Overview
Rubella, sometimes called German measles, is a contagious viral infection. In children it usually causes only a mild rash and a low fever, and a quarter to a half of infected people have no symptoms at all.
The reason rubella matters is pregnancy. WHO describes it as the leading vaccine-preventable cause of birth defects. Infection early in pregnancy can cause miscarriage, stillbirth, or a baby born with deafness, cataracts and heart defects.
Disease Summary
- Category
- Infectious Disease
- Cause
- Rubella virus
- Transmission
- Airborne droplets from coughing and sneezing
- Body System
- Multiple organ systems
- Preventable
- Yes
- Curable
- No
Symptoms
Common Symptoms
Symptoms usually appear 2 to 3 weeks after exposure. CDC reports that 25% to 50% of infected people develop no rash and no symptoms, yet can still spread the infection.
A Rash
A red spotted rash that WHO states usually starts on the face and neck and spreads within 24 hours. It lasts about 1 to 3 days.
Low Fever
WHO describes a low-grade fever, below 39 degrees Celsius, which distinguishes it from the higher fever of measles.
Swollen Glands Behind the Ears and in the Neck
Characteristic of rubella. CDC notes these may appear before the rash and last 5 to 8 days.
Red Eyes
Mild inflammation of the whites of the eyes, listed by both WHO and CDC.
Headache
Listed by CDC among the symptoms appearing 1 to 5 days before the rash.
Nausea and General Discomfort
A general sense of being unwell accompanies the other early symptoms.
Cough and Runny Nose
Listed by CDC among the symptoms that appear before the rash, along with sore throat in adults.
Joint Pain in Adults
WHO notes that adults, particularly women, may develop painful joints lasting 3 to 10 days. CDC reports this in up to 70% of adult women with rubella.
Danger Signs
Seek urgent medical attention immediately if any of the following symptoms develop.
Rubella or Rubella Exposure During Pregnancy
CDC states to contact a doctor immediately. This is the single most important danger signal in rubella, and it applies even without symptoms.
Confusion, Drowsiness or Seizures
Inflammation of the brain is a rare but recognised complication of rubella.
Unusual Bruising or Bleeding
A rare complication involving the platelets that help blood to clot.
Severe or Persistent Joint Pain and Swelling
Joint symptoms are common in adult women and usually settle in 3 to 10 days, so symptoms beyond that deserve review.
A Newborn With a Rash, Poor Feeding, Jaundice or No Response to Sound
These point to congenital rubella syndrome and need urgent paediatric assessment.
Diagnosis
Clinical Criteria, Used With Caution
CDC’s criteria are a sudden generalised spotted rash with fever plus one of joint pain, swollen neck glands or red eyes. CDC warns that clinical diagnosis of rubella is unreliable, because so many infections cause no symptoms.
Pregnancy Status and Gestational Age
These determine the entire management pathway, because risk to the baby is highest in the first trimester.
Examination for Rash and Swollen Glands
The rash begins on the face, spreads within 24 hours and lasts about 3 days. Swollen glands behind the ears may come first.
Laboratory Confirmation, Which Is Required
A confirmed case requires molecular detection of the virus or a documented rise in antibody levels. Appearance alone is never sufficient.
Testing Rash Illnesses That Are Not Measles
CDC directs that patients with suspected measles who test negative for measles are then evaluated for rubella.
Laboratory Tests
Rubella Molecular Test
A positive result confirms acute rubella. CDC states sensitivity is highest within the first three days of the rash.
Rubella IgM Antibody
Indicates recent infection. CDC advises that if the first sample is taken within 4 days of the rash and is negative, a second sample is collected at least 5 days after the rash appeared.
Paired Antibody Blood Tests
A fourfold rise between the two samples confirms the diagnosis.
Antibody Avidity Test
Helps separate a recent infection from long-standing immunity, which matters greatly when the person is pregnant.
Genetic Sequencing
Determines whether the virus was imported and tracks transmission chains.
Treatment
Supportive Care
CDC states there is no specific antiviral therapy for rubella. Care manages the fever, headache and discomfort while the infection resolves on its own.
Relief of Joint Pain
Simple pain relief eases the joint pain that affects up to 70% of adult women with rubella.
Isolation
CDC advises isolating patients for 7 days after the rash develops, because the contagious period runs from 7 days before to 7 days after it.
Vaccination After Delivery
The vaccine is a live vaccine and is not given during pregnancy. CDC advises that unimmunised pregnant women receive it immediately after delivery to protect future pregnancies.
Care for a Baby With Congenital Rubella Syndrome
There is no cure. Care addresses hearing loss, cataracts, heart defects and developmental support, and starting early makes a substantial difference.
Prevention
Rubella-containing vaccine in childhood
WHO states that a single dose gives more than 95% long-lasting immunity, similar to that from natural infection.
Check rubella immunity before pregnancy
CDC advises women to confirm their vaccination status with a doctor before becoming pregnant, because the vaccine cannot be given once pregnant.
Avoid pregnancy for four weeks after the vaccine
CDC advises waiting at least four weeks after the vaccine before becoming pregnant, because it is a live vaccine.
Do not give the vaccine during pregnancy
CDC advises unvaccinated pregnant women to wait until after delivery, and to receive the vaccine immediately afterwards.
Isolate cases for 7 days after the rash
This covers the infectious window and protects anyone pregnant in the household or workplace.
Introduce rubella vaccine through measles programmes
WHO advises countries that have not yet introduced rubella vaccine to do so through existing, well-established measles immunisation programmes.
Risk Factors
Pregnant Women Without Immunity
This is the group the entire rubella programme exists to protect.
