A single rubella infection during pregnancy can unleash a lifetime of consequences—yet many women remain unprotected.
Imagine a disease so mild that half of those infected don't even notice they have it, yet so dangerous it can cause devastating birth defects in unborn children. This is the paradox of rubella, often called German measles, a vaccine-preventable illness that continues to threaten maternal and child health in Odisha, India 6 .
While rubella typically causes little more than a rash and low-grade fever in most people, its teratogenic potential—the ability to cause fetal malformations—makes it particularly dangerous for pregnant women.
When infection occurs during early pregnancy, the virus can cross the placental barrier, leading to miscarriage, stillbirth, or a constellation of severe birth defects known as Congenital Rubella Syndrome (CRS) 6 .
In Odisha, where healthcare access remains challenging in many regions, understanding the burden of rubella infection among women of reproductive age has become an urgent public health priority. Recent studies conducted across tertiary care hospitals in the state reveal alarming patterns of susceptibility that demand immediate attention 2 .
The rubella virus belongs to the Togaviridae family and spreads through respiratory droplets when an infected person coughs or sneezes 6 . The virus initially replicates in the respiratory mucosa before spreading to lymph nodes and eventually entering the bloodstream 6 .
Approximately 25-50% of infected individuals show no symptoms at all, yet can still transmit the virus 6 . This silent transmission becomes especially problematic when asymptomatic infected individuals come into contact with pregnant women.
90% risk of multiple severe birth defects
10-20% risk of single organ defects, primarily deafness
Risk decreases significantly, with rare complications reported
Microcephaly, developmental delays, intellectual disabilities
Hearing loss (most common), cataracts, glaucoma
Patent ductus arteriosus, ventricular septal defects
Impaired somatic growth, hepatosplenomegaly
The World Health Organization estimates that approximately 100,000 children worldwide are born with CRS each year 6 , making rubella a leading cause of preventable birth defects globally.
To understand the actual burden of rubella exposure and infection among women in Odisha, researchers conducted a comprehensive hospital-based observational study from February 2012 to March 2017 2 .
Study Duration
Across Odisha
Included in Analysis
The investigation spanned five tertiary care hospitals across the state, focusing on the Regional Virology Research and Diagnostic Laboratory (VRDL) of the Regional Medical Research Center in Bhubaneswar as the central analysis site 2 .
The study enrolled 1,985 female participants aged 16-38 years who attended Obstetrics and Gynecology outpatient departments for regular checkups 2 . After accounting for samples that couldn't be processed due to insufficient quantity or technical errors, 1,951 samples were included in the final analysis 2 .
The research aimed to determine both recent infections (through IgM antibodies) and past exposure or immunity (through IgG antibodies) to the rubella virus. Additionally, polymerase chain reaction (PCR) testing was performed on select samples to detect active viral presence 2 .
The study design specifically allowed investigators to examine the relationship between rubella infection status and pregnancy outcomes, including associations with abortion history and gravida status (whether women were pregnant for the first time or had previous pregnancies) 2 .
The Odisha study employed multiple laboratory techniques to identify rubella infection and immunity status, each revealing different aspects of the virus interaction with the human immune system.
| Research Reagent | Function in Rubella Detection |
|---|---|
| IgG ELISA kits | Detects past infection or immunity through Immunoglobulin G antibodies |
| IgM ELISA kits | Identifies recent infection through Immunoglobulin M antibodies |
| PCR reagents | Amplifies viral genetic material to detect active infection |
| Viral RNA extraction kits | Isolates rubella virus RNA for molecular analysis |
| Enzyme-linked immunosorbent assay | Enzyme-based technique to detect antibodies against rubella |
Approximately 2 ml of blood was collected from each participant who provided written informed consent. Samples were transported maintaining cold chain conditions to preserve integrity.
Sera separated from blood samples were tested using enzyme linked immunosorbent assay kits manufactured by NovaTec Immundiagnostica GmbH, Germany. These tests qualitatively detected anti-rubella virus IgM and IgG antibodies.
For samples that tested negative for both IgG and IgM, or when recent infection was suspected, polymerase chain reaction testing was performed. Viral RNA was extracted using Qiagen kits from Germany, and a 185 bp DNA product was identified through 2% agarose gel electrophoresis. Nested PCR was then performed to obtain a final product size of 143bp.
Results were analyzed using STATA software version 16, with chi-square tests performed to calculate associations between recent and past infection with factors such as age, pregnancy status, and abortion history.
The combination of these techniques provided a comprehensive picture of both immediate infections and population immunity levels—critical data for designing effective vaccination strategies.
The findings from the Odisha study painted a concerning picture of rubella susceptibility among women of reproductive age, with particular vulnerability patterns emerging across different age groups.
| Age Group (years) | IgM Positive (%) | IgG Positive (%) | PCR Positive (%) |
|---|---|---|---|
| 16-20 | 3/158 (1.9%) | 128/191 (41.27%) | 0/62 (0%) |
| 21-25 | 2/413 (0.48%) | 307/513 (59.84%) | 0/105 (0%) |
| 26-30 | 2/232 (0.86%) | 182/305 (59.67%) | 1/59 (1.69%) |
| 31-35 | 0/43 (0%) | 31/58 (53.44%) | 0/17 (0%) |
| 36-38 | 0/3 (0%) | 3/3 (100%) | 0/3 (0%) |
The overall analysis revealed that 60.8% of tested women showed evidence of past rubella exposure through IgG antibodies, while less than 1% had evidence of recent infection through IgM antibodies 2 . One sample tested positive through PCR, indicating active viral presence 2 .
