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Q&A: What providers need to know about congenital rubella syndrome
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According to the CDC, rubella was eliminated in the United States in 2004. However, international travel can leave unvaccinated individuals vulnerable to infection.
Infection is especially concerning among women of childbearing age. According to the CDC, it is estimated that more than 100,000 infants around the world are born with congenital rubella syndrome annually.
In a letter to the editor published in Infection Control & Hospital Epidemiology, Ritu Cheema, MD, a health sciences clinical assistant professor of pediatric infectious diseases at the University of California, Davis Children’s Hospital, and colleagues described their experiences caring for a child with congenital rubella syndrome.
The child was born to a mother who recently immigrated from Afghanistan. The mother was vaccinated during the immigration process but was infected with rubella before she received the vaccine and was unaware that she was pregnant. Her child was born late preterm and first presented with a rash on the face and trunk, bilateral cataracts, a grade 4/6 systolic heart murmur and hypotonia.
Cheema said women of child-bearing age in the U.S., especially those who have traveled to or from developing countries, should be vaccinated against rubella to prevent congenital infection in their infant.
“There is more exposure to people from developing countries,” she said. “The risk is higher since there are so many medical exemptions. People have the opportunity to get vaccinated, but they are not. This is what puts them at risk for getting infected.”
Infectious Diseases in Children spoke with Cheema to find out what providers need to know about this condition. – by Katherine Bortz
Q: Why is it important that today’s providers are familiar with an illness that was eliminated from the U.S. more than a decade ago?
A: Our generation may not be familiar with the clinical presentation of this illness. Our aim was to heighten awareness of how this congenital viral syndrome presents. We saw a patient with congenital rubella syndrome, which triggered the literature. We wanted to share our experience.
If you don’t have a high level of suspicion, you could have a high chance of misdiagnosing congenital rubella syndrome. When you miss it, there would not only be negative prognostic effects by delaying referral to different subspecialties, but there would be an increased risk for spreading the infection further into the community by not following appropriate isolation precautions.
Q: Are there challenges in identifying congenital rubella syndrome?
A: People may think that just because the disease is eliminated, there’s no chance they’re going to see it. Clinical presentations can be confusing because its symptoms overlap with other congenital infections, specifically cytomegalovirus (CMV). Babies can present with a rash, which we call a blueberry muffin lesion. They are vascular, purplish, small, disseminated lesions on the face and trunk that can be seen with CMV. However, blueberry muffin rashes are one thing that should make people think of rubella, especially if they have associated findings of hepatosplenomegaly, microcephaly, petechiae and thrombocytopenia, which can also be seen with CMV.
CMV is much more common. You might just test for CMV. If the test for CMV is negative, you might stop testing. I would recommend that people consider congenital rubella in the appropriate settings.
There are other organ systems also involved with congenital rubella syndrome. Infants can have some hearing loss, cataracts and glaucoma. It can affect the heart. If you see a combination of the blueberry muffin rash, cataract and heart involvement, I would investigate that child for congenital rubella.
Q: How can early identification of congenital rubella syndrome affect a child’s outcomes?
A: Unfortunately, there is no treatment or antiviral agent that we can use for these children, so it’s more supportive care. Once the child is diagnosed, we can refer them to appropriate specialist care. If there is eye involvement, the child will need an ophthalmology evaluation. Even if hearing is normal, you’ll want to monitor them closely at regular intervals to make sure they continue to have normal hearing because they are at high risk for hearing loss. If there’s a heart defect, they should be seen by a cardiologist.
They may also have some developmental delays and may need follow-up with a physical therapist, occupational therapist and speech-language pathologist.
At the same time, there are infection control measures that need to be followed because the virus can shed in their respiratory secretions and urine for up to age 1 year. If we know that a child has congenital rubella syndrome, there will need to be contact isolation provided to ensure that they don’t spread it to other people, especially those who may not have been vaccinated. We say that contact isolation should be continued until there is no shedding, so up to age 1 year. But, if you have two negative rubella cultures or polymerase chain reaction tests from throat or urine samples 1 month apart after age 3 months, the child is no longer contagious and should be able to go into the regular public.
Q: Are the infection control measures for congenital rubella syndrome feasible?
A: I think most public health departments can facilitate testing earlier than age 1 year. In general, we don’t see patients having to be in contact isolation up to age 1 year too often.
When these patients are seen at pediatricians’ offices, they need to be put in a room where contact precautions need to be followed. Physicians need to wear gowns and gloves because there may be contact with a wet diaper and they may have contact with urine or saliva.
Q: In light of reduced vaccine uptake, could this condition make a comeback?
A: Absolutely. If people are less immunized, more people are at risk for getting it. In this population, who we’re most concerned about are pregnant women. Pregnant women should be screened for rubella and avoid exposure to people with rubella. If women have not received the vaccine, they should be vaccinated in the post-partum period so that they are protected for future potential pregnancies.
References:
CDC. Manual for the surveillance of vaccine-preventable diseases: Congenital rubella syndrome. https://www.cdc.gov/vaccines/pubs/surv-manual/chpt15-crs.html#maintenance. Accessed Aug. 23, 2019.
Gupta AM, Cheema R. Infect Control Hosp Epidemiol. 2019;doi:10.1017/ice.2019.214.
Disclosure: Cheema reports no relevant financial disclosures.