Control and Prevention of Rubella: Evaluation and Management of Suspected Outbreaks, Rubella in Pregnant Women, and Surveillance for Congenital Rubella Syndrome
Outbreaks of rubella continue to occur in the United States despite widespread use of the measles-mumps-rubella (MMR) vaccine. Throughout the mid- to late-1990s, rubella outbreaks were characterized by increased numbers of cases among adults born in countries that do not have or have only recently instituted a national rubella vaccination program. To address this change in disease epidemiology, CDC's National Immunization Program (NIP) developed the following recommendations in conjunction with public health officials in the field. Public health officials should implement appropriate responses to reports of suspected rubella to determine if an outbreak exists, evaluate its scope, and implement appropriate control measures. Health-care providers should be aware of the need for rubella prevention and control among women of childbearing age and of the appropriate follow-up for pregnant women exposed to rubella. Comprehensive surveillance for congenital rubella syndrome should begin during a rubella outbreak.
Since the licensure of the rubella vaccine in 1969, the number of cases of rubella in the United States has decreased 99%, from 57,686 cases in 1969 to 271 cases in 1999 (CDC, unpublished data, 2000). The epidemiology of rubella changed in the 1990s, including shifts in the age distribution, ethnicity, and country of origin of patients, and in the setting of outbreaks. During the early 1990s, most rubella cases in the United States occurred among persons aged <15 years; since the mid-1990s, persons aged >15 years have accounted for most reported cases. In 1999, adults accounted for 86% of cases, an increase from 41% in 1990, and 73% of persons with rubella were Hispanic, compared with 4% in 1991 (CDC, unpublished data, 2000). Most of these persons were foreign-born. In recent rubella outbreaks, most cases occurred among persons from Mexico and Central America. Moreover, outbreaks occurred predominantly in workplaces and communities; before the mid-1990s, outbreaks occurred mainly in religious communities, schools, jails, and other closed environments. Recently, rubella outbreaks have been identified in poultry and meat processing plants that employ large numbers of foreign-born workers.
The number of cases of congenital rubella syndrome (CRS) has also declined, and CRS now disproportionately affects infants born to foreign-born women. During 1997--1999, a total of 21/26 (81%) infants reported with CRS were Hispanic, and 24/26 (92%) were born to foreign-born mothers (CDC, unpublished data, 2000). Although
information on country of origin was not collected in 1991, a total of 8/42 (19%) infants with CRS were Hispanic. Identifying and managing susceptible pregnant women who might have been exposed to rubella is challenging, especially in communitywide outbreaks.
Congenital rubella infection (CRI) encompasses all outcomes associated with intrauterine rubella infection, including miscarriage, stillbirth, abortion, combinations of birth defects, or asymptomatic infection in the infant (also known as infection only) (1). Although serologic testing remains the most available laboratory method for confirmation, CRI also can be confirmed by reverse transcriptase polymerase chain reaction (RT-PCR) assays, which detect rubella virus (2).
Making best use of available technology will help rubella virus surveillance and ascertainment. For example, molecular typing of rubella virus is available to identify the origin of the virus as well as which virus strains are circulating. This information is necessary to document elimination of indigenous transmission. Universal programs to screen newborn hearing in the United States could help improve ascertainment of CRS cases because hearing impairment is the most common single defect associated with CRS (3). Performing serologic testing for rubella on infants who fail hearing screenings at birth could help identify CRS cases.
This report describes seven steps for evaluating and managing suspected rubella outbreaks. They were developed by NIP in conjunction with state and local public health officials based on experience with recent outbreaks in the United States (4,5). These steps are a) consider a single case of rubella a potential outbreak, b) confirm the diagnosis, c) conduct case investigations and vaccinate susceptible contacts, d) enhance active and passive surveillance measures, e) implement rubella control measures, f) conduct outreach in affected facilities and communities, and g) develop a plan for preventing future rubella outbreaks. This report also provides guidelines for evaluating and managing rubella in pregnant and nonpregnant women and evaluating infants for CRI.
