Transcript Document

Rubella –
German Measles
Dr. Harivansh Chopra,
DCH, MD
Professor,
Community Medicine,
LLRM Medical College,
Meerut.
[email protected]
Objectives of Lecture
1. To study the epidemiology of Rubella.
2. To study Rubella in pregnancy and its
management.
3. Understanding the manifestations of
Congenital Rubella.
4. Prevention of Rubella and strategies
for Rubella vaccination.
Dr. Harivansh Chopra
Why Rubella is k/a
“German Measles”?
The word "German" in the name of this
disease has nothing to do with the
country. The name likely comes from
the Latin term "germanus" meaning
"similar." And indeed, rubella and
measles (rubeola) share some
characteristics, but they're caused by
different viruses.
Dr. Harivansh Chopra
RUBELLA
(GERMAN / 3-DAY MEASLES)
Etiology  Pleomorphic RNA virus.
Family Togaviridae;
Genus Rubivirus.
Dr. Harivansh Chopra
RUBELLA
(GERMAN / 3-DAY MEASLES)
Epidemiology 
1. Spread by oral droplet or
transplacentally through
congenital infection.
Dr. Harivansh Chopra
RUBELLA
(GERMAN / 3-DAY MEASLES)
Epidemiology 
2. The period of infectivity is 7 days
prior to onset of rash and 7 days
after disappearance of rash.
3. The incubation period ranges
from 14 days to 21 days (average
= 18 days).
Dr. Harivansh Chopra
RUBELLA
(GERMAN / 3-DAY MEASLES)
Epidemiology 
4. Peak incidence of disease in
children 3-10 yrs. of age
(> 70% of cases in developed
countries occur in > 15 yrs.
old).
5. Many infections are sub
clinical with a ratio of 2:1;
inapparent to overt disease.
Dr. Harivansh Chopra
RUBELLA
(GERMAN / 3-DAY MEASLES)
Epidemology 
6. In closed population, almost
100% of susceptible individuals
may become infected. In family
setting spread of virus is less –
50-60%.
Dr. Harivansh Chopra
RUBELLA
(GERMAN / 3-DAY MEASLES)
Epidemiology
7. A single attack usually confers
permanent immunity.
8. Epidemics occurred every 6-9 years
before vaccine was available.
9. Infants with rubella are a source of
infection for older children who are
not immune & for non-immune
adults, including pregnant women
& nursery personnel.
Dr. Harivansh Chopra
RUBELLA
(GERMAN / 3-DAY MEASLES)
Epidemiology
10.Disease occurs in seasonal
pattern i.e. during the later
winter and spring, with
epidemics repeating every
4 – 9 years.
Dr. Harivansh Chopra
CLINICAL MANIFESTATIONS
OF RUBELLA
1. Prodromal phase – Mild catarrhal symptoms;
shorter than measles; may be so mild as to go
unnoticed.
2. Most characteristic sign is Retroauricular,
Posterior Cervical & Post-Occipital adenopathy
which is tender.
3. Lymphadenopathy is evident at least 24 hrs.
before rash appears & remains for 1 week or
more.
Dr. Harivansh Chopra
CLINICAL MANIFESTATIONS
OF RUBELLA
3. An enanthem may appear just before the
onset of skin rash. It is discrete rose spots on
soft palate that may coalesce into a red
bluish & extend over the fauces.
(Forchheimer spots)
4. Rash begins on face & spread quickly; rash
may be fading on face by the time it appears
on the trunk.
Dr. Harivansh Chopra
CLINICAL MANIFESTATIONS
OF RUBELLA
5. Rash is discrete maculo-papular with large
areas of flushing; spreads rapidly over the
entire body within 24 hrs.
6. Rubella without a rash has been described.
7. Fever is slight or absent during the rash &
persists for 1-2 or occasionally 3 days.
Dr. Harivansh Chopra
CLINICAL MANIFESTATIONS
OF RUBELLA
8. Anorexia, Headache & Malaise are
not common.
9. Spleen is often slightly enlarged.
10.Thrombocytopenia is rare.
