Rubella Clinical Information

Information on rubella for health professionals, including epidemiology, communicability, and treatment.

On this page:
Report suspect rubella cases
Laboratory testing
Epidemiology of rubella
Clinical presentation
Diagnosing rubella
Differential diagnoses
Communicability of rubella
Complications of rubella
Treating rubella
Recommended exclusion

Report suspect rubella cases

If you suspect rubella in a patient:

• Call MDH immediately at 651-201-5414 or toll-free at 1-877-676-5414 to report.
• Collect specimens for RT-PCR and serologic testing.

Laboratory testing

Refer to the Lab Testing for Rubella at the MDH-Public Health Laboratory for specimen collection instructions and requirements.

Epidemiology of rubella

Rubella was once common in the U.S. with about 50,000-60,000 cases (primarily in young children) reported annually. The last major epidemic in the U.S. occurred during 1964-1965, with about 12.5 million cases, resulting in 2,000 cases of encephalitis, 11,250 therapeutic or spontaneous abortions, 2,100 neonatal deaths, and 20,000 infants born with congenital rubella syndrome.

Following vaccine licensure in 1969, reported rubella cases decreased dramatically. Rubella was declared eliminated from the U.S. and the Americas in 2004 and 2015, respectively. Elimination means endemic transmission is no longer occurring, but sporadic cases can be imported from areas where rubella is still common. Continued success in maintaining rubella elimination depends upon keeping vaccination rates high.

Globally, an estimated 110,000 babies are born with congenital rubella syndrome every year, mostly in South East Asia and Africa.

Clinical presentation

Rubella clinical case definition (children/adults):

• Acute onset of generalized maculopapular rash
• Fever higher than 99°F (37.2°C)
• Arthritis, lymphadenopathy or conjunctivitis

Up to 50 percent of rubella infections may be subclinical. In children, rash is usually the first sign of disease and prodrome is rare. In older children and adults, there is usually a 1 to 5 day prodrome with low-grade fever, malaise, lymphadenopathy, and upper respiratory symptoms preceding the rash. Testalgia or orchitis may be present in post pubertal males. Forschheimer spots may be noted on the soft palate but are not diagnostic for rubella.

The rash usually occurs initially on the face and then progresses downwards towards the trunk and extremities. It lasts about 3 days, is fainter than measles rash and does not coalesce. It's often more prominent after a hot shower or bath.

Lymphadenopathy may begin a week before the rash and last several weeks. Post-auricular, posterior cervical, and sub-occipital nodes are commonly involved.

Congenital rubella syndrome (CRS) clinical case definition (infants/any of the following):

• Deafness, cardiac defects, eye defects, microcephaly, liver and spleen damage, developmental delay, bone alterations

When infection occurs during early pregnancy, the risk of fetal infection may be as high as 85 percent. The virus may affect all organs of the fetus and cause a variety of congenital defects, fetal death, spontaneous abortion, or premature delivery. CRS is rare when infection occurs after the 20th week of gestation.

Deafness is the most common complication of congenital rubella infection. Other possible manifestations include cataracts or congenital glaucoma, congenital heart disease (most commonly patent ductus arteriosus or peripheral pulmonary artery stenosis), pigmentary retinopathy, purpura, hepatosplenomegaly, jaundice, microcephaly, developmental delay, meningoencephalitis or radiolucent bone disease.

Diagnosing rubella

Most U.S. health care providers have never seen a case of rubella. Rubella cannot be diagnosed without proper laboratory testing.

Providers should consider rubella in patients who meet the clinical case definition for rubella or CRS. Since rubella is rare, providers should ask the patient about any known exposures or travel history (domestic or international) in the 30 days prior to symptom onset.

Differential diagnoses

Providers should also consider other infectious and non-infectious etiologies that may cause fever and generalized rash, including:

• Measles, Scarlet fever, Roseola infantum, Kawasaki disease, Erythema infectiosum (Fifth Disease), Coxsackievirus, Echovirus, Epstein-Barr virus, HIV, Pharyngoconjunctival fever, Influenza
• Dengue, Rocky Mountain spotted fever, Zika virus
• Dermatologic manifestations of Viral hemorrhagic fevers (VHFs)
• Toxic Shock Syndrome, cutaneous syphilis
• Drug reactions (e.g., antibiotics, contact dermatitis)

Communicability of rubella

If rubella is suspected, health care providers should follow the infection prevention steps in Minimize Measles Transmission in Health Care Settings as rubella mimics measles in the early stages of illness.

• The incubation period for rubella is about 14 days (range 12-23) from exposure to rash onset.
• Rubella is infectious from 7 days prior to 7 days after rash onset.
• Infants with CRS may shed virus for up to a year.
• Subclinical cases can transmit the virus.
• Airborne transmission via aerosolized droplet nuclei is the primary route of transmission.
• Airborne precautions are recommended.

Complications of rubella

Rubella is generally mild and self-limited. Rare complications of acquired rubella include thrombocytopenic purpura and encephalitis.

Treating rubella

• There is no specific antiviral therapy for rubella.
• Post-exposure use of vaccine or Immune Globulin (IG) is not effective for rubella.

Recommended exclusion

• Suspect and confirmed rubella cases should be isolated at home with no visitors until day 8 of rash (rash onset is considered day 0).
• Additional recommendations on exclusion or isolation should be made in collaboration with MDH and/or local health department.