Controlling Spread of Rubella

A. Isolation and Quarantine Requirements

Current recommendations of CDC and IDPH are as follows:

Non-congenital rubella:

Minimum Period of Isolation of Patient

7 days after onset of rash.

Minimum Period of Quarantine of Contact

Healthcare workers who are not appropriately immunized or do not have serologic evidence of immunity will be excluded from work from day 7 through day 21 after their last exposure. When multiple cases occur, susceptibles need to be excluded until 21 days after the onset of the last case at the workplace.

Congenital rubella:

Minimum Period of Isolation of Patient

Isolation from susceptible persons for the first year of life or until two cultures of clinical specimens (nasopharyngeal secretions or urine) obtained 1 month apart after 3 months old are negative for rubella virus. Household and other contacts should be adequately immunized.

Minimum Period of Quarantine of Contacts

No restrictions except for susceptibles. Same as for non-congenital rubella, above.

B. Protection of Contacts of a Case

Identify pregnant female contacts, especially those in their first trimester. Such contacts should be tested serologically for early infection and susceptibility (IgM and IgG) and advised accordingly.

C. Managing Special Situations

Control guidelines for three situations ---1) rubella in healthcare facilities, 2) when a pregnant woman has been exposed, and 3) infants with CRS—are presented below. Note that these situations are not mutually exclusive.

Situation 1: Rubella in healthcare facilities

If a confirmed or suspect case of rubella has visited a healthcare facility during his/her infectious period, contact the infection prevention staff and go over the following recommendations with them:

1. Identify all susceptible high-risk patients, volunteers and staff exposed to the rubella case. Pregnant women and immunosuppressed individuals should be referred to their healthcare providers to determine if they are immune.
   • Pregnancy and Immune Globulin. Routine use of IG for postexposure prophylaxis is not recommended, even for susceptible pregnant women, because IG does not guarantee prevention of fetal infection. The only time IG may be considered is when exposure occurs early in pregnancy and termination is not an option.
2. Identify all other susceptible exposed patients and staff at the facility. Primary care providers of exposed infants should be notified. 
3. Notify healthcare providers of all exposed patients.
4. Immunize all susceptible patients and staff. Live-virus rubella vaccine given after exposure has not been demonstrated to prevent illness, but theoretically could prevent illness if administered within 3 days of exposure. All susceptibles who are >12 months old (and for whom it is not contraindicated) should receive rubella vaccine given as the combined formulation of measles, mumps, rubella (MMR) vaccine.
   • Previous administration of human anti-Rho(D) immune globulin (RhoGam) does not generally interfere with an immune response to rubella vaccine. However, women who have received anti-Rho immune globulin should be serologically tested 6–8 weeks after vaccination to assure that seroconversion occurred. If other antibody-containing blood products are needed for other reasons, they should be administered at least 2 weeks before and deferred for up to 11 months after administration of MMR vaccine. (Refer to General Recommendations on Vaccination at: www.cdc.gov/vaccines/hcp/acip-recs/index.html
5. Exclude susceptible staff. Ideally, all hospital employees should be immune. It is important to note that screening programs alone are not adequate. Vaccination of susceptible hospital personnel, both male and female (e.g., volunteers, trainees, nurses, physicians) must follow. Unlike measles, vaccinating immediately postexposure does not prevent an individual from acquiring rubella. Therefore, all susceptible individuals without proof of immunity, including those just vaccinated, can become infectious and must be excluded on days 7 through 21 postexposure. They may return on the 22nd day. If additional cases occur, the exclusion period may need to be extended.
6. Isolate susceptible patients and suspect/confirmed cases. Susceptible patients >12 months of age should be vaccinated and placed on Droplet Precautions for days 7–21 after exposure. They may be taken off precautions on the 22nd day. All suspect and confirmed cases should be placed on Droplet Precautions during their infectious period. The infectious period for rubella is 7 days before rash onset through 7 days after rash onset.
7. Conduct surveillance for two incubation periods (46 days) after the last exposure in the facility, and report all suspect cases of rubella to the Iowa Department of Public Health at (800) 362-2736.
8. Place any new cases of rash illness on Droplet Precautions or exclude for 7 days after rash onset. A blood specimen should be obtained 3 days after rash onset and sent to SHL. New cases should be reported to the Iowa Department of Public Health.

Situation 2: Pregnant women who might have been exposed to Rubella

All exposed pregnant women should be screened to determine if they:

1. were infected during pregnancy,
2. are susceptible or
3. were immune before pregnancy.

Because of the seriousness of CRI, immunity must be documented by a verified, dated record of a positive serologic test. Pregnant women without documented immunity should be tested for the presence of rubella IgG and IgM antibodies as outlined in this section. Identifying susceptible pregnant women is critical, so they can be isolated from further exposure, monitored for infection, and vaccinated postpartum. Pregnant women with evidence of infection during pregnancy should be evaluated to verify rubella infection and determine gestational age at time of infection, if possible, to assess the possibility of risk to the fetus.

