Rubella (German measles)

Notification requirement for rubella

Rubella and congenital rubella are urgent notifiable conditions in Victoria. Medical practitioners and pathology services must notify suspected and confirmed cases immediately to the Department of Health by calling 1300 651 160 (24/7) and connecting to the relevant Local Public Health Unit. Pathology services must follow up with written notifications within 5 days.

This is a Victorian statutory requirement.

Primary school and children’s services exclusion for rubella

Children with rubella must not attended primary school and children’s services until they have fully recovered, but not before 7 days after the onset of rash.

Rubella contacts are not excluded.

For more information, see the School exclusion table.

Infectious agent of rubella

Rubella, also known as German measles, is caused by the rubella virus, a member of the Togaviridae family.

Identification of rubella

Clinical features

Rubella usually causes a mild self-limiting illness. Symptoms and signs may include:

• diffuse, punctate and maculopapular rash
• low-grade fever
• lymphadenopathy, particularly post-auricular, occipital and posterior cervical nodes
• coryza
• mild conjunctivitis
• headaches
• malaise.

Up to 50% of infections may be asymptomatic, particularly in children.

Complications may include arthralgia and, less commonly, arthritis, particularly among adult females. Other complications include otitis media and encephalitis.

Symptoms and signs of rubella are non-specific. Differential diagnosis may include other viral infections such as measles, human parvovirus (‘slapped cheek’), human herpesvirus 6 (roseola) as well as other infectious and non-infectious causes.

Congenital rubella

Rubella infection during pregnancy, particularly during the first trimester, can cause:

• miscarriage
• stillbirth
• birth defects.

Congenital rubella syndrome can cause serious birth defects such as:

• sensorineural deafness
• cataracts, microphthalmia, glaucoma, pigmentary retinopathy or chorioretinitis
• congenital heart defects such as peripheral pulmonary artery stenosis, patent ductus arteriosus or ventricular septal defects
• microcephaly, meningoencephalitis or developmental impairment.

Other associated complications in infants can include hepatosplenomegaly, radiolucent bone disease, acute pneumonitis, anaemia and thrombocytopaenia. Infants born with congenital rubella are also at increased risk of endocrine disorders and, very rarely, progressive rubella panencephalitis.

The risk of birth defects declines with infection later in gestation.

Diagnosis

Because rubella is uncommon in Australia and many rash illnesses resemble rubella, clinical diagnosis alone is unreliable. Discuss testing recommendations with an infectious diseases specialist or your Local Public Health Unit.

Laboratory diagnosis may include:

• Rubella polymerase chain reaction (PCR) test preferably using a throat or nasopharyngeal swab and/or urine sample
• Rubella IgM and IgG serology (acute and convalescent paired serology)
• Virus isolation by culture may also provide definitive laboratory evidence, although PCR testing is preferred where available.

Consider alternative diagnoses such as measles, parvovirus B19, roseola, enterovirus and other viral infections.

Incubation period of rubella virus

The incubation period is usually from 12 to 23 days.

Reservoir for rubella virus

Humans are the reservoir.

Mode of transmission of rubella virus

Rubella is transmitted by respiratory droplets or direct contact with respiratory secretions. During pregnancy, rubella can be transmitted from the pregnant mother to the foetus.

Period of communicability of rubella

A person with rubella is considered infectious from 7 days before until 7 days after the onset of the rash.

Infants with congenital rubella may shed rubella virus in pharyngeal secretions and urine for up to 12 months after birth and potentially transmit infection.

Susceptibility and resistance to rubella

Natural rubella infection generally confers lifelong immunity, but re-infections can rarely occur. Immunity from rubella-containing vaccination is long term and usually lifelong.

Maternal rubella antibodies are transferred across the placenta and provide temporary protection to infants born to immune mothers. This passive immunity typically persists for 6 to 9 months after birth.

