RUBELLARUBELLADr.T.V.Rao MDDr.T.V.Rao MD

What is RubellaWhat is Rubella

Rubella (German measles) is a disease Rubella (German measles) is a disease caused by the rubella virus. Rubella is caused by the rubella virus. Rubella is usually a mild illness. Most people who usually a mild illness. Most people who have had rubella or the vaccine are have had rubella or the vaccine are protected against the virus for the rest of protected against the virus for the rest of their lives. Because of routine vaccination their lives. Because of routine vaccination against rubella since 1970 , rubella is now against rubella since 1970 , rubella is now rarely reported.rarely reported.

History - RubellaHistory - Rubella

The Teratogenic property of the The Teratogenic property of the infection was documented by an infection was documented by an

Australian opthalmologist Greeg in Australian opthalmologist Greeg in 19411941

RubellaRubella( German Measles )( German Measles )

Rubella is also Rubella is also called as 3 day called as 3 day Measles or German Measles or German Measles.Measles.

Family – Family – TogaviridaeTogaviridae

Genus - Genus - RubivirusRubivirus In general belong In general belong

to Togavirus groupto Togavirus group

Rubella VirusRubella Virus

Rubella virus areRubella virus are

ss – RNA virusss – RNA virus

Diameter 50 – 70 nmDiameter 50 – 70 nm

Enveloped SphericalEnveloped Spherical

Virus carry Virus carry hemagglutinin hemagglutinin

Virus multiply in the Virus multiply in the cytoplasam of infected cytoplasam of infected cell.cell.

Prevailing GenotypesPrevailing Genotypes

Culturing the VirusCulturing the Virus

The virus can be The virus can be cultured and cultured and adopted to adopted to continuous cell continuous cell lineslines Rabbit kidney Rabbit kidney

cells (RK 13 )cells (RK 13 ) and and

Vero cellsVero cells

Main Clinical EventsMain Clinical Events

The clinical events occuring in the The clinical events occuring in the neonatal age is more important and neonatal age is more important and divided into two major groupsdivided into two major groups

1 Post Natal Rubella1 Post Natal Rubella

2 Congenital Rubella2 Congenital Rubella

How Adults acquire InfectionHow Adults acquire Infection

Acquired, (i.e. not congenital), Acquired, (i.e. not congenital), rubella is transmitted via airborne rubella is transmitted via airborne droplet emission from the upper droplet emission from the upper respiratory tract of active cases. The respiratory tract of active cases. The virus may also be present in the virus may also be present in the urine, feces and on the skin. There is urine, feces and on the skin. There is no carrier state: the reservoir exists no carrier state: the reservoir exists entirely in active human cases. The entirely in active human cases. The disease has an incubation period of 2 disease has an incubation period of 2 to 3 weeks. to 3 weeks.

Systemic events of Rubella Systemic events of Rubella InfectionInfection

Post natal RubellaPost natal Rubella Occurs in Neonates and Occurs in Neonates and

ChildhoodChildhood Adult infection occurs Adult infection occurs

through mucosa of the upper through mucosa of the upper respiratory tract spread to respiratory tract spread to cervical lymphnodescervical lymphnodes

Viremia devlops after 7 – 9 Viremia devlops after 7 – 9 dayday

Lasts for 13 – 15 daysLasts for 13 – 15 days Leads to development of Leads to development of

antibodiesantibodies The appearance of The appearance of

antibodies coincides the antibodies coincides the appearance of suggestive appearance of suggestive immulogic basis for the rashimmulogic basis for the rash

In 20 – 50 % cases of In 20 – 50 % cases of primary infections are primary infections are subclinicalsubclinical

Clinical findingsClinical findings

MalaiseMalaise Low grade feverLow grade fever Morbilliform rashMorbilliform rash Rash starts on Face Rash starts on Face

Extremities Extremities Rarely lasts more Rarely lasts more

than 5 daysthan 5 days No features of the No features of the

rash give clues to rash give clues to definitive diagnosis definitive diagnosis of Rubella.of Rubella.

