Symptoms:

• About 25% to 50% of people who get infected with rubella will not experience any symptoms.
• Young children who get infected with rubella typically have mild symptoms.
• If children do have symptoms, a red rash is generally the first sign. The rash usually begins on the face then spreads to the rest of the body.
• Most adults who get rubella usually have a mild illness, with low-grade fever, sore throat, and a rash that starts on the face and spreads to the rest of the body.
• Some adults may also have a headache, pink eye, and general discomfort before the rash appears.

Complications:
The most serious complication from rubella infection is the harm it can cause a pregnant person’s developing baby. Serious birth defects are more common if a pregnant person is infected early in their pregnancy, especially in the first trimester. These severe birth defects are known as congenital rubella syndrome (CRS) and may result in infants being born with one or more of the following conditions:

• Heart problems
• Loss of hearing and eyesight
• Intellectual disability
• Liver or spleen damage
• Low birth weight

In addition, up to 70% of adult women infected with rubella may experience temporary arthritis or joint pain, particularly in the fingers, wrists, and knees. This complication is uncommon in children and adult men.

If you think you or someone in your family may have symptoms or have been exposed to rubella, talk to your doctor.

Rubella spreads when an infected person coughs or sneezes. A person with rubella may spread the disease to others up to one week before the rash appears and remain contagious up to one week after.

It takes about 12 to 23 days after being around an infected person for someone to develop rubella.

If a pregnant person is infected with rubella, they can pass it on to their developing baby. See Pregnancy and Rubella to learn more.

If you are confirmed to have rubella, you should stay at home away from other people until the 8th day after your rash started. This will help you make sure that you do not spread rubella to others.

If you think you or your someone in your family may have rubella because you or they have symptoms, have not been vaccinated against rubella, and/or have been traveling: 

• Stay home and call your doctor right away and let them know your concerns.
• Your doctor may be able to determine if you have protection against rubella based on your vaccine record or previous lab results.
• Your doctor may also make special arrangements to evaluate you to limit risk to other patients and staff. If your doctor tells you to come in for testing, make sure to wear a facemask that covers your nose and mouth.
• Stay away from other people and stay away from places where there are large groups of people who are at higher risk of getting sick, such as schools, daycare, and hospital or urgent care waiting rooms, before speaking to your doctor. This will help you make sure that you do not spread rubella to others.

If you think you have been exposed to someone with rubella:

• Call your doctor right away to let them know that you may have been exposed to someone with rubella.
• Your doctor may be able to determine if you have protection against rubella based on your vaccine record or previous lab results.
• Your doctor may also make special arrangements to evaluate you to limit risk to other patients and staff. If your doctor tells you to come in for testing, make sure to wear a facemask that covers your nose and mouth.
• Do not leave your home until your doctor says it is okay. Stay away from places where there are large groups of people who are at higher risk of getting sick, such as schools, daycare, and hospital or urgent care waiting rooms. This will help you make sure that you do not spread rubella to others.

The best way to prevent rubella is to get the rubella vaccine. The rubella vaccine is safe and works very well in preventing rubella. One dose of the MMR or MMRV vaccine is about 97% effective at preventing rubella.

Everyone including children, teenagers, and adults should get two doses of rubella vaccine if they have never had rubella and were never vaccinated.

There are two types of rubella vaccines:

• Measles-mumps-rubella vaccine (MMR) for people who are 12 months old and older.
• Measles-mumps-rubella-varicella vaccine (MMRV) for people who are 12 months to 12 years old.

If you have insurance:

• Talk to your doctor or check with your local pharmacy to see what vaccines they offer.
• Most health insurance plans cover the cost of recommended vaccines for children and adults.

If you are uninsured or underinsured:

• Programs are available to help cover the cost of vaccines.
• Children 18 years or younger may receive vaccines at no cost through the Vaccines for Children (VFC) Program if they are:
  • Eligible for or are enrolled in Medi-Cal
  • American Indian or Alaskan Native
  • Uninsured (do not have health insurance)
  • Underinsured (private health insurance does not cover the full cost of vaccines)
• Adults who are uninsured or underinsured may be able to get free or low-cost vaccines at clinics enrolled in the Vaccines for Adults (VFA) program. For more information on who is eligible, read VFA Eligibility Based on Insurance Status.

