close

Log in

Access to premium content is restricted to healthcare professionals / registered members. Login with your email address to continue.

Forgot Your Password?

Don't have an account? Sign up

By signing in or creating an account, you agree to our Terms and conditions and Privacy notice

This site is intended for Healthcare Professionals only
Back to CKS

Child health Infections and infestations Pregnancy

Rubella

Last revised in July 2023

Rubella (also known as German measles) is an infection caused by viruses of the genus Rubivirus of the family Togaviradae.

Rubella: Summary

  • Rubella (also known as German measles) is a viral infection spread by direct contact with an infected person or droplet spread from respiratory secretions — it is preventable by vaccination. 
  • Most cases of rubella infection are mild and resolve spontaneously within a week. However, maternal infection in non-immune women during pregnancy can cause serious complications including miscarriage, stillbirth, and severe birth defects known as congenital rubella syndrome (CRS).
    • The severity and type of congenital defect likely to develop vary according to the stage of pregnancy when infection occurs — before 8–10 weeks gestation there is a high likelihood of multiple defects.
  • As a result of the childhood immunization programme, rubella is now uncommon in the UK, and CRS is very rare.
  • No clinical features are specific to rubella — diagnosis must be confirmed with laboratory investigations.
  • Clinical features consistent with rubella infection include:
    • Rash — typically starts on the face and neck before spreading down the body and becoming generalized — the rash is pink or light red, maculopapular, and usually present for 3–4 days.
    • Lymphadenopathy (most often suboccipital, postauricular, and cervical) — may precede rash and last for 2 weeks after the rash resolves.
    • Arthritis and arthralgia — more common in adult women.
    • Non-specific symptoms such as low-grade fever, headache, malaise, nausea, mild upper respiratory tract symptoms, and non-purulent conjunctivitis.
  • Rubella should be suspected in people with clinical features consistent with infection or with risk factors such as incomplete immunization and no evidence of previous infection; history of exposure to contacts with rubella within the last 3 weeks; or travel to an area endemic for rubella.
    • A low threshold of suspicion for rubella in pregnant women is essential — rubella must always be excluded in pregnant women with rubella-like rash, even when other causes are more likely and regardless of previous immunization history.
  • Rubella is a notifiable disease.
    • The local Health Protection Team (HPT) should be notified immediately if there is any clinical suspicion of rubella — they will advise on appropriate investigations to confirm the diagnosis.
  • Non-pregnant people with rubella infection should be advised to:
    • Rest, drink adequate fluids, and take paracetamol or ibuprofen (if appropriate) for symptomatic relief.
    • Stay away from school or work for at least 5 days after the initial development of the rash and avoid contact with pregnant women.
  • Non-pregnant people who have been in contact with confirmed or suspected rubella should be advised to seek medical advice if they develop symptoms and to avoid contact with pregnant women.
  • Pregnant women with confirmed rubella who are at a gestational age of 20 weeks or less should be referred urgently to an obstetrician for risk assessment and counselling.
    • After 20 weeks gestational age there is no documented risk of congenital rubella syndrome.
  • Serology testing should be arranged for pregnant women who have been in contact with possible rubella infection if they do not fulfil the criteria for immunity to rubella, and the HPT should be contacted. 

Have I got the right topic?

From birth onwards.

This CKS topic covers the management of suspected rubella, and the management of people who have been in contact with someone with rubella, including pregnant women.

This CKS topic does not cover the management of congenital rubella syndrome or the prevention of rubella with the combined measles, mumps, and rubella vaccine. There are separate CKS topics on Immunizations - childhood, Measles and Pre-conception - advice and management.

The target audience for this CKS topic is healthcare professionals working within the NHS in the UK, providing first contact or primary healthcare.

How up-to-date is this topic?

Changes

July 2023 — reviewed. A literature search was conducted in July 2023 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of this topic. 

Previous changes

November 2018 — reviewed. A literature search was conducted in October 2018 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of this topic. No major changes to recommendations have been made.

July 2015 — minor update. Ibuprofen has been removed as a treatment option for symptomatic relief of rubella infection, due to the lack of safety data for its use in early pregnancy.

July 2013 — reviewed. A literature search was conducted in July 2013 to identify evidence-based guidelines, UK policy, systematic reviews, and key RCTs published since the last revision of this topic. No major changes to recommendations have been made.

February 2013 — minor update. The 2013 QIPP options for local implementation have been added to this topic.

October 2012 — minor update. The 2012 QIPP options for local implementation have been added to this topic.

July 2011 — minor update. More precise paracetamol dosing for children has been introduced by the Medicines and Healthcare products Regulatory Agency. Prescriptions have been updated to reflect the revised dosing. 

August 2010 — minor update. Children (and adults) are now advised to stay away from school or work for 6 days after the onset of the rash.

March 2010 — minor update. Advice for people with suspected rubella to avoid contact with pregnant women corrected. 

August to December 2009 — this is a new CKS topic. The evidence-base has been reviewed in detail, and recommendations are clearly justified and transparently linked to the supporting evidence.

Update

New evidence

Evidence-based guidelines

No new evidence-based guidelines since 1 July 2023. 

HTAs (Health Technology Assessments)

No new HTAs since 1 July 2023. 

