COMMUNICABLE DISEASE MANUAL POLICIES/PROCEDURES
RUBELLA
OBJECTIVE:
Outbreak control primarily to prevent defects in the offspring of women
who acquire the disease during pregnancy.
DESCRIPTION:
An illness with all of the following characteristics: (1) Acute onset of
generalized maculopapular rash (small, fine pink spots, moves from
head to trunk and lasts 3 days), (2) temperature > 37.2º C (> 99º F), if
measured (usually less than 101°) and (3) arthralgia/arthritis, or
lymphadenopathy, or conjunctivitis (swelling and tenderness of the
lymph nodes in the neck, especially behind the ears). Transmission is
by person-to-person via airborne or droplets shed from the respiratory
secretions of infected persons. Incubation period is 14 days, range 1223 days. See Rubella Timeline below. Rubella is most contagious
when the rash first appears, but virus may be shed from 7 days before
to 5-7 days or more after rash onset.
EQUIPMENT:
MDSS User Manual -(disease specific form will be found in MDSS).
Also Rash Illness Investigation Form (IP-15), a four-fold or greater rise
in
Rubella
IgM
antibody
titer,
Rubella
Contact
Sheet,
Microbiology/Virology Test Requisition and Pamphlet, and MDCH
Notification of Serious Communicable Disease Fax if suspect or
confirmed case. Also, MDCH Web site at www.michigan.gov/mdch,
www.michigan.gov/cdinfo
and
CDC
Web
site
at
www.cdc.gov/ncidod/diseases.
POLICY:
Legal Responsibility: Michigan's communicable disease rules of Act No.
368 of the Public Acts of 1978, as amended, being 333.5111 of the
Michigan Compiled Laws. Follow-up time is immediately post
referral and entered into MDSS within 24 hours of receipt of
referral
PROCEDURE:
A.
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Case Investigation:
1.
Referral received from school, preschool, daycare,
family,
medical doctor,
laboratory results, or
automatically through MDSS. Use the Rash Illness
Investigation Form (IP-15) for a suspected rash to
determine if Rubella and if a positive rubella antibody
titer.
2.
Document all case investigation proceedings.
3.
Contact MD and/or client to start process of completing
disease specific form in MDSS, on same day as referral
received.
If probable or confirmed case, FAX
Notification of Serious Communicable Disease to
MDCH, and call MDCH Immunization Division by
phone at 517-335-8159.
4.
B.
C.
If
outbreak,
notify
CD
Supervisor,
Regional
Epidemiologist,
Medical
Director
and
Michigan
Department of Community Health by faxing Notification
of Serious Communicable Disease. .
Clinical Case Classification:
1.
Suspect: Any generalized rash illness of acute onset.
2.
Probable: A case that meets the clinical case definition,
has no or noncontributory serologic or virologic testing,
and is not epidemiologically linked to a laboratoryconfirmed case.
3.
Confirmed: A case that is laboratory confirmed or that
meets the clinical case definition and is epidemiologically
linked to a laboratory-confirmed case. Clinical diagnosis
of rubella is often inaccurate so laboratory confirmation is
important.
4.
Asymptomatic confirmed: A case in a person who is
asymptomatic that is laboratory-confirmed and is
epidemiologically-linked to a laboratory-confirmed case
that is clinically consistent with rubella.
5.
Comment: Serum rubella IgM test results that are falsepositive have been reported in persons with other viral
infections (e.g., acute infection with Epstein-Barr virus
[infectious mononucleosis], recent cytomegalovirus
infection, and parvovirus infection) or in the presence of
rheumatoid factor.
Lab Criteria for Diagnosis
1.
To confirm a case of rubella, obtain Measles IgM and
Rubella IgM serology within five (5) days of rash
onset, or paired Measles and Rubella IgG serology
with the convalescent serum 2-3 weeks after acute
and a viral throat swab or CCMS urine for PCR or
culture testing. It is important to collect serum and
viral throat swab together to confirm rubella.
To obtain MDCH Serology and Virology Specimen
Collection and Container Kits, call MDCH Laboratory
Support Unit at 517-335-9867.
Rubella testing is available free of charge through the
MDCH Laboratory; use of this service is strongly
encouraged. Arrangements must be made through the
MDCH VPD Surveillance Coordinator at 517-335-8159.
2.
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Client to be seen by private M.D. and Virology titer to be
ordered by physician. Private M.D. office visit and cost of
blood drawn is at the expense of client. Serology may be
sent to the Michigan Department of Community Health
for laboratory studies at no cost to client. No serology
ordered or drawn at Berrien County Health Department
without specific written order of Medical Director.
3.
Rubella Serology:
Purpose:
To confirm a case of rubella.
Specimen needed:
Serum, 2 ml.
MDCH lab kit:
Unit 8
MDCH test requisition form: DCH-0583 (formerly FB
200)
Preferred test: Rubella-specific IgM antibody (various
methodologies are available commercially). This test is
available at MDCH Laboratory.
Alternate tests: Paired IgG (demonstration of significant
rise in rubella IgG antibody between acute and
convalescent specimens).
Specimen collection/submission procedure:

