Rubella, also known as German or three-day measles, is an acute viral infection now largely irradicated due to vaccination introduced in 1969. Prior to that time, cyclic pandemics of the disease occurred every 6 to 9 years. Incidence of the disease, which is worldwide and affects both sexes equally, has been reduced by 99.7% in locations where vaccination is standard practice. In the United States, for example, there were only between 128 and 192 cases reported annually throughout the 1990's and 4 to 11 cases per year of congenital rubella syndrome, a result of fetal infection. Congenital rubella syndrome is associated with serious birth defects and developmental delay (see section entitled Pregnancy).

Rubella, from the family togavirus of the genus Rubivirus, affects only humans and is spread via airborne transmission of viral droplets shed from the respiratory secretions of infected persons. The incubation period varies from 12 to 23 days. Individuals are contagious for one week prior to the appearance of a rash and up to seven days following disappearance of the rash. Note that individuals are contagious even in subclinical cases. Infants with congenital rubella syndrome may excrete rubella virus in respiratory secretions and urine for up to 2 years.

• Lack of immunization
• Close contact by nonimmune individuals with infants who have congenital rubella syndrome (e.g., in the hospital or in day-care settings)
• Close contact, such as in the workplace, by nonimmune individuals with large numbers of people from countries without routine immunization

Symptoms are usually mild and up to half of all cases may be subclinical. The most distinctive sign of rubella is lymphadenopathy of the posterior auricular, cervical, and suboccipital lymph nodes. A rash is usually the first manifestation in younger children. In older children and adults, it is more common for a 1-to-5-day prodrome to occur before the onset of a rash; it may include low-grade fever, malaise, anorexia, swollen glands, and upper respiratory infection. Other symptoms may include:

• Acute onset of generalized maculopapular rash
• Temperature >99 degrees F (37.2 degrees C)
• Lymphadenopathy
• Arthritis/arthralgia; more common in older girls and women and may persist up to weeks and, rarely, months
• Conjunctivitis
• Testalgia/orchitis
• Mild pruritus

• Scarlet fever
• Measles (rubeola)
• Roseola infantum
• Infectious mononucleosis
• Toxoplasmosis
• Enteroviral infections accompanied by a rash
• Drug rashes

• Maculopapular rash that starts on the face and moves within 24 hours to the chest, upper arms, abdomen, and thighs
• Posterior auricular, cervical, and suboccipital lymphadenopathy
• Discrete rose colored spots (Forscheimer spots) on the soft palate that may coalesce into a red blush and extend to the throat area (appears just before onset of skin rash and occurs in 20% of patients)
• Slightly enlarged spleen

The diagnosis of rubella infection is most commonly confirmed with serologic tests and virus cultures. An enzyme-linked immunosorbent assay (ELISA) for IgG and IgM antibodies is the most common method of testing.

• Isolation of the rubella virus from nasopharynx or blood
• Detection of a significant (fourfold or greater) rise in the titer of IgG antibodies in paired acute-phase and convalescent-phase serum specimens
• Detection of rubella-specific IgM antibodies in one serum specimen; present in the first few days of illness; considered diagnostic

There is no specific antiviral therapy for rubella and treatment is supportive as the infection is generally self-limited with only rare complications. Individual symptoms, such as fever, arthritis and arthralgia, may be treated (see section entitled Drug Therapies).

• Antipyretic medication (acetaminophen or ibuprofen) for fever
• Analgesic, anti-inflammatory medication in the case of arthritis/arthralgia

There is some controversy surrounding routine vaccination against measles, mumps, and rubella (see section entitled Prevention) (Afzal et al. 2000; West and Roberts 1999). Some people may therefore seek alternative modalities in lieu of vaccination. However, there is no evidence that any complementary or alternative modality is effective in conferring immunity against rubella. Some of the complementary and alternative approaches noted below have been found useful in alleviating the symptoms of rubella.

The use of specific foods or nutrients to treat rubella infection has not been investigated in clinical trials. However, nutrients used to support the immune system in general include:

• Vitamin A
• Vitamin C
• Zinc

One in vitro study found that honey exhibited antiviral properties against rubella (Zeina et al. 1996). The exact mechanism by which honey exerts its antiviral properties is not known. The effect of honey in humans infected with rubella is unknown, although the authors speculate that further study into the antiviral compounds in honey may lead to the development of new antiviral agents.

The efficacy of herbal therapies in treating rubella infection has yet to be explored in scientific studies. However, to treat viruses in general, herbalists may recommend remedies that stimulate the immune system and that have antipyretic and antimicrobial properties. Based on clinical experience, practitioners have found the following herbs to be useful in treating the symptoms and complications associated with rubella infection (Blumenthal 1998; Blumenthal et al. 2000):

• Willow bark (Salix alba, S. purpurea L, S. fragilis L) as an antipyretic and analgesic
• Calendula flower (Calendula officinalis) for rash
• Hay flower (Poa spp.) used externally to relieve discomfort associated with arthritis

While formal scientific studies have not investigated the use of homeopathy in treating rubella, some common remedies used in treating the symptoms of rubella in children include:

• Aconitum napellus (monkshood)—Used for those experiencing sudden onset of fever, thirst, restlessness and anxiety, cold symptoms, sensitivity to light, dry cough 
• Belladonna (deadly nightshade)—Appropriate for patients who describe sudden onset of very high fever; thirst; hot, with flushed face and dilated pupils, but cold extremities; irritability; restless sleep accompanied by nightmares
• Byronia alba (wild hops)—Appropriate patient has predominance of respiratory symptoms; late onset of rash; aching; constipation; thirst
• Gelsemium (yellow jasmine)—Appropriate patient describes gradual onset of fever and chills, extreme fatigue and lethargy, cough, nasal discharge that burns upper lip
• Euphrasia (eyebright)—Used for patient with predominance of nasal discharge and eye symptoms; sensitivity to light; dry cough; headaches
• Pulsatilla (windflower)—Appropriate patient complains of fever and other symptoms worsening in the evening; child for whom this is appropriate tends to cry a lot and seeks to be held