Economic appraisals

No new economic appraisals relevant to England since 1 July 2023. 

Systematic reviews and meta-analyses

No new systematic review or meta-analysis since 1 July 2023. 

Primary evidence

New policies

No new national policies or guidelines since 1 July 2023. 

New safety alerts

No new safety alerts since 1 July 2023. 

Changes in product availability

No changes in product availability since 1 July 2023. 

Goals and outcome measures

Goals

To support primary healthcare professionals to:

  • Recognize the clinical features of rubella and risk factors that increase the likelihood of infection.
  • Notify the Health Protection Team of all cases of suspected rubella.
  • Confirm rubella through laboratory testing.
  • Give people with rubella (or their carers) self-care advice.
  • Appropriately refer susceptible immunocompromised people and pregnant women for specialist management.
  • Refer people with complications of rubella with appropriate urgency.
  • Encourage uptake of the combined measles, mumps, and rubella (MMR) vaccine, where appropriate.

Outcome measures

No outcome measures were found during the review of this topic.

Audit criteria

No audit criteria were found during the review of this topic.

QOF indicators

No QOF indicators were found during the review of this topic.

QIPP - Options for local implementation

No QIPP indicators were found during the review of this topic.

NICE quality standards

No NICE quality standards were found during the review of this topic.

Background information

What is it?

  • Rubella (also known as German measles) is a viral infection spread by direct contact with an infected person or droplet spread from respiratory secretions — it is preventable with vaccination.
    • In the UK, the routine childhood immunisation schedule includes two doses of the combined measles, mumps, and rubella (MMR) vaccine. 
  • Rubella is generally a mild infection, but it can cause serious complications in pregnancy (congenital rubella syndrome).
    • The risk of serious congenital defects is highest in the first trimester of pregnancy. 
  • Once infected or immunized, most people develop life-long immunity to rubella. On rare occasions, reinfection can occur, but it is usually sub-clinical and difficult to diagnose.
  • Rubella is a notifiable disease. 

[Bouthry, 2014; WHO, 2019; CDC, 2020a; UKHSA, 2022a; BMJ Best Practice, 2023; UKHSA, 2023a] 

What causes it?

  • Rubella is caused by a togavirus, which is the only member of the genus Rubivirus. 
    • Transmission occurs through direct contact with an infected person or droplet spread from nasopharyngeal secretions. 
    • The virus replicates in the nasopharynx and local lymph nodes and is then spread haematogenously to the rest of the body (including the placenta and foetus in pregnant women). 
    • Following exposure to the rubella virus, the incubation period is 14-21 days, with most people developing a rash 14-17 days after exposure — people with rubella are infectious from 7 days before symptoms appear to 4-10 days after the onset of rash. 
      • People with rubella are most infectious when the rash is erupting. 

[UKHSA, 2013; WHO, 2019; CDC, 2020a; UKHSA, 2022a; BMJ Best Practice, 2023]

How common is it?

  • Rubella infection in the UK
    • Before the introduction of routine vaccination, rubella was a common disease in the UK with most infections occurring in young children (aged 5–10 years) — more than 80% of adults had evidence of prior infection [UKHSA, 2013; BMJ Best Practice, 2023].
    • Since the measles, mumps, and rubella (MMR) vaccine was introduced, there has been a considerable decline in cases, and it is now uncommon in the UK [UKHSA, 2013; UKHSA, 2022b]. 
      • In England and Wales there were no laboratory-confirmed cases of rubella in 2020 or 2021 [UKHSA, 2022b]. 
  • Rubella infections in pregnancy
    • Worldwide, an estimated 100,000 cases of congenital rubella syndrome (CRS) occur each year [Lambert, 2015].
    • As vaccination uptake and rubella immunity are relatively high in the UK, rubella infection in pregnancy is uncommon, and CRS is very rare.
      • Pre-vaccination there were 200–300 CRS births during non-epidemic years and much higher numbers in epidemic years [Tookey, 2004].
    • Most identified infections in pregnancy in the UK are acquired abroad and in unvaccinated women — a study using data from the UK Hospital Episode Statistics database found that during the period 2003-16 [Bukasa, 2018]:
      • 31 rubella infections in pregnancy (0.23 per 100,000 pregnancies) were identified through routine surveillance — 26 of these were in women who were born abroad.
      • Five of the 31 rubella infections led to CRS in the infant and three had confirmed congenital rubella infection without CRS.
      • In addition, 7 infants were diagnosed with CRS where rubella infection in pregnancy had not been reported. Place of birth was known for 6 of the mothers — all were born outside the UK.

What are the complications?