11.Paraesthesia.
Dr. Harivansh Chopra
CLINICAL MANIFESTATIONS
OF RUBELLA
12. In older children Polyarthritis may with
Arthralgia & Swelling, Tenderness &
Effusion but without Residuum; Small
joints of hands are affected most
frequently. Duration is usually several days
to 2 weeks rarely for months.
13.Orchidalgia also reported.
Dr. Harivansh Chopra
DIFFERENTIAL DIAGNOSIS
Viral
Others
Measles.
Meningococcemia.
Roseola Infantum.
Typhoid fever.
Erythema Infectiosum.
Infectious
Mononucleosis.
Scarlet fever.
Live viral vaccine.
Drug eruption.
Dr. Harivansh Chopra
Risk of damage to fetus by Maternal Rubella
during pregnancy
Stage of
Gestation
(weeks)
when mother
is infected
Percentage
of fetus
infected
Percentage
of infected
fetus
damaged
Overall risk
damages to
fetus (in
percent)
< 11
90
100
90
11-16
55
37
20
17-26
33
0
0
27-36
53
0
0
Dr. Harivansh Chopra
DIAGNOSIS
Latex agglutination, enzyme immunoassay,
passive hemagglutination,
and fluorescent immunoassay appear
to be equal or superior to the HI test in
sensitivity.
Immunoglobulin (Ig) M antibodies are
detectable in the first few days of illness
and are considered diagnostic.
Dr. Harivansh Chopra
DIAGNOSIS
Detection of IgM antibodies, which do not
cross the placenta, in the newborn is
especially useful for the diagnosis of
congenital rubella syndrome.
Seroconversion, or a fourfold increase in
IgG titer, is diagnostic.
Dr. Harivansh Chopra
TREATMENT
SYMPTOMATIC
PARACETAMOL FOR FEVER
Dr. Harivansh Chopra
COMPLICATIONS
Complications are relatively
uncommon in childhood.
Encephalitis similar to that seen with
measles occurs in about 1 in 6,000
cases. The severity is highly
variable, and there is an overall
mortality rate of 20%
Thrombocytopenic purpura occurs
at an overall rate of 1 in 3,000
cases.
Dr. Harivansh Chopra
PREGNANCY & RUBELLA
Pregnant Female with unknown immune status
exposed to Rubella
ANTIBODY TESTING
SUSCEPTIBLE
NOT SUSCEPTIBLE
Abortion advised
Reassurance
Dr. Harivansh Chopra
PREGNANCY & RUBELLA
Female susceptible but
Abortion unacceptable
Rubella Immunoglobulin
0.55 ml/kg body weight given IM
Under no condition in pregnancy should an Active
Immunisation against Rubella be performed in
pregnancy.
Dr. Harivansh Chopra
CONGENITAL RUBELLA SYNDROME
1. IUGR is most common.
2. Cataract B/L or U/L; Associated
with micro-ophthalmia.
3. Blueberry skin lesion, similar to
CMV infection.
Dr. Harivansh Chopra
CONGENITAL RUBELLA SYNDROME
4. Myocarditis & structural cardiac
defects – PDA or Pulmonary Artery
Stenosis.
5. Hearing loss from Sensorineural
deafness.
6. May have active meningoencephalitis at birth; Later motor &
mental retardation.
Dr. Harivansh Chopra
CONGENITAL RUBELLA SYNDROME
7. Pneumonia.
8. Hepatitis.
9. Thrombocytopenic Purpura.
Dr. Harivansh Chopra
CONGENITAL RUBELLA SYNDROME
10.Pancreatitis.
11.Syndactyly.
12.Retinal lesions –
Salt and Pepper retinitis.
Dr. Harivansh Chopra
Prevention against Rubella
•
1.
2.
3.
4.
5.
Rubella Vaccine – RA 27/3
Produced in human diploid fibroblast.
Produces an immune response more
closely paralleling natural infection & largely
prevents sub clinical infection.
Single dose of 0.5 ml subcutaneously
Seroconversion in >95% vaccinees.
