Rubella (German Measles)

How rubella spreads

Rubella spreads through droplets when an infected person coughs or sneezes, and from mother to baby during pregnancy. The incubation period is 12 to 23 days, usually 14 to 17. People are contagious from about a week before to a week after the rash appears. Babies born with congenital rubella can shed the virus for a year or more.

Thanks to vaccination, rubella is rare in the US: endemic transmission was declared eliminated in 2004. Cases still occur in travelers and unvaccinated people, and rubella remains common in parts of the world with low vaccine coverage.

Symptoms

Up to half of people have no symptoms. When present:

• prodrome (1 to 5 days, more common in adults): low-grade fever, headache, mild pink eye, sore throat, runny nose, tiredness
• swollen, tender lymph nodes behind the ears, at the back of the head and in the neck, often before the rash
• rash: pink or light red spots that start on the face and spread down to the trunk and limbs within 24 hours, often merging, and fading in the same order over about 3 days
• joint pain and swelling in fingers, wrists and knees, especially in adolescent and adult women, lasting up to a month
• small red spots on the soft palate (Forchheimer spots) in some people

Rubella vs measles

Other rash illnesses that can look similar include roseola, parvovirus B19 (fifth disease), scarlet fever and allergic rashes.

Rubella in pregnancy

Rubella infection during pregnancy can infect the baby. The risk is highest early:

• in the first 12 weeks, up to about 85% of babies are affected
• between 13 and 20 weeks, risk falls substantially
• after 20 weeks, birth defects are rare

Congenital rubella syndrome (CRS) can cause:

• deafness (most common)
• eye defects: cataracts (see juvenile cataracts), glaucoma, retinal damage
• congenital heart defects, such as patent ductus arteriosus and pulmonary stenosis
• intellectual disability, small head size, developmental delay
• low birth weight, liver and spleen enlargement, low platelets, rash
• later diabetes and thyroid problems

Diagnosis

Because rubella looks like other rash illnesses, testing is important, especially in pregnancy:

• blood test for rubella IgM antibodies (recent infection) and rising IgG
• PCR from a throat, nose or urine swab
• prenatal testing if infection is suspected in pregnancy
• newborns with suspected CRS are tested with IgM and PCR

Rubella is a nationally notifiable disease in the US; clinicians report cases to public health.

Treatment

There is no antiviral treatment. Care is supportive:

• rest and fluids
• acetaminophen (paracetamol) for fever and joint pain, following the label dose; no aspirin for children or teenagers
• staying away from school, work and especially pregnant people for 7 days after the rash starts

Babies with CRS need multidisciplinary care for hearing, vision, heart and developmental needs.

Prevention

• MMR vaccine: two doses, at 12 to 15 months and 4 to 6 years. One dose gives about 97% protection against rubella.
• Women planning pregnancy should check their immunity and, if not immune, receive MMR at least 1 month before trying to conceive. MMR is not given during pregnancy; non-immune pregnant people are vaccinated after delivery.
• Adults without evidence of immunity, healthcare workers, college students and international travelers should be vaccinated.

Frequently asked questions

What are the symptoms of rubella?

Rubella usually causes a mild fever, swollen glands behind the ears and in the neck, and a pink rash that starts on the face and spreads downward, lasting about 3 days. Adults, especially women, may have joint pain. Many people have no symptoms.

Why is rubella dangerous in pregnancy?

Rubella can pass to the baby, especially in the first 12 weeks, causing miscarriage, stillbirth or congenital rubella syndrome. This can lead to deafness, cataracts, heart defects and intellectual disability. Vaccination before pregnancy prevents it.

What is the difference between rubella and measles?

Both cause rashes and are prevented by the MMR vaccine, but they are different viruses. Rubella is usually mild with a short-lived pink rash and swollen glands. Measles causes high fever, cough, red eyes and a longer rash, and can cause serious complications.

How long is rubella contagious?

People with rubella are contagious from about 7 days before to 7 days after the rash appears. They should avoid school, work and contact with pregnant people for 7 days after the rash starts. Babies with congenital rubella can be contagious for a year or longer.

Do adults need the rubella vaccine?

Adults born in 1957 or later without proof of immunity should receive at least one dose of MMR. Women who could become pregnant, healthcare workers, students and travelers are especially important to protect. A blood test can check immunity.