Ileal-lymphoid-nodular hyperplasia, non-specific colitis, and pervasive developmental disorder in children

BACKGROUND

We investigated a consecutive series of children with chronic enterocolitis and regressive developmental disorder.

METHODS

12 children (mean age 6 years [range 3-10], 11 boys) were referred to a paediatric gastroenterology unit with a history of normal development followed by loss of acquired skills, including language, together with diarrhoea and abdominal pain. Children underwent gastroenterological, neurological, and developmental assessment and review of developmental records. Ileocolonoscopy and biopsy sampling, magnetic-resonance imaging (MRI), electroencephalography (EEG), and lumbar puncture were done under sedation. Barium follow-through radiography was done where possible. Biochemical, haematological, and immunological profiles were examined.

FINDINGS

Onset of behavioural symptoms was associated, by the parents, with measles, mumps, and rubella vaccination in eight of the 12 children, with measles infection in one child, and otitis media in another. All 12 children had intestinal abnormalities, ranging from lymphoid nodular hyperplasia to aphthoid ulceration. Histology showed patchy chronic inflammation in the colon in 11 children and reactive ileal lymphoid hyperplasia in seven, but no granulomas. Behavioural disorders included autism (nine), disintegrative psychosis (one), and possible postviral or vaccinal encephalitis (two). There were no focal neurological abnormalities and MRI and EEG tests were normal. Abnormal laboratory results were significantly raised urinary methylmalonic acid compared with age-matched controls (p=0.003), low haemoglobin in four children, and a low serum IgA in four children.

INTERPRETATION

We identified associated gastrointestinal disease and developmental regression in a group of previously normal children, which was generally associated in time with possible environmental triggers.

HLA-DR class II associations with rubella vaccine-induced joint manifestations

HLA class II (HLA-DR) frequencies were examined in relation to incidence of acute arthralgia or arthritis in 283 white women who had received RA27/3 rubella vaccine (n = 146) or placebo (n = 137) postpartum. Leukocyte DNA was molecularly typed for HLA-DRB1 gene expression. Univariate analysis revealed higher frequencies of DR2 (odds ratio [OR], 4.8; 95% confidence interval [CI], 1.2-18.8) and DR5 (OR, 7.5; 95% CI, 1.5-37.5) but lower frequencies of DR4 (OR, 2.3; 95% CI, 1.1-4.9) and DR6 (OR, 2.8; 95% CI, 1.4-5.8), in rubella vaccinees compared with placebo recipients with arthropathy. Logistic regression modelling of DR, treatment, age, time postpartum, and arthropathy revealed that the odds of developing arthropathy was 1.9 times greater (95% CI, 1.07-3.44) after rubella vaccine than placebo. Risk for arthropathy (regardless of rubella vaccination) was also influenced by DR interactions: odds were 8 times greater in individuals with both DR1 and DR4 (95% CI, 1.45-44.02) and 7.1 times greater with both DR4 and DR6 present (95% CI, 1.85-27.52), suggesting that coexpression of these specificities may predispose to postpartum arthropathy.

[Rubella in Russia: the detection of congenital rubella and the vaccination strategy and procedures]

The work on the evaluation of the role of rubella infection in the development of congenital malformations in newborn infants, as well as the immunogenic activity and tolerability of live attenuated vaccine Rudivax (Pasteur Mérieux Connaught) was carried out in the process of selective immunization in the Perm region. The study made it possible to find out 15% of malformations in the structure of the congenital pathology of newborn infants, which appeared due to the infection of the fetus with rubella virus and were manifested by multiple development defects, congenital C.N.S. defects and valvular defects. The results of using vaccine Rudivax in the epidemiological trial demonstrated that the vaccine had high immunological activity and was well tolerated. The absence of postvaccinal complications after the injection of the live vaccine and the absence of the extinction of immunity in the presence antibodies were indicative of the possibility vaccination without preliminary serological examination.

