Rubella

Infection Control in Healthcare Personnel: Epidemiology and Control of Selected Infections Transmitted Among Healthcare Personnel and Patients (2024)

At a glance

Rubella from the Infection Control in Healthcare Personnel: Epidemiology and Control of Selected Infections Transmitted Among Healthcare Personnel and Patients (2024) guideline.

Recommendations

Recommendations

  1. For asymptomatic healthcare personnel with presumptive evidence of immunity to rubella (https://www.cdc.gov/mmwr/preview/mmwrhtml/rr6204a1.htm#Tab3) who have an exposure to rubella:
  • Work restrictions are not necessary.
  • Implement daily monitoring for signs and symptoms of rubella from the 7th day after their first exposure through the 23rd day after their last exposure.
  1. For asymptomatic healthcare personnel without presumptive evidence of immunity to rubella who have
    an exposure to rubella, exclude from work from the 7th day after their first exposure through the 23rd
    day after their last exposure.
  1. For healthcare personnel with known or suspected rubella, exclude from work for 7 days after the rash
    appears.

For recommendations about healthcare personnel who are pregnant or intending to become pregnant, please see the Pregnant HCP section.

Background

Rubella (German Measles, Three-Day Measles) is a viral rash illness that is typically mild, but that can lead to complications and death1. Although endemic in many countries in the world, rubella was declared eliminated in the US in 2004.2 The US elimination of rubella was reconfirmed in 2011, and maintenance of elimination was reported in 2014.34 No documented transmission of rubella to healthcare personnel (HCP) or others in US healthcare facilities has occurred since elimination was declared; however, imported cases of rubella and congenital rubella syndrome (CRS) have been reported, and HCP exposures have occurred.5 Rubella transmission in US medical settings was documented extensively in the decades before elimination, with serious consequences, including pregnancy terminations, disruption of hospital routine, absenteeism from work, and expensive containment measures.67891011121314151617

Prevention of transmission of the rubella virus in healthcare settings involves (a) ensuring healthcare personnel have presumptive evidence of immunity18; (b) using infection prevention and control practices as recommended by CDC (https://www.cdc.gov/infectioncontrol/guidelines/isolation/appendix/type-durationprecautions.html#R)19; and (c) excluding potentially infectious HCP from work.220 Recommendations for rubella vaccination of HCP are maintained by CDC and ACIP (https://www.cdc.gov/vaccines/hcp/acip-recs/vaccspecific/mmr.html).21

Occupational Exposure

Transmission of rubella occurs through deposition of respiratory, oral, or nasal secretions from an infected source person on the mucus membranes of a susceptible host. An exposure to rubella is generally defined as being within close proximity of an infectious source person (e.g., within approximately 6 feet of the patient) while unprotected (i.e., not wearing recommended personal protective equipment) or having mucous membrane contact with their secretions.2 The risk of virus transmission may increase depending on a number of factors (e.g., decreased room ventilation, increased exposure time, closer proximity to an infectious source person).

Clinical Features

Rubella is characterized by a mild, maculopapular rash; lymphadenopathy; and fever.1 The rash occurs in 50% to 80% of infected people and usually starts on the face, becomes generalized within 24 hours, and lasts a median of 3 days.1 Many rubella infections are not recognized because the rash resembles other rash illnesses.1 When rubella infection occurs during pregnancy, especially during the first trimester, congenital infection and serious consequences can result, including miscarriages, stillbirths and fetal deaths, and severe birth defects.2 Additional complications of rubella include arthralgia or arthritis, which may occur in up to 70% of adult women with rubella, and rarely thrombocytopenic purpura and encephalitis.1

The average incubation period of rubella virus is 17 days, with a range of 12 to 23 days.1 Persons with rubella are most infectious when the rash is erupting, but they can shed virus from 7 days before to 7 days after rash onset.12 Certain populations infected with rubella, such as infants with Congenital Rubella Syndrome, may excrete virus for prolonged periods, which may extend their infectious period.522 Approximately 25% - 50% of rubella infections are asymptomatic.1

Testing and Diagnosis

Clinical diagnosis of rubella is unreliable; therefore, cases are laboratory confirmed.2 Options for rubella testing include detection of the virus by Polymerase Chain Reaction (PCR), the presence of rubella-specific IgM antibody, or demonstration of a significant rise in IgG antibody from paired acute- and convalescent-phase sera.22 Virus detection and serologic testing can be used to confirm acute or recent rubella infection.2 Information on laboratory testing for rubella is available on the CDC website (https://www.cdc.gov/rubella/lab/index.html).23

Postexposure Prophylaxis

No evidence exists that postexposure vaccination is effective in preventing rubella infection622. and PEP after exposure to rubella is not typically offered. Due to the lack of evidence, even if HCP receive postexposure vaccination, they are still excluded from work as is recommended for those without presumptive evidence of immunity to rubella.

