Rubella

Straight to the point of care

Last updated: Jul 27, 2021

 Table of Contents
Overview 3
Summary 3
Definition 3

Theory 4
Epidemiology 4
Aetiology 4
Pathophysiology 4
Case history 5

Diagnosis 6
Approach 6
History and exam 8
Risk factors 9
Investigations 10
Differentials 12
Criteria 21
Screening 21

Management 22
Approach 22
Treatment algorithm overview 22
Treatment algorithm 23
Primary prevention 23
Secondary prevention 24
Patient discussions 24

Follow up 25
Monitoring 25
Complications 25
Prognosis 25

Guidelines 27
Diagnostic guidelines 27
Treatment guidelines 27

Online resources 29

References 30

Images 34

Disclaimer 42
Rubella Overview

Summary
Treatment of symptomatic rubella infection is largely supportive, as the illness is self-limiting.

The most important consequence of rubella infection is congenital rubella syndrome, which may result

OVERVIEW
from infection during pregnancy. Specialty consultation is strongly recommended for pregnant women with
exposure to rubella.

Rubella immunisation programmes have eliminated endemic spread of the virus in the UK and the Americas;
most cases are imported or associated with imported infections.

Definition
This topic focuses on postnatal rubella (German or 3-day measles), a mild, self-limiting, systemic infection
caused by rubella virus. Up to one half of all cases are asymptomatic. The common manifestations of
symptomatic infection include mild fever, a generalised rash, lymphadenopathy, conjunctivitis, and arthralgias
or arthritis. Maternal infection in pregnancy, particularly early in gestation, may cause spontaneous abortion,
fetal death, or a wide spectrum of anatomical and laboratory anomalies (congenital rubella syndrome).

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 Rubella Theory

Epidemiology
In the UK in the pre-vaccine era, rubella was uncommon under the age of 5 years, with the peak incidence
being at 5 to 10 years of age. Before the licensure of rubella vaccine in the US in 1969, rubella caused late-
THEORY

winter and early-spring epidemics at 3- to 9-year intervals. The incidence of endemic rubella in un-immunised
populations was highest in pre-school and young school-age children. In 2004, the US Centers for Disease
Control and Prevention (CDC) announced the elimination of endemic rubella in the US.[2] Between 2000
and 2018 there was a 97% decline in reported rubella cases, from 670,894 cases in 102 countries, to
14,621 cases in 151 countries.[3] At present, fewer than 10 people per year in the US are reported as having
rubella infection, and since 2012, all those with rubella infections had evidence of becoming infected while
living or traveling outside the US.[4] [5] Most cases now affect adolescents and young adults.[6] Hispanic
ethnicity was, in the past, an important epidemiological factor, but a region-wide control programme for
the Americas was adopted in 1997 and, in 2015, the Pan American Health Organization determined that
endemic transmission of rubella in the region had been eliminated.[7] In the World Health Organization
European Region progress towards rubella elimination is being made; rubella incidence declined from 234.9
cases per million population in 2005 to 0.7 cases per million by 2019.[8]

Endemic rubella and congenital rubella syndrome remain a global health problem, primarily of South East
Asia and Africa. Outbreaks have been reported in countries where vaccination rates are sub-optimal.[9] The
risk to un-immunised travellers to areas where rubella remains endemic may be high.

Aetiology
Rubella is caused by rubella virus, which is a togavirus and the only member of the genus Rubivirus .
Humans are the only natural host. The virus has a positive-stranded RNA genome and a glycolipid envelope.
There is only 1 antigenic type. Rubella virus is readily inactivated by chemical agents, low pH, heat, and
cold. It can be cultivated in a variety of cell lines. Cell-mediated immunity develops 2 to 4 weeks after
infection, and haemagglutination inhibition and neutralising antibodies directed against the virus peak at
approximately 4 weeks. Immunity following rubella usually persists for life, although recurrent infection has
been reported. Rubella vaccines are reported to be approximately 97% effective in preventing disease after
a single dose.[10] Most rubella infections in the US are imported from countries in which rubella is endemic
and affects un-immunised people.

Pathophysiology
Rubella is transmitted from human to human only by direct or droplet contact with infected body fluids, most
commonly nasopharyngeal secretions.[6] Patients may shed infectious virus from 7 to 30 days after infection
(from 1 week before to 2 weeks after the onset of rash). However, infants with congenital rubella syndrome
may be contagious for >1 year. The average incubation period is 14 days (range: 2 to 23 days), during which
time the virus replicates in the nasopharynx and local lymph nodes and then spreads haematogenously
throughout the body (including, in pregnant women, to the placenta and fetus). Systemic symptoms are due
to viral infection, but some manifestations (rash, thrombocytopenia, arthritis) probably have an immunological
basis.

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Rubella Theory

Case history
Case history #1

THEORY
A 35-year-old man presents with a 3-day history of low-grade fever, malaise, headache, and aching
knees. That morning he developed a rash on his face, which has now spread to his chest and arms.
His physical examination is notable for mild conjunctival injection, mild bilateral posterior auricular
lymphadenopathy, and a discrete erythematous papular rash on his face, trunk, and upper arms. The
patient is a business traveller from Nigeria who arrived in the United States a week prior to the onset of
his illness. He is unaware of his immunisation status and reports that a co-worker with whom he had close
contact had a similar rash recently.

Case history #2
A 2820-gram female infant is born to a 22-year old primigravidas mother at approximately 38 weeks'
gestation following an uncomplicated pregnancy. The baby has mild hepatosplenomegaly, numerous
purplish, firm, non-blanching skin nodules, scattered petechiae, and a grade 3 continuous murmur audible
at the left infraclavicular area. The baby's mother emigrated from Vietnam during the sixth month of her
pregnancy; she cannot recall having been immunised in childhood.

Other presentations
Postnatal rubella infection may be complicated by overt arthritis. This is more common in adults and
females and may persist for weeks to months. Thrombocytopenia occurs in approximately 1 out of 3000
cases, most commonly in children.[1] Serious haemorrhagic complications may occur. Rare complications
include neurological disorders, myocarditis, pericarditis, hepatitis, and bone marrow failure.

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 Rubella Diagnosis

Approach
Postnatal rubella is most commonly diagnosed by serological testing in patients who present with a
generalised maculopapular rash, fever >37.2°C (99°F), and arthralgia/arthritis, lymphadenopathy, or
conjunctivitis. Diagnostic testing is indicated for people with risk factors for rubella (under-immunisation,
known contact with a case of rubella, travel to a region of the world where rubella is endemic) and a clinical
picture consistent with rubella. Identifying contagious people may prevent the spread of rubella to susceptible
contacts, especially pregnant women. Diagnostic testing is also indicated for people who have risk factors
for rubella and who have potential complications of the disease, for example, arthritis, thrombocytopenia, or
encephalitis.

Clinical features
Rash is often the first manifestation of rubella in young children. The rash of rubella is erythematous,
discrete, maculopapular, and sometimes mildly pruritic, and may be accentuated by heat. It usually begins
on the face and spreads from the head to the feet. Occasionally there may be a petechial component to
the rash or palatal petechiae. The rash persists for an average of 3 to 4 days.