Seroconversion of a trivalent measles, mumps, and rubella vaccine in children aged 9 and 15 months

The serological response to MMR vaccine was evaluated in 109 9-month-old infants having no history of measles vaccination, and in 98 15-month-old children who had received monocomponent measles immunisation at 9 months. The combined vaccine contained Schwarz, Urabe Am9, and Wistar RA 27/3 live attenuated virus strains. Preimmunisation antibody levels were extremely low for the 9-month-old children, indicating that maternally-transmitted antibodies do not persist at this age. In the case of mumps, preimmunisation antibody levels were significantly higher in the 15-month-old than in the 9-month-old group. A difference between groups in terms of postimmunisation antibody titres was observed only for rubella, with titres being significantly higher in the older group. Seroconversion rates were high in both groups and no serious events attributable to vaccination were observed. The MMR vaccine can thus be administered to children as young as 9 months of age. Evidence for the efficacy of a two-dose schedule, i.e. at 9 and 15 months, is presented.

MMR2 immunization at 4 to 5 years and 10 to 12 years of age: a comparison of adverse clinical events after immunization in the Vaccine Safety Datalink project. The Vaccine Safety Datalink Team

BACKGROUND

The Advisory Committee on Immunization Practices recommends a second dose of measles, mumps, and rubella vaccine (MMR2) at age 4 to 5 years of age, whereas the American Academy of Pediatrics suggests MMR2 immunization at age 11 to 12 years of age. Because there is little information on whether the rate of adverse reactions to MMR2 immunization varies among these two age groups, we took advantage of differing immunization policies at two large HMOs to compare the frequency of clinical events after, and possibly related to, MMR2 immunization.

METHODS

Information was collected on clinical events plausibly associated to MMR immunization (seizures, pyrexia, malaise/fatigue, nervous/musculoskeletal symptoms, rash, edema, induration/ecchymoses, lymphadenopathy, thrombocytopenia, aseptic meningitis, and joint pain) in two cohorts. At three facilities at Northern California Kaiser (Oakland, CA), 8514 children received MMR2 immunization at age 4 to 6 years of age; at Group Health Cooperative (Seattle, WA) 18 036 children received MMR2 immunization at age 10 to 12 years of age. To account for age-related differences in health care use, within each HMO, clinical events in a 30-day period after immunization were compared with a 30-day period before vaccination.

RESULTS

Children 10 to 12 years of age were 50% more likely to have a clinical event after MMR2 immunization than in the period before immunization (odds ratio, 1.45; 95% confidence interval: 1.00,2.10). Children 4 to 6 years of age were less likely to have a visit for an event after immunization compared with the period before immunization (odds ratio, 0.64; 95% confidence interval: 0.40,1.01).

CONCLUSIONS

These results suggest that the risk for clinical events after MMR2 immunizations is greater in the 10- to 12-year age group.

Twenty years' experience of rubella vaccination in Sweden: 10 years of selective vaccination (of 12-year-old girls and of women postpartum) and 13 years of a general two-dose vaccination

Two different strategies for the prevention of rubella-induced malformations have now been practised in Sweden, both reaching 90% or more of the target populations. The first was initiated in 1973-1974 and targeted schoolgirls, susceptible women after pregnancy and women at special risk. The second programme-a two-dose measles, mumps, rubella vaccination (MMR) of both boys and girls at the ages of 18 months and 12 years-was introduced in 1982. The percentage of susceptible pregnant women was gradually reduced from 12% in 1975 to 2.8% in 1987 and to just below 2% in 1994. The majority of the non immune are unvaccinated, these being either Swedes born before 1963 or immigrants. Before 1974 on average 14 severely rubella damaged children were reported yearly. Between 1975 and 1985 only a mean of two cases per year were recorded. Since 1985 no child with the rubella syndrome has been registered.

Risk of chronic arthropathy among women after rubella vaccination. Vaccine Safety Datalink Team

CONTEXT

A review by the Institute of Medicine found a possible relationship between rubella vaccination and chronic arthritis among women.

OBJECTIVE

To evaluate the risk of persistent joint and neurologic symptoms in rubella seronegative women subsequently vaccinated with RA 27/3 rubella vaccine.

DESIGN

Retrospective cohort study based on computerized laboratory data and medical record review. Records were reviewed for symptoms occurring within 2 years before and after the date of serological testing and to identify vaccinees. Possible cases were evaluated by a rheumatologist blinded to serological findings and vaccination status.

SETTING

Large health maintenance organization in northern California.

PATIENTS

Women aged 15 to 59 years serotested for rubella during 1990 with continuous health plan membership for 2 years before and after the date of their serological test. Seronegative women immunized within 1 year of serotesting (n=971) were defined as exposed. Primary comparison groups included all unvaccinated, seronegative women (n=924) and randomly selected seropositive, unvaccinated women (n=2421) matched to exposed subjects on serological test date and age (+/-3 years).

