Rubella symptoms do not typically present until day 7 to 14 of the infection2. At first, the infected person will exhibit no symptoms but they are still contagious. Typically, the first perceptible symptom is inflamed lymph nodes behind the ears. Before symptoms appear, the virus incubates in the host for approximately one week before becoming outwardly apparent. The first sign is a rash that appears after a week of incubation and only lasts for about three days. This rash will start on the face before spreading down to the trunk and limbs3. The rash will then disappear in the in the reverse order.
In addition to swelling of the lymph nodes, joint pain can accompany the rash, but disappear when the rash disappears. Flu-like symptoms may also occur, including a fever, followed the aches and pains that are associated with Rubella, a cough, and a headache3. Only the rash and the joint pain distinguish Rubella from a cold or flu. Children and adults may experience differing symptoms with varying degrees of severity. For example, in adults the joint pain from Rubella could lead to arthritis, whereas this is unlikely to occur in pre-pubescent children.
Congenital Rubella Syndrome (CRS) Congenital Rubella Syndrome (CRS) is an infection that spreads to the baby of a pregnant woman who has contracted Rubella. The Rubella Virus is not at all harmful to the mother, but can be very serious to the fetus. In 80% of cases where pregnant women have contracted the Rubella Virus within the first 12 weeks of pregnancy, the baby has suffered with symptoms that are associated with Congenital Rubella3. The severity of CRS can differ depending on how far along the pregnancy is.
In most cases, the earlier the infection is contracted by the mother, the more severe the symptoms and the lasting disabilities will be; ases that occur later in the pregnancy yield lower risks15. Figure 4 shows the correlation between the gestation period and the severity of the symptoms in infants that have CRS. Sometimes spontaneous abortions can occur to women who are infected with Rubella at a very early stage in the pregnancy. Infection occurs in the fetus when the virus is transmitted through the placenta.
The damage to the fetus is multifactorial, including damage to existing cells and new cells that are dividing15. The infected cells seem to flake off in the lumen of the vessels, suggesting that Rubella is carried through the irculatory system into the fetus cells-as infected endothelium cell emboli15. These infected cells can cause fetal organ failure and lead to birth defets defects which result from CRS. During the early stages of gestation, the immune system of the fetus is new and unable to fight off the infection. This results in the lack of inflammatory response and can lead to cell necrosis15.
There are many abnormalities that can be caused by CRS, but the most common and most serious of the permanent abnormalities are heart defects, eye defects, brain damage, sensorineural or central auditory deafness, and CNS problems3. Potential heart defects include pulmonary artery stenosis, patent ductus arteriosus, and pulmonary arterial hypoplasia. The most common eye defect is cataracts, but may also include retinopathy and microphthalmos. Potential brain damage could include microcephaly while CNS problems may result in mental retardation, speech impediments, or language delays3.
Although all of these abnormalities can occur in conjunction, they can also occur independently. Cataracts occur in about one third of all cases of CRS and in many cases where the mother contracted Rubella before 8 weeks gestation. More than half of nfected children will have a heart defect, with about 30% of those heart defects being patent ductus arteriosus3. The most common abnormality is deafness, occurring either in conjunction with other abnormalities or independently. In cases where mothers contract Rubella after 12 weeks of gestation, fetal deafness will appear alone3.
While many mothers who have contracted Rubella will give birth to babies with immediately discernable CRS abnormalities, some newborns will exhibit no signs of CRS abnormalities until they have matured further. CRS is a progressive disease that advances due to the absence of an immediate immune esponse. The contraction of the infection at such an of prenatal development in combination with the persistence of the virus make the disease impossible for the newborn to fight off3. Among these more advanced symptoms, others such as arly stage deafness or the CNS disease can manifest.
Abnormalities that present years after birth can include hearing, diabetes, eye defects, and behaviour issues3. The reason that abnormalities can present months or even years after birth is because the Rubella Virus remains present throughout gestation period and thus the infection can stay active for a long period of time. The infection can be seen in a newborn’s CSF, and urine output for up to 23 months after birth3. History For the longest time, Rubella was always considered to be a form of measles.