  • Rubella can cause serious complications in pregnancy including miscarriage, stillbirth, and severe birth defects known as congenital rubella syndrome (CRS). 
    • The severity and type of congenital defects likely to develop vary according to the stage of pregnancy when infection occurs.
      • Infection in the first 8-10 weeks of pregnancy results in damage in up to 90% of surviving infants. 
      • The risk of damage declines to about 10-20% if infection occurs in weeks 11-16, and is rare with infection after 16 weeks, with only deafness reported following infections up to 20 weeks of pregnancy.  
    • CRS can lead to the development of one or more abnormalities including eye defects (such as cataracts), hearing impairment, cardiac abnormalities (such as patent ductus arteriosus and pulmonary artery stenosis), microcephaly, developmental delay, intra-uterine growth restriction, autism, inflammatory lesions of brain, liver, lungs and bone marrow, and endocrine abnormalities (such as diabetes mellitus and thyroid dysfunction).
  • Rubella rarely causes complications in otherwise healthy people.
    • Arthritis and arthralgia (most commonly in adult women) can occur and may persist for weeks or months, or recur. 
    • Bleeding disorders (thrombocytopenia) have been reported in about 1 in 3000 infections. 
    • Encephalitis has been reported in about 1 in 5000 cases — other rarely occurring neurological complications include myelitis, optic neuritis, peripheral neuritis, and Guillain-Barre syndrome.

[UKHSA, 2013; WHO, 2019; CDC, 2020b; UKHSA, 2022a; BMJ Best Practice, 2023]

What is the prognosis?

  • Most cases of rubella infection are mild (with transient rash and lymphadenopathy), and resolve spontaneously within a week — occasionally, joint inflammation and pain can occur (most often in adults).
  • However, maternal infection in non-immune women during pregnancy can cause serious congenital abnormalities (known as congenital rubella syndrome), lifelong disability, and foetal loss.  

[UKHSA, 2013; WHO, 2019; UKHSA, 2022a; BMJ Best Practice, 2023]

Diagnosis of rubella

When should I suspect rubella?

  • There are no clinical features specific to rubella infection — diagnosis cannot be made on clinical features alone, laboratory confirmation is required.
    • Symptoms and signs of rubella infection are similar to many other conditions, including other viral illnesses (such as parvovirus B19), toxoplasmosis, and allergic reactions. Rubella infection may be asymptomatic in up to 50% of people.
  • When present, clinical features develop 2–3 weeks after exposure and include:
    • Rash — present in 50-80% of cases, it typically starts on the face and neck before spreading down the body and becoming generalized. The rash is erythematous (pink or light-red), discrete, maculopapular, sometimes mildly pruritic, and transient (usually present for 3–4 days). 
    • Lymphadenopathy — may precede the rash by 5-10 days and last for 2 weeks after the rash resolves. The suboccipital (lower part of the back of the skull), postauricular (behind the ears), and cervical (neck) lymph nodes are most often affected.
    • Arthritis and arthralgia — arthralgia or arthritis is more common in adults and may occur in up to 70% of women with rubella.
    • Non-specific symptoms tend to affect adults more than children and in adults are sometimes prodromal — they include low-grade fever (less than 39°C), malaise, mild upper respiratory tract symptoms and non-purulent conjunctivitis.
  • Rubella should be suspected in people with clinical features consistent with infection or with risk factors:
    • It is essential to have a low threshold of suspicion for rubella in pregnant women, especially before 20 weeks gestation.
      • Rubella should be excluded even when other causes (such as measles, enterovirus, infectious mononucleosis, and streptococcal infection) are considered to be more likely. 
      • Women who have not spent their childhood years in the UK may be at increased risk.
    • Risk factors include:
      • Incomplete immunization and no evidence of previous infection — rubella is unlikely in people who have previously had rubella (although reinfection can occur). 
      • History of exposure to contacts with rubella within the last 3 weeks.
      • Travel to an area where rubella is endemic.

Basis for recommendation

This information is based on the chapter on Rubella in the UK Health Security Agency (UKHSA) document Immunisation against infectious disease (the 'Green Book') [UKHSA, 2013], the UKHSA Guidance on the investigation, diagnosis and management of viral illness, or exposure to viral rash illness, in pregnancy [UKHSA, 2022c], the BMJ Best Practice guide Rubella [BMJ Best Practice, 2023], a chapter on Rubella in the Centres for Disease Control and Prevention (CDC) Manual for the surveillance of vaccine-preventable diseases [CDC, 2020a], the Primary Care Dermatology Society (PCDS) chapter on Viral exanthems [PCDS, 2021], the World Health Organization (WHO) factsheet on Rubella [WHO, 2019], and expert opinion in a narrative review Rubella and pregnancy: diagnosis, management and outcomes [Bouthry, 2014].  

How should I assess a person with suspected rubella?

  • Take a history asking about:
    • Clinical features, including onset and progression. 
    • Risk factors for rubella infection, including:
      • Contact with a person who is unwell or has had a rash in the previous 3 weeks.
      • Lack of immunity — a person is considered to be immune if they are immunocompetent and have had either 2 doses of MMR vaccine or laboratory evidence of prior immunity. 
      • Travel to a country where rubella is endemic. 
    • The possibility of pregnancy. 
    • Past medical history (including immunosuppression) and drug history.
    • Other potential causes of symptoms.
  • Examine the person looking for clinical signs of rubella infection and complications:
    • Check vital signs including temperature. 
    • Look for a rash; lymphadenopathy; conjunctivitis; and respiratory, musculoskeletal, and neurological signs. 
  • Consider the need for investigations:
    • If there is any suspicion of rubella infection, immediately notify the local Health Protection Team (HPT) — rubella is a notifiable disease. 
    • Rubella cannot be accurately diagnosed through history and clinical features alone.
      • Arrange serology testing for all pregnant women.
      • For all other people, the Health Protection Team (HPT) will provide advice on testing (for example they may request an oral fluid sample). 
    • It is essential to have a low threshold of suspicion for rubella in pregnant women, especially before 20 weeks gestation.
      • Rubella must always be excluded in pregnant women with rubella-like rash, even when other causes are considered to be more likely and regardless of previous immunization history. 
      • Women who have not spent their childhood years in the UK may be at increased risk of rubella. 
    • Note: when rubella testing is requested in women with a rash illness, they will be also tested for parvovirus B19 infection.