MAIN OUTCOME MEASURES

Prevalence and incidence of chronic joint and neurologic symptoms during 1-year follow-up period stratified by age and serological findings, immunization, and postpartum status.

RESULTS

No significantly increased risk was associated with receipt of rubella vaccine for any outcome except for prevalence of carpal tunnel syndrome in vaccinated women at least 30 years old compared with seropositive, unvaccinated women (2.9% vs 1.4%; P=.03). A total of 34 women had onset of conditions within the 1-year follow-up period; 9 of these were in the group of seronegative, immunized women, of whom 6 had onset of symptoms within 6 weeks of vaccination. Among these 6 women, symptoms included transient arthritis or arthralgias (<6 weeks duration) in 4 women, arthralgia of indeterminate chronicity in 1 woman, and carpal tunnel syndrome in 1 woman. Postpartum women across all groups were less likely to be seen for nontraumatic arthropathies than nonpostpartum women (4.5% vs 7.2%, P=.08 in vaccinated women; 4.8% vs 8.1%, P=.09 in seronegative controls; and 4.8% vs 10.0%, P=.01 in seropositive controls).

CONCLUSIONS

In this large retrospective cohort analysis there was no evidence of any increased risk of new onset chronic arthropathies or neurologic conditions in women receiving the RA 27/3 rubella vaccine. These data support the continued vaccination of rubella-susceptible women to reduce the risk of congenital rubella syndrome.

Gelatin-specific humoral and cellular immune responses in children with immediate- and nonimmediate-type reactions to live measles, mumps, rubella, and varicella vaccines

BACKGROUND

This study was designed to investigate the development of both cellular and humoral immune responses to gelatin in patients with vaccine-related immediate and nonimmediate reactions. Our purpose was to define the nature of the responses in the different clinical states.

METHODS

Six patients with immediate reactions and 21 patients with nonimmediate reactions after inoculation of various live vaccines were studied. Measurement of gelatin-specific IgE was performed in all subjects. Gelatin-specific T-cell responses detected by an in vitro lymphocyte proliferation assay and by an assay for IL-2 responsiveness were investigated to compare the immune response in patients with the two types of reaction.

RESULTS

All six patients with immediate reactions had IgE responses to gelatin, whereas none of the 21 patients with nonimmediate reactions had any anti-gelatin IgE. All of the six patients with immediate reactions and 17 of the 21 patients with nonimmediate reactions exhibited positive T-lymphocyte responses specific to gelatin.

CONCLUSIONS

Immediate and nonimmediate reactions are caused by different types of allergy to gelatin, and cell-mediated immunity to gelatin may play an important role in the pathogenesis of nonimmediate reactions.

[Study and assessment of the antigenic activity and reactivity of rubella vaccine]

A total of 3422 adolescent girls and women of a reproductive age were vaccinated against rubella with French vaccine. Antigenic activity and reactogenicity of the vaccine were assessed in 97 girls, 100% seroconversion and weak reactogenicity was observed in seronegative vaccinees.

Safety and immunogenicity of concurrent administration of measles-mumps-rubella-varicella vaccine and PedvaxHIB vaccines in healthy children twelve to eighteen months old. The MMRV Study Group

OBJECTIVE

To determine the safety and immunogenicity of concurrent administration of measles-mumps-rubella-varicella vaccine (MMRV) and PedvaxHIB (Haemophilus influenzae type b conjugate vaccine) vs. M-M-R II and PedvaxHIB followed by an optional dose of VARIVAX 6 weeks later.

DESIGN

Healthy children, 12 to 18 months of age, were randomly assigned to two groups to receive (1) MMRV and PedvaxHIB given concurrently or (2) M-M-R II and PedvaxHIB followed by an optional dose of VARIVAX 6 weeks later.

SUBJECTS

The study group included 294 healthy children, ages 12 to 18 months, with a negative history of measles, mumps, rubella and varicella.

MAIN OUTCOME MEASURES

The seroconversion rate and magnitude of antibody responses when MMRV was given concurrently with PedvaxHIB compared with the antibody responses when VARIVAX was given 6 weeks after M-M-R II and PedvaxHIB.

