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For further information, see CMDT Part 32-02: Major Vaccine-Preventable Viral Infections

Key Features

Essentials of Diagnosis

  • Exposure 14–21 days before onset

  • No prodrome in children, mild prodrome in adults; mild symptoms (fever, malaise, coryza) coincide or precede eruption of rash by up to 5 days

  • Posterior cervical and postauricular lymphadenopathy 5–10 days before rash

  • Fine maculopapular rash of 3 days' duration; face to trunk to extremities

  • Leukopenia, thrombocytopenia

General Considerations

  • Transmitted by inhalation of infective droplets; it is moderately communicable

  • Disease is transmissible from 1 week before the rash appears until 15 days afterward

  • Infection usually confers permanent immunity


  • The last reported cases of endemic rubella and congenital rubella syndrome were in 2009 from the Americas region

  • In 2015, the WHO declared the Americas region free of rubella and congenital rubella syndrome

  • While 33 countries in Europe are declared free of rubella, some European countries are facing a challenge with lower immunization coverage among refugees and migrants

  • Worldwide, cases are decreasing due to widespread implementation of rubella-containing vaccines

  • On the other hand, the number of cases of congenital rubella syndrome is increasing, particularly in Southeast Asia

Clinical Findings

Symptoms and Signs

Postnatal rubella

  • Most cases are asymptomatic

  • Fever and malaise, usually mild, accompanied by tender suboccipital adenitis, may precede the eruption by 1 week

  • Early posterior cervical and postauricular lymphadenopathy is common

  • A fine, pink maculopapular rash appears and fades from the face, trunk, and extremities in rapid progression (2–3 days), usually lasting 1 day in each area

Congenital rubella

  • Infection has devastating effects on the fetus in utero

    • Fetal death

    • Preterm delivery

    • Teratogenic effects

  • Severity of symptoms is directly related to the gestational age

    • Fetal infection during the first trimester leads to congenital rubella in at least 80% of fetuses

    • An infection during the fourth month can lead to 10% risk of a single congenital defect

    • In the second trimester of pregnancy, deafness is the primary complication

  • The manifestations of congenital rubella syndrome can be divided into transient, permanent, and developmental

    • Transient manifestations: thrombocytopenic purpura, low birth weight, and hepatosplenomegaly

    • Other manifestations: early-onset cataracts and glaucoma, microphthalmia, hearing deficits, psychomotor retardation, congenital heart defects (patent ductus arteriosus, branch pulmonary artery stenosis)

Differential Diagnosis

  • Infectious mononucleosis

  • Measles

  • Echovirus infections

  • Coxsackievirus infections


  • Antibody testing can be performed on sera or saliva

  • Diagnosis of acute infection is based on elevated IgM antibody, fourfold or greater rise in IgG antibody titers, or isolation of the virus

  • IgM is detectable in 50% of persons on day 1 of the rash but in most on day 5 after rash ...

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