Low-grade fever of >37.2°C (99°F) occurs in up to 50% of infections. Prodromal malaise and other mild
constitutional symptoms are more common in adults than in children. Mild upper respiratory symptoms
are common in children of school age and adults, and may precede the onset of rash by several days.
Arthralgias and arthritis are common in adults (occurring in up to 70% of adult women) but uncommon in
children. The most common joints affected are the fingers, wrists, and knees. The onset of joint symptoms
usually coincides with the rash, and symptoms may persist for weeks. Rarely, symptoms may be recurrent
or chronic.[18]

Mild lymphadenopathy involving the post-auricular, posterior cervical, and occipital lymph node groups
occurs in almost all patients and may precede the onset of rash by up to 1 week. Nodes are typically non-
tender and mobile. Non-purulent conjunctivitis is reported in about 70% of adolescents and adults, but is
less common in children.
DIAGNOSIS

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Rubella Diagnosis

Postnatal rubella rash

Centers for Disease Control and Prevention (CDC) Public Health Image Library

Tests
Suspected cases of rubella should be confirmed by serological testing. Anti-rubella IgM can be detected
at the onset of clinical illness in almost all patients and persists for weeks to months. Because rubella is
a rare disease and the specificity of the test is <100%, many positive IgM tests will be false-positives. A
positive test, therefore, should always be confirmed by measuring anti-rubella IgG in paired acute and

DIAGNOSIS
convalescent sera (drawn 2 to 3 weeks apart), or by measuring IgG avidity. A 4-fold rise in serum rubella
IgG or seroconversion between acute and convalescent samples indicates acute infection and is useful
as a confirmatory test or if a false-negative rubella IgM is suspected. Low avidity IgG antibodies indicates
recent infection and high avidity IgG suggests a more distant infection. [CDC: laboratory protocols -
rubella] ([Link] [CDC: laboratory support for surveillance of vaccine-
preventable diseases] ([Link] Detection
of rubella RNA in direct clinical specimens or after incubation in tissue culture can also confirm infection.
Isolation of rubella virus from clinical specimens is diagnostic; however, viral culture is labour-intensive
and performed only in specialised reference laboratories. Molecular typing of rubella isolates by PCR is
invaluable for epidemiological purposes, and viral isolation should be attempted in all cases of confirmed
or strongly suspected rubella. Testing is especially important for pregnant women who may require expert
maternal-fetal management due to the risk of congenital rubella syndrome.

Typically, no other routine laboratory investigations are needed. An FBC may be obtained if patients
develop petechiae due to thrombocytopenia or if other more serious infections are suspected.

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 Rubella Diagnosis

History and exam

Key diagnostic factors
presence of risk factors (common)
• Strong risk factors include incomplete immunisation, exposure to infectious contacts, and international
travel.

maculopapular rash (common)

• Rash is often the first manifestation of rubella in young children. The rash of rubella is erythematous,
discrete, maculopapular, and sometimes mildly pruritic, and may be accentuated by heat.
DIAGNOSIS

Postnatal rubella rash

Centers for Disease Control and Prevention (CDC) Public Health Image Library
• It usually begins on the face and spreads from the head to the feet. Occasionally, there may be a
petechial component to the rash or palatal petechiae. The rash persists for an average of 3 to 4 days.

fever (common)
• Low-grade fever >37.2°C (99°F) occurs in up to 50% of infections.

arthralgias (common)
• Arthralgias are common in adults (occurring in up to 70% of adult women) but uncommon in children.
The most common joints affected are the fingers, wrists, and knees. The onset of joint symptoms
usually coincides with the rash and symptoms may persist for weeks. Rarely, symptoms may be
recurrent or chronic.[18]

lymphadenopathy (common)

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Rubella Diagnosis
• Mild lymphadenopathy involving the post-auricular, posterior cervical, and occipital lymph node groups
occurs in almost all patients and may precede the onset of rash by up to 1 week. Nodes are typically
non-tender and mobile.

incomplete immunisation (common)

• Un-immunised people or those whose immunisation status is unknown (e.g., people born in countries
where immunisation is not carried out or where measles-mumps-rubella [MMR] or measles-rubella
[MR] immunisation rates are low).

Other diagnostic factors

malaise (common)
• Prodromal malaise and other mild constitutional symptoms are more common in adults than in
children.

cory za or pharyngitis (common)

• Mild upper respiratory symptoms are common in school-age children and adults, and may precede the
onset of rash by several days.

arthritis (common)
• Arthritis is common in adults (occurring in up to 70% of adult women) but uncommon in children. The
most common joints affected are the fingers, wrists, and knees. The onset of joint symptoms usually
coincides with the rash and symptoms may persist for weeks. Rarely, symptoms may be recurrent or
chronic.[18]

conjunctivitis (common)
• Non-purulent conjunctivitis is reported in about 70% of adolescents and adults, but is less common in
children.[19]

Risk factors

DIAGNOSIS
Strong
incomplete immunisation
• In the US, 65% to 80% of rubella infections are reported in un-immunised people or those whose
immunisation status is unknown (i.e., people born in foreign countries where immunisation is not
carried out or where measles-mumps-rubella [MMR] or measles-rubella [MR] immunisation rates are
low).[2] Rubella vaccines are reported to be approximately 97% effective in preventing disease after a
single dose.[10]

exposure to infectious contact

• Rubella has been reported among susceptible contacts of people with rubella, often individuals who
have been infected abroad.[5] Up to 50% of cases are asymptomatic, so a negative exposure history
does not exclude rubella.

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 Rubella Diagnosis
international travel
• Rubella remains a global infectious disease concern, but vaccination efforts decreased reported cases
by 97% between 2000 and 2018.[3] By the end of 2018, 168 countries had introduced rubella vaccines
and global coverage was around 69%.[3] Since 2012, all people in the US with rubella infection had
evidence of becoming infected while living or traveling outside the US.[4] The risk to un-immunised
travellers to areas where rubella remains endemic or where outbreaks have been reported, particularly
in developing regions of Africa and Asia, may be high.[11]

Investigations
1st test to order

Test Result
serology IgM: positive in
acute serum; IgG:
• The most common diagnostic test is rubella-specific IgM serum
seroconversion or 4-fold
antibody. The preferred test is capture ELISA. False positive IgM
rise between acute and
tests are possible, so all positive IgM tests should be confirmed
by demonstrating a four-fold rise in rubella-specific IgG serum convalescent titres
concentrations between acute and convalescent sera (drawn 2-3
weeks apart), or by measurement of IgG avidity. Low avidity IgG
antibodies indicates recent infection and high avidity IgG suggests a
more distant infection. [CDC: laboratory protocols - rubella] (http://
[Link]/rubella/lab/[Link]) [CDC: laboratory support for
surveillance of vaccine-preventable diseases] ([Link]
vaccines/pubs/surv-manual/[Link])
FBC usually normal
• Occasionally thrombocytopenia may be present. This is thought to
have an immunological basis.
DIAGNOSIS