Locating Vaccine Clinics:

• A list of free and low-cost clinics in Los Angeles County.
• Interactive county map to locate free and low-cost vaccine clinics.
• Call 1-833-540-0473 (Public Health InfoLine) for a list of free or low-cost vaccine clinics. This includes Vaccines for Children (VFC) provider locations that serve Medi-Cal eligible children and uninsured or underinsured adults.

• Immunization Schedules: Birth to 6 Years Old | 7 to 18 Years Old | 19 Years Old and Older (AAP & AAFP)
• What You Need to Know: MMR Vaccine | MMRV Vaccine (Immunize.org)
• Rubella: Questions and Answers (Immunize.org)
• Rubella (German Measles): What Parents Need to Know (AAP)
• Rubella and Pregnancy (March of Dimes)
• Rubella (German Measles) (History of Vaccines)
• Travelers' Health: Travel Vaccines (LAC DPH)
• Paying for Vaccines (LAC DPH)

Consider rubella in unvaccinated patients who recently traveled internationally or a person who was exposed to a confirmed rubella case. Rubella presents nonspecifically with the following symptoms:

• Maculopapular rash (fainter than a measles rash) that starts on the face and progresses from head to feet, becomes generalized in 24 hours and lasts a median of 3 days.
• Other symptoms such as a low-grade fever, headache, conjunctivitis, rhinitis, and lymphadenopathy may occur 1-5 days before the rash.

Rubella is a mild viral illness, but it's very infectious and can lead to Congenital Rubella Syndrome (CRS), which can cause structural birth defects affecting the eyes and heart. When rubella infection occurs during pregnancy, especially during the first trimester, complications include miscarriages, and fetal deaths/stillbirths. At birth, infants may have signs and symptoms of CRS, including:

• Hearing impairment
• Eye anomalies including cataracts, congenital glaucoma or pigmentary retinopathy
• Congenital heart disease (most commonly, patent ductus arteriosus or peripheral pulmonary artery stenosis)
• Cognitive disabilities and developmental delays
• Fetal growth restrictions
• Liver and spleen damage including hepatitis and hepatosplenomegaly
• Bone abnormalities

CRS was eliminated from the United States in 2004, but cases can still be imported by a pregnant person who contracts rubella in an endemic country. Although rare, CRS can occur when a susceptible pregnant person acquires a mild or asymptomatic rubella infection early in pregnancy, and fetal anomalies are later noted on ultrasound or at birth. Maternal infection beyond 18 weeks gestation may result in congenital rubella infection (CRI) only and not signs and symptoms of CRS.

Universal childhood vaccine is important to eliminate community transmission of rubella and thus prevent acquisition during early pregnancy.

Please contact the LAC DPH Vaccine-Preventable Disease Control Program to report a case or obtain technical assistance with specimen collection or completion of forms for rubella or congenital rubella syndrome (CRS), or for any other vaccine-preventable disease. Consultation with VPDC is required before sending specimens to the Public Health Laboratory.

Suspected or confirmed rubella and CRS cases are to be reported within 7 calendar days of identification by electronic transmission (email or digital fax) or telephone per Title 17, California Code of Regulations (CCR), Section 2500.

• Weekday Telephone: 8:30 am to 5:00 pm: Call 213-351-7800
• After Hours: Call 213-974-1234, option 8
• Email: vpdc@ph.lacounty.gov
• Fax Number: 213-351-2782

Please send the patient’s medical records and any available immunization records and/or laboratory results via secure email or fax. For Congenital Rubella Syndrome, please also send any available information on the patient’s birth parent’s medical history, including vaccination records, travel history, and prenatal screening.

Clinical diagnosis of CRS and acute cases of rubella should be verified with laboratory testing. Consultation with VPDC is required before sending specimens to the Public Health Laboratory. Follow the Checklist for Managing Patients Suspected of Having Rubella for specific instructions.