Rubella is usually a mild febrile rash illness in adults and children. Other symptoms include lymphadenopathy, malaise, or conjunctivitis. Arthralgia and arthritis can occur in <70% of infected adult and adolescent females. Rare complications are thrombocytopenic purpura, encephalitis, neuritis, and orchitis. The incubation period for rubella is 12--23 days, and 20%--50% of rubella infections are asymptomatic. Persons with rubella are most infectious when rash is erupting, but can shed virus from 7 days before to 5--7 days after rash onset (i.e., the infectious period).
The most serious consequences of rubella result from infection during the first trimester of pregnancy. Rubella infection can affect all organs in the developing fetus and cause miscarriage, fetal death, and congenital anomalies. Up to 90% of infants born to mothers infected during the first 11 weeks of gestation will develop a pattern of birth defects called CRS (6); the rate of CRS for infants born to women infected during the first 20 weeks of pregnancy is 20%. Infants infected with rubella late in gestation do not exhibit clinical manifestations of CRS. Any infant infected with rubella in utero can shed virus for <1 year, sometimes longer (7).
The goal of the rubella vaccination program is to prevent the consequences of infection during pregnancy. Many countries do not have rubella vaccination programs or have only recently implemented such programs, and many adults throughout the world remain susceptible. In 1996, the World Health Organization (WHO) estimated that 36% of member countries offered routine rubella vaccination (8). In 1999, WHO estimated that 52% of countries offered routine rubella vaccination; in the Region of the Americas, 89% of countries used rubella vaccine (9). Adults in the United States who were born in countries where routine rubella vaccination was not offered are at higher risk for contracting rubella and having infants with CRS compared with adults born in the United States. Vaccinating foreign-born, susceptible adults can be challenging because they might have little or no contact with the U.S. health-care system. Thus, health-care providers who treat foreign-born adults should document their rubella immunity with a written record of a rubella-containing vaccine or by serologic testing. If problems arise in translating vaccination records from other countries, help is available from the CDC Immunization Information Hotline at (800) 232-2522 (English) or (800) 232-0233 (Spanish). WHO also has summarized current global vaccination policies for countries throughout the world (10).
Adequate proof of rubella immunity includes a) written documentation of receipt of >1 dose of a rubella-containing vaccine administered on or after the first birthday, b) laboratory evidence of immunity, or c) birth before 1957 (except for women who could become pregnant). However, during an outbreak, persons born before 1957 should not automatically be considered immune to rubella. Rubella immunity is defined as a hemagglutination inhibition antibody titer of >1:8, a hemolysis in gel result of >10 international units (IU), or an optical density by enzyme-linked immunoassay (EIA) above the limit set by the manufacturer (11). Persons who do not meet the above criteria are considered susceptible.
Rubella and CRS became notifiable diseases in the United States in 1966 and 1969, respectively. All 50 states require reporting of rubella and CRS (12). For information on these requirements, contact local or state health departments.
State and local health departments rely on health-care providers, laboratory personnel, and other public health workers to report confirmed, probable, and suspected cases of rubella and CRS so the departments can monitor the occurrences of these diseases and facilitate appropriate control measures. Health-care providers and laboratory personnel who suspect cases of rubella, CRS, or congenital rubella infection only should report them within 24 hours to their local health department. Health-care providers should not delay reporting suspected cases of rubella, CRS, and congenital rubella infection only while they wait for laboratory confirmation.
