RUBELLA (GERMAN MEASLES)

I. BACKGROUND The name rubella is derived from a Latin term meaning "little red." Rubella is generally a benign communicable exanthematous disease. It is caused by rubella virus, which is a member of the Rubivirus genus of the family Togaviridae. Nearly one half of individuals infected with this virus are asymptomatic. Clinical manifestations and severity of illness vary with age. For instance, infection in younger children is characterized by mild constitutional symptoms, rash, and suboccipital adenopathy; conversely, in older children, adolescents, and adults, rubella may be complicated by arthralgia, arthritis, and thrombocytopenic purpura. Rare cases of rubella encephalitis have also been described in children. The major complication of rubella is its teratogenic effects when pregnant women contract the disease, especially in the early weeks of gestation. The virus can be transmitted to the fetus through the placenta and is capable of causing serious congenital defects, abortions, and stillbirths. Fortunately, because of the successful immunization program initiated in the United States in 1969, rubella infection and congenital rubella syndrome rarely are seen today. See the images below. The few cases of rubella recorded in recent years involve susceptible individuals who have not been immunized with rubella vaccine and do not have a history of previous rubella infection. An independent panel convened by the Centers for Disease Control and Prevention (CDC) in 2004 found that about 91% of the US population is immune to rubella. This explains the decreased number of outbreaks of rubella and congenital rubella syndrome reported in the recent years. II. CAUSES

Rubella is caused by a virus that is spread through the air or by close contact. A person with rubella may spread the disease to others from 1 week before the rash begins, until 1 - 2 weeks after the rash disappears. Because the measles-mumps-rubella (MMR) vaccine is given to most children, rubella is much less common now. Almost everyone who receives the vaccine has immunity to rubella. Immunity means that your body has built a defense to the rubella virus. In some adults, the vaccine may wear off and not fully protect them. Women who may become pregnant and other adults may receive a booster shot. Children and adults who were never vaccinated against rubella may still get this infection.

III.

PATHOPHYSIOLOGY a. Postnatal rubella The usual portal of entry of rubella virus is the respiratory epithelium of the nasopharynx. The virus is transmitted via the aerosolized particles from the respiratory tract secretions of infected individuals. The virus attaches to and invades the respiratory epithelium. It then spreads hematogenously (primary viremia) to regional and distant lymphatics and replicates in the reticuloendothelial system. This is followed by a secondary viremia that occurs 6-20 days after infection. During this viremic phase, rubella virus can be recovered from different body sites including lymph nodes, urine, cerebrospinal fluid (CSF), conjunctival sac, breast milk, synovial fluid, and lungs. Viremia peaks just before the onset of rash and disappears shortly thereafter. An infected person begins to shed the virus from the nasopharynx 3-8 days after exposure for 6-14 days after onset of the rash. b. Congenital rubella syndrome Fetal infection occurs transplacentally during the maternal viremic phase, but the mechanisms by which rubella virus causes fetal damage are poorly understood. The fetal defects observed in congenital rubella syndrome

are likely secondary to vasculitis resulting in tissue necrosis without inflammation. Another possible mechanism is direct viral damage of infected cells. Studies have demonstrated that cells infected with rubella in the early fetal period have reduced mitotic activity. This may be the result of chromosomal breakage or due to production of a protein that inhibits mitosis. Regardless of the mechanism, any injury affecting the fetus in the first trimester (during the phase of organogenesis) results in congenital organ defects. IV. THE RUBELLA CHAIN y Causative Agent: filterable Paramyxovirus; Rubeola / measles virus y Incubation Period: Usually 10 days folliwng exposure; about 13-15 days before the rash appears y Period of Communicability : About 9 days (4 days before to 5 days after the appearance of the rash). It is most communicable at the height of the rash. y Mode of Transmission: Spread by direct (droplet/airborne; nasopharyngeal secretions) or inidrect contact (airborne) y Signs & Symptoms: Pre-eruptive/prodromal stage  Fever for 3-4 days, headache, sore throat/colds; body malaise  Excessive mucophurulent lacrimal discharge  Stimson sign puffiness of the eylids with red linear congestion of the lwoer conjunctivaKopliks spots phathognomoni enanthema of measles located on the buccal mucosa (inner part of the cheeks), characterized by fine red spots with bluish white spots at the center. Eruptive Stage  Maculopapular rashes  Reddish in color and blotchy in apprearance  First appearing around the 3rd day  Cephalocaudal appearance: at the hairline on the forehead, to the back of the ear, down the neck and then the whole body in 2-3 days  photosensitivity  peculiary brassy cough V. SIGNS AND SYMPTOMS