RESULTS

Healthy children, 12 to 18 months of age, who received MMRV and PedvaxHIB concurrently showed immune responses similar to those in the control group who received M-M-RII vaccine with PedvaxHIB followed by VARIVAX 6 weeks later. Antibody titers for varicella were significantly lower when MMRV was administered than when varicella vaccine was given separately (0.712-fold difference, P = 0.028). No vaccine-related serious adverse reactions were reported, and no clinically significant differences were seen in the safety profiles of the two treatment groups.

CONCLUSIONS

There were no statistically significant differences in the seroconversion rates between the two treatment groups for any of the antigens tested at 6 weeks and 1 year. Significantly lower geometric mean titers for varicella were noted in the group who received MMRV compared to VARIVAX given alone. Six-week seroconversion rates, persistence of immune responses at 1 year and the frequency of local and systemic reactions were comparable when MMRV was administered with PedvaxHIB compared with M-M-R II and PedvaxHIB followed by VARIVAX 6 weeks later.

[Mumps epidemic in vaccinated children in West Switzerland]

Since 1991, 6 years after the recommendation of universal childhood vaccination against measles, mumps, and rubella (MMR triple vaccine), Switzerland is confronted with a large number of mumps cases affecting both vaccinated and unvaccinated children. Up to 80% of the children suffering from mumps between 1991 and 1995 had previously been vaccinated, the majority with the Rubini vaccine strain. On the basis of a case-control study including 102 patients and 92 controls from the same pediatric population, a study of the humoral immune-response following vaccination with the Rubini vaccine in 6 young adult volunteers, and two different genetic studies, we investigated the complex problem of large scale vaccine failure in Switzerland. We conclude that the recently reported large number of Swiss mumps cases was caused by at least four interacting factors: 1. A vaccine coverage of 90-95% at the age of 2 years is necessary to interrupt mumps wild virus circulation. The nationwide vaccine coverage in Switzerland of some 80% in 27-36 month-old children is too low. 2. Primary vaccine failures (absence of seroconversion or unprotective low levels of neutralizing antibodies), as well as secondary vaccine failures due to the rapid decline of antibodies to mumps virus in our volunteers and controls, seem to be frequent after vaccination with the Rubini strain. 3. Despite its reported Swiss origin, the Rubini strain does not belong to the mumps virus lineages recently circulating in this area but is closely related to American mumps virus strains. 4. Differences in protein structure between the vaccine strain and the circulating wild type strains, and in particular a different neutralization epitope in the hemagglutinin neuraminidase protein, may additionally contribute to the lack of protection in vaccinated individuals.

Vaccine Safety Datalink project: a new tool for improving vaccine safety monitoring in the United States. The Vaccine Safety Datalink Team

OBJECTIVE

To fill the large "gaps and limitations" in current scientific knowledge of rare vaccine adverse events identified in recent reviews of the Institute of Medicine.

METHODS

Computerized information on immunization, medical outcomes, and potential confounders on more than 500 000 children 0 to 6 years of age is linked annually at several health maintenance organizations to create a large cohort for multiple epidemiologic studies of vaccine safety.

RESULTS

Analysis of 3 years of follow-up data shows that 549 488 doses of diphtheria-tetanus-pertussis (DTP) and 310 618 doses of measles-mumps-rubella (MMR) vaccines have been administered to children in the study cohort. Analyses for associations between vaccines and 34 medical outcomes are underway. Screening of automated data shows that seizures are associated with receipt of DTP on the same day (relative risk [RR], 2.1; 95% confidence interval [CI], 1.1 to 4.0) and 8 to 14 days after receipt of MMR (RR, 3.0; 95% CI, 2.1 to 4.2). The diversity of vaccination exposures in this large cohort permits us to show that an apparent association of seizures 8 to 14 days after Haemophilus influenzae type b vaccine (RR, 1.6; 95% CI, 1.2 to 2.1) was attributable to confounding by simultaneous MMR vaccination; the association disappears with appropriate adjustment (RR, 1.0; 95% CI, 0.7 to 1.4).

CONCLUSION

Preliminary design, data collection, and analytic capability of the Vaccine Safety Datalink project has been validated by replication of previous known associations between seizures and DTP and MMR vaccines. The diversity in vaccine administration schedules permits potential disentangling of effects of simultaneous and combined vaccinations. The project provides a model of public health-managed care collaborations in addition to an excellent infrastructure for safety and other studies of vaccines.

