Cases of congenital rubella may be the tip of the iceberg

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Cases of congenital rubella may be the tip of the iceberg

EDITORWe have diagnosed congenital rubella infection in another infant since publication of our two other cases as a lessonof the week.¹

The infant was born to a Sri Lankan primiparous woman who had lived in the United Kingdom for six years and had not travelledabroad in the recent past or had contact with rubella. The motherwas susceptible to rubella on routine antenatal testing at 12weeks' gestation. The infant was born at 34 weeks' gestation withintrauterine growth restriction and thrombocytopenia but no otherserious sequelae.

The infant and mother both tested positive for rubella IgM. The mother gave a clear history of a transient, non-itchy rashat 26 weeks' gestation. We could not find any social or communitylink between this mother and those in our two previouscases.

Rubella is highly infectious. In a recent case report from another London hospital rubella virus was nosocomially acquiredby an infant being cared for in the same neonatal nursery as aninfant with the congenital rubella syndrome.² As we know thatat least three infants are excreting rubella virus in north westLondon, we now test for rubella IgM in all infants with severe intrauterine growth restriction (birth weight <3rdcentile).

We believe that rubella infection may be underdiagnosed, given the recent decline in uptake of measles, mumps, and rubella(MMR) vaccination and the existence of at least five cases ofcongenital rubella infection in areas of London with large numbersof immigrant women from countries where rubella is endemic andchildhood vaccination is not routine. A review of antenatal screeningdata from maternity units in north London showed that 23% of primiparouswomen of Sri Lankan origin were susceptible to rubella on routineantenatal screening testing in 1996-9 (P Tookey, personalcommunication).

A high index of suspicion and appropriate investigation of any suspicious rash in pregnancy are needed if the devastatingeffects of the congenital rubella syndrome are to be preventedfrom again becoming widespread in the United Kingdom. Clear guidelineson the management of, and exposure to, rash in pregnancy are containedin a report fom a working party of the Public Health LaboratoryService.³

Primary healthcare workers and midwives need to be aware of the need for targeted immunisation before pregnancy and for extravigilance, particularly in women of childbearing age who haverecently arrived from countries where rubella isendemic.

Roslyn M Thomas, consultant paediatrician.
Nilesh M Mehta, specialist registrar, neonatal intensive care unit.
Northwick Park Hospital, Harrow HA1 3UJ ros.thomas@nwlh.nhs.uk

1.	Mehta NM, Thomas RM. Antenatal screening for rubellainfection or immunity? BMJ 2002; 325: 90-91[Full Text]. (13 July.)
2.	Sheridan E, Aitken C, Jeffries D, Hird M, Thayalasekaran P. Congenital rubella syndrome: a risk in immigrant populations. Lancet 2002; 359: 674-675[Medline].
3.	Morgan-Capner P, Crowcroft N. Guidance on the management of, and exposure to, rash illness in pregnancy (including consideration of the relevant antibody screening programmes in pregnancy). Report of a Public Health Laboratory Services working group. London: PHLS, 2000.

© BMJ 2002

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