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Rubella Diagnosis

Other tests to consider

Test Result
viral culture may be positive
• Rubella virus can be isolated from the nasopharynx, throat, urine,
blood, and CSF from about 1 week before to 2 weeks after the
onset of rash. Viral cultures are not routinely obtained because they
are labour-intensive and performed only in specialised reference
laboratories. Viral isolation is important from an epidemiological
perspective and should be attempted if rubella is strongly suspected.
Specimens should be obtained as early in the course of the illness
as possible. Information is available from the US Centers for Disease
Control and Prevention (CDC) laboratory protocols. [CDC: laboratory
protocols - rubella] ([Link]
reverse-transcriptase PCR may be positive
• Detection of rubella in direct clinical specimens or after incubation in
tissue culture.
• Available commercially and in some countries through government
health authorities. Specimens should be obtained as early in the
course of the illness as possible. Information is available from the US
Centers for Disease Control and Prevention (CDC). [CDC: laboratory
protocols - rubella] ([Link]
[CDC: laboratory support for surveillance of vaccine-preventable
diseases] ([Link]
[Link])

DIAGNOSIS

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 Rubella Diagnosis

Differentials

Condition Differentiating signs / Differentiating tests

symptoms
Measles (rubeola) • Measles is a more severe • Positive serum measles anti-
illness. Erythematous or IgM antibody is the preferred
brownish morbilliform rash test (sensitivity 83% to 89%,
spreads from the head specificity 87% to 100%).[20]
and neck downwards [21]
and persists for 3 to 7 • Significant rise in serum
days. Coryza, cough, and measles anti-IgG antibody
conjunctivitis are usual. in paired acute and
• A pathognomonic enanthem convalescent specimens.
(Koplik's spots) occurs • Isolation of measles virus
early in the disease. from throat, nasopharynx,
Complications are blood, or urine (usually
common, particularly in processed by public health
immunocompromised and and reference laboratories
malnourished people. only).

Koplik's spots
Centers for Disease
Control and Prevention
(CDC) Public Health
Image Library
DIAGNOSIS

Child with measles

showing the characteristic
red blotchy rash on his
buttocks and back during
the third day of the rash
Centers for Disease
Control and Prevention
(CDC) Public Health
Image Library

Roseola infantum (HHV-6, • Typically affects children <2 • Anti-IgG antibody

HHV-7, exanthem subitum, years of age.[22] Coryza, seroconversion between
sixth disease) conjunctivitis, and cervical or paired acute and
occipital lymphadenopathy convalescent specimens
may precede 3 to 7 is the preferred test.[23]
days of high fever and Increases in serum-specific

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Rubella Diagnosis

Condition Differentiating signs / Differentiating tests

symptoms
irritability. Development antibody occur with viral
of an erythematous or reactivation. Specific serum
pinkish maculopapular rash IgM testing is not reliable.
coincides with the resolution HHV-6 and HHV-7 are
of fever and persists for serologically cross-reactive.
hours to several days. • Positive HHV-6/HHV-7
Febrile seizures occur in nucleic acid amplification
10% to 15%. from serum or plasma
(sensitivity 90% to 100%,
specificity 100%). Cannot
distinguish acute infection
from reactivation.[24]
• Isolation of virus from
peripheral blood (usually
processed by public health
and reference laboratories
only).

Scarlet fever (group A • Most common in school-age • Group A streptococcal rapid

Streptococcus pyogenes) children. Usually associated antigen testing is 60% to
with streptococcal 85% sensitive and 90% to
pharyngitis, but occasionally 100% specific.[25] Negative
complicates skin and soft- results should be confirmed
tissue infection. by throat culture.
• Pharyngitis, anterior • Isolation of group A
cervical adenopathy, and streptococcus from throat
fever precede a confluent culture on blood agar is 80%
erythematous blanching to 98% sensitive and 100%
'sandpaper' rash that begins specific.
on the trunk and behind the
ears and is accentuated
in flexural creases. Rash
resolves with desquamation

DIAGNOSIS
in 3 to 8 days.
• Other features include
an erythematous-coated
'strawberry' tongue,
circumoral pallor, and
Pastia's lines (linear
erythematous lesions in
skinfolds, particularly elbows
and axillae).

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 Rubella Diagnosis

Condition Differentiating signs / Differentiating tests

symptoms

The scarlet fever rash

first appears as tiny red
bumps on the chest and
abdomen that may spread
all over the body; looking
like sunburn, the skin
feels like a rough piece
of sandpaper and rash
lasts about 2 to 5 days
CDC Public Health
Image Library

Erythema infectiosum • Most common in children. • Positive serum

(parvovirus B19, fifth Mild systemic symptoms antiparvovirus B19 IgM
disease) and/or fever are followed in is the preferred test in
7 to 10 days by a distinctive immunocompetent people
erythematous facial rash (90% sensitive, 99%
with a 'slapped cheek' specific).[26]
appearance. • Nucleic acid amplification of
• An erythematous lacy parvovirus B19 DNA from
maculopapular rash may serum or plasma is more
also appear on the trunk sensitive, but may remain
and spread peripherally positive for up to 9 months
to the arms and thighs. after acute infection.[27]
Occasionally the rash
may be atypical and
DIAGNOSIS

indistinguishable from that

of rubella. Arthralgias and
arthritis are more common
with increasing age.

Enteroviral infections • Incidence is highest in • Nucleic acid amplification of

(echovirus, infants and young children enteroviral RNA from blood
coxsackievirus) and in the summer and or CSF is the most rapid and
early autumn. Most common sensitive test.[28]
presentation is a non- • Isolation of enterovirus from
specific febrile illness. stool, rectal swabs, throat,
Neurological and GI blood, CSF, or urine.
symptoms and stomatitis • Sensitivity and specificity
may be prominent. vary, depending on the type
of virus, site of infection, and
time at which specimens are
obtained.

West Nile virus • Incidence highest in • Specific IgM by antibody

summer, coinciding with capture ELISA is >95%
mosquito activity. Fever sensitive and 83% to 99%
is generally higher than specific after the first week
that observed with rubella,

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Rubella Diagnosis

Condition Differentiating signs / Differentiating tests

symptoms
and headache, myalgias, of illness, but may persist for
and weakness are more >1 year.[29]
prominent. • Fourfold increase in virus-
• A diffuse erythematous specific serum antibody
maculopapular or titres. Cross-reactivity with
morbilliform rash, which other arboviruses may occur.
spares the palms and soles, Positive results should be
is more common in children confirmed by virus-specific
than adults. Neuro-invasive IgG.
disease occurs in 0.3% to • Isolation of virus from CSF
1.0% of patients. or serum.
• Virus-specific IgM in CSF or
amplification of viral nucleic
acid from CSF (neuro-
invasive disease).