Immunity persists for at least 14 – 16 years
and probably lifelong.
Dr. Harivansh Chopra
MMR Vaccine
•
Composition –
Live hyperattenuated Measles virus
(Schwartz strain) – 1000 TCID50
2. Live attenuated Mumps virus (Urabe AM 9
strain) – 5000 TCID50
3. Live attenuated Rubella virus (Wistar RA
27/3M strain) – 1000 TCID50
4. Stabilizer excipient (containing human
albumin)
1.
Dr. Harivansh Chopra
MMR Vaccine
•
Route and Dose –
0.5 ml Subcutaneous or Intramuscular.
2. Single dose between 12 and 15 months of
age (Recommended age).
3. Second dose recommended 6 months later
in children vaccinated below 12 months of
age, particularly in collective environment.
1.
Dr. Harivansh Chopra
MMR Vaccine
1.It is freezed dried
vaccine
2.Has to be
reconstituted with
distilled water
3.Reconstituted
vaccine must be
used as early as
possible
Dr. Harivansh Chopra
MMR Vaccine
1.
2.
It has shell life for
2 years
Must be stored
between
2-8 degree
centirgade
Dr. Harivansh Chopra
Complications of vaccine
1.
2.
3.
Fever
Rash
Rarely S.S.P.E
Dr. Harivansh Chopra
Contraindications to Rubella
1. Congenital or Acquired
immunodepressions. (An infection
with HIV should not be
contraindication to MMR vaccination,
but advised only under specialised
paediatric team).
2. True allergy to egg proteins.
Dr. Harivansh Chopra
Contraindications to Rubella
3. Recent injection of Immunoglobulins
(Vaccine must not be given till 3 months
after Immunoglobulin transfusion, or
Immunoglobulins must not be given 2
weeks after vaccination).
4. Pregnancy (Recipients of vaccine must
not be advised to become pregnant over
next 3 months).
Dr. Harivansh Chopra
Vaccination Strategy – Rubella
1. First protect women of
childbearing age (15 – 34 or
39 years of age).
2. Then interrupt transmission
of Rubella by vaccinating
children 1 – 14 years of age.
3. Subsequently vaccinating all
children at 1 year of age.
Dr. Harivansh Chopra
Conclusion
1. Rubella is a vaccine preventable
disease, which is very similar to
Measles in its presentation.
2. A relatively mild clinical manifestation
but hazardous to developing foetus if
contracted in pregnancy.
3. Affected foetus presents with a variety
of signs grouped under “Congenital
Rubella Syndrome”.
Dr. Harivansh Chopra
Dr. Harivansh Chopra
MCQ
1. Which of the following disease can
result in congenital anomaly in the
newborn child
1.
2.
3.
4.
HIV.
Hepatitis B.
Rubella.
All of the above.
Answer – 3.
Dr. Harivansh Chopra
MCQ
2. “Three day measles” is another
name for
1.
2.
3.
4.
Roseola Infantum.
Erythema Infectiosum.
Scarlet fever.
None of the above.
Answer – 4.
Dr. Harivansh Chopra
MCQ
3. The
most
characteristic
differentiating
feature
between
measles and rubella is
1.
2.
3.
4.
Type of rash.
Prodromal period.
Tender enlargement of cervical group of
glands.
Degree of fever.
Answer – 3.
Dr. Harivansh Chopra
MCQ
4. The efficacy of rubella vaccine is
1.
2.
3.
4.
80%
90%
95%
98%
Answer – 3.
Dr. Harivansh Chopra
MCQ
5. The pregnancy should be deferred
in the recipient of Rubella vaccine
for a period of
1.
2.
3.
4.
Next 1 month
Next 2 months
Next 3 months
Next 6 months
Answer – 3.
Dr. Harivansh Chopra
MCQ
•
1.
2.
3.
4.
Q-6 Incubation period of rubella is
1 – 7 days
7 – 14 days
14 – 21 days
21 – 28 days
Ans 3
Dr. Harivansh Chopra