Criteria for Rubella Case Classification
A clinical case of rubella is defined as an illness characterized by a) acute onset of generalized maculopapular rash; b) temperature >37.2 C (>99.0 F), if measured; and c) arthralgia/arthritis, lymphadenopathy (usually suboccipital, postauricular, and cervical), or conjunctivitis. Case classification for rubella is based on a clinical case definition and laboratory criteria for diagnosis (13). Cases are classified into one of the following categories:
Cases are also categorized by importation status:
Laboratory Diagnosis of Rubella
Laboratory diagnosis of rubella requires any one of the following:
Specimens submitted for rubella virus isolation or detection by RT-PCR can also be used for molecular typing. Molecular typing can help determine a) the origin of the virus, b) which virus strains are circulating in the United States, and c) whether these strains have become endemic in the United States. Specimens for molecular typing should be obtained as soon as possible after diagnosis. Appropriate specimens include throat swabs and cerebrospinal fluid. Specimens for molecular typing should be sent to CDC as directed by the state health department. For information on the procedure for obtaining specimens, contact CDC's National Center for Infectious Diseases, Respiratory and Enterovirus Branch, Measles Virus Section at (404) 639-3512.
Laboratory Procedures for Persons Exposed to Rubella Who Do Not Have Rash
Persons exposed to rubella, particularly pregnant women, should be tested for rubella infection. Asymptomatic rubella infection can be diagnosed by a positive rubella-specific IgM antibody test or a significant rise in IgG antibody level between acute- and convalescent-phase tests. The acute-phase IgG serum specimen should be collected as soon as possible after exposure, whereas the convalescent-phase IgG specimen should be collected >7--14 days (preferably 2--3 weeks) later.
Case Classification Criteria for Congenital Rubella Syndrome*
CRS results from rubella infection in utero, usually manifests in infancy, and is characterized by clinical signs or symptoms from the following categories:
a) Cataracts/congenital glaucoma, congenital heart disease (most commonly patent ductus arteriosus or peripheral pulmonic stenosis), hearing impairment, pigmentary retinopathy.
b) Purpura, hepatosplenomegaly, jaundice, microcephaly, developmental delay, meningoencephalitis, radiolucent bone disease.
Infants with CRS usually present with more than one of these signs or symptoms. However, infants may present with a single defect. Hearing impairment is the most common single defect.
Case classification for CRS is based on clinical findings and laboratory criteria for diagnosis (13). Cases are classified as follows:
CRS cases are also categorized by importation status:
Laboratory Diagnosis of Congenital Rubella Syndrome and Congenital Rubella Infection Only
Laboratory diagnosis of CRS or congenital rubella infection only requires any one of the following:
Specimens for molecular typing should be obtained from infants with CRS as soon as possible after clinical diagnosis. Appropriate specimens include throat swabs, cerebrospinal fluid, and cataracts from surgery. Specimens for molecular typing should be sent to CDC as directed by the state health department.
The seven steps described in this section are recommended for the evaluation, management, and surveillance of suspected rubella outbreaks (Box). They are based on recent experience with outbreaks in the United States (4,5). These recommendations can be used in settings beyond those discussed in this report.
Consider a Single Case of Rubella a Potential Outbreak
Because the incidence of rubella is low in the United States, health agencies should consider even one case a potential outbreak. Rubella is an infectious disease for which 20%--50% of cases are asymptomatic, and investigation of an apparently isolated case could reveal additional cases. Rubella transmission can occur in congregate settings such as households, workplaces, universities, jails, or communities. The type and size of the outbreak determines the magnitude of the response.
Most recent rubella outbreaks were first identified in the workplace. Facilities that employ many foreign-born workers (e.g., meat or poultry processing plants) are at greater risk for rubella outbreaks than those with mostly workers born in the United States. Initial reports can come from on-site health-care providers who have recently seen rash illness among employees.
Steps to Improve Ascertainment of Rubella Cases in the Workplace
Steps to Improve Ascertainment of Rubella Cases in the Community
Recently, investigations of workplace outbreaks have revealed spread to the community. The following steps can help identify cases in the community:
Confirm the Diagnosis
Because rubella has many symptoms in common with other rash illnesses, laboratory confirmation is required for case confirmation. Laboratory testing should be conducted for all suspected cases of rubella. IgM antibodies might not be detectable before 4--5 days after rash onset. If negative rubella IgM and IgG results are obtained from specimens taken before 4--5 days, repeat serologic testing (14).