Dengue virus • Dengue virus is a flavivirus • Nucleic acid amplification

that is transmitted to of dengue virus RNA from
humans through the bite serum, plasma, CSF, or
of Aedes mosquitos, tissue specimens is the most
blood transfusion, organ rapid and sensitive test in the
transplantation, occupational first week of illness.
exposure to infected blood, • Most patients have serum
or by in utero or perinatal anti-dengue IgM antibodies
infection.[30] detectable by ELISA
• Dengue is endemic in many assay by the fifth day of
countries in Asia, the Pacific, illness. These may remain
Africa, the Caribbean, and detectable for 2 to 3 months.
the Americas, including IgG antibodies increase
Puerto Rico, the US Virgin more slowly and remain
Islands, Samoa, and Guam. elevated for months to years;
Sporadic outbreaks have comparison of acute and
been reported in Florida, convalescent (with at least

DIAGNOSIS
Hawaii, and the Texas- 7 days between samples) is
Mexico border, but most useful in differentiating acute
cases in the United States from distant infections.
are acquired in endemic
regions by travellers or
immigrants.
• Symptomatic patients with
mild disease (dengue fever)
may present with fever,
severe headache, myalgias,
arthralgias, and a diffuse
erythematous maculopapular
rash. Retro-orbital pain
and mild haemorrhagic
signs are common. More
severe forms of disease are
characterised by bleeding
and shock due to plasma
leak and intravascular
volume depletion.

Chikungunya virus • Chikungunya virus is an • Nucleic acid amplification of

alphavirus that is transmitted chikungunya virus RNA from

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 Rubella Diagnosis

Condition Differentiating signs / Differentiating tests

symptoms
through the bite of Aedes serum or plasma is the most
mosquitos and, rarely, by rapid and sensitive test in the
perinatal infection.[31] first week of illness.
• Most patients present • Specific anti-chikungunya
with fever and severe joint IgM and neutralising
pain. Headache, myalgias, antibodies may be
arthritis, conjunctivitis, or detectable towards the
a maculopapular rash may end of the first week of
occur. Disease may be illness. Comparison of acute
more severe in neonates, and convalescent sera is
the elderly, and people recommended.
with underlying medical
conditions. Joint pain or
arthritis may persist or recur
over months to years.
• Chikungunya virus outbreaks
have been reported in
many countries in Africa,
Asia, Europe, the Pacific,
the Caribbean, and South
America. In the US, most
infections have been
reported in travellers
returning from these areas.
Locally-transmitted infections
have been reported in
Florida, Texas, Puerto Rico
and the US Virgin Islands.

Zika virus • Zika virus is a flavivirus that • Recommendations for Zika

is transmitted to humans virus testing may differ
through the bite of Aedes between guidelines and
mosquitoes, by sexual locations.[33] [34] [35]
DIAGNOSIS

contact with people infected • Zika virus can be tested

with Zika virus, blood by PCR during the first
transfusion, or by in utero or week after disease onset.
perinatal infection.[32] Specific IgM and neutralising
• Zika virus infection should antibodies begin to develop
be suspected in returned late in the first week of
travellers from endemic illness. Cross-reactions
areas or those with other with other flaviviruses
epidemiological risk factors. are common, so positive,
• Zika virus outbreaks have equivocal, or inconclusive
been reported in many tests should be confirmed
tropical and sub-tropical by plaque-reduction
regions of the world. Local neutralisation assay..
mosquito-borne transmission
has been reported in
Puerto Rico, the US Virgin
Islands, and American
Samoa. Most people with
Zika virus infection are
asymptomatic. Features of
symptomatic disease include
fever, a maculopapular
rash, arthralgia, myalgia,

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Rubella Diagnosis

Condition Differentiating signs / Differentiating tests

symptoms
headache, and conjunctivitis.
Symptoms are generally
mild and persist for days to
a week. Rare complications
include Guillain-Barre
syndrome. Complications
of Zika virus infection in
pregnant women include
fetal loss, microcephaly,
and congenital central
nervous system and ocular
abnormalities.

Secondary syphilis • A generalised polymorphous • Positive VDRL, RPR tests

maculopapular rash begins are 100% sensitive and 93%
on the trunk and typically to 99% specific.[36]
involves the palms and • Results should be confirmed
soles. Other common by a specific treponemal test
manifestations include (FTA-ABS, 100% sensitive
condyloma lata, mucosal and 94% to 100% specific).
lesions, and generalised • Identification of spirochaetes
lymphadenopathy. by dark-field examination
• Fever and other of scrapings from moist
constitutional symptoms mucocutaneous lesions.
are not prominent. Clinical
manifestations resolve
spontaneously or with
treatment over several
weeks to months.

DIAGNOSIS

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 Rubella Diagnosis

Condition Differentiating signs / Differentiating tests

symptoms

Patient with a syphilitic

roseola-like rash, similar
to that of viral eczema,
which developed on
her buttocks and legs
during the secondary
stage of the disease
Centers for Disease
Control and Prevention
(CDC) Public Health Image
Library; from the collection
of J. Pledger, BSS/VD;
used with permission

Infectious mononucleosis • High fever, exudative • Positive antiviral capsid

(Epstein-Barr virus) pharyngitis, cervical antigen (VCA) IgM
or generalised antibodies are detectable in
DIAGNOSIS

lymphadenopathy, the second week of illness

hepatosplenomegaly, and an and disappear over several
atypical lymphocytosis are months. Anti-VCA IgG
common in adolescents and antibody is also detectable
adults. early in infection and persists
• Periorbital oedema is for life, whereas anti-EBV-
frequently observed early in associated nuclear antigen
infection. Children are more (EBNA) antibody develops
likely to be asymptomatic weeks to months after
or have a mild form of infection. The presence of
illness. A polymorphous anti-VCA Ab and absence of
rash, usually on the trunk anti-EBNA Ab are diagnostic
and arms, occurs in up of acute infection (sensitivity
to 20% of cases. Rash is 95% to 100%, specificity
more common in patients 86% to 100%).[37]
treated with ampicillin and • Heterophile antibody testing
other penicillins. Sometimes (monospot) is sensitive (81%
conjunctival haemorrhage to 95%) and specific (98% to
may be seen. 100%) in school-age children
and adults, but is insensitive
in young children.

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Rubella Diagnosis

Condition Differentiating signs / Differentiating tests

symptoms

A conjunctival
haemorrhage of the right
eye of this patient with
infectious mononucleosis
Centers for Disease
Control and Prevention
(CDC) Public Health
Image Library; from the
collection of Thomas F.
Sellers, Emory University;
used with permission

Tongue and palate of

patient with infectious
mononucleosis
Centers for Disease
Control and Prevention
(CDC) Public Health

DIAGNOSIS
Image Library; from
the collection of Dr
Sellers, Emory University;
used with permission

Kawasaki's syndrome • Occurs almost exclusively • No specific diagnostic test is

in children <8 years of age. available.
Prominent features are a • Suggestive laboratory
persistent high fever, bulbar and diagnostic imaging
conjunctivitis, erythematous findings include sterile
changes of the mouth and pyuria, hepatitis, CSF
pharynx, and dry, cracked pleocytosis, pericardial
lips, swelling and pain of the effusion, gall bladder
hands and feet, and cervical hydrops, and coronary artery
lymphadenopathy. abnormalities.
• Irritability, abdominal pain,
diarrhoea, and vomiting
are common. Peri-ungual
desquamation may be noted
in the second week of the
illness. Coronary and other
arterial aneurysms may

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 Rubella Diagnosis

Condition Differentiating signs / Differentiating tests

symptoms
develop 1 to 4 weeks after
the onset of illness.