It was not until 1881 that Rubella was distinguished as its own virus by two German physicians-leading to its initial identification as ‘German measles’11. However, an outbreak in India among school children lead to the renaming of the virus as ‘Rubella’, meaning little red. “Rubella’ then replaced the name of German measles to distinguish it as a completely different disease. In 1941, the link between congenital Rubella and Rubella were linked. This idea was realized by an Australian opthomolagist, Norman McAlister Gregg, when he connected the number of cataracts in children to the number of pregnant women in his clinic11.
Throughout this year, there was an outbreak of Rubella among the troops in New South Wales, Queensland and Victoria11. The infection spread further when the Second World War occurred, and the further spread to the civilian population as troops started to return home and accidently infect their wives11. It wasn’t until 1962 that the Rubella Virus was isolated for the first time11. This was fortunate timing as the scientific reakthrough occurred right before one of the most extensive recorded outbreaks of Rubella. In 1963 and 1964, an outbreak of Rubella occurred in the United States11.
This pandemic first started in Europe and spread to the United States. During this outbreak, in the USA alone it was estimated that there was somewhere between 20,000 to 30,000 CRS cases and a total of 12. 5 million people infected with Rubella11. Of those infected, over 8,000 children were born deaf, more than 3,500 were born deaf and blind, and there were 11,000 fetal deaths11. In response to the epidemic, there was an increased emphasis on reventive measures for the Rubella Virus. In 1965 and 1966, the first attenuated vaccines of the Rubella Virus were created and the vaccine trials started11.
During this time the vaccine were licensed in different areas around the world. Different countries allowed different attenuated versions to be licenced, but in the United States there was a universal childhood programme for the vaccine11. In the UK however, there was only a selective vaccination program for pre-pubertal school girls to try to prevent CRS contraction and infection. It wasn’t until 1971 that the current vaccine of Rubella was licensed in the United States11. This MMR vaccination, accounted for the measles, mumps and Rubella Vaccine.
At the same time, the UK was experiencing their own outbreaks of Rubella and would continue to struggle with outbreaks in the years of 1979, and again in 198311. These epidemics in the UK mostly involved adolescent boys, young males, and some pregnant women. This pattern could be linked to the fact that the UK was only vaccinating pre-pubertal school girls, leading to a small minority of potentially unvaccinated females contracting the infection. With the outbreak over, the UK finally issued the MMR vaccine to all pre-school children in 198811. In 1989, a resurgence of Rubella occurred in the United States.
Following the resurgence, a second dose of the vaccine was determined to be administered between the ages of 4 and 511. This two dose vaccination was also accepted by the UK in 199611. Today there are still preventative measures to eliminate Rubella all together. Transmission Rubella is transmitted very easily. The infection spreads through respiratory transmission4, meaning that by breathing in the droplets that are in the air when an infected person coughs are sneezes, the virus spreads easily from person to person. These types of nasal or throat secretions of the infected ndividual lead to uninfected individuals getting infected.
Diagnosis The first indication or the Rubella Virus’ presence is a rash. Although an individual may be infected for up to 14 days before any symptoms show, there will be no indication unless blood or saliva is tested. The diagnosis can be difficult to confirm because of the variety of rashes that can occur from any number of causes. The most accurate way to differentiate Rubella from other rash-causing illnesses like measles, or the human herpesvirus 6 is testing for the Rubella-specific IgM and IgG antibodies that can be found in oral secretions15. High levels of IgM indicate the Rubella infection.
High levels of IgG indicate that a person has either had a Rubella infection previously and is fighting it again, or they have had the vaccination. In figure 5, the graph represents the correlation between IgG and IgM presence in individuals16. When IgM levels are low, IgG levels will be high, positively identifying the presence of the virus. When IgM levels are high, IgG levels are low because the body does not recognized the virus and is fighting off a completely unfamiliar infection. When there is no indication of either of the antibodies, the individual does not currently have, nor have they ver had the infection or vaccination before.
Treatment/ Prevention Currently there are no permanent treatments to stop Rubella once it has been contracted. When a person has contracted the Rubella Virus, doctors will tell the individual to isolate themselves approximately one week prior to when symptoms start until week after symptoms dissipate to reduce spreading. A blood or saliva test can only accurately test positive for the virus as early as one week prior to the first sign of symptoms, nowever there are ways to lessen the infection’s effects on pregnant women to prevent the transmission to the fetus.