Randomised double-blind placebo-controlled study on adverse effects of rubella immunisation in seronegative women

BACKGROUND

The objective of our study was to investigate the association of adverse clinical musculoskeletal and neurological events in healthy postpartum women with live attenuated (RA27/3 strain) rubella-virus vaccine, and to assess the frequency of acute and recurrent arthralgia and arthritis and associations with acute and recurrent muscle pain (myalgia) and neurological manifestations (paraesthesias).

METHODS

We used a randomised placebo-controlled, double-blind design in a community setting. 636 women were enrolled and, after 90 women dropped out, 546 healthy women aged 18-41 years, who were rubella seronegative on routine screening were immunised parenterally with either monovalent live attenuated (RA27/3 strain) rubella vaccine (n = 270) or saline placebo (n = 276) in the postpartum period. Outcome measures were the occurrence of acute and persistent or recurrent joint manifestations (arthralgia or arthritis) at 1, 3, 6, 9, and 12 months after immunisation. Occurrence of muscle pain (myalgia), and neurological symptoms (paraesthesia) was also assessed at the same times.

FINDINGS

543 women completed 1-month follow-up. 456 women completed the 12-month assessment. There were no differences at the time of immunisation between rubella vaccine and placebo groups in distribution of age, ethnic origin, parity, time between delivery and immunisation, breastfeeding history, or histories of earlier rubella vaccination or joint complaints. Results indicated a significantly higher incidence (p = 0.006; odds ratio = 1.73 [95% CI = 1.17-2.57]) of acute joint manifestations in rubella-vaccine recipients (30%) than in placebo recipients (20%). Frequency of chronic (recurrent) arthralgia or arthritis was only marginally significant (p = 0.042; 1.58 [1.01-2.45]).

INTERPRETATION

RA27/3 rubella vaccine given to seronegative women during the postpartum period was significantly associated with development of acute arthralgia or arthritis. Although the numbers of women assessed and length of follow-up revealed only marginally significant differences in persistent or recurrent joint manifestations between rubella vaccine and placebo recipients, it is possible that susceptible women who are given rubella vaccination may experience this outcome.

Risk of hospitalization because of aseptic meningitis after measles-mumps-rubella vaccination in one- to two-year-old children: an analysis of the Vaccine Safety Datalink (VSD) Project

OBJECTIVE

To assess the level of increased risk, if any, of hospitalizations for aseptic meningitis after Jeryl-Lynn mumps strain measles-mumps-rubella (MMR) vaccine in the Vaccine Safety Datalink population.

STUDY DESIGN

A possible increased risk of aseptic meningitis 8 to 14 days after receipt of MMR was observed in a preliminary screening analysis of automated data from the Vaccine Safety Datalink (VSD) project Year 2 analysis. To further evaluate this association a retrospective 10-year matched case-control study was undertaken in the four health maintenance organizations (HMOs) in the VSD project. Cases ascertained from a broad scan of the automated data were validated against a standard case definition. Two controls matched on age, sex, HMO and HMO membership were assigned per case.

RESULTS

The VSD project involves the cooperative collection of automated vaccination and medical outcome data from four large HMOs that currently have 500,000 children younger than 7 years of age under surveillance. Review of automated screening results from the first 2 years of data revealed a possible increased risk of aseptic meningitis 0 to 14 days after MMR with a relative risk of 3.61 (95% confidence interval, 1.0 to 13.1) although the total number of cases was small. Although the automated data had suggested a possible association of aseptic meningitis with MMR containing the Jeryl-Lynn strain of mumps, review of validated hospitalized cases during the observation period did not reveal evidence of an increased risk of aseptic meningitis after MMR containing the Jeryl-Lynn strain of mumps (odds ratio < 1.0 for all analyses).

CONCLUSION

Although it is recognized that hospitalized cases represent a minority of the total cases of aseptic meningitis, it is reassuring that in this evaluation no increased risk of aseptic meningitis after MMR vaccine was found.

[Neurological involvement following triple virus vaccine]

INTRODUCTION

Prophylactic immunization against measles, rubella and mumps is carried out using a trivalent vaccine. The second dose is recommended at 11-12 years-old. Neurological complications have been described after vaccination for measles and rubella. All cases occurred several days after vaccination.

CLINICAL CASES

We describe four girls aged between 10 and 11 years old who were vaccinated on the same day. Almost immediately they complained of symptoms in the vaccinated arm. These were pain, paresthesia, coldness, pallor and sweating of the hand. On the following days there was loss of strength and alterations in sensation. All laboratory, radiological, neurophysiological and psychiatric studies were normal. Immunological study showed changes in the immunohumeral response to the vaccine. Complete recovery was made.