Rubella RashesRubella Rashes When epidemics When epidemics

occur with similar occur with similar features it is features it is more suggestive more suggestive of Rubella of Rubella epidemicsepidemics

Other Enterovirus Other Enterovirus infections can infections can produce similar produce similar manifestationsmanifestations..

Other manifestations and Other manifestations and complicationscomplications

May produce May produce transient Arthritis, transient Arthritis, in women in in women in particular.particular.

Serious Serious complications complications areare

ThrombocytopeniaThrombocytopenia

PurpuraPurpura

EncephalitsEncephalits

Immunity - RubellaImmunity - Rubella Antibodies appear in Antibodies appear in

serum as rash fades serum as rash fades and antibody titers and antibody titers raiseraise

Rapid raise in 1 – 3 Rapid raise in 1 – 3 weeksweeks

Rash in association Rash in association with detection of IgM with detection of IgM indicates recent indicates recent infection.infection.

IgG antibodies persist IgG antibodies persist for lifefor life

Immunity - ProtectsImmunity - Protects

One attack of One attack of Rubella infection, Rubella infection, protects for lifeprotects for life

Immune mothers Immune mothers transfer antibodies transfer antibodies to off springs who to off springs who are in turn are are in turn are protected for 4 – 6 protected for 4 – 6 months.months.

Diagnosis of Rubella in Diagnosis of Rubella in AdultsAdults

Clinical Diagnosis is unreliableClinical Diagnosis is unreliable Many viral infections mimic RubellaMany viral infections mimic Rubella Specif diagnosis of infection withSpecif diagnosis of infection with

1 Isolation of virus1 Isolation of virus

2 Evidence of seroconversion2 Evidence of seroconversion

Isolation and Identification of Isolation and Identification of virusvirus

Nasopharyngeal or Nasopharyngeal or throat swabs taken 6 throat swabs taken 6 days prior or after days prior or after appearance of rash is appearance of rash is a good source of a good source of Rubella virusRubella virus

Using cell cultured in Using cell cultured in shell vial antigens can shell vial antigens can be detected by be detected by ImmunofluresecentetImmunofluresecentetmehodsmehods

Serology In RubellaSerology In Rubella Hemagglutination Hemagglutination

inhibition test for inhibition test for Rubella is of Diagnostic Rubella is of Diagnostic significancesignificance

ELISA tests are greater ELISA tests are greater importanceimportance

A raise in Antibody titers A raise in Antibody titers must be demonostrated must be demonostrated between two serum between two serum samples taken at least samples taken at least 10 days apart.10 days apart.

Or Detection of Rubella Or Detection of Rubella specific IgM must be detected specific IgM must be detected in a single specimen.in a single specimen.

EpidemiologyEpidemiology

Rubella is world wide in distributionRubella is world wide in distribution Occurs round the year,Occurs round the year, Epidemics occur every 20 – 25 yearsEpidemics occur every 20 – 25 years Infection is transmitted by respiratory Infection is transmitted by respiratory

routeroute The use of Rubella vaccine has now The use of Rubella vaccine has now

eliminated both epidemic and endemic eliminated both epidemic and endemic Rubella in USA and several developed Rubella in USA and several developed countriescountries

Treatment and PreventionTreatment and Prevention

Rubella is a mild self limited illness.Rubella is a mild self limited illness. No specific treatment or Antiviral No specific treatment or Antiviral

treatment is indicated.treatment is indicated. However Laboratory proved and However Laboratory proved and

clinically missed Rubella in the Ist 3-4 clinically missed Rubella in the Ist 3-4 months of pregnancy is associated months of pregnancy is associated with fetal infections.with fetal infections.

Congenital Rubella SyndromeCongenital Rubella Syndrome

Maternal viremia with Rubella infection Maternal viremia with Rubella infection during pregnancy may result in infection during pregnancy may result in infection of placenta and fetus.of placenta and fetus.