Conduct Case Investigations and Vaccinate Susceptible Contacts
Case investigation and identification of contacts should be conducted for all suspected cases of rubella. In addition, asymptomatic confirmed cases should be investigated and contacts identified. A descriptive analysis of an outbreak allows health agencies to focus control measures --- especially vaccination --- on persons most in need. Cases of rubella occurring in vaccinated persons within 7--10 days after vaccination should be investigated, and specimens should be obtained for virus isolation to determine if rash is attributable to vaccine virus or wild virus.
Any direct contact with a patient with rubella during the infectious period (i.e., 7 days before to 5--7 days after rash onset) is defined as exposure. Contact can include (but is not limited to) living in the same household, attending the same class or social function, or working side-by-side on a production line. Although rubella transmission is usually associated with repeated exposure, transmission has been documented after a single exposure.
Depending on resources available, investigation of contacts of patients with rubella might need to be prioritized based on the probability of transmission. The first priority should be persons who share households or persons in a congregate environment who share space (e.g., side-by-side workers on a production line) with a patient. The second priority should be persons who share or have shared environments with a potential for contact (e.g., places of worship, parties, social gatherings), but who did not knowingly have direct contact with a patient. If resources allow, investigation of contacts can be extended to geographic areas or groups at risk where disease has been documented.
Every effort should be made to identify all susceptible pregnant women who might have been exposed to a patient and test them for rubella immunity. For example, in a workplace outbreak, pregnant women who have contact with patients (including coworkers and household contacts) should be evaluated for rubella immunity. In communitywide outbreaks, health-care workers who treat pregnant women should be alerted to the outbreak and advised to verify rubella immunity in pregnant women.
Steps for Locating Exposed Contacts for Further Investigation
Information That Should be Obtained from Patients With Rubella
--- Relationship to outbreak (i.e., whether case is sporadic or part of an identified outbreak).
--- Travel history.
--- Contact with others who have recently traveled (i.e., import status [indigenous, state-to-state, or international], state name, and country name [and state within the country]).
Enhance Active and Passive Surveillance Measures
Components of Surveillance for Rubella in an Outbreak Setting
In addition to prospective surveillance, retrospective case finding should be conducted for 6 weeks (i.e., two incubation periods) before the first identified case. If evidence indicates that the outbreak was in progress during this time, retrospective case finding should continue until no further cases are identified.
Steps to Identify Cases Retrospectively
Implement Rubella Control Measures
During a rubella outbreak, the following control measures should be taken:
Control Measures for Specific Settings
Congregate Environments. Congregate environments include households, jails, day cares, schools, military settings, workplaces, places of worship, athletic events, and other social gatherings. Control measures recommended for these settings are as follows:
Health-Care Settings. Health-care settings include hospitals, doctors' offices, clinics, nursing homes, and other facilities where patients receive subacute or extended care. Control measures recommended for these settings include excluding and vaccinating health-care workers without adequate evidence of immunity, particularly in settings where pregnant women could be exposed.
All persons who work in health-care facilities or who have contact with any patients should be immune to rubella. Any exposed health-care worker who does not have adequate evidence of immunity should be excluded from duty beginning 7 days after exposure to rubella and continuing through either a) 21 days after last exposure or b) 5--7 days after rash appears. Susceptible, exposed health-care workers who are vaccinated should be excluded from direct patient care for 23 days (i.e., the longest incubation period) after the last exposure to rubella because no evidence exists that postexposure vaccination is effective in preventing rubella infection in persons already infected at the time of vaccination. Because birth before 1957 does not guarantee immunity, health-care facilities should strongly recommend a dose of MMR vaccine to workers born before 1957 who do not have serologic evidence of immunity.