CONCLUSIONS

The different types of post-vaccination complications described to date are reviewed, together with conditions showing features such as those described, particularly the reflex sympathetic syndrome. Possible reasons for the poor immunohumoral response to the vaccine in these patients are discussed.

Food allergy to gelatin in children with systemic immediate-type reactions, including anaphylaxis, to vaccines

BACKGROUND

Anaphylaxis to measles-mumps-rubella vaccines has been reported. We have suspected that most such reactions are caused by gelatin contained in the vaccines.

OBJECTIVE

To confirm the relation between systemic allergic reactions to vaccines and the presence of anti-gelatin IgE, we measured anti-gelatin IgE in children who demonstrated allergy to gelatin-containing vaccines. Furthermore, to clarify the relation between allergic reactions to gelatin in vaccines and foods, we surveyed the occurrence of allergic reactions to gelatin-containing foods in the same children.

METHODS

Serum samples were taken from 26 children who had systemic immediate-type reactions, including anaphylactic shock, to vaccines and the same number of children without allergic reactions. Specific IgE to gelatin in these samples was measured. We then surveyed whether these children had allergic reactions to gelatin-containing foods before and after vaccination.

RESULTS

Twenty-four of the 26 children with allergic reactions to vaccines had anti-gelatin IgE ranging from 1.2 to 250 Ua/ml. Seven had allergic reactions on ingestion of gelatin-containing foods. Of these, two had reactions before vaccination, and five had reactions after vaccination. All the control children without allergic reactions to vaccines had no anti-gelatin IgE.

CONCLUSION

We reconfirmed a strong relationship between systemic immediate-type allergic reactions, including anaphylaxis, to vaccines and the presence of specific IgE to gelatin. Moreover, some of the children also had allergic reactions to food gelatin before or after vaccination.

Optic neuritis following measles/rubella vaccination in two 13-year-old children

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Study of young women vaccinated against rubella virus for 10 years in Taiwan

Since the licensing of the rubella virus vaccine (RA 27/3 strain) in 1979, clinical studies on the RA 27/3 strain vaccine, which gives rise to high titer antibody, have been reported. In the present study, this vaccine was used to examine the immune response in young women. Volunteers without the previous immunity to rubella virus screened by hemagglutination inhibition (HAI), latex agglutination (LA), fluorescence immunoassay (FIA) and solid-phase immunoassay (SPIA) tests were injected with Rudivax vaccine or Meruvax II vaccine. Adverse reactions occurred between 10 and 20 days after vaccination in 30% of the volunteers. After 28-35 days, vaccinees developed antibodies against rubella virus. The titer of rubella antibody reached it's peak from the 40th day through the 100th day. One year after vaccination, the geometric mean titer (GMT) of rubella virus antibody still remained over 1 : 64 (HAI) and 1 : 38.2 (FIA), and SPIA IgG RI mean was 2.80. Two years later, the antibody titers were 1 : 52 by HAI and 1 : 32.1 by FIA, and SPIA IgG RI mean was 2.75. After 5 years, the antibody titers were 1 : 48.6 (HAI) and 1 : 28.2 (FIA), and SPIA IgG RI mean was 2.74. After 10 years, the anti-rubella virus antibody titers were 1 : 38.9 (HAI) and 1 : 25.1 (FIA), and SPIA IgG RI mean was 2.42. LA antibody still remained seropositive. In conclusion, the rubella vaccine RA 27/3 is safe and efficient, and it is applicable for the control of the rubella in Taiwan.

[Acute thrombocytopenic purpura following rubella vaccination]

A case of acute thrombocytopenic purpura following rubella vaccination is reported. A 3-year-old boy developed purpura on the 22nd days after rubella vaccination. His platelet count was 34 x 10(3)/microliter. Platelet-associated IgG was elevated, but the amount of megakaryocytes in bone marrow aspirates was within the normal range, suggesting immune mechanism-associated thrombocytopenia. He recovered spontaneously within one month. Thrombocytopenic purpura is a well-documented complication of natural rubella infection. Attention should be paid rubella vaccination-associated thrombocytopenia, though it seems to be less frequent than after natural infections.