Regardless of the point in pregnancy in which the exposure occurred (because of the possibility of late effects), and regardless of whether the woman had symptoms of rubella (because of the high proportion of asymptomatic infections). Diagnostic testing of the baby will be necessary if rubella infection in the mother was not reliably ruled out, as reflected below:

Regardless of the point in pregnancy in which the exposure occurred (because of the possibility of late effects), and regardless of whether the woman had symptoms of rubella (because of the high proportion of asymptomatic infections). Diagnostic testing of the baby will be necessary if rubella infection in the mother was not reliably ruled out, as reflected below:

Situation 3: Infants with CRS

In cases of suspect or confirmed CRS in an infant, contact the infection prevention staff in any facility in which the infant was seen, as well as care providers of the mother and the infant and review the following recommendations with them:

1. Immediately place all suspect cases of CRS on Contact Precautions. Infants with CRS shed virus in their urine and nasopharyngeal secretions and can remain infectious for 1 year or more after birth. Both the American Academy of Pediatrics in the Red Book and the Centers for Disease Control and Prevention (CDC) in the CDC Guidelines for Isolation and Precautions in Hospitals recommend Contact Precautions.
2. Place all suspect cases of rubella on Droplet Precautions during their infectious period. The infectious period for rubella is from 7 days before until 7 days after rash onset.
3. Identify all high-risk patients and staff exposed to the CRS and/or rubella case(s). Pregnant women and immunosuppressed individuals should be referred to their healthcare providers to determine if they are immune.
4. Pregnancy and Immune Globulin. Routine use of IG for postexposure prophylaxis is not recommended, even for susceptible pregnant women, because IG does not guarantee prevention of fetal infection. The only time IG may be considered is when infection occurs early in pregnancy and termination is not an option.
5. Identify all other susceptible exposed patients and staff at the facility. Healthcare providers of exposed infants should be notified. If a baby with CRS has been in a nursery where visitors and other family members have spent significant amounts of time, the immunity of those exposed to the baby should be evaluated.
6. Notify healthcare providers of all exposed patients.
7. Immunize all susceptible patients and staff. Live-virus rubella vaccine given after exposure has not been demonstrated to prevent illness, but theoretically could prevent illness if administered within 3 days of exposure. All susceptibles who are >12 months old (and for whom it is not contraindicated) should receive rubella vaccine given as the combined formulation of measles, mumps, rubella (MMR) vaccine.
   • Previous administration of human anti-Rho(D) immune globulin (RhoGam) does not generally interfere with an immune response to rubella vaccine. However, women who have received anti-Rho immune globulin should be serologically tested 6–8 weeks after vaccination to assure that seroconversion occurred. If other antibody-containing blood products are needed for other reasons, they should be administered at least 2 weeks before and deferred for up to 11 months after administration of MMR vaccine.
8. Exclude susceptible staff. Unlike measles, vaccinating immediately postexposure does not prevent an individual from acquiring rubella. Therefore, all susceptible individuals without proof of immunity, including those just vaccinated, can become infectious and must be excluded on days 7 through 21 postexposure. They may return on the 22nd day. If additional cases occur, the exclusion period may need to be extended.
9. Isolate susceptible patients and suspect/confirmed cases. Susceptible patients >12 months old should be vaccinated and placed on Droplet Precautions for days 7–21 after exposure. They may be taken off precautions on the 22nd day. All suspect and confirmed cases should be placed on Droplet Precautions during their infectious period. The infectious period for rubella is 7 days before until 7 days after rash onset.
10. Collect specimens for diagnostic testing on infants with suspect CRS and their mothers.
11. Conduct surveillance for two incubation periods (46 days) after the last exposure in the facility, and report all suspect cases of rubella to IDPH (800) 362-2736.
12. Take the opportunity to review the facility’s policy on post-partum immunization of susceptible women. Birthing facilities should be encouraged to adopt a policy of routine post-partum vaccination.

D. Preventive Measures

Vaccination, including routine childhood vaccination, catch-up vaccination of adolescents, and targeted vaccination of high-risk adult groups (such as international travelers and adults born outside the US), is the best preventive measure. Workers born outside the United States are a potentially susceptible population in which outbreaks may occur after importation of the virus from areas where rubella is endemic. Vaccinating against rubella in workplaces is a strategy to reach this susceptible population and can be a critical step in eliminating indigenous rubella.

The continuing occurrence of rubella among women of childbearing age indicates the need to continue vaccination of susceptible women in this age group. The absence of evidence of vaccine teratogenicity suggests that the practice is safe. Vaccination of susceptible women of childbearing age should:

• be part of routine general medical and gynecological outpatient care;
• take place in all family-planning settings; and
• be provided routinely before discharge from any hospital, birthing center, or other medical facility, unless a specific contraindication exists. (Note: Previous administration of human anti-Rho(D) immune globulin (RhoGam) does not generally interfere with an immune response to rubella vaccine. However, women who have received anti-Rho immune globulin should be serologically tested 6–8 weeks after vaccination to assure that seroconversion occurred.)

Rubella Vaccination of women of childbearing age:

Women who are pregnant or who intend to become pregnant within 4 weeks should not receive live rubella or MMR vaccine. The Advisory Committee on Immunization Practices (ACIP) recommends that vaccine providers ask a woman if she is pregnant or likely to become pregnant in the next 4 weeks. Those who are pregnant or intend to become pregnant should not be vaccinated. All other women should be vaccinated after being informed of the theoretical risks of vaccination during pregnancy and the importance of not becoming pregnant during the 4 weeks following vaccination. ACIP does not recommend routine pregnancy screening of women before rubella vaccination.

Please refer to the most current versions of the ACIP statement on measles, rubella, and mumps (listed under References, below), Iowa HHS Immunization Guidelines, and Iowa HHS Iowa’s Vaccine for Children Program Eligibility Criteria for details about MMR vaccine, the recommended schedule, who should and shouldn’t get the vaccine, and who is eligible to receive state-supplied vaccine. These, as well as other relevant resources, are available  at (319) 398-5133.

Iowa Dept. of Public Health, Reviewed 7/15