Public health significance and occurrence of rubella

Rubella has become rare in Victoria following the introduction of rubella-containing vaccines in routine childhood vaccination. However, rubella still occurs worldwide and imported cases and infection among unvaccinated individuals continue to be detected.

Although most infections are mild, rubella remains an important public health concern because of the risk of serious outcomes associated with infections during pregnancy.

Control measures for rubella

Immunisation

Vaccination is the most important preventive measure against rubella.

In Australia, rubella-containing vaccines are available as combination vaccines as the measles, mumps, rubella (MMR) vaccine and measles, mumps, rubella and varicella (MMRV) vaccine. MMRV vaccine is not recommended for people aged 14 years and over.

Free rubella-containing vaccines are available for eligible people under the National Immunisation Program and Victorian Government-funded program. These vaccines are available from general practices, community pharmacies, Aboriginal Health Services and local council immunisation services.

National Immunisation Program (NIP) Schedule:

• Infants aged 12 months (MMR) and 18 months (MMRV).
• Catch-up vaccination for people under 20 years, and refugees and humanitarian entrants of any age.

Refer to the Australian Immunisation Handbook for recommendations for adults. Eligibility under the NIP is linked to eligibility for Medicare benefits.

Victorian Government funded program:

• Infants from 6 months to less than 12 months of age prior to overseas travel. This dose is in addition to the scheduled MMR vaccine disease recommended at ages 12 (MMR) and 18 months (MMRV) under the NIP.
• All people born during or after 1966 without evidence of receiving 2 documented doses of valid a rubella-containing vaccine or without serological evidence of immunity.

People without Medicare eligibility are still eligible to receive a Victorian Government-funded vaccine.

Healthcare and childcare workers should receive rubella vaccination, if not immune.

Rubella immunity screening during pregnancy

Rubella-containing vaccines are live attenuated vaccines and are not suitable in pregnancy.

Anyone who is planning pregnancy should have their rubella immunity assessed before conception where possible. Those without evidence of immunity should receive a rubella-containing vaccine before becoming pregnant. Anyone who receives a rubella-containing vaccine should avoid becoming pregnant for at least 28 days after receiving the vaccine.

Routine antenatal screening for rubella immunity is recommended. Pregnant women who are not immune to rubella should avoid exposure to rubella during pregnancy and receive a rubella-containing vaccine after delivery. Pregnant women who develop symptoms of rubella or who may have been exposed to rubella should be promptly assessed.

Control of case

There is no specific treatment for rubella.

• Children with rubella must not attend primary school or children’s services until 7 days after rash onset or until fully recovered, whichever is longer.
• People with rubella should remain at home while infectious and should not attend secondary school, work or public places during this period.
• Cases should avoid contact with others, particularly infants under 12 months, pregnant women and people with immunocompromise while infectious.

Pregnant women with, or suspected to have, rubella should be urgently referred for specialist obstetric assessment. Medical practitioners should seek advice from an infectious diseases, obstetric and/or neonatal/paediatric specialist as relevant.

Hospitalised cases (including suspected cases) should be isolated in a single room using contact and droplet precautions while infectious.

Control of contacts

The public health response prioritise identification of:

• pregnant contacts
• household contacts
• healthcare exposures
• childcare, school, work and social contacts.

Contact should be advised of their exposure to rubella and advised to monitor for symptoms for 23 days after last exposure.

Pregnant contacts require urgent clinical assessment. Management may include review of rubella immunity, rubella serology and consideration of post-exposure prophylaxis with normal human immunoglobulin (NHIG) for susceptible pregnant contacts. Where indicated, NHIG should be administered within 5 days after exposure.

Non-pregnant contacts who are susceptible to rubella may be offered a rubella-containing vaccine, noting it is unlikely to reduce the risk of illness related to this exposure.

Control of environment

Not applicable.

Outbreak measures for rubella

Suspected outbreaks should be reported immediately to the Department of Health.

Public health actions may include case finding, contact tracing, enhanced surveillance and vaccination activities where indicated.