28 INFECTIOUS DISEASE, DISASTER PLANNING & WOUND CARE | 2019 | www.elitecme.com a) 5. b) 10. c) 35. d) 70. COMPLICATIONS OF RUBELLA Rubella does not commonly cause com- plications. When they do occur, they are more frequent in adults than in children. Encephalitis can occur as a result of rubella infection. This occurs, on average, once per every 6,000 cases of rubella. Females are more commonly affected with encephalitis than males—and adults more than children. Various hemorrhagic complications can occur due to rubella and can affect up to one person for every 3,000 cases of rubella. Hemorrhagic adverse effects occur more commonly in children than in adults and may be caused by lowered platelet levels or vascular damage. Examples of hemorrhagic complica- tions that can be caused by rubella include: • Low platelet count (thrombocytopenia); • Stomach or intestinal bleeding (gastroin- testinal hemorrhage); • Bleeding in the brain (cerebral hemor- rhage); or • Bleeding in the kidneys (intrarenal hemorrhage). Other complications of rubella include inflammation of the nerves (neuritis), orchi- tis, and rarely, a late syndrome of progressive panencephalitis, or a widespread swelling of the brain (CDC, 2016-2). CONGENITAL RUBELLA SYNDROME (CRS) CRS occurs when the rubella virus infects pregnant women. CRS may be the most seri- ous complication associated with this virus. A rubella epidemic in 1964-1965 resulted in approximately 20,000 infants born in the U.S. with CRS. As a result, the primary goal of the rubella vaccination in the U.S. is to curb this disorder. The rubella virus can cross the placenta when the virus spreads to the mother’s bloodstream. Congenital defects can be caused by cell destruction and the obstruction of cell division. The sever- ity of adverse effects on the fetus depends greatly on the period of gestation at which the mother becomes infected with rubella. Infection during early gestation can lead to the most severe adverse reactions; up to 85% of infants born to mothers infected during the first trimester will be affected by rubella infection. Congenital defects are rare if the mother becomes infected with rubella after the 20th week of gestation (CDC, 2016-2). Since prenatal infection with the rubella virus can affect any organ system, various congenital defects can occur—up to, and including, fetal death or premature delivery. The most common manifestation of CRS is deafness, especially when rubella infection occurs sometime after four months of ges- tation. Hearing loss is often the only clinical manifestation of CRS. Congenital defects of the eye can also be caused by rubella infection. These defects include glaucoma, cataracts, ret- inal disease, and microphthalmia (abnormally small eyeballs) (CDC, 2016-2). Congenital heart defects can occur in up to half of infants born to mothers infected with rubella in the first two months of gestation. Cardiac abnormalities caused by CRS include: • Patent ductus arteriosus: The ductus arte- riosus, a vessel between the aorta and pul- monary artery, remains open. This allows oxygen-rich aortic blood to mix with oxy- gen-poor pulmonary blood and puts a strain on the heart; • Ventricular septal defects, or holes in the heart, allow blood to flow through the heart inappropriately; • Pulmonic stenosis, or an obstruction of blood flow from the heart to the pulmonary artery; • Coarctation, or the narrowing of the aorta. This increases how hard the heart has to pump to provide the body with blood (CDC, 2016-2). Congenital neurologic effects, such as microcephaly, behavioral disorders, and intel- lectual disabilities, can be caused by rubella. CRS can also cause higher-than-expected rates of autism. Other congenital abnormalities that can be caused by rubella include enlarged spleen, hepatitis, jaundice, and bone lesions (CDC, 2016-2). The onset of some manifestations of CRS can be delayed for two to four years. Children with CRS can develop diabetes later in their childhood. Progressive encephalopathy can also occur in older children with CRS (CDC, 2016-2). Evidence-Based Practice: In order to char- acterize the contagiousness of infants suffer- ing from CRS, Sugishita et al. prospectively followed a total of 15 infants born with CRS. In order to accomplish this, investigators col- lected throat swabs and analyzed them for the presence of rubella virus until two negative samples were obtained. The proportion of sub- jects with viral shedding decreased with regu- larity after birth. At birth, all subjects tested positive for rubella virus; this dropped to 92% by one to two months of age. By six months after birth, the virus was present in about 34% of subjects, and almost 17% at 12 months of age. As a result of these findings, the investi- gators concluded that it is critical to monitor viral shedding in CRS patients and take mea- sures to facilitate adequate infection preven- tion (Sugishita, et al. 2016). Rubella vaccination has resulted in a sig- nificant decrease in the incidence of rubella accompanied by a parallel drop in the instances of CRS. To illustrate this, there were a total of 57,686 reported cases of rubella and 31 instances of CRS in 1969. During the period of time spanning from 1993 to 2000, the annual incidence of U.S. rubella cases ranged from 128-364. During that same period of time, CRS cases ranged from four through nine annually. Since 2001, the U.S. rubella cases ranged from seven to 23, with zero to three instances of CRS annually. It is import- ant to note that there were two rubella out- breaks recorded between 2001 and the present. These outbreaks were generally thought to have been initiated through importation of the rubella virus from other countries (Ezike, 2017). The majority of reported congenital rubella syndrome cases occurred in infants born to Hispanic women who were from countries where routine rubella vaccination was not commonly practiced. On an international level, rubella and congenital rubella syndrome con- tinue to maintain a presence. This is especially true in Romania, Eastern Europe, and South America, where routine vaccination against rubella has not yet been fully established (Ezike, 2017). Prevention through immuniza- tion is the most important method of mini- mizing the occurrence of CRS (CDC, 2016-2). Nursing Consideration: CRS is likely the most worrisome complication associated with rubella. As a result, it is critical to prevent rubella in women who may become pregnant. Nurses and ANPs in contact with patients of CONTINUING EDUCATION  |