If a pregnant woman contracts the Rubella Virus, doctors will prescribe her human immunoglobulin or, if available, Rubella hyper immune globulin. These medications will not stop the virus all together, but it will reduce the presence of the virus in the blood in order to reduce the damage to the fetus3. The only way to completely prevent Rubella is to get vaccinated. The first attenuated live vaccine was licensed in 1969, and several modifications have been made since3.
In 1969 three different strains of the live attenuated virus was created, HPV-77 grown in a dog kidney, HPV-77 grown in a duck embryo, and cendehill grown in a rabbit kidney11. At this time a strain of RA 27/3 human diploid fibroblast vaccine was licenced in Europe11. Soon after the combination vaccine for measles, mumps, Rubella (MMR) became part of the vaccination programs. At this point, HPV-77 in the dog kidney and cendehill were being used in the MMR vaccine. It wasn’t until 1979 that HPV-77 and cendehill were discontinued and the RA 27/3 strain replaced them11.
This change resulted from the study of the side effects associated with the strains. HPV-77 dog kidney was found to cause excessive joint pain. It was also determined that the percentage of reinfection from the strain of RA 27/3 was only 5% whereas the rate of reinfection of HPV-77 dog kidney and cendehill was 50%11. A second dose of the MMR vaccine is normally given to kids to children aged of 3-5 and no later than age 11-12 to give extra protection against the three different viruses3. Although two doses are required, the first dose of the Rubella vaccine is likely to induce long-term immunity as compared to measles and mumps.
Figure 6 shows the correlation between the Rubella Virus and CRS, and the introduction of the MMR vaccine with a second dose. Rubella Today Rubella is still prominent in present day. With many countries not having the MMR vaccine in their program, often due to a lack of funding, Rubella has not yet been eradicated. Because humans are the only host of Rubella, it has high potential to be eradicated if necessary actions are taken4. The World Health Organization (WHO) has set many goals in attempting to eradicate Measles and Rubella.
Each goal was set within a timeline: by 2010 WHO had hoped to eliminate CRS in the Americas and achieved this goal in 20094. In 2012 WHO came up with a Measles initiative, also known as the Measles and Rubella initiative, which created a strategic plan spanning 2012-202017. This initiative set goals for 2015 and 2020. In 2015 the WHO had hoped to eliminate Measles, CRS and Rubella in certain regions, including Europe 17. Originally set for 2015, this goal unfortunately had to be extended as WHO experienced difficulties executing their initiatives.
Other regions for the 2015 goal included South-East Asian regions, African regions, and East Mediterranean regions4. The WHO goal for 2020 is to eliminate measles and Rubella in 5 WHO regions17. Implementation of this includes the spread of vaccination and requiring the two doses of MMR, close communication with and monitoring of these areas, and ongoing research to fight the spread of the disease17. The WHO is currently working on this goal and recently announced that on April 25, 2016 Measles and Rubella was eliminated from Malta 18. Figure 7 shows the countries that have implemented Rubella vaccines into their vaccine programs for infants.
This figure is from 2014 and the number of countries is expected to continue to increase. Current discourse suggests that because Measles is making a comeback in North America, Rubella or CRS could also. This resurgence is happening because of the anti-vaccination movement and parents not allowing their kids to get the MMR vaccine. Parents have believed the Wakefield article that falsifies studies showing that the vaccine causes autism in children. This is scientifically-proven false, but parents continue to believe in anti-vaccinations campaigns and choose not to vaccinate their kids.
Although there have been several reported cases of Measles, Rubella will not likely be comparable to the amount of Measles cases. This is due to the fact that although two doses of Rubella are recommended, one dose seems to be enough to stop the transmission of the virus4. The other reason ist lower levels of herd-immunity are required for Rubella than for Measles. This means that less people need the Rubella vaccine than the Measles vaccine in order for unvaccinated children to be infected. This can be shown in table 1 which compares the three different viruses encompassed within the MMR vaccine.
