Rubella infection in pregnant women

Key facts

Rubella is a contagious, generally mild viral infection that occurs most often in children and young adults.
Rubella infection in pregnant women may cause fetal death or congenital defects known as congenital rubella syndrome (CRS).
Worldwide, over 100 000 babies are born with CRS every year.
There is no specific treatment for rubella but the disease is preventable by vaccination.

Rubella is an acute, contagious viral infection. While the illness is generally mild in children, it has serious consequences in pregnant women causing fetal death or congenital defects known as congenital rubella syndrome (CRS).

The rubella virus is transmitted by airborne droplets when infected people sneeze or cough. Humans are the only known host.

In children, the disease is usually mild, with symptoms including a rash, low fever (<39°C), nausea and mild conjunctivitis. The rash, which occurs in 50–80% of cases, usually starts on the face and neck before progressing down the body, and lasts 1–3 days. Swollen lymph glands behind the ears and in the neck are the most characteristic clinical feature. Infected adults, more commonly women, may develop arthritis and painful joints that usually last from 3–10 days.

Once a person is infected, the virus spreads throughout the body in about 5-7 days. Symptoms usually appear 2 to 3 weeks after exposure. The most infectious period is usually 1–5 days after the appearance of the rash.

When a woman is infected with the rubella virus early in pregnancy, she has a 90% chance of passing the virus on to her fetus. This can cause miscarriage, stillbirth or severe birth defects known as CRS. Infants with CRS may excrete the virus for a year or more.
Congenital rubella syndrome

Children with CRS can suffer hearing impairments, eye and heart defects and other lifelong disabilities, including autism, diabetes mellitus and thyroid dysfunction – many of which require costly therapy, surgeries and other expensive care.

The highest risk of CRS is in countries where women of childbearing age do not have immunity to the disease (either through vaccination or from having had rubella). Before the introduction of the vaccine, up to 4 babies in every 1000 live births were born with CRS.

Large-scale rubella vaccination during the past decade has practically eliminated rubella and CRS in many developed and in some developing countries. In April 2015, the WHO Region of the Americas became the first in the world to be declared free of endemic transmission of rubella.

CRS rates are highest in the WHO African and South-East Asian regions where vaccine coverage is lowest.

The rubella vaccine is a live attenuated strain that has been in use for more than 40 years. A single dose gives more than 95% long-lasting immunity, which is similar to that induced by natural infection.

Rubella vaccines are available either in monovalent formulation (vaccine directed at only one pathogen) or more commonly in combinations with other vaccines such as with vaccines against measles (MR), measles and mumps (MMR), or measles, mumps and varicella (MMRV).

Adverse reactions following vaccination are generally mild. They may include pain and redness at the injection site, low-grade fever, rash and muscle aches. Mass immunization campaigns in the Region of the Americas involving more than 250 million adolescents and adults did not identify any serious adverse reactions associated with the vaccine.
WHO response

WHO recommends that all countries that have not yet introduced rubella vaccine should consider doing so using existing, well-established measles immunization programmes. To-date, three WHO Regions have established goals to eliminate this preventable cause of birth defects.

In April 2012, the Measles Initiative – now known as the Measles & Rubella Initiative – launched a new Global Measles and Rubella Strategic Plan which covers the period 2012-2020. The Plan includes new global goals for 2015 and 2020.
By the end of 2015

Reduce global measles deaths by at least 95% compared with 2000 levels.
Achieve regional measles and rubella/congenital rubella syndrome (CRS) elimination goals.

By the end of 2020

Achieve measles and rubella elimination in at least 5 WHO regions.

The strategy focuses on the implementation of 5 core components:

achieve and maintain high vaccination coverage with 2 doses of measles- and rubella-containing vaccines;
monitor the disease using effective surveillance, and evaluate programmatic efforts to ensure progress and the positive impact of vaccination activities;
develop and maintain outbreak preparedness, rapid response to outbreaks and the effective treatment of cases;
communicate and engage to build public confidence and demand for immunization;
perform the research and development needed to support cost-effective action and improve vaccination and diagnostic tools.

Based on the 2016 Midterm Review of the Global Vaccine Action Plan, rubella control is lagging as 45 Member States still have not yet introduced the vaccine and two regions (African and Eastern Mediterranean) have not yet set rubella elimination or control targets.

The WHO Strategic Advisory Group of Experts on Immunization (SAGE) recommends an increased focus on improving national immunization systems in general, to ensure additional gains in controlling rubella can be made.

One region (the Americas) successfully eliminated the endemic transmission of rubella, and congenital rubella syndrome end was verified in 2015.

As one of the founding members of the Measles & Rubella Initiative, WHO provides technical support to governments and communities to improve routine immunization programmes and hold targeted vaccination campaigns. In addition, the WHO Global Measles and Rubella Laboratory Network supports the diagnosis of rubella and CRS cases and tracking of the spread of rubella viruses.