How tragic when a mild illness, scarcely worse than a cold, can cause such devastating effects on babies. Young parents, beware!
Rubella is one of the classic rash illnesses of childhood. In ancient times, it was lumped in with measles, scarlet fever, and smallpox. For a while, it was thought to be halfway between measles and scarlet fever. It became known as scarlatina morbillosa (which means measles-like scarlet fever), rubeola scarlatinosa (which means scarlet-fever like measles), or hybrid measles.
A little more than a hundred years ago, it became clear that while rubella was similar to both measles and to scarlet fever, it was different. It became the third of the non-pox childhood rash illness (third disease). German scientists did most of the work (German measles), although some French scientists made important contributions (French measles). For a while, it was also called roseola, though we now know that rubella and roseola are distinctly different infections.
The main value in identifying this illness was that parents could relax! Rubella was much less serious than either measles or scarlet fever. If your child had a rash and a fever, this was the diagnosis you wanted the doctor to make.
Then in the 1940s everything changed. An Australian ophthalmologist named Normann Gregg observed that large numbers of cataracts and other birth defects occurred right after rubella outbreaks. He suggested that if pregnant women caught rubella, the unborn baby might be damaged. And Dr. Gregg was ridiculed.
At the time, the idea that an infection could hurt a baby was considered preposterous! The placenta was considered an unbreachable barrier that protected the baby from all illnesses, chemicals, toxins, drugs, alcohol, tobacco–any insult from the outside world.
Dr. Gregg became a laughingstock. But within a few years, his observations proved true. This opened a new era in children’s health.
Today rubella is known as one of the TORCH infections (toxoplasmosis, others, rubella, CMV, and herpes). These infections in the mother cause many miscarriages, and affect up to 5 percent of all babies who live to be born. They are among the leading causes of birth defects and newborn deaths. A baby born with birth defects resulting from its mother’s rubella infection is said to have congenital rubella syndrome. Thankfully this is now exceedingly rare.
Rubella tends to arrive in epidemics, with major epidemics every six to nine years. The virus that causes rubella was first discovered in 1962, which helped scientists to learn a great deal by studying the 1964 epidemic.
There were 1.8 million people known to be sick with rubella in that epidemic. There were 20,000 known fetal deaths and about 30,000 infants born with severe birth defects.
An intense, worldwide effort to develop a rubella vaccine began in 1965.
Immediately after the introduction of the rubella vaccine in 1969, epidemics virtually disappeared in the U.S. Since then, there have been fewer than 120 cases of congenital rubella syndrome reported each year in the U.S., a reduction of well over 99 percent. In the U.S., most women who get rubella are unimmunized women who catch the disease during an outbreak at a college campus.
Epidemics still occur in many countries around the world, only one plane flight away. Rubella is most common in the late winter and early spring (March, April, and May in the northern hemisphere) both during epidemics and in the off years. Only humans get rubella.
In 2004, rubella and congenital rubella syndrome (CRS) were considered eradicated from the United States. Sadly there are still sporadic cases, often as a result of international travel. Of the six cases of infants with CRS in the United States since 2004, five of the mothers were thought to be infected while in a foreign country. (http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6212a3.htm)
For children and adults who get rubella, it is usually a mild disease (often very similar to an adenovirus or enterovirus infection). The classic illness includes a rash, swollen glands, and low-grade fever. Sometimes there’s a sore throat. Adults usually feel sick before the rash; for children, the rash is often the first symptom.
The rash usually begins on the face and spreads down and out to the hands. Swollen glands are prominent, especially behind the ears and on the back of the head. But many people have rubella without the swollen glands or without the rash–often with no symptoms at all, except for the effect on an unborn baby.
Sometimes rubella can cause arthritis, either briefly or permanently. Other complications, such as encephalitis, are more rare.
Congenital rubella syndrome (the possible result of a baby being infected before birth) is usually much more severe. The birth defects can include blindness, deafness, heart defects, behavior disorders, mental retardation, bone disease, liver disease, and “blueberry muffin skin” (dark areas of pooled blood).
The early first trimester is the period of greatest risk, when most babies of infected mothers will have birth defects if they survive. By the fourth month, the risk of congenital rubella syndrome when a mother is infected drops to about 5 percent.
Rubella is very contagious. People can be contagious for up to two weeks before they have symptoms, and for six days or more afterward. Rubella can be spread by direct contact, airborne transmission, and droplet transmission.
Ninety to 100 percent of people who are not immune will get rubella if exposed.
The rash in uncomplicated rubella usually lasts for three days in a child or adult. If it weren’t for the rash, most would feel fine going to work or school even during the height of the illness.
Some remain uncomfortable for 7 to 10 days.
Complications from rubella can be permanent.
Congenital rubella syndrome is a lifelong consequence of a brief “cold” that may not even have been noticed by the pregnant woman.
Rubella infection in children or adults can be diagnosed by blood tests or by nasal swabs.
Congenital rubella syndrome can be diagnosed with blood tests if the testing is done in the first year of life. After that, it is very difficult to be certain what caused the defects, although certain patterns make some causes more likely than others.
For children and adults with rubella, treatments are aimed at relieving symptoms, if any.
For congenital rubella syndrome, an array of support services may be helpful, such as physical and occupational therapies, cardiac surgery, or eye surgery.
Rubella vaccine within three days of exposure might help to prevent rubella, but it should not be given to pregnant women. (And women should not become pregnant within three months of having the vaccine.)
Routine rubella vaccination of young children is the best way to prevent congenital rubella syndrome. It is stunningly effective. Even one dose generally gives long-term immunity in 95 percent or more of those immunized.
People who attend or work in schools, day cares, health-care facilities, or who might spend time around pregnant women or around those who do, should take particular care to be immunized.
Women who might become pregnant should verify that they are immune.
German measles, Congenital rubella syndrome, Third disease, French measles, False measles, Scarlatina morbillosa, Hybrid measles.