- Women infected in the first trimester, where WHO reports a 90% chance of passing the virus to the baby
- Women who never received a rubella-containing vaccine
- Women whose immunity was never checked before pregnancy
- Women in communities where the vaccine has not been introduced
Babies With Congenital Rubella Syndrome
The consequences are lifelong and there is no cure.
- Babies with hearing loss, which is the commonest feature
- Babies with cataracts, glaucoma or heart defects
- Babies with developmental delay and low birth weight
- Infected infants may shed the virus for a year or longer
Children and Young Adults Where Coverage Is Low
WHO states rubella is most common in children and young adults.
- Communities where rubella vaccine has not been introduced
- Countries where coverage is below the level needed to interrupt transmission
- Unvaccinated older children and adolescents
- Women of childbearing age in those same communities
Adult Women
Adult women get the most symptomatic illness from rubella itself.
- CDC reports joint pain or arthritis in up to 70% of adult women with rubella
- Joint symptoms are rare in children and men
- Symptoms usually last 3 to 10 days
- Women of childbearing age are the priority group for catch-up vaccination
Complications
Congenital Rubella Syndrome
The most serious complication. WHO calls rubella the leading vaccine-preventable cause of birth defects, and there is no cure.
Miscarriage and Stillbirth
WHO states that rubella infection during pregnancy may result in miscarriage or fetal death, with the most severe damage occurring early in pregnancy.
Joint Pain and Arthritis
CDC reports this in up to 70% of adult women with rubella. It is rare in children and men and usually settles in 3 to 10 days.
Low Platelet Count With Bleeding
A rare complication affecting the cells that help blood to clot.
Inflammation of the Brain
A rare complication of rubella that requires hospital care.
Prolonged Shedding by Infected Babies
WHO states that infants with congenital rubella syndrome may shed the virus for a year or longer, which is a risk to susceptible contacts.
When to Seek Medical Care
Pregnancy With Rubella or Rubella Exposure
CDC states to contact a doctor immediately. Do not wait for symptoms.
Before Pregnancy, to Check Immunity
A simple blood test establishes whether you are protected, and there is time to be vaccinated if you are not.
A Rash With Fever Plus Joint Pain, Swollen Neck Glands or Red Eyes
These meet the clinical criteria and require laboratory testing to confirm or exclude rubella.
Confusion, Drowsiness, Seizures or Unusual Bleeding
These point to the rare complications and need urgent assessment.
A Newborn Who Fails a Hearing Test or Has Cataracts or a Heart Murmur
These are features of congenital rubella syndrome and need urgent paediatric review.
Prognosis
Rubella in Children Is Usually Mild
WHO describes a rash, low fever, nausea and mild eye inflammation, with the rash lasting 1 to 3 days. Many children have no symptoms at all.
Adult Joint Symptoms Settle in Days to Weeks
WHO gives 3 to 10 days for the painful joints that affect adults, particularly women.
Congenital Rubella Syndrome Is Severe and Permanent
CDC reports that 33% of affected infants die before their first birthday, and that survivors may have hearing loss, eye and heart defects and developmental delay.
Vaccination Has Changed the Picture Dramatically
WHO reports a 97% fall in global rubella cases between 2000 and 2022, and states a single dose gives more than 95% long-lasting immunity.
Differential Diagnosis
Measles
A different virus that causes higher fever and a more extensive, longer-lasting rash. CDC directs that suspected measles cases testing negative are evaluated for rubella.
Parvovirus Infection
Causes a rash and joint pain that closely mimic rubella, and it is a known cause of false positive rubella antibody results.
Scarlet Fever
Caused by a bacterium, with a sore throat and a rash that feels like sandpaper, and confirmed by a throat swab.
Dengue Fever
Causes fever with a rash and severe muscle pain, and is separated by specific testing and travel history.
Kawasaki Disease
Causes prolonged high fever with red eyes, mouth changes and swollen hands and feet, rather than a rash that settles in three days.
References
World Health Organization: Rubella
WHO fact sheet on rubella, congenital rubella syndrome, vaccination and global coverage.
CDC: Clinical Overview of Rubella
Clinical features, laboratory testing, complications and isolation guidance.
CDC: Pregnancy and Rubella
Risks in pregnancy, features of congenital rubella syndrome and vaccination timing.
CDC: Rubella and Congenital Rubella Syndrome Fast Facts
Global figures on rubella, congenital rubella syndrome and vaccine introduction.
Frequently Asked Questions
Why is rubella dangerous in pregnancy?
WHO states that a woman infected early in pregnancy has a 90% chance of passing the virus to her baby, and that the most severe damage occurs in the first trimester. The result can be miscarriage, stillbirth or congenital rubella syndrome, which causes hearing loss, eye and heart defects and developmental delay. There is no cure for it.
Is rubella the same as measles?
No. Rubella is sometimes called German measles, but it is caused by a completely different virus. Rubella is generally milder, with a rash lasting about three days and a fever below 39 degrees Celsius, while measles causes higher fever and a more extensive rash.
Can I have rubella without a rash?
Yes. CDC reports that 25% to 50% of people infected with rubella develop no rash and no symptoms, but can still spread the infection. This is why CDC states that a clinical diagnosis is unreliable and why immunity is checked with a blood test.
How many rubella doses are needed and how well do they work?
WHO states that a single dose gives more than 95% long-lasting immunity. Many countries give two doses of the combined measles, mumps and rubella vaccine. Follow the schedule where you live.
How long is someone with rubella contagious?
CDC states the contagious period runs from 7 days before the rash appears to 7 days after, and recommends isolating patients for 7 days after the rash develops. Infants with congenital rubella syndrome may shed the virus for a year or longer.