Cutaneous drug reactions • Medications commonly • Clinical diagnosis based

associated with cutaneous on exposure history,
reactions include antibiotics resolution after withdrawal
and anticonvulsants. Many of the implicated drug, and
drug-induced rashes have exclusion of other potential
characteristic features causes. Eosinophilia
(erythema multiforme, is suggestive, but not
urticaria). diagnostic, of cutaneous
drug reactions.

Bullous erythema
multiforme
Centers for Disease
Control and Prevention
(CDC) Public Health Image
Library; from the collection
of Dr John Noble, Jr;
used with permission

Juvenile rheumatoid • Systemic-onset juvenile • There is no definitive

arthritis rheumatoid arthritis laboratory test. Leukocytosis,
commonly affects children thrombocytosis, anaemia,
and adolescents. Children elevated ESR, and elevated
are often ill-looking. Typically serum ferritin concentrations
there are daily high-spiking are suggestive.
DIAGNOSIS

fevers that, in the absence of

therapy, persist for weeks to
months.
• The rash is evanescent,
salmon-coloured, and
linear and typically involves
the trunk and extremities.
The presence of the rash
often coincides with fever.
Mild hepatosplenomegaly
and myalgias (or muscle
tenderness) are common.
Serositis may occur.
• Many patients develop
a chronic synovitis of ≥1
joints, but the onset of joint
involvement may be delayed.

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Rubella Diagnosis

Criteria
Centers for Disease Control and Prevention 2013 case definition[38]
Suspected

• Any generalised rash illness of acute onset that does not meet the criteria for probable or confirmed
rubella or any other illness.
Probable

• Absence of a more likely diagnosis and all of the following:

• Acute onset of generalised maculopapular rash

• Fever >37.2°C (99°F), if measured
• Arthralgia, arthritis, lymphadenopathy, or conjunctivitis
• Lack of epidemiological linkage to a laboratory-confirmed case
• Non-contributory or no serological or virological testing.

Confirmed

• A person with or without symptoms who has laboratory evidence of rubella infection confirmed by one
or more of the following tests:

• Isolation of rubella virus

• Detection of rubella-virus specific nucleic acid by polymerase chain reaction
• IgG seroconversion or a significant rise in serum rubella IgG antibody titres between acute- and
convalescent-phase sera as measured by any standard serological assay
• Positive serological test for rubella IgM antibody (note: false-positives are reported in people
with some other acute viral illnesses and in the presence of rheumatoid factor).
• Or, an illness characterised by all of the following:

DIAGNOSIS
• Acute onset of generalised maculopapular rash
• Fever >37.2°C (99°F), if measured
• Arthralgia, arthritis, lymphadenopathy, or conjunctivitis
• Epidemiological linkage to a laboratory-confirmed case of rubella.

Screening
Post-pubertal females should be assessed for rubella susceptibility at annual health examinations, family
planning visits, and visits to sexually transmitted infection clinics.[39] If these patients are found to be
susceptible by serological screening or their immunisation status is undocumented, they should be
immunised with measles-mumps-rubella (MMR) vaccine unless they are known to be pregnant.

People at increased risk of rubella infection (travellers to rubella endemic countries) should be assessed for
susceptibility to rubella and, if susceptible, should be immunised with MMR vaccine unless they are known to
be pregnant.

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 Rubella Management

Approach
Postnatal rubella is generally a mild, self-limiting condition. In non-pregnant patients, treatment is supportive.
No specific antiviral therapy is available. The disease is usually so mild that symptomatic treatment is usually
unnecessary, except for those with arthritis who may feel better with a non-steroidal anti-inflammatory drug
for a brief period.

Pregnant: susceptible to and exposed to rubella

Pregnant women with known exposure to rubella who are susceptible include those without immunity to
rubella or who have uncertain immunity (no or unknown immunisation history and no previous serological
testing). Regardless of symptoms, they should be referred to a high-risk perinatal specialist and a
paediatric infectious disease specialist to evaluate the likelihood of fetal infection and risk of sequelae.
Pregnancy termination is an option for those at high risk of delivering a child with neonatal rubella.

High dose polyclonal immunoglobulin may be of benefit for preventing clinical rubella but is not routinely
recommended for this purpose because there is insufficient evidence for prevention of congenital rubella
in the fetus.[40] This option may be considered for post-exposure prophylaxis if a pregnant woman will not
consider termination of the pregnancy.[39]

Treatment algorithm overview

Please note that formulations/routes and doses may differ between drug names and brands, drug
formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

Acute ( summary )
pregnant: susceptible to and
exposed to rubella

1st specialist referral

adjunct intramuscular immunoglobulin

non-pregnant: symptomatic rubella

1st supportive care

MANAGEMENT

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Rubella Management

Treatment algorithm
Please note that formulations/routes and doses may differ between drug names and brands, drug
formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

Acute
pregnant: susceptible to and exposed
to rubella

1st specialist referral

» Pregnant women with known exposure to

rubella who are susceptible to rubella or who
have uncertain immunity (no or unknown
immunisation history and no previous serological
testing), whether or not they are symptomatic,
should be referred to a high-risk perinatal
specialist and a paediatric infectious disease
specialist to evaluate the likelihood of fetal
infection and risk of sequelae. Pregnancy
termination is an option for those at high risk of
delivering a child with neonatal rubella.
adjunct intramuscular immunoglobulin
Treatment recommended for SOME patients in
selected patient group
Primary options

» normal immunoglobulin human: 0.55 mL/kg

intramuscularly as a single dose

» High dose polyclonal immunoglobulin may be

of benefit for preventing clinical rubella but is not
routinely recommended for this purpose because
there is insufficient evidence for prevention
of congenital rubella in the fetus.[40] This
option may be considered for post-exposure
prophylaxis if a pregnant woman will not
consider termination of the pregnancy.[39]
non-pregnant: symptomatic rubella

1st supportive care

» Postnatal rubella is generally a mild, self-

limiting condition that requires only symptomatic
therapy. No specific antiviral therapy is
available. A brief course of an NSAID, if no
contraindication exists, may be helpful for
patients with arthritis.
MANAGEMENT

Primary prevention
The rubella vaccine is a live attenuated virus. In the UK, it is available combined with both live attenuated
measles and mumps vaccine (MMR vaccine). The first dose is given at 1 year of age and the second dose is
given before school entry, at around 3 years and 4 months old.[12]

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 Rubella Management
Two live attenuated viral vaccines for the prevention of rubella are available in the US, a trivalent measles-
mumps-rubella formulation (MMR) and a quadrivalent measles-mumps-rubella-varicella formulation
(MMRV; licensed for use in people aged ≤12 years only).[10] [13] [14] [CDC: rubella vaccination] (https://
[Link]/vaccines/vpd/rubella/[Link]) The RA 27/3 strain rubella component of each of these
vaccines is identical. Rubella vaccines are reported to be approximately 97% effective in preventing
disease after a single dose.[10] Although 1 dose of rubella vaccine is highly protective, 2 doses of a rubella-
containing vaccine are recommended for children and adolescents because of the 2-dose recommendations
for measles- and mumps-containing vaccine and to provide additional protection to people who experience
primary vaccine failure. Depending on age and risk of exposure, 1 or 2 doses are recommended for
susceptible adults.[10] [14] In countries where there is a very low incidence of measles, mumps and rubella,
clinical diagnosis of rubella should not be considered acceptable evidence of immunity.[10] Local guidelines
on immunisation should be consulted.

