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PEDIATRICS Vol. 108 No. 6 December 2001, pp. 1389-1390
Congenital Rubella Infection Control Problem
To the Editor—Zimmerman and Reef’s report regarding congenital rubella syndrome (CRS)1 did not address the challenging infection control issues posed when the diagnosis of CRS is considered. Our recent experience may be instructive for others.
In October 2000, a neonate with a patent ductus arteriosus was admitted to a multi-bed room at our hospital. The infant’s mother reported a febrile illness with rash during the 5th week of her pregnancy in Honduras, which she identified as "rubeola." The infant was managed by cardiology and seen in consultation by hematology, infectious diseases, ophthalmology, and neurology. Although CRS was mentioned in the differential diagnoses of several physicians, the patient was not isolated until the 7th day of hospitalization. This may in part be because early prenatal records were unavailable and that those involved in the patient’s care did not recognize that "rubeola" is Spanish for rubella. On the 14th day of hospitalization rubella-specific immunoglobulin M was reported in the patient’s serum. Later, cultures of the patient’s nasopharyngeal secretions grew rubella.
Five infants who shared the multi-bed room with the case patient and 261 staff including employees, volunteers, and medical contract staff were potentially exposed. Of the patients, 3 were aged 3 days to 2 months and were born at term to rubella immune mothers. The remaining 2 were born at 31 weeks’ gestation and were therefore followed for a month after exposure to confirm rubella seronegativity. Initially, baseline immune status was known on 213 (82%) of the staff. Ultimately, 251 (96%) were documented to be rubella-immune. One seronegative employee was furloughed and a second was immunized and allowed to continue working. The rubella status of the remaining 8, all nonemployee physicians, remains undocumented. No secondary cases were identified.
Over the past 3 years in Washington State, there have been seven documented cases of postnatal rubella. Six of 7 occurred in individuals born in Russia or Thailand (personal communication, Epidemiology and Immunization Section, Public Health King County, Seattle, WA). In addition, 83.3% of laboratory-confirmed cases of CRS in the United States between 1997 and 1999 were born to Hispanic mothers.2 When evaluating for congenital infection, CRS should be considered in infants of foreign-born mothers from countries that do not routinely immunize for rubella. When the diagnosis of CRS is considered, patients should be placed in contact isolation until CRS can be ruled out. While 96% of exposed employees and volunteers were confirmed as immune, lack of documentation for certain groups, notably physicians, hampered efforts to perform postexposure investigation. Immune status documentation should be required for all personnel who have direct patient contact within health care institutions, including physicians.
Danielle M. Zerr, MD, MPH*,
Joan Heath, RN, BSN, CIC
Diane Riggert, RN, MPH, COHN-C
Edgar K. Marcuse, MD, MPH*,
* Department of Pediatrics
University of Washington Children’s Hospital and Regional Medical Center
Seattle, WA 98105
REFERENCES
- Zimmerman L, Reef SE. Incidence of congenital rubella syndrome at a hospital serving a predominantly Hispanic population, El Paso, Texas. Pediatrics.2001; 107(3):. Available at: http://www.pediatrics.org/cgi/content/full/107/3/e40
- CDC. Measles, rubella, and congenital rubella syndrome—United States and Mexico, 1997–1999. MMWR Morb Mortal Wkly Rep.2000; 49:1048–1050[Medline]
In Reply—
We thank the correspondents for sharing their experience related to the challenges of infection control issues posed when the diagnosis of congenital rubella syndrome (CRS) is considered. We also underscore the importance of performing rubella-specific immunoglobulin M testing as soon as CRS is suspected. If CRS is suspected in an infant but tests performed shortly after birth are negative, the infant should be retested at age 1 month. Efforts should also be made to obtain clinical specimens for virus isolation from all cases. The infant discussed by Zerr and colleagues was not laboratory-confirmed for rubella infection until the 14th day of hospitalization, allowing for multiple exposures of other infants and hospital staff and resulting in a significant amount of time and intensive effort in investigation of these contacts. Studies show that infants with CRS can shed virus for prolonged periods of time, up to a year in some cases, representing a source of infection to susceptible individuals. The Advisory Committee on Immunization Practices recommends that all health care workers are immune to rubella. As Zerr and colleagues discuss, although the incidence of CRS is low in the United States, CRS should be considered in all infants with manifestations consistent with CRS, particularly in infants of foreign-born women from countries who do not vaccinate against rubella or from countries who have only recently instituted rubella vaccination programs. It is crucial then to place these infants in contact isolation until CRS is ruled out or confirmed. If CRS is confirmed, the infant is considered infectious until 1 year of age or until 2 cultures of pharyngeal and urine specimens obtained at least 1 month apart are negative for virus after age 3 months.
Laura Zimmerman, MPH
Susan E. Reef, MD
Epidemiology and Surveillance Division, National Immunization Program
Centers for Disease Control and Prevention
Atlanta, GA 50333
PEDIATRICS (ISSN 1098-4275). ©2001 by the American Academy of Pediatrics
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