^Chapter Contents
Immunisation against infectious disease
28: Rubella
NOTIFIABLE
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The disease
Rubella is a mild disease caused by a togavirus. There may be a mild prodromal illness involving a low-grade fever, malaise, coryza and mild conjunctivitis. Lymphadenopathy involving post-auricular and sub-occipital glands may precede the rash. The rash is usually transitory, erythematous and mostly seen behind the ears and on the face and neck. Clinical diagnosis is unreliable as the rash may be fleeting and is not specific to rubella.
Rubella is spread by droplet transmission. The incubation period is 14 to 21 days, with the majority of individuals developing a rash 14 to 17 days after exposure. Individuals with rubella are infectious from one week before symptoms appear to four days after the onset of the rash.
Complications include thrombocytopaenia (the rate may be as high as one in 3000 infections) and post-infectious encephalitis (one in 6000 cases) (Lokletz and Reynolds, 1965; Plotkin and Orenstein, 2004). In adults, arthritis and arthralgia may occasionally be seen after rubella infection; chronic arthritis has rarely been reported (Plotkin and Orenstein, 2004).
Maternal rubella infection in pregnancy may result in fetal loss or in congenital rubella syndrome (CRS). CRS presents with one or more of the following:
cataracts and other eye defects
deafness
cardiac abnormalities
microcephaly
retardation of intra-uterine growth
inflammatory lesions of brain, liver, lungs and bone marrow.
Infection in the first eight to ten weeks of pregnancy results in damage in up to 90% of surviving infants; multiple defects are common. The risk of damage declines to about 10 to 20% with infection occurring between 11 and 16 weeks gestation (Miller et al., 1982). Fetal damage is rare with infection after 16 weeks of pregnancy, with only deafness being reported following infections up to 20 weeks of pregnancy. Some infected infants may appear normal at birth but perceptive deafness may be detected later (Miller et al., 1982; Plotkin and Orenstein, 2004).
History and epidemiology of the disease
Before the introduction of rubella immunisation, rubella occurred commonly in children, and more than 80% of adults had evidence of previous rubella infection (Morgan Capner et al., 1988).
Rubella immunisation was introduced in the UK in 1970 for pre-pubertal girls and non-immune women of childbearing age to prevent rubella infection in pregnancy. Rather than interrupting the circulation of rubella, the aim of this strategy was to directly protect women of childbearing age by increasing the proportion with antibody to rubella; this increased from 85 to 90% before 1970 to 97 to 98% by 1987 (Vyse et al., 2002). Surveillance for congenital rubella was established in 1971 to monitor the impact of the vaccination programme. During the period 1971–75 there were an average of 48 CRS births and 742 terminations annually in the UK (Tookey and Peckham, 1999) (see Figure 28.1).^
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Universal immunisation against rubella, using the measles, mumps and rubella (MMR) vaccine, was introduced in October 1988. The aim of this policy was to interrupt circulation of rubella among young children, thereby protecting susceptible adult women from exposure. At the same time, rubella was made a notifiable disease. A considerable decline in rubella in young children followed the introduction of MMR, with a concomitant fall in rubella infections in pregnant women – from 167 in 1987 to one in 2003.
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Let's not go back to just immunising adults, please.