Adverse reactions to MMR vaccines are infrequent. The most common adverse reactions include low-grade
fever, transient rash, and lymphadenopathy.[10] Multiple studies have failed to demonstrate a link between
MMR vaccines and autism.[15] [16] [17]

Secondary prevention
Patients with postnatal rubella should be isolated for 7 days after the onset of rash. Droplet and standard
precautions are recommended for hospitalised patients.[39]

Contact isolation is recommended for congenitally infected infants until 2 serial nasopharyngeal and urine
cultures obtained after 3 months of age are sterile, or for the first year of life.

Post-pubertal women should be assessed for susceptibility to rubella at all healthcare encounters. If these
women are found to be susceptible by serological screening or their immunisation status is undocumented,
they should be immunised with measles-mumps-rubella (MMR) vaccine unless they are known to be
pregnant.

Routine antenatal screening for rubella immunity is recommended. If the patient is susceptible, MMR should
be given in the immediate postnatal period.

People at increased risk of rubella infection (healthcare professionals, educators, childcare workers) should
be assessed for susceptibility to rubella and, if susceptible, should be immunised with MMR vaccine.
[CDC: rubella] ([Link] [Pan American Health Organization/WHO: rubella] (http://
[Link]/hq/[Link]?option=com_topics&view=article&id=48&Itemid=40768&lang=en)

Patient discussions
Mild analgesics or NSAIDs may be helpful in the management of constitutional and joint symptoms.

Parents should be aware of the importance of immunisation. [CDC: rubella - make sure your child gets
vaccinated] ([Link]
MANAGEMENT

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Rubella Follow up

Monitoring
Monitoring

FOLLOW UP
In general, no specific follow-up is required. Women who acquire rubella during pregnancy should be
managed in consultation with experts in fetal-maternal medicine and infectious diseases.

Complications

Complications Timeframe Likelihood

thrombocytopenia short term low

Occurs in approximately 1 in 3000 cases, most commonly in children.[1] Thrombocytopenia is probably

immune-mediated. Serious haemorrhagic complications may occur.

encephalitis short term low

Complicates 1 in 5000 cases of rubella.[41] The overall prognosis is good, but severe disease with
permanent neurological sequelae has been reported.[41] [42] No specific therapy is available for rubella
encephalitis. Supportive therapy as needed is indicated.

congenital rubella syndrome long term high

Maternal infection in pregnancy, particularly early in gestation, may cause spontaneous abortion, fetal
death, or a wide spectrum of anatomical and laboratory anomalies.

Women who acquire rubella during pregnancy should be managed in consultation with experts in fetal-
maternal medicine and infectious diseases.

neurological complications variable low

Rare neurological complications include progressive sclerosing panencephalitis, myelitis, optic neuritis,
peripheral neuritis, and Guillain-Barre's syndrome.

Symptoms typically develop several days after the rash. The overall prognosis is good, but severe disease
with permanent neurological sequelae has been reported.[41] [42]

Prognosis

Postnatal rubella is generally a mild illness that resolves spontaneously over several days to 1 week. The
most important consequence of postnatal rubella infection is congenital rubella syndrome.

Arthritis
Arthralgias and arthritis may persist for weeks or months or recur, particularly in adult women. However, the
overall prognosis for joint function is good.

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 Rubella Follow up

Pregnant women
Maternal infection in non-immune women during pregnancy, particularly early in gestation, may cause
spontaneous abortion, fetal death, or a wide spectrum of anatomical and laboratory anomalies (congenital
FOLLOW UP

rubella syndrome).

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Rubella Guidelines

Diagnostic guidelines

United Kingdom

Antenatal care for uncomplicated pregnancies (ht tps://[Link]/

guidance/CG62)
Published by: National Institute for Health and Care Excellence Last published: 2019

Treatment guidelines

United Kingdom

Immunisation against infectious disease 'The Green Book': Rubella (ht tps://
[Link]/government/collections/immunisation-against-infectious-

GUIDELINES
disease-the-green-book)
Published by: Public Health England Last published: 2018

Europe

Immunisation guidelines for Ireland (ht tps://[Link]/eng/health/

immunisation/hcpinfo/guidelines)
Published by: Royal College of Physicians of Ireland Last published: 2016

North America

Recommended child and adolescent immunization schedule for ages 18 years

or younger, United States, 2021 (ht tps://[Link]/vaccines/schedules/hcp/
imz/[Link])
Published by: Centers for Disease Control and Prevention Last published: 2021

Recommended adult immunization schedule for ages 19 years or older, United

States, 2021 (ht tps://[Link]/vaccines/schedules/hcp/imz/[Link])
Published by: Centers for Disease Control and Prevention Last published: 2021

Prevention of measles, rubella, congenital rubella syndrome, and mumps

(ht tps://[Link]/vaccines/hcp/acip-recs/vacc-specific/[Link])
Published by: Centers for Disease Control and Prevention Last published: 2013

Asia

IAP guidebook on immunization (ht tps://[Link]/iap-guidebook-on-

immunization)
Published by: Indian Academy of Pediatrics Last published: 2019

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GUIDELINES Rubella Guidelines

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Rubella Online resources

Online resources
1. CDC: rubella vaccination ([Link] (external link)

2. CDC: laboratory protocols - rubella ([Link] (external link)

3. CDC: laboratory support for surveillance of vaccine-preventable diseases ([Link]

vaccines/pubs/surv-manual/[Link]) (external link)

4. CDC: rubella - make sure your child gets vaccinated ([Link] (external
link)

5. CDC: rubella ([Link] (external link)

6. Pan American Health Organization/WHO: rubella ([Link]

option=com_topics&view=article&id=48&Itemid=40768&lang=en) (external link)

ONLINE RESOURCES

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 Rubella References

Key articles
• Centers for Disease Control and Prevention. Rubella/German measles: 2013 case definition. 2013
REFERENCES

[internet publication]. Full text ([Link]

References
1. Morse EE, Zinkham WH, Jackson DP. Thrombocytopenic purpura following rubella infection in
children and adults. Arch Int Med. 1966 Apr;117(4):573-9. Abstract ([Link]
pubmed/5948411?tool=[Link])