Basis for recommendation

These recommendations are based on the chapter on Rubella in the UK Health Security Agency (UKHSA) document Immunisation against infectious disease (the 'Green Book') [UKHSA, 2013], the UKHSA Guidance on the investigation, diagnosis and management of viral illness, or exposure to viral rash illness, in pregnancy [UKHSA, 2022c], Notifiable diseases and causative organisms: how to report [UKHSA, 2023a], and UK Measles and rubella elimination strategy 2019 [UKHSA, 2019], the BMJ Best Practice guide Rubella [BMJ Best Practice, 2023], a chapter on Rubella in the Centres for Disease Control and Prevention (CDC) Manual for the surveillance of vaccine-preventable diseases [CDC, 2020a], expert opinion in a narrative review Rubella and pregnancy: diagnosis, management and outcomes [Bouthry, 2014], and what CKS considers good medical practice. 

What else might it be?

Other conditions that can present with similar clinical features to rubella include:

  • Parvovirus B19 
    • Parvovirus B19 is the virus that causes erythema infectiosum (also known as fifth disease or slapped-cheek syndrome, particularly common in children). It is a self-limiting illness that, in addition to a bright red rash on the cheeks, may cause a red, lacy rash on the rest of the body.
    • In adults, parvovirus can cause rash, fever, and joint inflammation that can be indistinguishable from rubella.
    • Parvovirus B19 can have harmful effects on the foetus, and pregnant women with a rubella-like rash are usually also tested for parvovirus B19 infection. 
    • For more information, see the CKS topic on Parvovirus B19 infection.
  • Measles 
    • Measles causes a characteristic erythematous and maculopapular rash with a similar distribution to rubella. However, both the rash and accompanying symptoms of viremia (malaise, fever, loss of appetite, cough, rhinorrhoea, and conjunctivitis) tend to be more severe than in rubella, particularly in children. For further information, see the CKS topic on Measles.
  • Other viral infections including:
    • Herpesvirus type 6 (roseola infantum), enterovirus (for example coxsackievirus and echovirus), and cytomegalovirus.  
    • Tropical viruses including alphaviruses and flaviviruses (for example dengue virus, West Nile virus, chikungunya virus, and Zika virus) — consider tropical viruses if the person has recently travelled to an endemic area. 
  • Other infections including:
    • Scarlet fever — for further information, see the CKS topic on Scarlet fever.
    • Kawasaki disease, syphilis, and toxoplasmosis.
  • Drug reactions, for example, mononucleosis reaction with some penicillins (such as amoxicillin).

Basis for recommendation

This information is based on the UK Health Security Agency (UKHSA) Guidance on the investigation, diagnosis and management of viral illness, or exposure to viral rash illness, in pregnancy [UKHSA, 2022c], the BMJ Best Practice guide Rubella [BMJ Best Practice, 2023], and expert opinion in a narrative review Rubella and pregnancy: diagnosis, management and outcomes [Bouthry, 2014].

Management

Scenario: Non-pregnant - suspected rubella or possible exposure

From birth onwards.

Management of suspected rubella or possible exposure in a non-pregnant person

If there is clinical suspicion of rubella infection:

  • Contact the local Health Protection Team (HPT) immediately. 
    • Rubella is a notifiable disease:
      • The UK Health Security Agency (UKHSA) provides information on how to report a notifiable disease. In Scotland, this information is available from Health Protection Scotland.
      • A notification form should be completed immediately and sent to the HPT within 3 days.   
      • An immediate oral fluid sample may be requested — if positive, further testing may be carried out for confirmatory and genotyping purposes. 
      • Samples may also be tested for other infections that can present with similar clinical features (such as measles). 
  • Advise the person (or their carer): 
    • That rubella is usually a mild, self-limiting condition that typically resolves within a week. 
    • That there is no specific treatment for rubella — they should rest, drink adequate fluids, and take paracetamol or ibuprofen (if appropriate) for symptomatic relief (aspirin should be avoided in children younger than 16 years of age). 
    • To stay away from school or work for at least 5 days after the initial development of the rash. 
    • To avoid contact with pregnant women: 
      • Pregnant women who develop a rash, or have been in direct contact with someone with a rash who is potentially infectious, should be advised to consult a doctor or midwife immediately.
      • For further information, see the section on contact with suspected or confirmed rubella in pregnancy.
    • To inform clinical staff of confirmed or suspected infection prior to attending medical areas, until known to be non-infectious or uninfected.
    • To minimise the risk of spread of infection to others by simple hygiene measures such as covering their mouth and nose with a disposable tissue and washing their hands after using or disposing of tissues. 
    • That specific follow-up is usually not necessary — complications are rare and results of tests can be relayed by phone. However, they should seek urgent medical advice if symptoms do not settle as expected or new features suggestive of complications of rubella develop — arrange urgent assessment in secondary care if serious complications (such as haemorrhagic complications or encephalitis) are suspected.
    • To get up-to-date with their vaccinations, if applicable, once they have recovered from the acute symptoms.  
      • For further information, see the CKS topic on Immunizations - childhood.
      • Adult women of childbearing age should avoid getting pregnant for at least 4 weeks after receiving MMR vaccine. 