• Electroacupuncture: A form of acupuncture in which specific meridian points are stimulated with electrodes applied to the skin, rather than with needles, has been reported as a successful treatment in two cases of visual and hearing impairments associated with congenital rubella syndrome (see section entitled Pregnancy) (Galewski 1999).
• Acupuncture may also be useful in alleviating the pain associated with many forms of arthritis. Arthritis is a potential complication of rubella (see sections entitled Signs and Symptoms and Complications/Sequelae) (NIH 1997).

Therapeutic massage may be useful in alleviating the pain associated with different forms of arthritis, which may result from rubella infection (see sections entitled Signs and Symptoms and Complications/Sequelae) (Greene 2000).

Although antibodies develop in 99% of those vaccinated, immunity is conferred in only 90% to 95% of vaccine recipients (Gershon 1998; Maldonado 2000). The live attenuated vaccine is derived from the RA 27/3 strain of rubella virus and can be administered in one of three forms:

• As a single-antigen preparation
• Combined with mumps vaccine
• As part of the measles-mumps-rubella (MMR) vaccine

It is recommended that all children receive two doses of rubella vaccine (usually as part of the MMR vaccine) at least 4 weeks apart, and that all persons born in or after 1957 have documentation of at least one dose of MMR. Persons born prior to 1957 are considered immune; premenopausal women of childbearing age, though, should still receive vaccine or demonstrate immunity even if they were born before that year (Behrman 2000). The first dose of MMR is given to infants on or after (not before) they reach 12 months of age. The second dose should be given to children at 4 to 6 years of age. The American Academy of Pediatrics recommends that healthcare professionals ensure that all 11 to 12-year-old children have received two doses of MMR and to vaccinate any child over that age who has not. The Centers for Disease Control and Prevention recommends that particular emphasis be placed on vaccinating susceptible adults in colleges, workplaces, and healthcare settings.

There continues to be much controversy surrounding the MMR vaccine in particular, linking it to disorders such as autism and inflammatory bowel disease (Afzal et al. 2000; Wakefield et al. 1998). However, an epidemiological study investigating a link between the incidence of autism and the introduction of the MMR vaccine in the US and the UK found no temporal association (Taylor et al. 1999). There have also been studies suggesting a link between the DTP vaccine and the rise in incidence of atopic disease, particularly asthma (Farooqi and Hopkin 1998; Hurwitz and Morgenstern 2000; Odent and Kimmel 1994). The question remains as to what, if any, association exists between these vaccines and other diseases. The bottom line is that vaccination remains the only reliable method for preventing individual cases as well as for maintaining immunity among the general population.

Administration of the vaccine is contraindicated under the following conditions:

• History of severe allergic reaction following a prior dose of rubella vaccine or to a vaccine component (e.g., gelatin, neomycin)
• Pregnancy (or trying to become pregnant)
• Immunodeficiency or immunosuppression, including the use of high-dose corticosteroids
• Moderate to severe acute illness
• Receiving antibody-containing blood products (e.g., immune globulin, whole blood or packed red blood cells, intravenous immune globulin) within 3 months

It has also been suggested that extreme caution be practiced in administering MMR vaccine to anyone with a history of egg-induced anaphylaxis (Wood and Doran 1995).

When rubella infection occurs after birth, complications are uncommon and occur in adults more often than in children. Possible complications include:

• Arthritis or arthralgia—Occurs almost exclusively in women; fingers, wrists, and knees tend to be affected. Develops concurrent with rash and may take several weeks to resolve. Chronic arthritis is rare.
• Encephalitis—Similar to that seen in measles; occurs in 1 in 5,000 to 1 in 6,000 cases and more frequently in adults (especially in women) than in children. The severity varies significantly between individuals; up to 50% of people affected by this complication may die from it.
• Hemorrhagic manifestation—Thrombocytopenic purpura is most common; occurs in approximately 1 in 3,000 cases and more often in children than in adults. Gastrointestinal, cerebral, or intrarenal hemorrhage may occur. May produce short-term (days) or long-term (months) effects, but most patients recover.
• Orchitis, neuritis, and progressive panencephalitis
• Rubella infection during pregnancy—complications include spontaneous abortion and stillbirth, as well as congenital rubella syndrome in the child (see section entitled Pregnancy)

In most cases of postnatal rubella infection, lifelong immunity is conferred and full recovery without permanent side effects occurs.

Fetal infection can produce a set of severe defects known as congenital rubella syndrome. Gestational age at the time of infection determines the likelihood and severity of fetal malformations. Infection during the first trimester of pregnancy increases the likelihood of producing more severe fetal malformations as well as those involving more organ systems.

There are several consequences of congenital infection:

• Transient—intrauterine growth retardation and low birth weight, thrombotic thrombocytopenic purpura, hepatosplenomegaly, anemia, jaundice, and pneumonia
• Permanent—sensorineural deafness, pulmonic stenosis, atrial or ventricular septal defects, patent ductus arteriosus, glaucoma, microphthalmia, chorioretinitis, and bilateral or unilateral cataracts
• Developmental—mental retardation, behavioral disorders, diabetes mellitus, thyroid disease, and growth hormone deficiency

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