After an incubation period of 1421 days, German measles causes symptoms that are similar to the flu. The primary symptom of rubella virus infection is the appearance of a rash (exanthem) on the face which spreads to the trunk and limbs and usually fades after three days (that is why it is often referred to as three-day measles). The facial rash usually clears as it spreads to other parts of the body. Other symptoms include low grade fever, swollen glands (sub occipital & posterior cervical lymphadenopathy), joint pains, headache and conjunctivitis. The swollen glands or lymph nodes can persist for up to a week and the fever rarely rises above 38 oC (100.4 oF). The rash of German measles is typically pink or light red. The rash causes itching and often lasts for about three days. The rash disappears after a few days with no staining or peeling of the skin. When the rash clears up, the skin might shed in very small flakes where the rash covered it. Forchheimer's sign occurs in 20% of cases, and is characterized by small, red papules on the area of the soft palate. Rubella can affect anyone of any age and is generally a mild disease, rare in infants or those over the age of 40. The older the person is the more severe the symptoms are likely to be. Up to two-thirds of older girls or women experience joint pain or arthritic type symptoms with rubella. The virus is contracted through the respiratory tract and has an incubation period of 2 to 3 weeks. During this incubation period, the patient is contagious typically for about one week before he develops a rash and for about one week thereafter.

VI.

DIAGNOSIS

Rubella virus specific IgM antibodies are present in people recently infected by Rubella virus but these antibodies can persist for over a year and a positive test result needs to be interpreted with caution. The presence of these antibodies along with, or a short time after, the characteristic rash confirms the diagnosis. VII. PREVENTION

There is a safe and effective vaccine to prevent rubella. The rubella vaccine is recommended for all children. It is routinely given when children are 12 - 15 months old, but is sometimes given earlier during epidemics. A second vaccination (booster) is routinely given to children ages 4 - 6. MMR is a combination vaccine that protects against measles, mumps, and rubella. Women of childbearing age usually have a blood test to see if they have immunity to rubella. If they are not immune, women should avoid getting pregnant for 28 days after receiving the vaccine. Those who should not get vaccinated include:
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Women who are pregnant Anyone whose immune system is affected by cancer, corticosteroid medications, or radiation treatment.

Great care is taken not to give the vaccine to a woman who is already pregnant. However, in the rare instances when pregnant women have been vaccinated, no problems have been detected in the infants. VIII. TREATMENT

No treatment will shorten the course of rubella infection, and symptoms are so mild that treatment usually isn't necessary. However, doctors often recommend isolation from others especially pregnant women during the infectious period. If you contract rubella while you're pregnant, discuss the risks to your baby with your doctor. If you wish to continue your pregnancy, you may be given antibodies called hyperimmune globulin that can fight off the infection. This can reduce your symptoms but doesn't eliminate the possibility of your baby developing congenital rubella syndrome. Support of an infant born with congenital rubella syndrome varies depending on the extent of the infant's problems. Children with multiple complications may require early treatment from a team of specialists. IX. NURSING MANAGEMENT

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a. Control Proper disposal of nasopharyngeal secretions. Cover nose and mouth Isolate the client Medical aspsis will not prevent the spread of measles because it is an airborne disease b. Care CBR Adequate nutrition; increase fluids; Vitamin C Prevent ye and ear infections Avoid exposure to draft. Never sponge with cold water.

Sources: http://en.wikipedia.org/wiki/Rubella http://www.nlm.nih.gov/medlineplus/ency/article/001574.htm http://www.mayoclinic.com/health/rubella/DS00332/DSECTION=treatments-and-drugs http://emedicine.medscape.com/article/968523-overview#showall http://www.nursedirectory.net/nursing-reviewer/rubella/