If the person has been in contact with confirmed or suspected rubella:

  • Advise the person (or their carer) to seek medical advice if they develop symptoms — if symptoms suggestive of rubella develop, the local HPT must be contacted immediately and laboratory confirmation will be required. 
    • Susceptible people who have been in contact with confirmed or suspected rubella should avoid contact with pregnant women. 

Basis for recommendation

These recommendations are based on the chapter on Rubella in the UK Health Security Agency (UKHSA) document Immunisation against infectious disease (the 'Green Book') [UKHSA, 2013], the UKHSA guidance Notifiable diseases and causative organisms: how to report [UKHSA, 2023a], UK Measles and rubella elimination strategy 2019 [UKHSA, 2019], Health protection in children and young people settings, including education [UKHSA, 2023b], and Guidance on the investigation, diagnosis and management of viral illness, or exposure to viral rash illness, in pregnancy [UKHSA, 2022c], the BMJ Best Practice guide Rubella [BMJ Best Practice, 2023], the NHS patient information on Rubella (German measles) [NHS, 2022], and what CKS considers good medical practice.   

Notification and confirmation of diagnosis
  • Rubella has been a notifiable disease in the UK since 1988 — health professionals have a legal obligation to report all clinically diagnosed cases [UKHSA, 2019]. Notification should be based on clinical suspicion and should not await laboratory confirmation [UKHSA, 2013].
  • Laboratory confirmation of rubella in non-pregnant people is necessary for surveillance purposes rather than management of the individual. Detection, confirmation, and classification of all suspected cases is required as part of the commitment of all member states of the World Health Organization (WHO) European Region to eliminate measles and rubella [UKHSA, 2019].
Promote vaccine uptake
  • Rubella is preventable by immunization with 2 doses of the measles, mumps, and rubella (MMR) vaccine — every opportunity to pick up on missed vaccines and ensure high uptake of the MMR vaccine should be taken [UKHSA, 2013; UKHSA, 2019].
  • Women planning pregnancy or undergoing fertility treatment should be up to date with their routine vaccinations, including MMR [UKHSA, 2022c]. 
    • All women without evidence of immunity should be offered MMR vaccination before pregnancy — there is no requirement for rubella antibody levels to be tested.
    • Universal screening of all pregnant women is no longer recommended and was stopped in April 2016.
    • The UKHSA [UKHSA, 2013] advises that there is no evidence that rubella-containing vaccines are teratogenic, however, as a precaution, MMR vaccine should not be given to women known to be pregnant and if MMR vaccine is given to adult women, they should be advised to avoid pregnancy for one month.
Prevention of transmission
  • The UKHSA advises that children with suspected rubella should be kept away from school or nursery for 5 days after the development of the rash [UKHSA, 2023b] and this can be reasonably extrapolated to adults.
  • However, as people can be infectious for up to 7 days before the onset of the rash to 10 days after rash onset [UKHSA, 2022c; CDC, 2020a], CKS recommends it is prudent for the affected person to avoid contact with pregnant women during this time period. 

Scenario: Pregnant - suspected/confirmed rubella or possible exposure

From age 13 years onwards (Female).

How should I manage suspected or confirmed rubella in a pregnant woman?

If rubella is suspected in a pregnant woman:

  • Contact the local Health Protection Team immediately. 
    • Rubella is a notifiable disease:
    • Laboratory investigation is necessary for all pregnant women regardless of previous testing, immunization status, or stage of pregnancy. 
    • The Health Protection Team will advise on appropriate investigations — depending on the clinical situation, testing for other infections with similar clinical features (such as parvovirus B19 and measles) may be carried out simultaneously: 
      • Clearly state on requests that the patient is pregnant and ensure details accompanying samples are accurate and complete.
      • Discuss with the HPT who will supply the test results and arrange ongoing management in pregnancy if rubella is confirmed.
  • If rubella infection is confirmed and the woman is in the first 20 weeks of pregnancy, or there is any doubt about the gestational age:
    • Refer urgently to obstetrics (fetal medicine) for risk assessment, counselling, and management. Risk to the foetus is dependent on the stage of pregnancy: 
      • Beyond 20 weeks gestation there have been no published case reports of congenital rubella syndrome (CRS). 
      • Between 16–20 weeks gestation there is a low chance of deafness occurring. 
      • Between 11–16 weeks gestation there is a 10-20% risk of CRS.
      • Before 8–10 weeks gestation there is a 90% risk of CRS and a high likelihood of multiple defects. 
    • There are no effective treatments to prevent CRS — human normal immunoglobulin is not recommended routinely for post-exposure prophylaxis in pregnant women as there is no evidence that it is effective, but it may be considered in secondary care when termination of pregnancy is unacceptable. Further diagnostic tests may be indicated (for example amniocentesis or fetal blood sampling). 
  • If rubella infection is diagnosed in pregnancy and gestation is confirmed to be greater than 20 weeks: 
    • The woman can be reassured that there have been no reported cases of CRS after this gestational age.
    • If found to be non-immune, rubella immunization should not be administered in pregnancy but may be given post-partum. 
  • If viral pathogens other than rubella are identified: 
    • Seek specialist advice on management as some (such as parvovirus B19, varicella-zoster, herpes simplex and cytomegalovirus) are associated with congenital infection.
    • Guidance on Viral Rash in Pregnancy is available from the UKHSA.
  • Advise all women with suspected or confirmed infection:
    • On self-care measures — rest and drink adequate fluids. Paracetamol can be taken for symptomatic relief if required.
    • To stay off work for at least 5 days after the initial development of the rash.
    • To avoid contact with other pregnant women.
    • To inform clinical staff of confirmed or suspected infection prior to attending medical areas until known to be non-infectious or uninfected. 
    • To minimise the risk of spread of infection to others by simple hygiene measures such as covering their mouth and nose with a disposable tissue and washing their hands after using or disposing of tissues.
    • To seek urgent medical advice if symptoms do not improve or features suggestive of complications of rubella develop. 
      • Arrange urgent assessment in secondary care if serious complications (such as haemorrhagic complications or encephalitis) are suspected.