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Content Source:
National Center for Emerging and Zoonotic Infectious Diseases (NCEZID)
  1. Centers for Disease Control and Prevention. Rubella (German Measles, Three-Day Measles) For Healthcare Professionals. Updated December 31, 2020. Accessed October 7, 2022, https://www.cdc.gov/rubella/hcp.html
  2. Lanzieri T, Redd S, Abernathy E, Icenogle J. Chapter 14: Rubella. Centers for Disease Control and Prevention, Updated March 6, 2020. Accessed October 7, 2022, https://www.cdc.gov/vaccines/pubs/surv-manual/chpt14-rubella.html
  3. Rubella and congenital rubella syndrome control and elimination - global progress, 2000-2014. Releve epidemiologique hebdomadaire. Sep 25 2015;90(39):510-6.
  4. Rubella vaccines: WHO position paper. Releve epidemiologique hebdomadaire. Jul 15 2011;86(29):301-16.
  5. Robyn M, Dufort E, Rosen JB, et al. Two Imported Cases of Congenital Rubella Syndrome and Infection-Control Challenges in New York State, 2013-2015. Journal of the Pediatric Infectious Diseases Society. May 16 2017;doi:10.1093/jpids/pix028
  6. Immunization of health-care personnel: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recommendations and reports : Morbidity and mortality weekly report Recommendations and reports. Nov 25 2011;60(Rr-7):1-45.
  7. Greaves WL, Orenstein WA, Stetler HC, Preblud SR, Hinman AR, Bart KJ. Prevention of rubella transmission in medical facilities. JAMA. 1982;248(7):861-864. doi:10.1001/jama.1982.03330070049029
  8. Gladstone JL, Millian SJ. Rubella exposure in an obstetric clinic. Obstetrics and gynecology. Feb 1981;57(2):182-6.
  9. Nosocomial rubella infection - North Dakota, Alabama, Ohio. MMWR Morbidity and mortality weekly report. 1981;29(52):630-631.
  10. Strassburg MA, Imagawa DT, Fannin SL, et al. Rubella outbreak among hospital employees. Obstetrics and gynecology. Mar 1981;57(3):283-8.
  11. Fliegel PE, Weinstein WM. Rubella outbreak in a prenatal clinic: management and prevention. American journal of infection control. Feb 1982;10(1):29-33.
  12. Polk BF, White JA, DeGirolami PC, Modlin JF. An outbreak of rubella among hospital personnel. The New England journal of medicine. Sep 04 1980;303(10):541-5. doi:10.1056/nejm198009043031001
  13. McLaughlin MC, Gold LH. The New York rubella incident: a case for changing hospital policy regarding rubella testing and immunization. American journal of public health. Mar 1979;69(3):287-9.
  14. Heseltine PN, Ripper M, Wohlford P. Nosocomial rubella--consequences of an outbreak and efficacy of a mandatory immunization program. Infection control: IC. Sep 1985;6(9):371-4.
  15. Rubella in hospitals--California. MMWR Morbidity and mortality weekly report. Jan 28 1983;32(3):37-9.
  16. Centers for Disease Control and Prevention. Exposure of patients to rubella by medical personnel - California. Morbidity and Mortality Weekly Report. 1978;27(15):123.
  17. Centers for Disease Control and Prevention. Rubella in hospital personnel and patients - Colorado. Morbidity and Mortality Weekly Report. 1979;28(28):325-7.
  18. Centers for Disease Control and Prevention. CDC’s Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings. Updated November 29, 2022. Accessed April 3, 2023. https://www.cdc.gov/infectioncontrol/guidelines/core-practices/index.html
  19. Siegel JD, Rhinehart E, Jackson M, Chiarello L, and the Healthcare Infection Control Practices Advisory Committee. Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings (2007) Appendix A: Type and Duration of Precautions Recommended for Selected Infections and Conditions: Rubella. Updated July 22, 2019. Accessed February 28, 2023. https://www.cdc.gov/infectioncontrol/guidelines/isolation/appendix/type-duration-precautions.html#R
  20. Siegel JD, Rhinehart E, Jackson M, Chiarello L. 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Health Care Settings. American journal of infection control. Dec 2007;35(10 Suppl 2):S65-164. doi:10.1016/j.ajic.2007.10.007
  21. Centers for Disease Control and Prevention. MMR Advisory Committee on Immunization Practices (ACIP) Vaccine Recommendations (Measles, Mumps and Rubella). Updated November 28, 2022. Accessed December 16, 2022. https://www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/mmr.html
  22. Lanzieri T, Haber P, Icenogle J, Patel M. Epidemiology and Prevention of Vaccine-Preventable Diseases: Rubella. Centers for Disease Control and Prevention,. Updated August 18, 2021. Accessed October 7, 2022, https://www.cdc.gov/vaccines/pubs/pinkbook/rubella.html
  23. Centers for Disease Control and Prevention. Rubella (German Measles, Three-Day Measles): Laboratory Testing. Updated December 31, 2020. Accessed December 16, 2022. https://www.cdc.gov/rubella/lab/index.html
  • McLean HQ, Fiebelkorn AP, Temte JL, Wallace GS. Prevention of Measles, Rubella, Congenital Rubella Syndrome, and Mumps, 2013: Summary Recommendations of the Advisory Committee on Immunization Practices (ACIP): TABLE 3. Acceptable presumptive evidence of immunity to measles, rubella, and mumps. Updated June 14, 2013. Accessed April 3, 2023. https://www.cdc.gov/mmwr/preview/mmwrhtml/rr6204a1.htm#Tab3