Collect at least five (5) ml of whole blood in redtop or other tube without anticoagulant. Separate
serum from blood by centrifugation and pour into
PLASTIC serum tube; store at 2E – 8EC, or
freeze serum if it cannot be shipped and received
in MDCH Laboratory within three (3) days. DO
NOT FREEZE WHOLE BLOOD.

Timing:
For IgM testing:
Collect serum at clinical
presentation or as soon as possible after. Note:
IgM antibodies may not be detectable before day
five (5) after rash onset. Rubella IgM tests that
are negative and were collected less than five (5)
days after the rash onset should be repeated
using sera collected five (5) or more days after
rash onset.
For paired IgG testing:
Acute-phase specimen:
rash onset as possible.
Collect as soon after
Convalescent-phase specimen: Collect 10-30
days (no earlier than 10 days) after acute-phase
specimen.
Test will be done when both specimens are
received (specimens can be sent individually or
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acute can be held at 2-8º C and sent to laboratory
with convalescent specimen). If the specimens
are sent to MDCH laboratory separately, be sure
to indicate on the test requisition form that this is
an acute serum and that the convalescent
specimen will follow in approximately 10-14 days.
Label specimen(s) with patient’s name, date of
birth, and date of specimen collection.
Complete MDCH Microbiology/Virology Test
Requisition form DCH-0583 (formerly FB 200);
complete all information in the Patient Information
and Specimen Information sections. Request
rubella IgM and measles IgM (codes 2830 and
2820, respectively) in the other section of the
Test Requested area.
Note: Testing for measles is encouraged for
all suspected rubella cases (likewise, testing
for rubella is encouraged for all suspected
measles cases).
Be sure MDCH Immunization Division has been
notified of the case investigation.
Ship specimens on a cold pack by overnight
delivery if possible. Mail specimens to:
Michigan Department of Community Health
Bureau of Laboratories DASH Unit
3350 N. Martin Luther King Blvd.
Building 44, Room 155
Lansing MI 48909
4.
Rubella Virology/Molecular Epidemiology Studies:
Purpose:
Viral isolates are important for
molecular epidemiologic surveillance, specifically
to help determine:
 the geographic origin of the virus;
 the viral strains circulating in the U.S.; and
 whether these strains have become
endemic in the U.S.
Note: Specimens for rubella virology should be
routinely collected along with serum when
investigating potential rubella cases. Do not
delay collection of viral specimens until
serologic confirmation is obtained, since the
success of virus isolation is most likely with
specimens collected within seven (7) days of rash
onset. Do not collect viral specimens if more than
ten (10) days has elapsed since rash onset.
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Note:
Viral isolates are sent to CDC for
molecular analysis.
Specimens:
Throat swabs; urine
MDCH Lab Kit: Unit 45
Specimen Container(s):
For throat swabs: Viral Transport Media test
tube.
For urine: 50 ml centrifuge tube or other sterile
container.
Specimen collection/submission procedure:
 Throat swabs:
 Collect within four (4) days of rash onset.

Use sterile swabs to wipe the back of
throat; try to collect epithelial cells.

Place swab in a tube containing 2-3 ml of
viral transport medium; submerge swab in
transport medium and express the swab
against the inside wall of the specimen
container. Discard swab, or leave in tube,
but make sure tube cap is securely
screwed on; swab shaft may need to be
cut down in order to fit if swab is to be left
in tube.

Keep specimens at 4º C (refrigerated).