2. Centers for Disease Control and Prevention. Achievements in public health: elimination
of rubella and congenital rubella syndrome - United States, 1969-2004. Morb Mortal Wkly
Rep. 2005 Mar 25;54(11):279-82. Abstract ([Link]
tool=[Link])

3. World Health Organization. Rubella fact sheet. Oct 2019 [internet publication]. Full text (https://
[Link]/en/news-room/fact-sheets/detail/rubella)

4. Centers for Disease Control and Prevention. Rubella (German measles, three-day measles). Dec 2020
[internet publication]. Full text ([Link]

5. Papania MJ, Wallace GS, Rota PA, et al. Elimination of endemic measles, rubella, and congenital
rubella syndrome from the Western hemisphere: the US experience. JAMA Pediatr. 2014
Feb;168(2):148-55. Full text ([Link]
Abstract ([Link]

6. Lanzieri T, Haber P, Icenogle JP, et al. Rubella. In: Hamborsky J, Kroger A, Wolfe C, eds. CDC
The Pink Book: Epidemiology and prevention of vaccine-preventable diseases. Dec 2020 [internet
publication]. Full text ([Link]

7. Pan American Health Organization; World Health Organization. Elimination

of rubella and congenital rubella syndrome in the Americas. Fact Sheet 2015.
Apr 2015 [internet publication]. Full text ([Link]
option=com_content&view=category&layout=blog&id=831&Itemid=761&lang=en)

8. O'Connor P, Jankovic D, Zimmerman L, et al. Progress toward rubella elimination - World

Health Organization European Region, 2005-2019. MMWR Morb Mortal Wkly Rep. 2021
Jun 11;70(23):833-9. Full text ([Link]
s_cid=mm7023a1_w) Abstract ([Link]
tool=[Link])

9. Centers for Disease Control and Prevention (CDC). Nationwide rubella epidemic--Japan, 2013.
MMWR Morb Mortal Wkly Rep. 2013 Jun 14;62(23):457-62. Full text ([Link]

30 This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Jul 27, 2021.
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Rubella References
preview/mmwrhtml/[Link]) Abstract ([Link]
tool=[Link])

REFERENCES
10. McLean HQ, Fiebelkorn AP, Temte JL, et al; Centers for Disease Control and Prevention.
Prevention of measles, rubella, congenital rubella syndrome, and mumps, 2013: summary
recommendations of the Advisory Committee on Immunization Practices. MMWR Recomm Rep. 2013
Jun 14;62(RR-04):1-34. Full text ([Link]
Abstract ([Link]

11. Lambert N, Strebel P, Orenstein W, et al. Rubella. Lancet. 2015 Jun 6;385(9984):2297-307. Abstract
([Link]

12. Public Health England. Complete routine immunisation schedule. July 2020 [internet publication]. Full
text ([Link]

13. Centers for Disease Control and Prevention. Recommended child and adolescent immunization
schedule for ages 18 years or younger, United States, 2021. Feb 2021 [internet publication]. Full text
([Link]

14. Centers for Disease Control and Prevention. Recommended adult immunization schedule for ages
19 years or older, United States, 2021. Feb 2021 [internet publication]. Full text ([Link]
vaccines/schedules/hcp/imz/[Link])

15. Maglione MA, Das L, Raaen L, et al. Safety of vaccines used for routine immunization of
U.S. children: a systematic review. Pediatrics. 2014 Aug;134(2):325-37. Full text (https://
[Link]/content/134/2/[Link]) Abstract ([Link]
pubmed/25086160?tool=[Link])

16. Hviid A, Hansen JV, Frisch M, et al. Measles, mumps, rubella vaccination and autism: a nationwide
cohort study. Ann Intern Med. 2019 Apr 16;170(8):513-20. Full text ([Link]
fullarticle/2727726/measles-mumps-rubella-vaccination-autism-nationwide-cohort-study) Abstract
([Link]

17. Di Pietrantonj C, Rivetti A, Marchione P, et al. Vaccines for measles, mumps, rubella, and
varicella in children. Cochrane Database Syst Rev. 2020 Apr 20;4:CD004407. Full text (https://
[Link]/cdsr/doi/10.1002/14651858.CD004407.pub4/full) Abstract (http://
[Link]/pubmed/32309885?tool=[Link])

18. Tingle AJ, Allen M, Petty RE, et al. Rubella-associated arthritis. I: comparative study of joint
manifestations associated with natural rubella infection and RA 27/3 rubella immunisation. Ann
Rheum Dis. 1986 Feb;45(2):110-4. Full text ([Link]
pdf/[Link]) Abstract ([Link]
tool=[Link])

19. Gross PA, Portnoy B, Mathies AW Jr, et al. A rubella outbreak among adolescent boys. Am J
Dis Child. 1970 Apr;119(4):326-31. Abstract ([Link]
tool=[Link])

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 Rubella References
20. Perry RT, Halsey NA. The clinical significance of measles: a review. J Infect Dis. 2004 May 1;189
Suppl 1:S4-16. Full text ([Link]
Abstract ([Link]
REFERENCES

21. Ratnam S, Tipples G, Head C, et al. Performance of indirect immunoglobulin M (IgM) serology tests
and IgM capture assays for laboratory diagnosis of measles. J Clin Microbiol. 2000 Jan;38(1):99-104.
Full text ([Link] Abstract ([Link]
pubmed/10618071?tool=[Link])

22. Jackson MA, Sommerauer JF. Human herpesviruses 6 and 7. Pediatr Infect Dis J. 2002
Jun;21(6):565-6. Abstract ([Link]

23. American Academy of Pediatrics Committee on Infectious Diseases. Human herpesvirus 6 (including
roseola) and 7. In: Kimberlin DW, Brady MT, Jackson MA, et al, eds. 2018-2021 Report of the
Committee on Infectious Diseases: red book. Elk Grove Village, IL: American Academy of Pediatrics;
2018.

24. Chiu SS, Cheung CY, Tse CY, et al. Early diagnosis of primary human herpesvirus 6 infection in
childhood: serology, polymerase chain reaction, and virus load. J Infect Dis. 1998 Nov;178(5):1250-6.
Full text ([Link] Abstract ([Link]
pubmed/9780243?tool=[Link])

25. Tanz RR, Gerber MA, Kabat W, et al. Performance of a rapid antigen-detection test and
throat culture in community pediatric offices: implications for management of pharyngitis.
Pediatrics. 2009 Feb;123(2):437-44. Abstract ([Link]
tool=[Link])

26. Doyle S, Kerr S, O'Keeffe G, et al. Detection of parvovirus B19 IgM by antibody capture enzyme
immunoassay: receiver operating characteristic analysis. J Virol Methods. 2000 Nov;90(2):143-52.
Abstract ([Link]

27. Corcoran A, Doyle SJ. Advances in the biology, diagnosis and host-pathogen interactions
of parvovirus B19. Med Microbiol. 2004 Jun;53(Pt 6):459-75. Full text (https://
[Link]/content/journal/jmm/10.1099/jmm.0.05485-0#tab2) Abstract (http://
[Link]/pubmed/15150324?tool=[Link])

