A search for persistent rubella virus infection in persons with chronic symptoms after rubella and rubella immunization and in patients with juvenile rheumatoid arthritis

Peripheral blood polymorphonuclear leukocytes, mononuclear cells, and plasma and nasopharyngeal specimens were obtained from 6 subjects with persistent symptoms following rubella immunization, 1 subject with persistent symptoms following rubella, 11 children with juvenile rheumatoid arthritis, 17 recently immunized control subjects, and 1 control subject with acute clinical rubella. Rubella virus was isolated from the blood or nasopharynx of four of the 18 control subjects. In contrast, rubella virus was not recovered from any specimens from the seven subjects with persistent symptoms following immunization or natural infection or from the 11 children with juvenile rheumatoid arthritis. A polymerase chain reaction assay detected rubella virus in the blood from three of 14 control subjects but not in the blood from two subjects with persistent symptoms following rubella immunization or in that from three children with juvenile rheumatoid arthritis. We have not been able to confirm the findings of others who have reportedly recovered rubella virus from lymphocytes of persons with persistent symptoms following rubella or rubella immunization.

The measles/rubella immunisation campaign in Scotland

This report describes why the 1994 measles/rubella immunisation campaign was necessary, reviews its implementation, and provides information on its impact in Scotland where 60,504 children were immunised. Data on suspected adverse reactions to the measles/rubella vaccine are also presented. A large UK measles epidemic was predicted by independent researchers, and action in response was planned in accordance with the recommendations of the Joint Committee on Vaccination and Immunisation. As a result, the epidemic predicted for England and Wales was averted and the epidemic which had occurred in the West of Scotland was prevented from spreading to the East. Laboratory-confirmed cases of measles and rubella are now rare in all parts of the UK, especially in the age group targeted by the campaign. Most reported adverse reactions were mild and self-limiting: only one child per 6,700 vaccinated in the UK was reported to have suffered any adverse reaction. Immediate, serious reactions were either allergic or were described as convulsions (most associated with immediate syncope); all of these children recovered fully. Later onset neurological problems were reported at rates no higher than expected from normal population incidence.

Thrombocytopenic purpura after measles, mumps and rubella vaccination: a retrospective survey by the French regional pharmacovigilance centres and pasteur-mérieux sérums et vaccins

BACKGROUND

Thrombocytopenic purpura (TP) after vaccination with measles, mumps and rubella has occasionally been reported.

OBJECTIVES

To evaluate the incidence and characteristics of thrombocytopenic purpura reported in France after measles, mumps or rubella vaccination with monovalent or multivalent vaccines.

METHODS

A retrospective epidemiologic survey was conducted. All confirmed cases of TP reported spontaneously either to the French Regional Pharmacovigilance Centres or to the manufacturer (Pasteur-Mérieux Sérums et Vaccins) between 1984 and June 30, 1992, were reviewed.

RESULTS

Sixty cases of TP in children between 1 and 11 years of age occurred 2 to 45 days after administration of 1 of 7 vaccines. The reported incidence of TP varied from 0.17 and 0.23/100,000 doses of measles or rubella vaccines, respectively, given alone to 0.87/100,000 doses of combined measles-rubella vaccines and 0.95/100,000 doses of the measles-mumps-rubella vaccine. The mean platelet count was 8000 +/- 6000/mm3 and was lower than 10,000/mm3 in 58% of cases. The immediate outcome was favorable in 89.5% of cases.

CONCLUSIONS

According to the clinical course and biologic findings, vaccine-associated TP appears to be similar to that occurring after natural measles or rubella infections and is not distinguishable from acute childhood idiopathic thrombocytopenic purpura not associated with vaccination. Such observations, combined with a clear temporal relationship between measles-mumps-rubella vaccination and the occurrence of TP, make a causal relationship highly plausible. Nevertheless the incidence of these events remains relatively low with a favorable immediate outcome.

Bacterial meningitis after MMR immunisation

Two children developed bacterial meningitis within five days of measles-mumps-rubella (MMR) immunisation. Diagnosis was delayed because symptoms were attributed to the vaccine, although both had a raised C-reactive protein. Fever or rash within five days of MMR vaccination are unlikely to be due to the vaccine and a raised C-reactive protein suggests bacterial infection.