[Thrombocytopenic purpura after isolated or combined vaccination against measles, mumps and rubella]

A retrospective epidemiological survey was conducted to evaluate the incidence and characteristics of thrombocytopenic purpura (TP) reported in France following measles, mumps or rubella vaccination with monovalent or multivalent vaccines. Sixty cases of TP were reported i.e an incidence/100,000 doses of 0.23 and 0.17 for measles or rubella vaccines respectively given alone, to 0.87 for combined measles-rubella vaccine and 0.95 for MMR vaccine. The mean age was 21 +/- 12 months and the delay of diagnosis was 16 +/- 6 days after vaccination. Thrombopenia was severe (mean platelet count: 8000 +/- 6000/mm3) and always associated with purpura. The immediate outcome was favourable in 89.5 per cent of cases. Vaccine-associated TP appears to be similar to acute childhood idiopathic thrombocytopenic purpura but the clear temporal relationship between MMR vaccination and the occurrence of TP make a causal relationship highly plausible. Acute TP seems a rare complication of measles-rubella and MMR vaccination but clinicians had to be informed of the possibility of their occurrence. Acute TP following vaccination should be reported by physicians to their Regional Drug Surveillance Centre.

Chronic arthropathy and musculoskeletal symptoms associated with rubella vaccines. A review of 124 claims submitted to the National Vaccine Injury Compensation Program

OBJECTIVE

To report the outcome of 124 claims of chronic arthropathy associated with rubella vaccine submitted to the National Vaccine Injury Compensation Program.

METHODS

Medical records and testimony were reviewed separately by physicians and Special Masters to determine the clinical diagnosis and eligibility for compensation under the Program.

RESULTS

Among the 124 subjects with chronic arthropathy, the onset occurred between 1 week and 6 weeks after the rubella vaccination in 72, and < 1 week or > 6 weeks after the vaccination in 52. Various conditions developed in the 2 onset groups (1-6 weeks postvaccination, < 1 week or > 6 weeks postvaccination), including, respectively, unspecified arthritis (n = 29, n = 1), specified arthritis (n = 11, n = 19), arthralgia (n = 24, n = 7), fibromyalgia (n = 4, n = 11), and multiple symptoms with minimal arthralgia or myalgia (n = 4, n = 14). Concordance of medical recommendations by Program physicians and Special Masters' decisions in 56 completed claims was 91%, with awards mainly to patients with chronic unspecified arthritis and arthralgia.

CONCLUSION

The Program and the US Court of Federal Claims have accepted a causal relationship between currently used rubella vaccine in the US and some chronic arthropathy with an onset between 1 week and 6 weeks after vaccine administration.

Measles pneumonitis following measles-mumps-rubella vaccination of a patient with HIV infection, 1993

The Advisory Committee on Immunization Practices (ACIP) recommends measles-mumps-rubella vaccine (MMR) for all persons asymptomatically infected with human immunodeficiency virus (HIV) and recommends that MMR be considered for all symptomatic HIV-infected persons who would otherwise be eligible for measles vaccine, because measles virus infection can cause severe illness and death in such persons. Serious or unusual adverse events in HIV-infected persons after receiving MMR have not been reported previously. This report summarizes the investigation of a case of progressive vaccine-associated measles pneumonitis in a person with acquired immunodeficiency syndrome and provides interim recommendations for the use of measles-containing vaccine among HIV-infected persons.

National Advisory Committee on Immunization (NACI). Supplementary statement MMR vaccine and anaphylactic hypersensitivity to egg or egg-related antigens

The fourth edition of the Canadian Immunization Guide (1993) recommends that "persons who have a history of anaphylactic hypersensitivity to hens' eggs (urticaria, swelling of the mouth and throat, difficulty in breathing or hypotension) should not be given measles vaccine except under special precautions." The precautions outlined include skin testing with diluted vaccine and graded challenge vaccination if the skin test is positive. Results of several recent studies have questioned such a cautious approach. NACI has reviewed all available data and revised its guidelines accordingly. The following revised guidelines are a major departure from the previously published recommendations. They will appear in the next edition of the Canadian Immunization Guide. A measles-rubella combination vaccine (Mo-Ru Viraten Berna TM) recently licensed in Canada contains no avian proteins and therefore can be used without regard to egg allergy.

