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Rubella

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Reporting Obligations

Individuals who have or may have rubella shall be reported to the local Health Unit. Laboratory confirmed cases are to be reported by phone as soon as identified.

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Epidemiology

Aetiologic Agent

Rubella virus (family Togaviridae) is the cause of this vaccine preventable disease.

Clinical Presentation

A mild febrile viral disease presenting with an erythematous maculopapular rash and few constitutional symptoms including low-grade fever, headache, malaise, mild coryza and conjunctivitis. The rash starts on the face, becomes generalized in 24 hours and lasts a median of 3 days. Serious complications are rare, with up to 50% of infections being subclinical, however encephalitis can occur as well as arthritis/ arthralgia, particularly among adult females. The main goal of immunization is the prevention of rubella infection in pregnant women which may give rise to congenital rubella syndrome (CRS) or congenital rubella infection in the infant (CRI).

CRS can result in miscarriage, stillbirth and fetal malformations, including congenital heart disease, cataracts, deafness and intellectual disabilities. The greatest risk of fetal damage following maternal infection is highest in the first trimester (90%) which is reduced as the pregnancy progresses and is very uncommon after the 20th week.

Modes of Transmission

Person to person via direct or droplet contact from nasopharyngeal secretions. Infants with congenital rubella syndrome may shed virus for up to one year after birth.

Incubation Period

From 14–21 days.

Period of Communicability

The rubella virus is very contagious and transmission can occur 1 week before and at least 4 days after the appearance of the rash. Infants with CRS may shed virus for up to one year after birth.

Risk Factors/Susceptibility

Rubella-susceptible persons are all individuals who have not received at least one dose of rubella-containing vaccine. Immunity is usually permanent after immunization and natural infection.

Diagnosis and Laboratory Testing

Laboratory confirmation of infection in the absence of immunization with rubella-containing vaccine in the last 7–42 days is needed for a confirmed case. Tests include any of the following:

  • Isolation of rubella virus in culture from clinical samples (throat, NP swabs/aspirates, urine)
  • Nucleic acid amplification test (NAT) to detect rubella virus RNA
  • Serology for rubella IgM antibody
  • A significant (i.e., fourfold or greater) rise in rubella Immunoglobulin G (IgG) antibody level or a seroconversion using a recommended IgG assay in paired acute and convalescent sera.

Note: IgM serology has the potential for false positive findings. Further confirmation (IgG paired serology or rubella virus detection) is required in cases specifically where there is no established epidemiological link such as travel or exposure history. Because of the implications of acute rubella infection in a pregnant woman and the potential for a false positive IgM result, avidity testing of Rubella IgG antibodies is recommended for pregnant women with a positive IgM result when there is no change in observed rubella IgG levels. Although in North America most people consider a rubella IgG level of >10 IU/ml to confer immunity against rubella infection, the actual level that correlates with protection has not been fully defined.

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Treatment and Case Management

There is no specific treatment for rubella infection. Advise case to avoid contact with pregnant females and exclude from work, school and other activities for 7 days from the onset of the rash. All those who are close contacts and are susceptible to rubella will be notified by Public Health staff.

Control of rubella infection is needed primarily to prevent infection in susceptible pregnant females and congenital rubella syndrome. Educate women of childbearing years about the importance of knowing their rubella immunization status. Screening of all pregnant women is recommended to determine susceptibility to rubella and facilitate post-partum immunization of susceptible women. This is important especially for adolescent females and women who have emigrated from countries where rubella is still endemic.

Patient Information

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Additional Resources

Ontario Hospital Association. “Rubella Surveillance Protocol for Ontario Hospitals.”

Ministry of Health and Long-Term Care. “Publicly Funded Immunization Schedule for Ontario”, December 2016.

References

Ministry of Health and Long-Term Care. Infectious Diseases Protocol, 2019.