Ep 64 Rubella: Timing is Everything

Despite facing numerous health challenges and adversities from a young age, Kimberly Cowley's story is one of resilience and determination. Born with congenital heart defects, hearing and vision loss, and the rare condition tetralogy of fallot, Kimberly's survival was considered a long shot. Her early life was filled with hospital stays and struggles in school due to her disabilities. Her parents, who were young and dealing with their own health issues, were unable to provide the necessary support and advocacy. Kimberly faced bullying and loneliness, but her will to live and prove her detractors wrong drove her to endure numerous heart surgeries and live a quiet, independent life. She uses various tools to navigate the world and has become an advocate for vaccinations, which could have saved her from her condition had they been available earlier. Kimberly's story is a reminder of the importance of advocacy, determination, and the power of the human spirit to overcome even the most significant challenges.

We discussed the biology of Rubella, a single stranded positive RNA virus that was recently reclassified from the Togaviridae family to the Metonaviridae family in the genus Arbovirus. Rubella is primarily transmitted via large particle aerosols and causes a systemic infection, spreading quickly throughout the body. It infects a wide range of cell types due to an unknown receptor on human cells. The virus is known for causing Congenital Rubella Syndrome when someone is infected during pregnancy, leading to major complications for the fetus. We also mentioned the availability of merchandise related to the podcast on the website, as well as resources for further reading on the topic. The episode delves deeper into the history and implications of Rubella, including its transmission, symptoms, and prevention methods. Stay tuned for more fascinating insights on this topic and others.

Rubella, or German Measles, is a virus that can infect various cell types and cause damage by directly killing infected cells. However, it primarily affects humans and is usually associated with mild, self-limited symptoms, including a rash that starts on the face and spreads quickly. The illness is often milder in children than adults, and while complications like arthralgias, encephalitis, and congenital rubella syndrome are possible, they are rare. The most significant impact of Rubella is the risk of congenital rubella syndrome when a pregnant woman contracts the virus for the first time during the first trimester, leading to various birth defects in the developing fetus.

Rubella, a virus that can infect a pregnant person, has significant effects on a developing fetus during the embryonic stage, even before it becomes a fetus. Unlike in grown adults where rubella causes symptoms through direct cell death, in a fetus, the virus inhibits cell growth and division, leading to a reduction in cell mass and potential developmental issues. Rubella can infect various cells, and it's transmitted through multiple bodily fluids, not just respiratory. In the fetus, rubella is a chronic infection, and its interaction with the underdeveloped immune system adds to the complexity of the effects. Additionally, when rubella infects the endothelial cells of the blood vessels in a developing fetus, it can cause severe downstream effects, including heart defects and developmental issues in various organs.

The timing of a mother's rubella infection during pregnancy significantly impacts the severity and long-term effects on the fetus. Infections during the first 12 weeks almost always result in fetal malformations or problems, while infections after 16-18 weeks have minimal downstream effects. The virus can affect various parts of the fetus, leading to transient manifestations (such as jaundice, hepatitis, and a blueberry muffin rash) or permanent manifestations (like deafness). There are also late-onset problems that may not be detectable at birth but become apparent later in life. It's important to note that these infants can be very sick, and while transient manifestations tend to clear on their own, they often come with additional complications. Early infections can also result in pregnancy loss, but the exact proportion of this outcome is unknown.

Congenital Rubella Syndrome (CRS) can cause a range of health issues, primarily affecting the ears, heart, and vision. Approximately two-thirds of babies born with CRS experience hearing loss, while around half have heart defects. A quarter of these babies develop cataracts or other vision problems. These complications can occur during organ development or from tissue damage and scarring. Long-term or delayed manifestations include conditions like type 1 diabetes, thyroid dysfunction, and vascular problems. The vaccine for rubella, a live attenuated virus, provides immunity in 95% of people and lasts up to 21 years. The origins of the rubella virus are uncertain, but it's believed to have originated in Asia. Despite the availability of the vaccine, the virus persists due to its contagious nature and the need for consistent vaccination coverage.

Recent discoveries have revealed the existence of two new viruses, Rohugavirus and Russelavirus, which are closely related to rubella. These viruses were found in various mammal species, raising concerns about potential zoonotic spillover events. The new findings also offer opportunities for comparative studies and exploring different animal models to better understand the wide-ranging impacts of the rubella virus on the body and the fetus. Looking back in history, the debate over whether rubella was a distinct disease or just a variant of measles or scarlet fever was ongoing until the 18th century. The name "German measles" was popularly used, but it is not the name we use today. It wasn't until the 19th century that rubella was widely accepted as a separate disease, despite early descriptions and research. Despite the progress made, hesitancy to accept rubella as a separate disease persisted within the medical community.