An update on vaccine safety

Vaccination has dramatically reduced the number of annual cases of pertussis, diphtheria, measles and congenital rubella syndrome. Although side effects of immunizations can occur, serious adverse events are rare for all vaccines commonly used in the United States. Infantile spasms and sudden infant death syndrome are not associated with childhood vaccines. Compared with whole-cell pertussis vaccine, acellular pertussis vaccines are significantly less likely to produce moderate reactions such as fever, fussiness, pain, drowsiness, anorexia and local redness or swelling. Despite the documented safety and efficacy of childhood vaccines, concerns about vaccine safety increase when diseases such as measles, pertussis and rubella are no longer common. Parents need to be reminded that their child is susceptible to these diseases, that these diseases are preventable by reasonably safe and effective immunizations and that their child needs a series of vaccines at regular intervals by the age of two years. Since 1994, all physicians have been required by law to use the Vaccine information Statements for measles-mumps-rubella vaccine, diphtheria and tetanus toxoids and pertussis vaccine, poliovirus vaccines and tetanus and diphtheria toxoids for adults.

Case series analysis of adverse reactions to vaccines: a comparative evaluation

A modified cohort method has been proposed for estimating the relative incidence of rare adverse reactions after vaccination. The method requires only a sample of the cases, thus avoiding the need for following large population cohorts or selecting controls. This case series method has statistical power equivalent to that of the full cohort method when the risk periods after vaccination are short and vaccine coverage is high. The method also eliminates confounding by variables associated with both the outcome and avoidance of vaccination. In this paper, the cohort, case-control, and case series methods are reviewed, and their underlying assumptions and performances are compared. Theoretical results are illustrated using data on febrile convulsions after measles-mumps-rubella vaccination in the United Kingdom.

Adverse events associated with MMR vaccines in Japan

The largest nationwide active surveillance of four Measles-Mumps-Rubella (MMR) vaccines was conducted in Japan. A total of 1255 pediatricians actively participated in the study, which comprised 8.6% of all members of the Japanese Pediatric Society. The total number of registered recipients of MMR vaccines was 38 203. They were arbitrarily given one of the MMR vaccines produced by three makers (Takeda, Osaka city, Kitasato Minato-ku. Tokyo and Biken Suita city, Japan) or the standard MMR vaccine made of designated strains (Kitasato's measles-AIK-C, Biken's mumps-Urabe Am9 and Takeda's rubella-To336) produced by Takeda, Kitasato and Biken and were observed for 35 days. The rates of virologically confirmed aseptic meningitis per 10,000 recipients were 16.6, 11.6, 3.2 and 0 for the standard MMR, Takeda MMR, Kitasato MMR and Biken MMR vaccines, respectively. The incidence of convulsions between 15 and 35 days was the highest with the standard MMR vaccine and the incidence of fever associated with vomiting occurring between 15 and 35 days (symptoms relevant to aseptic meningitis) were also the highest with the standard MMR vaccine. The incidence of parotid swelling was the lowest with Takeda MMR vaccine. This surveillance revealed that incidences of aseptic meningitis after administration of the standard MMR vaccine and of Biken MMR vaccine were different. This posed questions about the manufacturing consistency of the Urabe Am9 mumps virus vaccines. On the other hand, the National Institute of Health found that the biological characteristics of the Urabe Am9 mumps virus contained in the standard MMR vaccine and in the Biken MMR vaccine were different. The Biken Company reported that the mumps vaccine in the standard MMR vaccine was a mixture of two Urabe Am9 mumps vaccine bulks; one identical to that contained in the Biken MMR vaccine and the other produced by a different manufacturing process.

Safety and immunogenicity of a combined live attenuated measles, mumps, rubella, and varicella vaccine (MMR(II)V) in healthy children

An investigational tetravalent combined measles, mumps, rubella, and varicella vaccine and measles-mumps-rubella and varicella vaccines at separate injection sites given at the same visit were evaluated with respect to safety and cell-mediated and humoral immune responses at 6 weeks and 1 year after vaccination. Varicella seroconversion rates and lymphocyte proliferation responses were 100% for both vaccine groups at 6 weeks and 1 year. However, the antibody titer to varicella was lower in the combined vaccine group at 6 weeks, but there was no statistical difference in cell-mediated immune responses. One-year geometric mean titers were not statistically different. Seroconversion rates for measles, mumps, and rubella were 100% for both vaccine at 6 weeks and 1 year. Long-term follow-up of these immune responses is planned.