Confirmatory Laboratory Tests for Acute Rubella

• Rubella RT-PCR of nasopharyngeal (NP) or throat swabs, urine specimens, and/or cerebrospinal fluid (CSF) is confirmatory for acute rubella.
  • NP swabs are the preferred sample type for detecting rubella RNA in suspected acute infections. Throat swabs are acceptable alternatives if NP swabs are not feasible.
  • Use viral transport media to collect NP and throat swabs.
• Rubella IgM - A positive IgM result is only considered confirmatory for acute rubella if paired with a low IgG avidity result.
  • Otherwise, a positive IgM is only considered presumptive laboratory evidence of rubella and would need to be accompanied by known exposure to a laboratory-confirmed rubella case or a past history of a negative IgG result.
• Rubella IgG - Paired acute and convalescent rubella IgG results showing a significant rise (defined as seroconversion or at least a 4-fold rise in titer) is considered confirmatory for acute rubella.

Confirmatory Laboratory Tests for Congenital Rubella Syndrome

• Rubella RT-PCR of nasopharyngeal (NP) or throat swabs, urine specimens, and/or cerebrospinal fluid (CSF) is confirmatory for CRS in infants.
  • NP swabs are the preferred sample type for detecting rubella RNA in suspected CRS cases. Throat swabs are acceptable alternatives if NP swabs are not feasible. Collect specimens as close to birth as possible in infants with suspected CRS to maximize the likelihood of detecting rubella virus RNA.
  • Use viral transport media to collect NP and throat swabs.
• Rubella IgM - Test suspected infants as close to birth as possible and again at 1 month of age if the initial IgM test is negative. The presence of rubella IgM in an infant is confirmatory for CRS.
• Rubella IgG - The presence of rubella IgG in an infant that does not drop at the expected rate of a twofold dilution per month is confirmatory for CRS.

If a commercial lab cannot perform testing, please call the Los Angeles County Department of Public Health Vaccine-Preventable Disease Control (VPDC) Program at 213-351-7800 to arrange testing through the Public Health Laboratory (PHL).

• Specimen Storage: Store specimens refrigerated at 2-8°C until transportation to PHL or commercial lab can be arranged. Transport refrigerated specimens on cold packs to the laboratory as soon as possible.

The California Department of Public Health recommends that persons who do not have evidence of immunity should get vaccinated. Vaccination is the best way to prevent rubella and CRS and their complications.

• MMR and MMRV vaccines are both safe and highly effective vaccines to protect against rubella.
• In immunocompetent individuals, 1 dose of a rubella-containing vaccine is 97% effective against rubella, with a range of 94-100%.
• Non-immune healthcare personnel should receive 2 doses of MMR vaccine, separated by at least 28 days.

MMR and MMRV Vaccine Recommendations for Children and Adults

MMR Vaccine Recommendations for Adults
In general, adults without presumptive evidence of immunity should receive at least 1 dose of the MMR vaccine, and certain adults may need 2 doses depending on their risk factors.

• Adults who are going to be in a setting that poses a high risk for rubella transmission should make sure they have had two doses separated by at least 28 days.
• The preferred injection site for adults is the posterior triceps aspect of the upper arm.

Pregnancy is a contraindication to vaccination with live virus vaccines, including MMR and MMRV. The American College of Obstetricians & Gynecologists (ACOG) recommends avoiding pregnancy for 4 weeks after receipt of MMR.

Administration Data: California healthcare providers are required to report data on all valid immunizations that they administer to their patients into the California Immunization Registry (CAIR) within 2 weeks of administration per AB 1797.

Administration Errors: Healthcare providers are strongly recommended to report all vaccine administration errors to the Institute for Safe Medication Practices.

Adverse Events: Healthcare providers are required to report any adverse event on the reportable events list to the Vaccine Adverse Event Reporting System (VAERS) per HR 5546.

Storage and Handling: For general recommendations and guidance access the Vaccine Storage and Handling Job Aids.

• Checklist: Managing Patients Suspected of Having Rubella (LAC DPH)
• B73 (LAC DPH): Rubella, Acute or Postnatal | Rubella, Congenital
• Rubella Quicksheet (CDPH)
• Immunization Schedules: Birth to 18 Years (AAP) | 19 Years and Older (AAFP) | CA Healthcare Personnel (CDPH)
• Vaccine Information Statements (Immunize.org): MMR | MMRV
• Standing Orders for Administering MMR: Adults | Children and Teens (Immunize.org)
• Ask the Experts: MMR (Measles, Mumps, and Rubella) Vaccination (Immunize.org)
• Los Angeles Health Alert Network (LAHAN) (LAC DPH)