Pan American Health Organization · 1st edition, 2026 · 45 pages
Standardized surveillance framework for detecting, investigating, and classifying CRS cases to verify sustained elimination in the Americas
- Issuer
- Pan American Health Organization
- Edition
- 1st edition, 2026
- Audience
- National surveillance programme managers, epidemiologists, paediatricians, obstetricians, laboratory personnel, public health officials
- Evidence
- Expert consensus based on PAHO technical advisory group recommendations and WHO surveillance standards
- Reviewed
- 16 Oct 2026 · GMJ
What this guideline says
GMJ summary
These guidelines, published by the Pan American Health Organization in 2026, provide a comprehensive technical framework for congenital rubella syndrome (CRS) surveillance to maintain elimination in the Americas, certified in 2015. The last endemic CRS case was reported in Brazil in 2009, but ongoing circulation of rubella virus in other global regions poses a reintroduction risk, with 18 imported CRS cases documented in Canada and the United States (2010–2024) in infants whose mothers contracted rubella outside the Region.
The guidelines standardize case definitions, laboratory diagnosis algorithms, investigation procedures, and performance indicators. A suspected CRS case is an infant under 12 months with congenital anomalies (cataracts, congenital glaucoma, retinitis pigmentosa, congenital heart defects, or hearing impairment) or whose mother had suspected/confirmed rubella during pregnancy. Laboratory-confirmed cases require positive serology (IgM in children <6 months, or persistent IgG at high titers in paired samples for those 6–11 months) or viral detection by RT-PCR. Blood, respiratory (nasal/pharyngeal swab), and urine samples should be obtained in all suspected cases.
Active institutional case-finding (reviewing medical records in birthing facilities and specialty clinics for cardiac, eye, or hearing conditions) and active community case-finding complement passive surveillance. Surveillance targets include ≥1 suspected case per 10,000 live births annually, ≥80% of cases adequately investigated within 48 hours, and ≥80% with adequate laboratory samples analyzed in proficient laboratories. Infants with confirmed CRS may shed virus until 1 year of age; monthly virological monitoring is recommended until two negative RT-PCR results ≥4 weeks apart are obtained in children over 3 months.
Key points
For clinicians — doses and thresholds as stated in the guideline
- Suspected CRS case: infant <12 months with cataracts, congenital glaucoma, retinitis pigmentosa, congenital heart disease, or hearing impairment; or maternal rubella during pregnancy.
- Laboratory confirmation: anti-rubella IgM in children <6 months; in those 6–11 months, persistent IgG at high titers in paired samples collected 1 month apart, processed simultaneously.
- Collect blood, respiratory (nasal or pharyngeal swab), and urine samples in all suspected cases at first contact for serology and viral detection (RT-PCR).
- In children <1 month with negative IgM, collect second blood sample after 4 weeks to detect IgM (which may not yet be detectable in first month of life).
- Laboratory-confirmed case: suspected case with ≥1 Group A sign and positive laboratory test. Clinically confirmed: suspected case with ≥2 Group A signs or 1 Group A + 1 Group B sign, without laboratory confirmation.
- Group A signs: cataracts, congenital glaucoma, retinitis pigmentosa, congenital heart defects, hearing impairment. Group B signs: purpura, splenomegaly, microcephaly, developmental delay, meningoencephalitis, radiolucent bone disease, jaundice within 24 hours of birth.
- Monitor viral shedding monthly until two negative RT-PCR results ≥4 weeks apart are obtained in children >3 months of age; isolation measures continue until then.
- Surveillance targets: ≥1 suspected case per 10,000 live births annually; ≥80% investigated within 48 hours; ≥80% with adequate laboratory samples; ≥80% of samples received by laboratory within 5 days of collection.
Indicators for monitoring the performance of the congenital rubella syndrome surveillance system
Table extracted from the guideline
| Criterion | Indicator | Target |
|---|---|---|
| Reporting rate | Annual rate of suspected CRS cases per 10,000 live births | ≥1 per 10,000 |
| Adequate investigation | % of suspected CRS cases adequately investigated (all 8 data points) within 48 hours of reporting | ≥80% |
| Adequate sample for serology | % of suspected cases with adequate blood samples for serological testing analyzed in proficient laboratory | ≥80% |
| Timeliness of sample transport | % of samples (serological or virological) received by laboratory within 5 days of collection | ≥80% |
| Timeliness of serological results | % of serological results reported by laboratory within 4 days of receiving sample | ≥80% |
| Timeliness of case detection | % of CRS and CRI cases detected within 3 months of birth | ≥80% |
| Adequate sample for viral detection | % of confirmed cases with adequate samples for viral detection analyzed in proficient laboratory | ≥80% |
| Monitoring of viral shedding | % of confirmed cases with ≥2 negative viral detection tests, after 3 months of age, ≥1 month apart | ≥80% |
Source: Pan American Health Organization, Guidelines for surveillance of congenital rubella syndrome in the Region of the Americas. Reproduced in summary form.
From the guideline
Verbatim
“The rash is usually accompanied by fever or low-grade fever, general malaise, retroauricular or occipital lymphadenopathy, and arthralgia, in particular in adults. Approximately 50% of cases may be subclinical.”
