Rubella (German Measles or Three-Day Measles)

Basic Information

This form of measles is both mildly contagious and mild in constitutional symptoms. It is considered a generally benign disease and usually resolves spontaneously. But the disease takes on much more serious overtones when women in the early months of pregnancy are infected -- infants born to these mothers can be stillborn or have dramatic congenital defects.

Rubella is an RNA virus spread by:

infected airborne droplets
close contact with an infected person

A red rash spreading quickly from the face and neck downward to the body (to the trunk and other extremities) is a characteristic sign of the illness. The rash lasts for two to three days. Besides the skin, rubella affects the lymph glands.

Children from five to nine years old are most susceptible to rubella but it is also commonly seen in young adults. Rubella is not as contagious as measles so less children on the whole are infected. That means that approximately fifteen percent of young adult women are at risk for the disease. Rubella affects young adult males as well, but the greatest hazard of the disease is to infants born to infected mothers.

The incubation period is usually of a two- to three-week duration, and an infected person is contagious one week before the appearance of the rash to one week after its disappearance. It is believed that congenitally infected infants can be contagious for many months following birth.

A vaccine for rubella first introduced in 1969 has decreased the incidence of the disease -- but not enough. In those over fifteen years of age, twenty percent still lack antibodies to rubella. Hence congenital rubella still is both a danger and a reality and a more aggressive vaccination program needs to be followed before congenital rubella is eradicated. Limited outbreaks continue to occur, usually in the spring. Major outbreaks appear at six- to nine-year intervals. In the military rubella epidemics have caused severe and deadly outbreaks of encephalitis. College students and hospital employees are also at increased risk. Since 1988 rubella and congenital rubella has been on the rise.

Symptoms

Symptoms appearing in children include:

headache
fever (mild)
lymphadenopathy (swollen lymph glands in the neck)
red rash moving from face and neck down the body -- lasts two to three days (similar to but less extensive than the measles rash)
minor skin discoloration that fades a day after rash disappears
throat appears red, but is not sore

Symptoms appearing in adults, except for the red rash and swollen lymph glands in the neck, are often less marked than symptoms in children but occasionally appear:

stiff joints or joint pain
malaise
fever
headache

In men:

testicular pain

Diagnosis/Treatment

Physical examination of the patient -- noting the always-present red rash and swollen lymph glands -- are central to making a diagnosis of rubella. Other diseases mimicking rubella should be ruled out at this time. They include:

measles
secondary syphilis
infectious mononucleosis
scarlet fever

Treatment is not usually indicated since symptoms are mild and resolve on their own, and the patient has a lifetime immunity against the disease after initial infection.

Cases of congenital rubella do not usually have such happy endings. During the first three months of gestation the virus is responsible for intrauterine infection, damaging blood vessels and cells. The fetus may be stillborn or present manifestations that are:

temporary (i.e. low birth weight)
permanent (i.e. deafness, cataracts)
developmental (i.e. mental retardation)

Both mother and infant can be diagnosed by viral culture and by blood test.

Unfortunately there is little treatment that will help mother or infant at this stage. Early in pregnancy women who have rubella should be informed by a sympathetic, knowledgeable health care provider and/or gynecologist about risks to the fetus. A frank, yet empathetic discussion about options should follow. Options or choices may include:

immune globulin for exposure early in pregnancy (though benefits are unclear)
termination of pregnancy

Additionally infected infants are prone later in life (often in their teens) to progressive rubella -- a situation occurring when the rubella virus is reactivated. Serious health problems including seizures, mental deterioration and progressive spasticity can develop with no specific treatment for this disorder.

That is why infected children must be kept away from pregnant women so that they will not be exposed to the disease. Children should be kept home from school until the rash has been gone for at least a week, not only so that other children will not become infected, but also to reduce the risk of rubella to teachers or school workers who may be pregnant. Also any pregnant woman who has come into contact with an infected child should be notified. Keep the child at home and make sure that the child has plenty of rest and drinks plenty of fluid if fever is present. Nonaspirins are allowed for fever reduction but do not give an infected child under sixteen aspirin because of the association with Reye's syndrome.

PREVENTION

Fortunately rubella can be prevented because of an effective vaccine. Rubella vaccines are often given as part of the MMR (measles, mumps, rubella) vaccine that is given in two shots, one in infancy and the other in early childhood. (See Childhood Immunizations for vaccination schedule.) Adolescents and adults may also be vaccinated (See Adult Immunizations for vaccination schedule.) But pregnant women or patients who are immunocompromised should not be vaccinated because the vaccine shots consist of live, attenuated rubella virus. Women who are vaccinated as adults should not become pregnant until three months after receiving the vaccination.

If you or your child has rubella, or you are concerned about congenital rubella or want information about immunizations, please contact your health care provider promptly.