Basis for recommendation

These recommendations are based on the chapter on Rubella in the UK Health Security Agency (UKHSA) document Immunisation against infectious disease (the 'Green Book') [UKHSA, 2013] UK Health Security Agency (UKHSA) guidance Notifiable diseases and causative organisms: how to report [UKHSA, 2023a], Health protection in children and young people settings, including education [UKHSA, 2023b], and Guidance on the investigation, diagnosis and management of viral illness, or exposure to viral rash illness, in pregnancy [UKHSA, 2022c], the BMJ Best Practice guide Rubella [BMJ Best Practice, 2023], the NHS patient information on Rubella (German measles) [NHS, 2022], and what CKS considers good medical practice.  

Notification and confirmation of diagnosis
  • Rubella has been a notifiable disease in the UK since 1988 — health professionals have a legal obligation to report all clinically diagnosed cases [UKHSA, 2019]. Notification should be based on clinical suspicion and should not await laboratory confirmation [UKHSA, 2013].
  • Detection, confirmation and classification of all suspected cases is required as part of the commitment of all member states of the World Health Organization (WHO) European Region to eliminate measles and rubella [UKHSA, 2019].
Investigation in pregnancy
  • Further investigations are recommended in pregnant women with a rubella-like rash regardless of the results of previous testing or immunization status. This is because of the possibility of laboratory or documentation error, failed immunization, symptomatic rubella reinfection, or parvovirus B19 infection [UKHSA, 2022c].
  • Although there have been no case reports of congenital rubella syndrome after 20 weeks gestation, investigations to confirm the diagnosis are still recommended after this period as [UKHSA, 2022c]:
    • Specific diagnosis will aid management of contacts.
    • Immunoglobulin assays may provide information on the date of infection in relation to the gestational age.
    • The diagnosis may be helpful for future management, for example, postnatal administration of combined measles, mumps, and rubella (MMR) vaccine.
Prevention of transmission
  • The UKHSA advises that children with suspected rubella should be kept away from school or nursery for 5 days after the development of the rash [UKHSA, 2023b] and this can be reasonably extrapolated to adults.
  • However, as people can be infectious for 7 days before the onset of the rash to 10 days after rash onset [CDC, 2020a; UKHSA, 2022c], CKS recommends it is prudent for the affected person to avoid contact with pregnant women during this time period. 

How should I manage contact with suspected or confirmed rubella in pregnancy?

  • Contact the local Health Protection Team immediately.
    • Liaison with the HPT may help to confirm whether or not the contact is a known case. 
  • If the woman fulfils the criteria for immunity — reassure her that the likelihood of rubella infection is remote, that no investigation for rubella is necessary, but she must return if a rash develops. 
    • Evidence of protection against rubella includes at least two documented doses of rubella vaccine, or at least one rubella antibody screening test (before or at the time of exposure) that detected IgG antibodies. 
    • Investigations for other infections with similar clinical features (such as parvovirus B19 and measles) may be necessary.
  • If the woman does not fulfil the criteria for immunity to rubella — arrange serology testing as soon as possible. Investigations for other infections with similar clinical features (such as parvovirus B19 and measles) may be carried out in addition to rubella.
    • Clearly state on requests that the patient is pregnant and ensure details accompanying samples are accurate and complete. 
    • If rubella IgM is not detected and IgG is detected — reassure the woman that the likelihood of rubella infection is remote and advise her to return if a rash develops. 
    • If rubella IgM and IgG are not detected — the woman is susceptible to rubella. Retest after 4 weeks. 
    • If rubella IgM is detected (regardless of IgG result) — arrange a second confirmatory test.   
  • Advise the woman to inform their midwife, GP, or obstetrician urgently if they develop a rash at any time in pregnancy. Until they are assessed and confirmed to be uninfected or non-infective, they should:
    • Avoid contact with other pregnant women (including in antenatal clinics or maternity settings). 
    • Inform clinical staff of suspected infection prior to attending any medical area. 
  • Arrange follow-up for unvaccinated women to be immunized with MMR vaccine after delivery — rubella immunization should not be administered in pregnancy but may be given post-partum. 