Persistent rubella infection after erroneous vaccination in an immunocompromised patient with acute lymphoblastic leukemia in remission

A 16-year-old male patient with acute lymphoblastic leukemia in complete remission and on maintenance treatment with weekly oral methotrexate and daily oral 6-mercaptopurine for 3 months was immunized in error with the WI-RA 27/3-HDC live attenuated rubella vaccine. Increasing rubella HAI antibodies were noted from 3 to 7 months post-vaccination as well as high levels of IgM antibody up to 8 months in three different tests. High HAI antibody titers persisted for 12-18 months after vaccination. Persisting rubella virus was indicated by PCR detection of rubella-specific nucleic acid in whole blood, non-stimulated and stimulated mononuclear cells 8 months following vaccination. Further attempts to detect rubella virus RNA in two subsequent blood samples were negative. Since acute arthritis and arthralgia occurred in the second month (days 51-63) after vaccination, antileukemic chemotherapy had to be interrupted. Evidence of higher risk for chronic or relapsing rubella-associated arthropathy in immunologically compromised patients and the need to interrupt antileukemic chemotherapy should warrant immunoprophylaxis with polyvalent immune globulin in rubella-susceptible patients who are immunocompromised.

Absence of an association between rubella vaccination and arthritis in underimmune postpartum women

In a double-blind historical cohort study, 485 underimmune women who received rubella vaccine post-partum during 1985-1990 and 493 controls matched for age, place of residence and date of delivery were queried by phone concerning joint complaints following the pregnancy in question. Those reporting joint symptoms were invited for a personal interview at which joint symptoms and dates of their occurrence were explored in detail. Nineteen women in the vaccinated group (3.9%) and 16 from the control group (3.2%) were judged to have had joint symptoms compatible with the study definition of arthritis. The difference was not statistically significant. Thus, we were unable to find evidence for an association between rubella vaccination of underimmune adult women vaccinated post-partum and the subsequent development of arthritis. Rubella vaccine should continue to be used to immunize susceptible adult women against rubella in order to further the goal of elimination of the congenital rubella syndrome.

Reasons for non-uptake of measles, mumps, and rubella catch up immunisation in a measles epidemic and side effects of the vaccine

OBJECTIVE

To investigate the reasons for poor uptake of immunisation (non-immunisation) and the possible side effects of measles, mumps, and rubella vaccine in a catch up immunisation campaign during a community outbreak of measles.

DESIGN

Descriptive study of reasons for non-immunisation and retrospective cohort study of side effects of the vaccine.

SETTING

Secondary schools in South Glamorgan.

SUBJECTS

Random cluster sample of the parents of 500 children targeted but not immunised and a randomised sample of 2866 of the children targeted.

MAIN OUTCOME MEASURES

Reasons for non-immunisation; symptoms among immunised and non-immunised children.

RESULTS

Immunisation coverage of the campaign was only 43.4% (7633/17,595). The practical problems experienced included non-return of consent forms (6698/17,595), refusal of immunisation (2061/10,897 forms returned), and absence from school on day of immunisation (1203/8836 children with consent for immunisation). The most common reasons cited for non-immunisation were previous measles infection (145/232), previous immunisation against measles (78/232), and concern about side effects (55/232). Symptoms were equally common among immunised and non-immunised subjects. However, significantly more immunised boys than non-immunised boys reported fever (relative risk 2.31 (95% confidence interval 1.36 to 3.93)), rash (2.00 (1.10 to 3.64), joint symptoms (1.58; 1.05 to 2.38), and headache (1.31 (1.04 to 1.65)).

CONCLUSIONS

Many of the objections raised by parents could be overcome by emphasising that primary immunisation does not necessarily confer immunity and that diagnosis of measles is unreliable. Measles, mumps, and rubella vaccine is safe in children aged 11-15.

Safe administration of the measles vaccine to children allergic to eggs

BACKGROUND

The safety of administering the combined measles-mumps-rubella (MMR) vaccine to patients who are allergic to eggs has been debated for decades because of concern about potential anaphylaxis, since the live attenuated virus used in the vaccine is grown in cultured chick-embryo fibroblasts.

METHODS

We recruited 54 children (mean age, 18.5 months) who had not previously been vaccinated and were allergic to eggs. The children's histories of allergy were confirmed with skin tests and double-blind, placebo-controlled food-challenge tests; some children also underwent skin testing with the MMR vaccine. We then routinely administered the vaccine to the children in one subcutaneous (0.5-ml) dose.

RESULTS

All 54 children had positive results on skin testing with egg. Allergy to eggs was confirmed in 26 of the children by convincing histories of anaphylaxis after the ingestion of eggs, in 22 children by food-challenge tests, and in 6 patients by convincing histories of recent allergic reactions occurring after the ingestion of eggs. Of the 17 children who underwent skin testing with the MMR vaccine, 3 had positive results. All 54 children received the MMR vaccine as a single subcutaneous injection; none had an immediate or delayed adverse reaction.

CONCLUSIONS

The MMR vaccine can be safely administered in a single dose to children with allergy to eggs, even those with severe hypersensitivity.