When researchers compared adolescent (16-20 years) and young adult (21-35 years) groups, they found a significant association between IgG antibodies and age, with older participants more likely to show evidence of past infection and consequent immunity 2 .
| Patient Category | Odds Ratio for Adverse Outcome | Key Finding |
|---|---|---|
| Anti-rubella positive women | 13.14 (4.94-34.97) | Significantly higher odds of abortion |
| Primi-gravida women | 43.6 (5.9-322) | Dramatically increased odds of complications |
The statistical analysis revealed particularly alarming findings regarding pregnancy outcomes. Women who tested positive for rubella infection faced over 13 times higher odds of abortion compared to their non-infected counterparts 2 . Even more strikingly, women pregnant for the first time (primi-gravida) showed a staggering 43.6 times higher odds of complications when infected with rubella 2 .
These findings underscore the profound impact rubella infection can have on pregnancy outcomes, particularly for women in their first pregnancy who may lack immunity from previous exposures.
Immune (IgG Positive)
Susceptible (IgG Negative)
Recently Infected (IgM Positive)
While Odisha has made remarkable progress in childhood immunization—achieving 90.5% full immunization coverage, the highest among all Indian states—a significant protection gap remains for rubella specifically 1 5 . The state has aligned with national goals to eliminate measles and rubella by 2026 and has launched comprehensive Information, Education, and Communication materials to accelerate this elimination program 1 5 .
However, the current vaccination strategy primarily focuses on children through the Measles-Rubella (MR) vaccine campaign, leaving adolescent and adult women unprotected unless they were fortunate enough to receive vaccination in childhood or develop natural immunity through infection.
This gap becomes particularly problematic considering that a substantial proportion of women in their prime reproductive years remain susceptible to rubella infection. The Odisha study found that nearly 40% of women aged 16-20 lacked protective IgG antibodies, leaving them vulnerable if exposed during pregnancy 2 .
India's Universal Immunization Programme includes the MR (Measles-Rubella) vaccine but does not include protection against mumps, which would be covered in the MMR (Measles, Mumps, Rubella) vaccine used in many countries .
Public health experts have called for reintroducing the MMR vaccine into India's immunization program to address the recent resurgence of mumps outbreaks across several states .
Closing the rubella immunity gap among women of reproductive age requires a multi-pronged approach combining routine immunization, targeted vaccination campaigns, and robust surveillance systems.
Establishing school-based and community-based vaccination programs targeting girls aged 15-18 years could significantly reduce the pool of susceptible women entering their reproductive years. This pre-pregnancy immunization strategy is considered one of the most effective approaches for preventing CRS.
Implementing routine rubella antibody testing during early prenatal care would identify susceptible women who could be vaccinated immediately after delivery. This approach protects subsequent pregnancies without risking the current one.
Leveraging Odisha's successful child immunization infrastructure to extend protection to women of reproductive age through Anganwadi centers and maternal health clinics.
"Immunising children and pregnant women remains our topmost priority. It is the most cost-effective and life-saving public health intervention. Together, we must ensure no child is left behind."
The economic and ethical imperative for action is clear. As Minister Mahaling emphasized, vaccination remains the most cost-effective and life-saving public health intervention available.
The silent threat of rubella to pregnancy outcomes in Odisha represents a preventable tragedy. Research reveals that a significant proportion of women entering their reproductive years remain susceptible to rubella infection, with potentially devastating consequences for their unborn children 2 .
The scientific evidence is clear: rubella infection during pregnancy, particularly in the first trimester, carries dramatically increased risks of miscarriage, stillbirth, and severe birth defects collectively known as Congenital Rubella Syndrome 6 . The Odisha study further confirms these risks, showing that infected women face over 13 times higher odds of abortion, with first-time pregnant women being particularly vulnerable 2 .
Yet solutions exist. Rubella is entirely preventable through vaccination, and the infrastructure for delivering protection is within reach. Odisha has already demonstrated leadership in immunization, achieving the highest full immunization coverage among all Indian states 1 5 .
The state has reaffirmed its commitment to eliminating measles and rubella by 2026 through a collaborative approach involving multiple government departments and community participation 1 5 .
By extending this commitment to include adolescent girls and women of reproductive age, Odisha can build a protective shield that ensures no child suffers the lifelong consequences of congenital rubella infection. The path forward requires integrating rubella prevention into existing maternal and child health programs, strengthening surveillance systems, and empowering women with knowledge about rubella risks and prevention.
As we stand at the intersection of scientific knowledge and public health action, the opportunity to eliminate rubella as a threat to maternal and child health in Odisha has never been more achievable. With concerted effort and sustained commitment, a future free from the shadow of rubella is within our grasp.