Communitywide Rubella Outbreaks. When communitywide outbreaks occur, the following steps are recommended:
Conduct Outreach in Affected Facilities and Communities
Outreach activities should begin during the outbreak investigation and should convey the seriousness of rubella infection and the importance of rubella vaccination and other control efforts. Outreach activities also provide an opportunity to reinforce the importance of persons seeking medical advice for rubella-like illnesses and of health-care workers reporting rubella.
In the workplace, outreach activities should focus on educating workers and employers regarding rubella and its consequences, using such strategies as educational sessions, flyers, letters, and E-mail. Stress that persons who work in a place where an outbreak is in progress and who live with or have contact with someone who is pregnant should be vaccinated unless known to be immune.
A communitywide outbreak can be most effectively contained if public health agencies form partnerships with community leaders, health-care providers, and groups with a history of effective community involvement. These persons can act as liaisons between public health agencies and the community. Outreach activities in the community should include the following:
Develop a Plan for Preventing Future Rubella Outbreaks
Prevention of future rubella outbreaks includes ensuring high levels of rubella immunity, vaccinating susceptible persons, maintaining rubella and CRS surveillance and reporting, and preparing an appropriate and rapid response when a case of rubella is identified. To make the most effective use of resources to prevent CRS and control rubella, state and local health authorities might want to identify and prioritize counties and communities in order of decreasing risk and conduct vaccination or education campaigns accordingly. Depending on cost and available resources, health department personnel might decide to target all counties and communities in the state or limit the campaigns to those at highest risk for rubella outbreaks based on known or suspected susceptibility patterns and the likelihood of introduction of rubella into the community. Based on the current epidemiology of rubella, counties most at risk appear to be those with substantial numbers of adolescents and young adults born and raised in countries that do not have a history of routine rubella vaccination.
All states should conduct activities for the prevention of CRS or CRI, including the following:
In addition, states that have had recent rubella outbreaks or a recent indigenous CRS case or that have identified populations at high risk for rubella outbreaks might want to emphasize rubella control as well as CRS prevention through the following activities:
At workplaces where recent rubella outbreaks have occurred or high numbers of persons at risk for rubella are employed, state health departments should
In communities that have had recent rubella outbreaks or where large numbers of persons at risk for rubella reside, state health departments should
This section summarizes information available in the most recent ACIP statement on MMR vaccination (17). In the United States, most rubella vaccination is administered as part of the MMR vaccine. Approximately 21--28 days are required for development of protection following vaccination.
Persons generally are presumed immune to rubella if they a) have documentation of vaccination with >1 dose of MMR or other live, rubella-containing vaccine administered on or after the first birthday, b) have laboratory evidence of immunity, or c) were born before 1957 (except women who could become pregnant). Susceptible adults born after 1957 who do not have a medical contraindication should receive >1 dose of MMR vaccine for protection against rubella and two doses >1 month apart if at high risk for exposure to measles (17). Birth before 1957 is not acceptable evidence for rubella immunity for women who could become pregnant.
Contraindications and Precautions
Following is a summary of contraindications and precautions for administration of MMR vaccine. For more detailed information, consult the most recent ACIP statement on MMR vaccination (17).
MMR vaccine should not be administered to persons who have experienced severe allergic reactions to a previous dose of a rubella-containing vaccine or to a vaccine component (e.g., gelatin or neomycin). Allergy to egg is not a contraindication.
MMR vaccine should not be administered to women known to be pregnant or attempting to become pregnant. Because of the theoretical risk to the fetus, women should be counseled to avoid becoming pregnant for 3 months after receipt of a rubella-containing vaccine (18). If a pregnant woman is vaccinated or becomes pregnant within 3 weeks after receipt of vaccine, she should be counseled regarding the theoretical basis of concern for the fetus. However, receipt of rubella-containing vaccine during pregnancy should not ordinarily be a reason to consider termination of pregnancy. Women who are susceptible to rubella and not vaccinated because they are pregnant or might become pregnant within the next 3 months should be advised regarding the potential risk for CRS and the importance of being vaccinated as soon as they are no longer pregnant (17).
