Public health priority: Routine.
PHU response time: Respond to probable and confirmed cases within 1 working day of notification for congenital rubella syndrome. Enter probable and confirmed cases on NCIMS within 5 working days.
Case management: Recommend exclusion from work, school, preschool, child care for ≥4 days from the onset of rash.
Contact management: Pregnant contacts should seek medical advice.
To monitor the epidemiology of the disease to inform the development of better prevention strategies.
A confirmed case requires laboratory definitive evidence only.
A probable rubella case requires:
An epidemiological link is established when there is:
Congenital rubella infection (CRI) is reported based on relevant evidence from a live or stillborn infant, miscarriage or pregnancy termination. Congenital rubella syndrome (CRS) is reported as a subset of congenital rubella infection with additional clinical evidence (see following).
A confirmed case (CRI) requires either:
The mother has confirmed rubella infection during pregnancy (see definition for Rubella – non-congenital).
A probable case (CRI) requires either:
A conﬁrmed case (CRS) requires:
A live or stillborn infant with any of the following compatible defects:
A probable case (CRS) requires:
Rubella is to be notified by:
Probable and confirmed cases should be entered onto NCIMS.
The rubella virus.
Rubella is transmitted by droplet infection and direct contact with nasopharyngeal secretions of infectious cases.
The typical incubation period is 14 to 17 days, up to 21 days.
Rubella is communicable for about 7 days before and at least 4 days after rash onset.
Infants with congenital rubella syndrome may shed the virus for months after birth.
The usual clinical presentation is a mild febrile illness with a diffuse punctate and maculopapular rash. The rash typically starts on the face, becoming generalised over 24 hours and lasts 3 days.
Children usually present with few or no constitutional symptoms, but adolescents and adults may have a 1 to 5 day prodrome of low-grade fever, headache, malaise, anorexia, mild coryza and conjunctivitis. Cervical lymphadenopathy (typically posterior auricular, posterior cervical and suboccipital lymph nodes) is characteristic and precedes the rash by 5 to 10 days. Asymptomatic infection is common.
Adolescents and adults (especially females) can sometimes develop transient polyarthralgia of fingers, wrists and knees. Encephalitis and thromobocytopenia are rare complications.
Infection in pregnancy can result in congenital rubella syndrome (see below), miscarriage or stillbirth. The risk of CRS is up to 90% if maternal infection occurs during the first 10 weeks of gestation. Defects are rare when maternal infection occurs after the 20th week of gestation.
Congenital rubella syndrome is characterised by:
Within 1 working day of notification of a case of congenital rubella syndrome, begin follow-up investigation. Follow up other cases at the discretion of the PHU Director.
Within 5 working days of notification enter probable and confirmed cases on NCIMS.
The response to a notification will normally be carried out in collaboration with the case's health carers. But regardless of who does the follow-up, PHU staff should ensure that action has been taken to:
The case or relevant care-giver should be informed about the nature of the infection and the mode of transmission.
Emphasis should be placed on the importance of following the recommended immunisation schedule.
Recommend exclusion from work, school, preschool, child care or other settings where there are susceptible individuals, especially young children, infants and pregnant women, for at least 4 days from the onset of rash.
Only people who are immune to rubella should have contact with an infant with congenital rubella syndrome. These children should be presumed infectious at least through to 1 year of age unless nasopharyngeal and urine cultures are negative for rubella virus after 3 months of age.
Direct contact with respiratory secretions from the case is generally considered significant. Contacts include people living in the same household, or who are in the same class, at the same social function, or work in the same area as the case.
Immunoglobulin given after exposure to an infectious case is not effective in preventing rubella infection.
MMR should be offered to susceptible contacts if they have no contraindications to vaccination. While MMR will not avert disease in those already infected and incubating infection, it may be effective in preventing subsequent infection if there is likely to be ongoing exposure.
All pregnant women with exposure to an infectious case should be offered urgent serological testing, irrespective of their history of previous vaccination, or history of past clinical infection or a positive rubella antibody result. Refer to The Australian Immunisation Handbook for additional details.
Susceptible contacts (or parents/guardians) can be alerted to the risk of infection through distribution of a factsheet through the school or workplace and they should watch for signs or symptoms of rubella occurring within 21 days of exposure. They should not have contact with pregnant women during this period.
Pregnant contacts should seek medical advice from their clinician for assessment of immunity and further counselling.
Exposed health care workers without adequate proof of immunity should be excluded from work for 21 days after exposure to an infectious case.