The name of a disease plays an essential role in its identification and understanding. In 1866, a British Royal Artillery Surgeon proposed the name "rubella" for the disease previously known as rutum or German measles. Although the term "German measles" persisted due to confusion and anti-German sentiment during World Wars 1 and 2, the proposal of "rubella" eventually caught on. The early 20th century saw significant advancements in medicine, including the shift from qualitative descriptions to scientific observation and measurement. This period also marked the development of specialized fields in medicine, making it possible to identify and address diseases more effectively. Despite the fear and impact of diseases like tuberculosis and polio, the mildness of rubella at the time made it a low priority for research and development of a vaccine. However, the importance of disease nomenclature highlights the evolving understanding of health and medicine throughout history.

The connection between a rubella infection during pregnancy and congenital abnormalities was first identified by Australian pediatric ophthalmologist, Norman McAllister Greg, in 1941. This discovery was significant because at the time, the idea of an infectious disease affecting a fetus had not been considered, and the link was initially suggested by mothers in the waiting room of Greg's clinic. Greg's unique perspective as both a clinician and a researcher allowed him to investigate this phenomenon further and make the connection. The historical context of the time, including the ongoing World War 2 and the increasing specialization in medicine, also played a role in enabling this discovery. Greg's willingness to listen to his patients and consider their hypotheses led to the identification of congenital rubella syndrome, which has since been linked to a range of health issues beyond just eye problems.

During World War II, the movement of troops led to widespread rubella epidemics, causing an increase in congenital rubella cases. The diagnosis of rubella was difficult due to its similarities with other diseases and the high rate of asymptomatic infections. Doctor Greg's hypothesis linking rubella to congenital defects was met with skepticism initially, but as more data emerged, the link became more accepted. The discovery of the dangers of rubella during pregnancy raised awareness and led to efforts to minimize the risk of infection, including public education and prophylaxis, before the development of a vaccine.

During the rubella epidemics in the 1960s, the societal response was shaped by a lack of knowledge, resources, and empathy. The media framed children with Congenital Rubella Syndrome (CRS) as a social problem due to the overwhelming strain on institutions and families. This was a time when society lacked the knowledge and resources to adequately care for people with disabilities, often leading to institutionalization. The social stigma and shame associated with having a child with congenital defects also compounded the issue. The media attention reached new heights during the 1963-1965 epidemic due to the fresh memories of polio and the Thalidomide scandal, which put the fear of birth defects into the public consciousness. Approximately 12.5 million people were infected, and around 20,000 babies were born with CRS, causing immense stress and emotional turmoil for families. The societal response serves as a reminder of the importance of empathy, knowledge, and resources in addressing public health crises.

The combination of the thalidomide scandal and the rubella epidemic in the early 1960s played a significant role in shifting the narrative around abortion from one of secrecy and illegality to one of informed choice and women's rights. During this time, seeking an abortion was often a dangerous and stigmatized experience, with women facing moral judgment and even criminal charges. However, the public discussions surrounding thalidomide and rubella brought attention to the importance of informed consent and the right to make personal health decisions. This led to legal battles and the eventual passing of laws that protected a woman's right to access information about her own health and to make decisions about her pregnancy. Unfortunately, this progress was not evenly applied to all communities, and people of color continued to face discrimination and bias in the medical system. Overall, these events marked a turning point in the history of abortion in the US, paving the way for more open and inclusive discussions and policies.

The development and implementation of the rubella vaccine in the late 1960s and 1970s led to one of the most successful vaccination campaigns in history, resulting in a dramatic decrease in rubella cases and the elimination of the disease in the US by 2004. Over the past 20 years, the global vaccination coverage for rubella has significantly increased, leading to a 97% decrease in reported rubella cases, despite challenges such as lapsed vaccination rates and lack of access to vaccinations in some areas. This progress is a testament to the importance of vaccines in preventing infectious diseases and improving public health.

The number of reported rubella cases has increased in recent years, with 71% of countries conducting surveillance and reporting to the World Health Organization. However, the goal of eliminating measles and rubella by 2020, set by the World Health Organization, has not been achieved yet. The Americas were declared free of endemic rubella in 2015, but some countries in the region have experienced endemic transmission of measles, which could potentially lead to rubella outbreaks. The focus is on vaccination campaigns and ensuring every child has access to the rubella vaccine. The status of rubella is a reminder of the importance of continued efforts to eliminate these diseases. Sources include academic papers, books, and reports from organizations like the World Health Organization.

Maintaining good hygiene, specifically washing your hands, is crucial in preventing the spread of diseases. This was emphasized during our discussion. It's a simple yet powerful habit that can make a significant impact on public health. Despite the importance of this practice, it's surprising how often it's overlooked. So, remember to wash your hands regularly to keep yourself and those around you healthy. It's a small act with a big impact. Let's all do our part in promoting good hygiene and keeping our communities healthy. Until next time, stay clean and stay safe!