A new method for active surveillance of adverse events from diphtheria/tetanus/pertussis and measles/mumps/rubella vaccines

We describe a new method for active post-marketing surveillance of vaccine safety based on patient records. We studied the association between diphtheria/tetanus/pertussis (DTP) vaccination and febrile convulsion, and between measles/mumps/rubella (MMR) vaccination and febrile convulsion and idiopathic thrombocytopenic purpura (ITP) in five district health authorities in England by linking vaccination records with computerised hospital admission records. We found an increased relative incidence for convulsions 0-3 days after DTP vaccination. The effect was limited to the third dose of vaccine for which the attributable risk (all ages) was 1 in 12,500 doses. Completion of vaccination by 4 months instead of 10 months after the change in the UK to an accelerated immunisation schedule may have resulted in a 4-fold decrease in febrile convulsions attributable to DTP vaccine. 67% of admissions for a convulsion 6-11 days after MMR vaccination were attributable to the measles component of the vaccine (risk 1 in 3000 doses). An excess of admissions for a convulsion 15-35 days after MMR vaccination was found only for vaccines containing the Urabe mumps strain (1 in 2600 Urabe doses). There was a causal association between MMR vaccination and ITP resulting in admission 15-35 days subsequently; there was no evidence of a mumps strain-specific effect. The estimated absolute risk of 1 in 24,000 doses was 5 times that calculated from cases passively reported by clinicians. This finding emphasises the need for active surveillance of adverse events. The record linkage method that we used is an effective way to identify vaccine-attributable adverse events.

Lack of adverse reactions to measles, mumps, and rubella vaccine in egg-allergic children

BACKGROUND

Controversy exists regarding allergic reactions to measles, mumps, and rubella (MMR) vaccine in egg-allergic patients. To date there have been only isolated reports describing egg-allergic patients with anaphylaxis to MMR vaccine.

OBJECTIVE

Our study was designed to monitor possible adverse reactions in egg-allergic children receiving MMR vaccine.

METHODS

Initially prick and intradermal testing with MMR vaccine was carried out. The first 120 children were screened in this fashion, with frequent irritant reactions occurring with skin testing but no subsequent reactions when full-strength vaccine was administered. The subsequent 380 children received the undiluted MMR vaccine without prior skin testing.

DESIGN

Over an 8-year period, MMR vaccine was given to 500 egg-allergic children in outpatient setting.

RESULTS

No anaphylactic reactions were observed in any of the 500 children immunized with MMR vaccine. Five children showed minor rashes within two hours of administration of the MMR vaccine.

CONCLUSIONS

It is therefore felt the previously reported adverse reactions to MMR vaccine represent reactions to other vaccine components rather than the suspected egg antigens. The presence of egg allergy should therefore not be considered a contraindication to MMR immunization.

Food allergy in infants and children: clinical evaluation and management

A total of 122 infants and children up to age 17 (69 males and 53 females) who were referred for food allergy to the Pediatric Allergy and Clinical Immunology Unit were evaluated by complete history, emphasizing the implicated foods, clinical presentation and involvement of various organ systems, physical examination, and prick skin tests to food allergens. Fourteen infants with a history of egg white allergy and positive skin tests to egg white also underwent skin tests (prick and intradermal in 1:100 dilution) to measles-mumps-rubella (MMR) vaccine; 35 children under 3 years old had 41 oral challenges with the suspected foods; and 9 children over 3 years old had 12 oral challenges with the suspected foods. We found that cow milk/humanized milk formula, egg white, soybean, and peanut are the main allergenic foods in the pediatric population. Thirteen children had 13 positive oral challenges: 12 to cow milk/humanized milk formula and one to egg white. Symptoms reproduced by oral challenges included urticarial and erythematous rash, conjunctival itching, angioedema, abdominal pain, vomiting, diarrhea, and rhinorrhea. No anaphylactic shock was reported. Negative skin test has an excellent predictive accuracy for negative oral challenge with the suspected food in children > 3 years old. The negative predictive accuracy of cow milk skin test in children < 3 years was 73%. Positive skin test is not a good predictor of a clinical reaction to food. Oral food challenge performed cautiously in a medical setting is the "gold standard" for diagnosis. MMR vaccine can be safely administered to infants with egg white allergy after skin tests with the vaccine are performed.

The elimination of indigenous measles, mumps, and rubella from Finland by a 12-year, two-dose vaccination program

BACKGROUND

In the 1970s measles, mumps, and rubella were rampant in Finland, and rates of immunization were inadequate. In 1982 a comprehensive national vaccination program began in which two doses of a combined live-virus vaccine were used.