Ship specimens on a cold pack by
overnight delivery if possible.
If immediate, cold shipment (within 48 hours)
cannot be arranged or is not convenient:
Throat swab can be removed from the transport
medium after allowing one (1) hour for elution of
virus. The specimen can then be frozen at -70º C
and shipped on dry ice.
 Urine specimens
 Collect within four (4) days of rash onset.
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
Collect 50-100 ml of urine in a clean urine
specimen container (50 ml centrifuge
tubes work well).

First morning void is preferable. Collect
urine clean catch mid-stream.

Centrifuge at 2500 X g for 15 minutes at
4º C to pellet the sediment. Re-suspend
the sediment in 2-3 ml of viral transport
medium or any cell culture medium.

Ship frozen at -70º C on dry ice. If dry ice
is not available, store at 4º C and ship on
a cold pack.
If centrifugation is not available, do not freeze
the urine sample. The entire urine specimen
should be stored at 4º C and shipped to the
laboratory on a cold pack.
 Label all specimen containers with patient’s
name, date of birth, and date of specimen
collection.
 Complete a MDCH Microbiology/Virology Test
Requisition, form DCH-0583 (formerly FB
200) for each specimen.
Complete all
information in the Patient Information and
Specimen Information sections.
Indicate
Rubella virus by culture – test code 2260 –
in the other section of the Test Requested
area.
 Mail specimens to:
Michigan Department of Community Health
Bureau of Laboratories DASH Unit
3350 N. Martin Luther King Blvd.
Building 44, Room 155
Lansing MI 48909
5.
D.
Control Measures
1.
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When a pregnant woman is exposed to Rubella, a
specimen should be obtained ASAP and tested
for Rubella Igg antibody.
The presence of
antibody in a properly performed test indicates
that the individual is immune and not at risk. If
antibody is not detectable, a second blood
specimen approximately three (3) weeks later
should be tested. If antibody is present in the
second specimen, infection can be assumed to
have occurred. If the test is negative, it should be
repeated six (6) weeks after the exposure to
Rubella.
School and daycare children should be excluded for
seven (7) days after onset of the rash.
E.
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2.
Pregnant women who have been exposed to rubella
should be tested ASAP.
3.
The routine use of immune globulin (IG) for postexposure
prophylaxis of rubella in early pregnancy is not
recommended.
Administration of IG should be
considered only if termination of the pregnancy is not an
option.
4.
Previously,
rubella
reimmunization
was
not
recommended. However, in conjunction with the recently
recommended 2-dose measles immunization schedule, 2
doses of rubella vaccine now are given routinely.
Upon orders of Supervisor and/or Medical Director, the
following should be done quickly.
1.
Revaccination should include siblings and persons born
in or after 1957 who do not have proof of receiving
vaccine on or after first birthday or evidence of rubella
immunity. One dose of rubella vaccine should be given
as an MMR.
2.
Record search of daycare, etc., to determine who has not
had two (2) doses of MMR on or after 12 months.
3.
EXCLUDE FROM SCHOOL all children not vaccinated
with two (2) doses of MMR vaccine on or after 12
months. May re-enter daycare if proof provided of
vaccination. Must have one (1) month between MMR’s
and unvaccinated children may re-enter day care after
having one (1) MMR. If they are not vaccinated (per
waiver or noncompliance) wait until 14 days after rash
onset date of last reported case.
4.
Health Department to provide clinic for all children who
have not been vaccinated with two (2) doses of MMR
vaccine on or after 12 months.
5.
MMR’s should be given in preschools or day care centers
who have not had one (1) dose of MMR or vaccinated
prior to 12 months.
6.
Protocol applies to local rubella outbreak.
7.
Mass revaccination of entire community not necessary
and too costly.
8.
In the event of death, obtain and send copies of hospital
discharge summary, death certificate, and autopsy report
to MDCH VPD Surveillance Coordinator.
9.
Educate contacts and public. An excellent Questions
and Answer Rubella Information Sheet from the
Immunization Action Coalition is located with your Fact
Sheets in this policy.
F.
Complete case investigation using the disease specific forms
located in MDSS.
(See MDSS User Manual for entry
instructions.)
1.
Copy disease specific form and send to address below.
Address: Michigan Department of Community Health
Immunization Division
Attn: Immunization Coordinator
201 Townsend Street
PO Box 30195
Lansing MI 48913
G.
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Refer to current Red Book, current Control of
Communicable Disease Manual, current Epidemiology and
Prevention of Vaccine-Preventable Diseases, and VPD
Guidelines at www.michigan.gov/immunize.