The growth rate of fetal cells are reduced.The growth rate of fetal cells are reduced. Results in fewer number of cells after the Results in fewer number of cells after the

birth.birth. Lead to deranged and hypo plastic organ Lead to deranged and hypo plastic organ

development.development. Results in structural damage and Results in structural damage and

abnormalitiesabnormalities

Rubella infection – At Rubella infection – At various trimestersvarious trimesters

IIstst trimester infections lead to abnormalities in 85 trimester infections lead to abnormalities in 85 % of cases. and greater damage to organs% of cases. and greater damage to organs

22ndnd trimester infections lead to defects in 16 % trimester infections lead to defects in 16 % > 20 weeks of pregnancy fetal defects are > 20 weeks of pregnancy fetal defects are

uncommonuncommon However Rubella infection can also lead to fetal However Rubella infection can also lead to fetal

deaths, and spontaneous abortion.deaths, and spontaneous abortion. The intrauterine infections lead to viral excretion The intrauterine infections lead to viral excretion

in various secretion in newborn upto 12-18 in various secretion in newborn upto 12-18 months.months.

Clinical FindingsClinical Findings( Congenital Rubella Syndrome )( Congenital Rubella Syndrome )

May be transient effects in infants.May be transient effects in infants. Permanent manifestations may be Permanent manifestations may be

apparent at birth, become apparent at birth, become recognized during the first year.recognized during the first year.

Developmental abnormalities appear Developmental abnormalities appear during childhood and adolescents.during childhood and adolescents.

Classical Triad of RubellaClassical Triad of Rubella

Classical TriadClassical Triad CataractCataract Cardiac Cardiac

abnormalitiesabnormalities DeafnessDeafness

Other manifestationsOther manifestations Growth retardationGrowth retardation

RashRash HepatosplenomegalyHepatosplenomegaly

JaundiceJaundice MeingoencephalitisMeingoencephalitis CNS defects lead to CNS defects lead to moderate to profound moderate to profound

mental retardationmental retardation

Other Neurological manifestionsOther Neurological manifestions

Problems in balanceProblems in balance Motor skills in Motor skills in

preschool children preschool children altered.altered.

A rare complication of A rare complication of Pan encephalitis can Pan encephalitis can occur in second occur in second decade with decade with Congenital rubella Congenital rubella syndrome may syndrome may progress to death.progress to death.

Diagnosis ofDiagnosis ofCongenital Rubella SyndromeCongenital Rubella Syndrome

Demonstration of Demonstration of Rubella antibodies Rubella antibodies of IgM in a new of IgM in a new born is diagnostic born is diagnostic value. As IgM value. As IgM group donot cross group donot cross the placenta and the placenta and they are produce in they are produce in the infected fetus,the infected fetus,

Treatment, Prevention, Treatment, Prevention, ControlControl

No specific treatment is No specific treatment is availableavailable

CRS can be prevented CRS can be prevented by effective by effective immunization of the immunization of the young children and young children and teenage girls, remain teenage girls, remain the best option to the best option to prevent Congenital prevent Congenital Rubella Syndrome.Rubella Syndrome.

The component of The component of Rubella in MMR vaccine Rubella in MMR vaccine protects the vaccinatedprotects the vaccinated

MMR VaccineMMR Vaccine The The MMR vaccineMMR vaccine is a mixture of three live is a mixture of three live

attenuated viruses, administered via injection for attenuated viruses, administered via injection for immunization against measles, mumps and immunization against measles, mumps and rubella. It is generally administered to children rubella. It is generally administered to children around the age of one year, with a second dose around the age of one year, with a second dose before starting school (i.e. age 4/5). The second before starting school (i.e. age 4/5). The second dose is not a booster; it is a dose to produce dose is not a booster; it is a dose to produce immunity in the small number of persons (2-5%) immunity in the small number of persons (2-5%) who fail to develop measles immunity after the who fail to develop measles immunity after the first dose In the United States, the vaccine was first dose In the United States, the vaccine was licensed in 1963 and the second dose was licensed in 1963 and the second dose was introduced in the mid 1990s. It is widely used in introduced in the mid 1990s. It is widely used in all National, Universal Immunization programmes all National, Universal Immunization programmes

Created for Awareness on Created for Awareness on Rubella for Medical and Rubella for Medical and Paramedical studentsParamedical students

Dr.T.V.Rao MDDr.T.V.Rao MD

EmailEmail

doctortvrao@gmail.comdoctortvrao@gmail.com