Clinical and social status of patients with congenital rubella

Systematic Review of the Manifestations of Congenital Rubella Syndrome in Infants and Characterization of Disability-Adjusted Life Years (DALYs)

Congenital rubella syndrome (CRS) continues to cause disability among unvaccinated populations in countries with no or insufficient rubella vaccine coverage to prevent transmission. We systematically reviewed the literature on birth outcomes associated with CRS to estimate the duration, severity, and frequency of combinations of morbidities. We searched PubMed, the Science Citation Index, and references from relevant articles for studies in English with primary data on the frequency of CRS manifestations for ≥20 cases and identified 65 studies representing 66 study populations that met our inclusion criteria. We abstracted available data on CRS cases with one or more hearing, heart, and/or eye defect following maternal rubella infection during the period of 0-20 weeks since the last menstrual period. We assessed the quality and weight of the available evidence using a modified Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Most of the evidence originates from studies in developed countries of cohorts of infants identified with CRS in the 1960s and 1970s, prior to the development of standardized definitions for CRS and widespread use of vaccine. We developed estimates of undiscounted disability-adjusted life years (DALYs) lost per CRS case for countries of different income levels. The estimates ranged from approximately 19 to 39 for high-income countries assuming optimal treatment and from approximately 29 to 39 DALYs lost per CRS case in low- and lower- middle-income countries assuming minimal treatment, with the lower bound based on 2010 general global burden of disease disability weights and the upper bound based on 1990 age-specific and treatment-specific global burden of disease disability weights. Policymakers and analysts should appreciate the significant burden of disability caused by CRS as they evaluate opportunities to manage rubella.

Humoral beta-cell autoimmunity is rare in patients with the congenital rubella syndrome

The congenital rubella syndrome (CRS) is associated with increased risk for diabetes and thyroid disease. However, the mechanisms by which the rubella virus may cause these diseases are poorly characterized. Previous studies were carried out before modern immunological methods were available. The present study aimed at evaluating whether autoimmune mechanisms are involved in the pathogenesis by analysing antibodies to biochemically characterized autoantigens. The incidence of clinical diabetes, thyroid disease, coeliac disease and related antibodies (islet cell antibodies, ICA; insulin autoantibodies, IAA; antibodies to the tyrosine phosphatase related IA-2 molecule, IA-2 A and glutamic acid decarboxylase, GADA; thyroid peroxidase, TPO; tissue transglutaminase, TTGA; and gliadin, AGA) and HLA risk genotypes were analysed in 37 subjects affected by or exposed to rubella during fetal life (mean age 22.5 years). One patient had diabetes and four patients had clinical hypothyroidism at the time of the examination. ICA, IAA, GADA or IA-2 A were not detected in any of the patients, while five patients tested positive for TPO antibodies. Coeliac disease or TTGA were not observed. Eight patients carried the HLA-DR3-associated HLA-DQB1*02-DQA1*05 haplotype. These results provide no evidence of an increased frequency of markers for humoral beta-cell autoimmunity in patients with CRS suggesting that diabetes in CRS may be caused by other than autoimmune mechanisms.

Low-birth-weight and congenital rubella syndrome: effect of gestational age at time of maternal rubella infection

Birth weights of 42 full-term patients with congenital rubella syndrome were analyzed. All of these infants were products of pregnancies in which the exact dates of the maternal first day of last menstrual period and of the time of onset of the mothers' rubella rash were known. The range of time of maternal rubella associated with low-birth-weight was in the gestational age interval from 16 to 100 days. Low-birth-weight may have a relationship with time of maternal rubella rather than with the type of defects, i.e., cataract, heart disease, and deafness.

Fingerprints in congenital rubella following maternal gamma globulin

The fingertip skin ridge patterns of ten children with the congenital rubella syndrome whose mothers had received gamma globulin following exposure to german measles during pregnancy were compared with those of 29 patients whose mothers had not received gamma globulin and with those of 162 control children. Statistical evaluation of the pattern profiles by the Mann-Whitney U-test showed that the dermatoglyphics of the two groups of patients differed significantly from each other. Each group also differed from the control children: there was a significant (p less than 0.001) increase in whorls in patients whose mothers had not had gamma globulin, but an increase (p = 0.001) in ulnar loops in those whose mothers had received gamma globulin.

Congenital rubella

The original concept of the rubella syndrome as a triad of abnormalities affecting the eye, heart, and hearing organs has changed dramatically in the past 30 years. This paper describes the various clinical manifestations of congenital rubella now recognized and the varied consequences of rubella virus infection upon the fetus. The pathogenesis of intrauterine rubella is discussed in relation to the immunologic response of the fetus and to possible mechanisms of cell and tissue damage. The need for preventive measures is discussed in relation to the total number of children damaged annually and the importance of multiple defects leading to severe handicaps. Active immunization procedures to prevent congenital rubella defects are reviewed, with comments on the differences between vaccination policies in the United Kingdom and in the United States. The importance of surveillance of congenital rubella defects is emphasized; details of the National Rubella Surveillance Scheme in the United Kingdom are discussed.

Birthweight and subsequent growth of children exposed to rubella infection in utero

Birthweight, and head circumference and body weight at preschool age were studied in a group of 212 children exposed to maternal rubella infection. Birthweights were compared to standards for birthweights of British children according to gestational age and birth rank. Children with detectable rubella antibody at the time of the examination were regarded as seropositive and those with no detectable antibody as seronegative. It was shown that the mean birthweight of seronegative and seropositive children without rubella defects did not differ significantly from the 50th centile or from each other, but that those who were seropositive with defects had significantly lower birthweights. Head circumference and body weight were similarly compared to current British standards. Head circumference at follow-up was normal in seronegative and seropositive children without defects, but significantly low in seropositive children with defects, even if retinopathy was the sole defect. The findings for body weight at follow-up were similar, reflecting absence of catch-up growth in weight in the children with congenital rubella defects. This study has shown that intrauterine growth retardation does not present as the sole manifestation of maldevelopment in congenital rubella.

Clinical and laboratory study of children exposed in utero to maternal rubella

Clinical and serological findings are described in 218 children aged 1 to 4 years who were exposed in utero to maternal rubella infection, and who were apparently normal at birth. 84 children were reassessed at 6 to 8 years of age. At the first examination, 23% of children had rubella-like defects, the most common of which was deafness associated in some cases with retinopathy. There was a close correlation between the incidence of rubella defects and both the time of exposure to maternal rubella and the presence or absence of rubella antibodies in the blood at the first examination (1 to 4 years). Children who were seropositive and who were exposed to maternal rubella before the 20th week of pregnancy were at highest risk. Of the 84 children who were reassessed at 6 to 8 years of age, further defects were detected in 9 out of the 49 seropositive children. No further defects were encountered in the seronegative group. 17% of initially seropositive children showed loss of antibody by the second examination, but this, with one exception, was confined to normal children with low antibody titres. These findings stress the importance of long-term follow-up in children at greatest risk.