun rubella vaccination programs or are improving their programs. Overall there has been dramatic progress towards controlling rubella worldwide, but rubella still remains endemic in other parts of the world and thus importable. Vaccination is highly efficacious with 95%+ rates of immunity after 1 dose of vaccine. Vaccination programs in some countries use single agent Rubella. In the U.S. rubella vaccine is routinely incorporated into measles vaccine which is given twice, giving an additional safeguard for rubella.

Questions for Further Discussion
1. How common is rubella in your own country or region of the world?
2. List common congenital infections and their presentations.
3. How common is measles in your own country or region of the world?
4. What services are available locally for children with congenital rubella syndrome?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for this topic: Rubella

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

Centers for Disease Control. Achievements in Public Health: Elimination of Rubella and Congenital Rubella Syndrome — United States, 1969-2004. MMWR. March 25, 2005.
Available from the Internet at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5411a5.htm (cited 4/2/2012).

American Academy of Pediatrics. Rubella, In Pickering LD, Baker CJ, Kimberlin DW, Long SS, eds. Red Book: 2009 Report of the Committee on Infectious Diseases. 28th edit. Elk Grove Village, IL: American Academy of Pediatrics; 2009;579-584.
Centers for Disease Control. Progress Toward Control of Rubella and Prevention of Congenital Rubella Syndrome — Worldwide, 2009. MMWR. October 15, 2010.
Available from the Internet at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5940a4.htm (cited 4/2/2012).

Muscat M, Zimmerman L, Bacci S, Bang H, Glismann S, Molbak K, Reef S; the EUVAC.NET group. Toward rubella elimination in Europe: An epidemiological assessment.Vaccine. 2012 Mar 2;30(11):1999-2007.

ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.

  • Systems Based Practice
    26. Partnering with health care managers and health care providers to assess, coordinate, and improve health care and how these activities can affect system performance are known.

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital