For healthcare providers
Minnesota Department of Health
Rubella Clinical Information
Epidemiology of rubella
Rubella is no longer considered endemic in the United
States. However, continued success depends upon
maintaining high vaccination rates, because cases of
rubella continue to be imported into the United States.
Rubella disease can occur anytime of the year, but is
most frequently seen during late winter and spring.
• Rubella is characterized by a mild, maculopapular
rash. The rubella rash occurs in 50– 80% of
rubella-infected persons.
• Children usually develop few or no constitutional
symptoms. Adults, however, may experience a 1–5
day prodrome of low-grade fever, headache,
malaise, mild coryza, and conjunctivitis.
• Postauricular occipital and posterior cervical
lymphadenopathy is characteristic and precedes the
rash by 5-10 days.
• Arthralgia or arthritis may occur in up to 70% of
adult women with rubella.
• Rare complications include thrombocytopenic
purpura and encephalitis.
Prevention of congenital rubella syndrome (CRS) is
the focus of rubella outbreak control and vaccination
efforts. When infection occurs during pregnancy,
especially during the first trimester, the risk of fetal
infection may be as high as 90%. The virus may affect
all organs of the fetus and cause a variety of congenital
defects. Infection may lead to fetal death, spontaneous
abortion, or premature delivery. While fetal infection
may occur throughout pregnancy, CRS is rare when
infection occurs after the 20th week of gestation.
Diagnosing rubella
Many rash illnesses, especially measles and scarlet
fever, mimic rubella infection. Up to 50% of rubella
infections may be subclinical. In diagnosing rubella,
clinicians should consider:
• Including both rubella and measles in the
differential diagnosis of patients presenting with an
acute generalized rash and fever.
• Ordering serology tests only if the clinical case
definition is met; otherwise, false positive results
may be detected.
• Collecting specimens for both culture and serology.
Acute rubella infection is lab confirmed by the presence
of one or more of the following:
• a positive rubella-specific IgM antibody,
• a significant rise in IgG antibody from paired acute
and convalescent sera,
• a positive viral culture for rubella, or
•
detection of the virus by reverse transcriptionpolymerase chain reaction (RT-PCR).
Refer to MDH “Lab Testing for Rubella” fact sheet.
Rubella is characterized by the following:
• Acute onset of a maculopapular rash lasting < 3 days
• Fever > 99°F (>37.2°C)
• Arthralgia, arthritis, lymphadenopathy, or
conjunctivitis
Measles is characterized by the following:
• A generalized maculopapular rash lasting ≥3 days
• Fever ≥ 101oF (38.3°C)
• Cough, coryza, or conjunctivitis
Treating rubella
Treatment is supportive. Rubella disease is normally
mild and self-limited.
Communicability of rubella
• Persons with rubella are infectious from 7 days
before rash onset to 5 to 7 days after rash onset.
• The disease is most contagious when the rash is
erupting.
• The virus is shed in nasopharyngeal secretions and
spreads when secretions get into mucous
membranes such as the mouth, nose, eyes, or nonintact skin.
• The virus is also spread when nasopharyngeal
secretions (droplets) are sprayed during coughing
and sneezing.
• Prolonged and intimate contact are key variables
for transmission.
• The incubation period for rubella is usually 16 to
18 days but can range from 14 to 21 days.
Preventing transmission of rubella
Vaccination is the primary means to prevent disease.
To prevent transmission of rubella in healthcare
settings:
• Patients suspected to have rubella should be placed
in private rooms. In addition to Standard
Precautions, Droplet Precautions should be
followed until 7 days after rash onset.
• Room doors can remain open and special
ventilation is not required.
• If measles is suspected, the patient should be
placed in a negative pressure room. Airborne
Precautions should be followed until 4 days after
rash onset.
Reporting: Rubella is a reportable disease. Report suspect cases of rubella immediately to the Minnesota Department of
Health. MDH can facilitate testing and exposure follow-up. Call 612-676-5414 or toll-free 877-676-5414.
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Rubella Clinical Information – page 2
To prevent the transmission of rubella in school and
work settings:
• Exclude persons suspected to have rubella from
school or work until 7 days after onset of the rash,
or until rubella has been ruled out.
Handling exposure to rubella
Neither rubella vaccine nor immune globulin (IG) is
effective for post-exposure prophylaxis of rubella.
Vaccination recommendations
• All persons born in 1957 or later should have at
least one dose of MMR vaccine, or documented
serologic evidence of immunity.
• Children should receive two doses of rubella
vaccine, given as MMR.
• Give the first dose at 12 to 15 months of age and
the second dose at school entry (4 to 6 years of
age) or, if not given at school entry, by age 12.
• Persons born outside the U.S. are especially
unlikely to be vaccinated.
• Women should be vaccinated at least 4 weeks
before becoming pregnant.
Exposure to rubella during pregnancy
If a pregnant woman is exposed to rubella and her
immune status is unknown, test a blood specimen for
rubella IgG antibody to determine immunity. If not
detectable, collect a second specimen 2 to 3 weeks later
and run concurrently with the first (paired sera). If
negative, collect a third specimen 6 weeks after
exposure and test concurrently with the first specimen.
Negative tests indicate that no infection occurred.1
Immune globulin (IG) is not routinely recommended
for post-exposure prophylaxis of rubella in early
pregnancy or in any other circumstances; [however,
disease may be modified or suppressed] IG does not
prevent rubella infection or viremia. Administering IG
may provide an unwarranted sense of security, as
infants with congenital rubella have been born to
women who received IG shortly after exposure.
Regardless of these limitations, administration of IG
may be considered if the pregnancy is not terminated.
In such cases, intramuscular administration of 20 ml of
immune globulin within 72 hours of rubella exposure
may reduce—but will not eliminate—the risk for
rubella.2
Vaccination and pregnancy
Women who are pregnant or intend to become pregnant
within 4 weeks should not receive rubella vaccine.
Prior to administering rubella or MMR vaccine, the
Immunization Program
P.O. Box 9441
Minneapolis, MN 55440-9441
612-676-5414, 1-877-676-5414
www.health.state.mn.us/immunize
Advisory Committee on Immunization Practices
(ACIP) recommends that vaccine providers ask females
of childbearing age if they are pregnant or likely to
become pregnant in the next 4 weeks. Women who are
pregnant or intend to become pregnant should be
counseled about the potential risk for CRS and the
importance of being vaccinated as soon as they are no
longer pregnant.2
If a pregnant woman is inadvertently vaccinated or if
she becomes pregnant within 4 weeks after vaccination,
counsel her about the concern for the fetus. MMR
vaccination during pregnancy should not ordinarily be a
reason to consider termination of the pregnancy.
Vaccinate females of childbearing age who are not
pregnant after advising them of the theoretical risks of
vaccination during pregnancy and the importance of not
becoming pregnant during the 4 weeks following
vaccination.
Outcomes after vaccination during
pregnancy
Subclinical fetal infection has been detected
serologically in approximately 1%-2% of infants born
to susceptible vaccinees, regardless of the vaccine
strain. Data collected by the CDC in the Vaccine in
Pregnancy (VIP) Registry from 1971 to 1989 found no
evidence that CRS occurred in offspring of the 321
susceptible women who received rubella vaccine and
who continued pregnancy to term. The observed risk of
vaccine-induced malformation was 0%, with a
maximum theoretical risk of 1.6%, based on 95%
confidence limits (1.2% for all types of rubella
vaccine). Since the risk of the vaccine to the fetus
appears to be extremely low, if it exists at all, routine
termination of pregnancy is not recommended.3
The Vaccine in Pregnancy Registry maintained by the
Centers for Disease Control and Prevention for rubella
was discontinued in 1989.
1. Red Book: 2003 Report of the Committee on Infectious
Diseases 26th edition. 26 ed. Elk Grove Village, IL: American
Academy of Pediatrics; 2003.
2. Watson JC, Hadler SC, Dykewicz CA, Reef S, Phillips L.
Measles, mumps, and rubella--vaccine use and strategies for
elimination of measles, rubella, and congenital rubella syndrome
and control of mumps: recommendations of the Advisory
Committee on Immunization Practices (ACIP). MMWR Recomm
Rep. May 22 1998; 47(RR-8): 1-57.
3. Epidemiology and prevention of vaccine-preventable diseases.
8th ed. Atlanta, Ga.: Dept. of Health & Human Services, Centers
for Disease Control and Prevention; Washington DC: printed
and distributed by the Public Health Foundation; 2004.
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