Basis for recommendation

These recommendations are based on the chapter on Rubella in the UK Health Security Agency (UKHSA) document Immunisation against infectious disease (the 'Green Book') [UKHSA, 2013], the UKHSA Guidance on the investigation, diagnosis and management of viral illness, or exposure to viral rash illness, in pregnancy [UKHSA, 2022c], and the UK Standards for microbiology investigations. Investigation of exposure to vesicular and non-vesicular rash in pregnancy [UKHSA, 2021].

Investigation
  • The UKHSA recommends that [UKHSA, 2021]:
    • Pregnant contacts of people with maculopapular rash should be investigated for parvovirus B19, rubella, and measles immunity in parallel if clinically indicated. If the contact has a laboratory-confirmed rash it is only necessary to test for that virus.
    • Regardless of a request for specific rubella or parvovirus B19 testing, pregnant women should simultaneously be investigated for immunity to both infections unless their immune status is already known. 
      • If immunization history or tests indicate immunity to all viruses under investigation, the woman can be reassured but must be advised to seek medical advice if she develops symptoms.
    • Pregnant women should report all rashes, regardless of known immunity or vaccination status. 
Prevention of transmission
  • The UKHSA advises that children with suspected rubella should be kept away from school or nursery for 5 days after the development of the rash [UKHSA, 2023b] and this can be reasonably extrapolated to adults.
  • However, as people can be infectious for 7 days before the onset of the rash, to 10 days after rash onset [CDC, 2020a; UKHSA, 2022c], CKS recommends it is prudent for the affected person to avoid contact with pregnant women during this time period. 
Arranging follow-up for unvaccinated women to be immunized 
  • Rubella is preventable by immunization with 2 doses of the measles, mumps, and rubella (MMR) vaccine — every opportunity to pick up on missed vaccines and ensure high uptake of the MMR vaccine should be taken [UKHSA, 2013; UKHSA, 2019].
  • The UKHSA [UKHSA, 2013] advises that there is no evidence that rubella-containing vaccines are teratogenic, however, as a precaution, MMR vaccine should not be given to women known to be pregnant and if MMR vaccine is given to adult women, they should be advised to avoid pregnancy for one month.

Supporting evidence

These recommendations are largely based on the chapter on Rubella in the UK Health Security Agency (UKHSA) document Immunisation against infectious disease (the 'Green Book') [UKHSA, 2013], the UKHSA guidance Notifiable diseases and causative organisms: how to report [UKHSA, 2023a], UK Measles and rubella elimination strategy 2019 [UKHSA, 2019], Health protection in children and young people settings, including education [UKHSA, 2023b], and Guidance on the investigation, diagnosis and management of viral illness, or exposure to viral rash illness, in pregnancy [UKHSA, 2022c], and the BMJ Best Practice guide Rubella [BMJ Best Practice, 2023]. The rationale for individual recommendations is outlined in the relevant basis for recommendation sections of the topic.

How this topic was developed

This section briefly describes the processes used in developing and updating this topic. Further details on the full process can be found in the About Us section and on the Clarity Informatics website.

Search strategy

A literature search was conducted for guidelines, systematic reviews and randomized controlled trials on primary care management of Rubella, with additional searches in the following area:

  • Risk of congenital rubella syndrome in pregnancy after 20 weeks' gestation

Search dates

October 2018 - July 2023

Key search terms

Various combinations of searches were carried out. The terms listed below are the core search terms that were used for Medline.

  • exp Rubella/, exp Rubella virus/, rubella.tw., german measles.tw.
  • exp Rubella Syndrome, Congenital/, congenital rubella syndrome.tw.

Sources of guidelines

Sources of systematic reviews and meta-analyses

  • The Cochrane Library:
    • Systematic reviews
    • Protocols
    • Database of Abstracts of Reviews of Effects
  • Medline (with systematic review filter)
  • EMBASE (with systematic review filter)

Sources of health technology assessments and economic appraisals

Sources of randomized controlled trials

  • The Cochrane Library:
    • Central Register of Controlled Trials
  • Medline (with randomized controlled trial filter)
  • EMBASE (with randomized controlled trial filter)

Sources of evidence based reviews and evidence summaries

Sources of national policy

Patient experiences

Sources of medicines information

The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.

Stakeholder engagement

Our policy

The external review process is an essential part of CKS topic development. Consultation with a wide range of stakeholders provides quality assurance of the topic in terms of:

  • Clinical accuracy.
  • Consistency with other providers of clinical knowledge for primary care.
  • Accuracy of implementation of national guidance (in particular NICE guidelines).
  • Usability.

Principles of the consultation process

  • The process is inclusive and any individual may participate.
  • To participate, an individual must declare whether they have any competing interests or not. If they do not declare whether or not they have competing interests, their comments will not be considered.
  • Comments received after the deadline will be considered, but they may not be acted upon before the clinical topic is issued onto the website.
  • Comments are accepted in any format that is convenient to the reviewer, although an electronic format is encouraged.
  • External reviewers are not paid for commenting on the draft topics.
  • Discussion with an individual or an organization about the CKS response to their comments is only undertaken in exceptional circumstances (at the discretion of the Clinical Editor or Editorial Steering Group).
  • All reviewers are thanked and offered a letter acknowledging their contribution for the purposes of appraisal/revalidation.
  • All reviewers are invited to be acknowledged on the website. All reviewers are given the opportunity to feedback about the external review process, enabling improvements to be made where appropriate.