From January 1971 through April 1989, CDC followed to term 321 known rubella-susceptible women who were vaccinated within 3 months before or 3 months after conception. Ninety-four women received HPV-77 or Cendehill vaccines, one received vaccine of unknown strain, and 226 received RA 27/3 vaccine (the only rubella vaccine presently used in the United States). None of the 324 infants born to these mothers had malformations compatible with CRI, but five had evidence of subclinical rubella infection, two of whom were exposed to RA 27/3 vaccine (17). Based on these data, the estimated risk for serious malformations attributable to RA 27/3 vaccine ranges from zero to 1.6% (17). Breast-feeding is not a contraindication to receiving MMR vaccine.
MMR vaccine should not be administered to persons with severe immunodeficiency from any cause. Persons with mild immunosuppression (e.g., from asymptomatic human immunodeficiency virus [HIV] infection or short-term or low-dose steroid use) may be vaccinated.
Health-care providers should evaluate whether to administer MMR vaccine to
Vaccine Information Statements (VIS)
The National Childhood Vaccine Injury Act (NCVIA) requires all health-care providers in the United States who administer MMR vaccine to provide a copy of the relevant VIS to either an adult vaccinee, or in the case of a minor, to a parent or legal representative (18). Health-care providers are not required to obtain the signature of the patient, parent, or legal representative acknowledging receipt of the VIS. However, to document that the VIS was given, health-care providers must note in each patient's permanent medical record at the time a VIS is provided the date printed on the VIS and the date the VIS is administered to the vaccine recipient, parent, or legal representative. NCVIA also requires that health-care providers note the following information in the patient's permanent medical record:
Reporting of Adverse Events
The National Vaccine Injury Act of 1986 requires physicians and other health-care providers who administer vaccines to maintain permanent immunization records and to report occurrences of adverse events for selected vaccines (17). Serious adverse events (i.e., all events requiring medical attention), regardless of whether they are suspected to have been caused by vaccine, should be reported to the Vaccine Adverse Event Reporting System (VAERS). VAERS forms and instructions are available in the FDA Drug Bulletin and the Physicians' Desk Reference or by calling the 24-hour VAERS information recording at (800) 822-7967.
RUBELLA PREVENTION AND CONTROL AMONG WOMEN OF CHILDBEARING AGE
Guidelines for rubella prevention and control among women of childbearing age differ depending on the likelihood of exposure to rubella. Identifying women who could have been exposed is critical so they can receive appropriate testing and follow-up. Guidelines for testing and follow-up for all women of childbearing age, pregnant women for whom rubella exposure is unlikely, and pregnant women who might have been exposed to rubella are outlined in the following sections.
All Women of Childbearing Age
Health-care providers who treat women of childbearing age should routinely determine rubella immunity and vaccinate those who are susceptible and not pregnant. Proof of immunity can be either a verified record of vaccination or a positive IgG antibody serologic test. Rubella-susceptible women who a) do not report being pregnant, b) are not likely to become pregnant in the next 3 months, and c) do not have other contraindicating conditions should be vaccinated. Before vaccination, each patient should be counseled to avoid pregnancy for 3 months after vaccination because of the theoretical risk for vaccine virus affecting the fetus. Because routine pregnancy screening is not recommended before rubella vaccination, patients should be counseled regarding the theoretical risk to the fetus from inadvertent vaccination of a pregnant woman.
Pregnant Women Without Likely Exposure
Even when no outbreaks have been reported and no rubella exposure has occurred, health-care providers should routinely conduct a rubella IgG test for all pregnant women at the earliest prenatal visit. A positive rubella IgG antibody test indicates rubella immunity, and health-care providers can assume that immunity was acquired before pregnancy. Women who are found to be susceptible should be monitored for signs of rubella during pregnancy and vaccinated postpartum. Susceptible pregnant women should be advised to avoid contact with persons with rash illness.
