Measles, German (Rubella)

Measles, German (Rubella) is a topic covered in the 5-Minute Clinical Consult.

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  • A generally self-limited viral infection of children and adults, characterized by a mild, maculopapular rash, lymphadenopathy, and slight fever. Complications in normal populations are rare. Nonimmune women infected with rubella while pregnant may have devastating fetal effects.
  • 25–50% of all rubella infections are asymptomatic (1,2)[A].
  • System(s) affected: hematologic; nervous; pulmonary; exocrine; ophthalmologic; skeletal
  • Synonym(s): German measles; 3-day measles
Pregnancy Considerations
  • Pregnancy-associated rubella infection may lead to congenital rubella syndrome (CRS) with potentially devastating fetal outcomes.
  • CRS is present in up to 90% of fetuses exposed during the 1st trimester (2)[A].
  • Screening pregnant women for rubella immunity and vaccinating nonimmune women is the most effective strategy to prevent CRS (2)[A].
  • Although no case of vaccine-associated CRS has been reported, women should not become pregnant for at least 28 days after vaccination because vaccine-type virus can cross the placenta (2)[A].
  • Polymerase chain reaction (PCR) determination of viral RNA in amniotic fluid and fetal blood sampling allow for rapid diagnosis of fetal infection after 15 weeks’ gestation (3)[B].


  • 50- to 70-nm RNA togavirus of genus Rubivirus (1)
  • 13 genotypes have been identified (4).
  • A live attenuated vaccine has been available in the United States since 1969. Primary use is to prevent CRS.
  • Since 2004, all U.S. cases of rubella have been imported, most are inadequately immune travelers (1).
  • Average incubation: 14 days; ranges 12 to 23 days
  • Infectious period between 7 days before and 5 to 7 days after rash onset
  • Transmitted primarily via respiratory droplets
  • Most common in late winter and early spring
  • Humans are only natural hosts (1).

  • U.S. incidence: <10/100,000 since 2001
  • Declared eliminated (no endemic transmission for 12+ months) from the United States in 2004. However, primarily due to disease in international travelers, vaccine avoidance, and lack of routine pediatric care in migrant populations, cases are still reported annually.
  • 667 cases from 27 states (a record number) reported to the CDC in 2015
  • Still occurs in developing countries with 100,000 cases of CRS reported annually worldwide

Etiology and Pathophysiology

  • Virus invades the respiratory epithelium, replicates in nasopharynx and regional lymph nodes, and spreads hematogenously. Infected patients shed virus from the nasopharynx 3 to 8 days after inoculation. Shedding lasts 7 or more days after onset of rash.
  • Disease typically progresses from a prodromal stage (1 to 5 days) to lymphadenopathy (5 to 10 days) to an exanthematous, pruritic, maculopapular rash. Petechiae on the soft palate (Forchheimer spots) may precede or accompany the rash. Rash starts on the face and spreads outward to the trunk and extremities, sparing the palms and soles (14 to 17 days after onset of prodromal symptoms). The rash typically lasts an average of 3 days.
  • Rubella first described by German scientists in the early 1800s as a variant of measles or scarlet fever
  • 1962 to 1965: global pandemic resulting in an estimated 12.5 million cases in the United States, with 2,000 cases of encephalitis; 11,250 cases of therapeutic or spontaneous abortions; 2,100 neonatal deaths; and 20,000 infants born with CRS (1)[A]

Children with CRS and children with type 1 diabetes share a high frequency of HLA-DR3 histocompatibility Ag and a high prevalence of islet cell Ab.

Risk Factors

Inadequate immunization, inadequate immunity after prior vaccination, immunodeficiency states, immunosuppressive therapy, crowded living/working conditions, international travel (1)[A]

General Prevention

  • Vaccination is the most effective preventive strategy.
  • Available combined with mumps, measles, rubella (MMR) or with varicella (MMR-V). Isolated rubella vaccine is not available in the United States.
    • Adults: 1- or 2-dose MMR vaccine schedule is recommended for those born after 1957. When 2 doses are used, each must be ≥28 days apart.
    • Pediatric: A 2-dose MMR vaccine schedule is recommended with the first dose given at ages 12 to 15 months; second dose recommended either at 4 to 6 years or at 11 to 12 years of age
    • Special pediatric cases: In special circumstances (e.g., upcoming international travel), the second dose may be given prior to 4 years of age but no sooner than 28 days since the initial dose.
    • Children 6 to 11 months of age may also receive a single dose prior to international travel but should be revaccinated with full 2-dose schedule starting at 12 months of age.
    • Children with HIV should receive MMR vaccine at 12 months of age if no contraindications exist. In the event of an outbreak, immediate vaccination of infants 6 to 11 months old is recommended (2)[A].
    • Vaccination is recommended for nonimmune people in the following groups: prepubertal boys and girls, all women of reproductive age, college students, daycare personnel, health care workers, and military personnel.
  • Contraindications to vaccine: pregnancy, immunodeficiency (except HIV infection), within 3 months of IVIG or blood administration, severe febrile illness, or hypersensitivity to vaccine components. Patients who receive rubella vaccine do not transmit rubella to others, although the virus can be isolated from the pharynx. Breastfeeding is not a contraindication to vaccination (1)[A].
  • During outbreaks, serologic screening before vaccination is not recommended because rapid mass vaccination is needed to stop disease spread (2)[A].
  • MMR vaccine is not associated with autism (4)[A],(5)[B].
  • Children who receive the MMR-V vaccine have a 2-fold increase in risk of febrile seizures compared with those who receive MMR and varicella vaccines separately (5)[B].
  • Routine rubella antibody (IgG) screening is recommended during pregnancy (4)[A].

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