28. Vuorinen T, Vainionpaa R, Hyypia T. Five years' experience of reverse-transcriptase polymerase

chain reaction in daily diagnosis of enterovirus and rhinovirus infections. Clin Infect Dis. 2003 Aug
1;37(3):452-5. Full text ([Link] Abstract (http://
[Link]/pubmed/12884172?tool=[Link])

29. Tilley PA, Walle R, Chow A, et al. Clinical utility of commercial enzyme immunoassays during the
inaugural season of West Nile virus activity, Alberta, Canada. J Clin Microbiol. 2005 Sep;43(9):4691-5.
Full text ([Link] Abstract ([Link]
pubmed/16145128?tool=[Link])

30. Centers for Disease Control and Prevention. Dengue. July 2020 [internet publication]. Full text (https://
[Link]/Dengue)

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Rubella References
31. Centers for Disease Control and Prevention. Chikungunya virus. Sep 2019 [internet publication]. Full
text ([Link]

REFERENCES
32. Centers for Disease Control and Prevention. Zika virus. Nov 2019 [internet publication]. Full text
([Link]

33. Centers for Disease Control and Prevention. Zika virus: testing for Zika. Jun 2019 [internet publication].
Full text ([Link]

34. World Health Organization. Laboratory testing for Zika virus infection. Oct 2018 [internet publication].
Full text ([Link]

35. Pan American Health Organization, World Health Organization. Algorithm for detecting Zika virus
(ZIKV). [internet publication]. Full text ([Link]
[Link])

36. Muller I, Brade V, Hagedorn HJ, et al. Is serological testing a reliable tool in laboratory diagnosis of
syphilis? meta-analysis of eight external quality control surveys performed by the German Infection
Serology Proficiency Testing Program. J Clin Microbiol. 2006 Apr;44(4):1335-41. Full text (http://
[Link]/cgi/content/full/44/4/1335) Abstract ([Link]
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37. Bruu AL, Hjetland R, Holter E, et al. Evaluation of 12 commercial tests for detection of Epstein-
Barr virus-specific and heterophile antibodies. Clin Diagn Lab Immunol. 2000 May;7(3):451-6.
Full text ([Link] Abstract ([Link]
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38. Centers for Disease Control and Prevention. Rubella/German measles: 2013 case definition. 2013
[internet publication]. Full text ([Link]

39. American Academy of Pediatrics, Kimberlin DW, Brady MT, Jackson MA, Long SS. Red Book, 30th
Edition (2015). 2015 Report of the Committee on Infectious Diseases, 30th Edition. 2015. Elk Grove
Village, IL: American Academy of Pediatrics; 2015.

40. Young MK, Cripps AW, Nimmo GR, et al. Post-exposure passive immunisation for preventing rubella
and congenital rubella syndrome. Cochrane Database Syst Rev. 2015 Sep 9;(9):CD010586. Full text
([Link] Abstract (http://
[Link]/pubmed/26350479?tool=[Link])

41. Sherman FE, Michaels RH, Kenny FM. Acute encephalopathy (encephalitis) complicating rubella:
report of cases with virological studies, cortisol-production determinations, and observations at
autopsy. JAMA. 1965 May 24;192:675-81. Abstract ([Link]
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42. Bechar M, Davidovich S, Goldhammer G, et al. Neurological complications following rubella

infection. J Neurol. 1982;226(4):283-7. Abstract ([Link]
tool=[Link])

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 Rubella Images

Images
IMAGES

Figure 1: Postnatal rubella rash

Centers for Disease Control and Prevention (CDC) Public Health Image Library

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IMAGES
Figure 2: Koplik's spots
Centers for Disease Control and Prevention (CDC) Public Health Image Library

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IMAGES Rubella Images

Figure 3: Child with measles showing the characteristic red blotchy rash on his buttocks and back during the
third day of the rash
Centers for Disease Control and Prevention (CDC) Public Health Image Library

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IMAGES
Figure 4: The scarlet fever rash first appears as tiny red bumps on the chest and abdomen that may spread
all over the body; looking like sunburn, the skin feels like a rough piece of sandpaper and rash lasts about 2
to 5 days
CDC Public Health Image Library

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IMAGES Rubella Images

Figure 5: Patient with a syphilitic roseola-like rash, similar to that of viral eczema, which developed on her
buttocks and legs during the secondary stage of the disease
Centers for Disease Control and Prevention (CDC) Public Health Image Library; from the collection of J.
Pledger, BSS/VD; used with permission

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IMAGES
Figure 6: A conjunctival haemorrhage of the right eye of this patient with infectious mononucleosis
Centers for Disease Control and Prevention (CDC) Public Health Image Library; from the collection of
Thomas F. Sellers, Emory University; used with permission

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Figure 7: Tongue and palate of patient with infectious mononucleosis

Centers for Disease Control and Prevention (CDC) Public Health Image Library; from the collection of Dr
Sellers, Emory University; used with permission

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IMAGES
Figure 8: Bullous erythema multiforme
Centers for Disease Control and Prevention (CDC) Public Health Image Library; from the collection of Dr
John Noble, Jr; used with permission

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Contributors:

// Authors:

Elisabeth Adderson, MD
Associate Member
St. Jude Children's Research Hospital, Associate Professor of Pediatrics, University of Tennessee Health
Sciences Center, Memphis, TN
DISCLOSURES: EA declares that she has no competing interests.

// Peer Reviewers:

Elizabeth Barnet t, MD, FAAP

Director of International Clinical Maxwell Finland Laboratory for Infectious Diseases
Boston Medical Center, Associate Professor of Pediatrics, Boston University School of Medicine, Boston,
MA
DISCLOSURES: EB has received research grant support from Sandipasteen and Intercell and received an
honorarium to attend a meeting sponsored by Novartis. She receives royalties from the sale of a book she
edited.

Suzanne M. Garland, MBBS, MD, FRCPAm FAChSHM, FRANZCOG ad eundem

Director of Microbiological Research
Head of Clinical Microbiology and Infectious Diseases, Royal Women's Hospital, Senior Consultant of
Microbiology, Royal Children's Hospital, Professor, Faculty of Medicine, Dentistry and Health, Department of
Obstetrics and Gynaecology, University of Melbourne, Melbourne, Australia
DISCLOSURES: SMG has received advisory board fees and grant support from Commonwealth Serum
Laboratories and GlaxoSmithKline, and lecture fees from Merck and GSK. SMG has received funding
through her institution to conduct HPV vaccine studies for MSD and GSK.

Robert S. Duszak, OD, FAAO

Co-Director of Residency Program and Consulting Staff
Philadelphia Veterans Affairs Medical Center, Consulting Staff, Nemours Health Clinic & Mayfair Eye
Associates, Adjunct Clinical Faculty, Pennsylvania College of Optometry, Salus University, Philadelphia, PA
DISCLOSURES: RSD declares that he has no competing interests.