An IgM test should not be used to determine rubella immune status; IgM is used to diagnose acute and recent rubella infection. The TORCH (i.e., toxoplasmosis, rubella, cytomegalovirus, and herpes) panel includes a test for rubella IgG antibodies as well as a test for rubella IgM antibodies. Because of the potential for false-positive IgM results, a TORCH panel should not be used to determine rubella immunity. Rubella IgM testing should be performed on pregnant women who report symptoms of rubella or susceptible pregnant women who might have been exposed to rubella to rule out acute or recent infection.
Screening and Follow-Up of Pregnant Women Who Might Have Been Exposed to Rubella
Because the consequences of rubella infection during pregnancy are serious, every effort must be made to identify all women of childbearing age exposed to a person with confirmed, probable, or suspected rubella. Women found to be susceptible and not pregnant should be vaccinated as outlined previously (see All Women of Childbearing Age). Susceptible household contacts of pregnant women should also be vaccinated.
All exposed pregnant women should be screened to determine if they a) were infected during pregnancy, b) are susceptible, or c) 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.
Immunoglobulin (IG) does not prevent rubella or mumps infection after exposure and is not recommended for that purpose (18). Administration of IG after exposure to rubella will not prevent infection or viremia, but might modify or suppress symptoms and create an unwarranted sense of security. Therefore, IG is not recommended for routine postexposure prophylaxis of rubella in early pregnancy or any other circumstance. Infants with congenital rubella have been born to women who received IG shortly after exposure. Administration of IG should be considered only if a pregnant woman who has been exposed to rubella will not consider termination of pregnancy under any circumstances. In such cases, intramuscular administration of 20 mL of IG within 72 hours of rubella exposure might reduce --- but will not eliminate --- the risk for rubella.
During an outbreak, the following steps should be taken to evaluate and follow up with pregnant women who had contact with a person with confirmed, probable, or suspected rubella:
SURVEILLANCE FOR CONGENITAL RUBELLA SYNDROME
Consequences of CRI during pregnancy include abortion, miscarriage, stillbirth, and a pattern of birth defects called CRS. The most common congenital defects related to CRS are cataracts, heart defects, hearing impairment, and developmental delay. Other less specific signs and symptoms of CRS include purpura, hepatosplenomegaly, jaundice, microcephaly, meningoencephalitis, and radiolucent bone disease.
Pregnant women with known rubella exposure should receive follow-up care. Surveillance for CRI and CRS should be implemented when confirmed or probable rubella cases are documented in a setting where pregnant women might have been exposed. The following steps are recommended to achieve these goals:
The following steps are recommended for follow-up and surveillance for CRS and congenital rubella infection only cases:
Rubella outbreak control is essential for eliminating indigenous rubella and preventing CRS and CRI. Strategies for rubella outbreak control include defining target populations for rubella vaccination, ensuring that susceptible persons within the target populations are vaccinated rapidly (or excluded from exposure if a contraindication for vaccination exists), and maintaining rubella and CRS surveillance (18). Control measures should be implemented as soon as a case of rubella is identified. Maintaining control measures is essential when pregnant women are possible contacts of patients with rubella. Susceptible pregnant women who are exposed to rubella should be thoroughly evaluated for possible rubella infection.
* Most of the wording in this section comes directly from the case definitions developed by CDC and the Council of State and Territorial Epidemiologists (CSTE) (CDC. Case definitions for infectious conditions under public health surveillance. MMWR 1997;46[No. RR-10]:30).
* Special Supplemental Nutrition Program for Women, Infants, and Children.
*CSTE recommends that states use CDC's Epidemic Information Exchange (Epi-X) to disseminate outbreak information. Information on Epi-X is available at <http://www.cdc.gov/programs/research5.htm>.
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