Editor’s perspective
Why this matters for Georgia and the region
Prof. Giorgi Pkhakadze, MD, MPH, PhD
Editor-in-Chief, Georgian Medical Journal · Chair, Public Health Institute of Georgia · WHO consultant, health and migration
As chair of Georgia's Public Health Institute, I recognize the direct applicability of these PAHO surveillance standards to our European Region elimination context. Georgia introduced rubella vaccine nationwide in 2004 and conducts integrated measles-rubella surveillance, but the documented imported CRS cases in North America underscore the persistent reintroduction risk in our similarly mobile populations along Turkish, Armenian, and Azerbaijani borders. I would stress to Georgian paediatricians the critical need to obtain three sample types—blood, respiratory, and urine—in every suspected case, since our 2019–2020 national review found inadequate sampling in 40% of investigations. The guideline's active case-finding methodology, particularly reviewing medical records in paediatric cardiology and ophthalmology centres for cataracts and heart defects in infants under 12 months, offers a practical tool for verifying system sensitivity in our eight epidemiological silent regions that reported zero suspected cases in 2023–2024. The realistic implementation challenge is maintaining RT-PCR capacity and WHO laboratory accreditation in our Lugar Centre reference laboratory, which requires sustained budget allocation for quality assurance and participation in the Global Measles and Rubella Laboratory Network proficiency testing, especially as rubella case volumes decline post-elimination.
ORCID 0000-0001-7609-4515 · Perspective written for the GMJ Guidelines Library, 16 Oct 2026
Applicability
Georgia and the South Caucasus
Georgia and South Caucasus countries are members of the WHO European Region, which has also achieved rubella elimination (verified 2017). These PAHO guidelines provide a robust technical framework directly applicable to the region. National programmes should adapt the active case-finding methodology to local contexts, particularly in areas with cross-border mobility (Turkish, Russian, Iranian borders), migrant and refugee populations, and districts with suboptimal rubella vaccination coverage. Integration with existing congenital anomaly registries, newborn hearing screening programmes, and paediatric cardiology/ophthalmology referral networks would strengthen passive surveillance. Laboratory capacity for rubella serology and RT-PCR should be maintained in national reference laboratories accredited within the Global Measles and Rubella Laboratory Network, with quality assurance reviews. The surveillance target of ≥1 suspected CRS case per 10,000 live births can be adapted based on national birth cohort size (Georgia ~50,000 annual births, so ≥5 suspected cases reported annually would demonstrate system sensitivity).
Questions this guideline answers
Quick answers
When should I suspect congenital rubella syndrome?
Suspect CRS in any infant under 12 months with cataracts (uni- or bilateral), congenital glaucoma, retinitis pigmentosa, congenital heart defect (especially patent ductus arteriosus, pulmonary stenosis), or hearing impairment. Also suspect if the mother had confirmed or suspected rubella during pregnancy, even if the infant appears asymptomatic.
What samples should I collect from a suspected CRS case?
Collect blood for serology (IgM and IgG), a respiratory sample (nasal or pharyngeal swab in viral transport medium), and urine at first contact. In infants under 1 month with negative IgM, repeat blood sample after 4 weeks. In infants 6–11 months, collect a second blood sample 1 month later for paired IgG testing (process both samples simultaneously to compare titers).
How do I interpret rubella serology in infants aged 6–11 months?
IgM may not be detected after 6 months in ~50% of CRS cases. If IgG is positive, it could be maternal antibodies or infant-produced antibodies. Collect a second sample 1 month later and process both simultaneously. Persistently positive IgG at stable or increasing titers indicates congenital infection; declining titers to undetectable suggest maternal antibodies and the case is ruled out.
How long do infants with confirmed CRS shed rubella virus?
Most infants with CRS shed virus until 1 year of age, though some with dysgammaglobulinemia may shed longer. Monitor viral shedding monthly using RT-PCR on respiratory or urine samples until two negative results obtained at least 4 weeks apart in children over 3 months of age. Maintain isolation precautions until viral shedding stops.
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- Issuer
- Pan American Health Organization
- Type
- Guidelines and Technical Manuals
- Edition
- 1st edition, 2026
- Status
- Current
- Published
- 2026-06-29
- Languages
- English
- Scope
- Region of the Americas
- Audience
- National surveillance programme managers, epidemiologists, paediatricians, obstetricians, laboratory personnel, public health officials
- Pages
- 45
- Licence
- CC BY-NC-SA 3.0 IGO
- ISBN
- 978-92-75-13118-3 (PDF)
- Evidence
- Expert consensus based on PAHO technical advisory group recommendations and WHO surveillance standards
- Record history
- Created 16 Oct 2026 · updated 16 Oct 2026 · next check Apr 2027
Pan American Health Organization. Guidelines for surveillance of congenital rubella syndrome in the Region of the Americas. Washington, D.C.: PAHO; 2026. Available from: https://doi.org/10.37774/9789275131183GMJ Guidelines Library records are original summaries written by the GMJ editorial team from the issuer’s published document and reviewed by a physician. They do not replace the full guideline. The document is the copyright of its issuer and is linked, not hosted. Spotted an error or a newer edition? Tell the Guidelines Desk.
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