Stakeholders

  • Key stakeholders identified by the CKS team are invited to comment on draft CKS topics. Individuals and organizations can also register an interest to feedback on a specific topic, or topics in a particular clinical area, through the Getting involved section of the Clarity Informatics website.
  • Stakeholders identified from the following groups are invited to review draft topics:
    • Experts in the topic area.
    • Professional organizations and societies (for example, Royal Colleges).
    • Patient organizations, Clarity has established close links with groups such as Age UK and the Alzheimer’s Society specifically for their input into new topic development, review of current topic content and advice on relevant areas of expert knowledge.
    • Guideline development groups where the topic is an implementation of a guideline.
    • The British National Formulary team.
    • The editorial team that develop MeReC Publications.
  • Reviewers are provided with clear instructions about what to review, what comments are particularly helpful, how to submit comments, and declaring interests.

Patient engagement

Clarity Informatics has enlisted the support and involvement of patients and lay persons at all stages in the process of creating the content which include:

  • Topic selection
  • Scoping of topic
  • Selection of clinical scenarios
  • First draft internal review
  • Second draft internal review
  • External review
  • Final draft and pre-publication

Our lay and patient involvement includes membership on the editorial steering group, contacting expert patient groups, organizations and individuals.

Evidence exclusion criteria

Our policy

Scoping a literature search, and reviewing the evidence for CKS is a methodical and systematic process that is carried out by the lead clinical author for each topic. Relevant evidence is gathered in order that the clinical author can make fully informed decisions and recommendations. It is important to note that some evidence may be excluded for a variety of reasons. These reasons may be applied across all CKS topics or may be specific to a given topic.

Studies identified during literature searches are reviewed to identify the most appropriate information to author a CKS topic, ensuring any recommendations are based on the best evidence. We use the principles of the GRADE and PICOT approaches to assess the quality of published research. We use the principles of AGREE II to assess the quality of published guidelines.

Standard exclusions for scoping literature:

  • Animal studies
  • Original research is not written in English

Possible exclusions for reviewed literature:

  • Sample size too small or study underpowered
  • Bias evident or promotional literature
  • Population not relevant
  • Intervention/treatment not relevant
  • Outcomes not relevant
  • Outcomes have no clear evidence of clinical effectiveness
  • Setting not relevant
  • Not relevant to UK
  • Incorrect study type
  • Review article
  • Duplicate reference

Organizational, behavioural and financial barriers

Our policy

The CKS literature searches take into consideration the following concepts, which are discussed at the initial scoping of the topic.

  • Feasibility
    • Studies are selected depending on whether the intervention under investigation is available in the NHS and can be practically and safely undertaken in primary care.
  • Organizational and Financial Impact Analysis
  • Studies are selected and evaluated on whether the intervention under investigations may have an impact on local clinical service provision or national impact on cost for the NHS. The principles of clinical budget impact analysis are adhered to, evaluated and recorded by the author. The following factors are considered when making this assessment and analysis.
    • Eligible population
    • Current interventions
    • Likely uptake of new intervention or recommendation
    • Cost of the current or new intervention mix
    • Impact on other costs
    • Condition-related costs
    • In-direct costs and service impacts
    • Time dependencies
  • Cost-effectiveness or cost-benefit analysis studies are identified where available. 

We also evaluate and include evidence from NICE accredited sources which provide economic evaluations of recommendations, such as NICE guidelines. When a recommended action may not be possible because of resource constraints, this is explicitly indicated to healthcare professionals by the wording of the CKS recommendation.

Declarations of interest

Our policy

Clarity Informatics requests that all those involved in the writing and reviewing of topics, and those involved in the external review process to declare any competing interests. Signed copies are securely held by Clarity Informatics and are available on request with the permission of the individual. A copy of the declaration of interest form which participants are asked to complete annually is also available on request. A brief outline of the declarations of interest policy is described here and full details of the policy is available on the Clarity Informatics website. Declarations of interests of the authors are not routinely published, however competing interests of all those involved in the topic update or development are listed below. Competing interests include:

  • Personal financial interests
  • Personal family interest
  • Personal non-financial interest
  • Non-personal financial gain or benefit

Although particular attention is given to interests that could result in financial gains or losses for the individual, competing interests may also arise from academic competition or for political, personal, religious, and reputational reasons. An individual is not obliged to seek out knowledge of work done for, or on behalf of, the healthcare industry within the departments for which they are responsible if they would not normally expect to be informed.

Who should declare competing interests?

Any individual (or organization) involved in developing, reviewing, or commenting on clinical content, particularly the recommendations should declare competing interests. This includes the authoring team members, expert advisers, external reviewers of draft topics, individuals providing feedback on published topics, and Editorial Steering Group members. Declarations of interest are completed annually for authoring team and editorial steering group members, and are completed at the start of the topic update and development process for external stakeholders.

Competing interests declared for this topic:

None.

References

Change privacy settings