METHODS

Public health nurses at 1036 child health centers administered the vaccine to children at 14 to 18 months of age and again at 6 years, and also to selected groups of older children and young adults. Vaccination was voluntary and free of charge. In follow-up studies, we focused on rates of vaccination, reasons for noncompliance, adverse reactions, immunogenicity, persistence of antibody, and incidence of the three diseases. Since 1987, paired serum samples have been collected from all patients with suspected cases of measles, mumps, or rubella.

RESULTS

Over a period of 12 years, 1.5 million of the 5 million people in Finland were vaccinated. Coverage now exceeds 95 percent. The vaccine was efficient and safe, even in those with a history of severe allergy. No deaths or persistent sequelae were attributable to vaccination. The most frequent complication requiring hospitalization was acute thrombocytopenic purpura, which occurred at a rate of 3.3 per 100,000 vaccinated persons. The 99 percent decrease in the incidence of the three diseases was accompanied by an increasing rate of false positive clinical diagnoses. In 655 vaccinated patients with clinically diagnosed disease, serologic studies confirmed the presence of measles in only 0.8 percent, mumps in 2.0 percent, and rubella in 1.2 percent. The few localized outbreaks were confined to patients in the partially vaccinated age groups. There are now fewer than 30 sporadic cases of each of the three diseases per year, and those are probably imported.

CONCLUSIONS

Over a 12-year period, an immunization program using two doses of combined live-virus vaccine has eliminated indigenous measles, mumps, and rubella from Finland. Serologic studies show that most reported sporadic cases are now due to other causes, but a continued high rate of vaccination coverage is essential to prevent outbreaks resulting from exposure to imported disease.

Diagnosing allergies: when to test, when to refer

Recent progress in allergy diagnosis has produced a bewildering variety of tests. These guidelines will help you sort out which ones you can perform and which are best left to a specialist.

Low incidence of adverse experiences after measles or measles-rubella mass revaccination at a college campus

A postvaccination questionnaire and review of student and employee clinic visits were carried out at Notre Dame University in the spring of 1990 after mass campus revaccination with measles or measles-rubella vaccines in the autumn of 1989, in order to assess the incidence of adverse experiences after revaccination. Rates of adverse experiences (AE), which included chiefly local injection site discomfort and flu-like symptoms, among respondents were 6.6% and 13.4%, male and female students, respectively, and 9.3% and 25%, male and female employees, respectively. Rates of joint-related complaints (4%) were lower than reported after primary vaccination, particularly in young adult women. AEs in general, and joint reaction rates in particular, were generally mild and transient, and only 0.23% resulted in a clinic visit. Revaccination of prior vaccinees appears to be associated with relatively low AE rates.

Adverse events associated with childhood vaccines other than pertussis and rubella. Summary of a report from the Institute of Medicine

In September 1993, the Institute of Medicine released a report entitled Adverse Events Associated With Childhood Vaccines: Evidence Bearing on Causality. The report examined putative serious adverse consequences associated with administration of diphtheria and tetanus toxoids; measles, mumps, and measles-mumps-rubella vaccines; oral polio vaccine and inactivated polio vaccine; hepatitis B vaccines; and Haemophilus influenzae type b (Hib) vaccines. The committee spent 18 months reviewing all available scientific and medical data, from individual case reports (published and unpublished) to controlled clinical trials. The committee found that the evidence favored the rejection of a causal relation between diphtheria and tetanus toxoids and encephalopathy, infantile spasms, and sudden infant death syndrome, and between conjugate Hib vaccines and susceptibility to Hib disease. The committee found that the evidence favored acceptance of a causal relation between diphtheria and tetanus toxoids and Guillain-Barré syndrome and brachial neuritis, between measles vaccine and anaphylaxis, between oral polio vaccine and Guillain-Barré syndrome, and between unconjugated Hib vaccine and susceptibility to Hib disease. The committee found that the evidence established causality between diphtheria and tetanus toxoids and anaphylaxis, between measles vaccine and death from measles vaccine-strain viral infection, between measles-mumps-rubella vaccine and thrombocytopenia and anaphylaxis, between oral polio vaccine and poliomyelitis and death from polio vaccine-strain viral infection, and between hepatitis B vaccine and anaphylaxis. For five vaccine-related adverse events, there was no evidence identified. For the remaining 33 vaccine-related adverse events, the evidence was inadequate to accept or reject a causal relation.

Measles, mumps, rubella vaccine administration in egg-sensitive children: systemic reactions during vaccine desensitization

In egg-sensitive children, measles-mumps-rubella (MMR) vaccination may cause acute allergic reactions; therefore, current recommendations are to perform skin testing with the commercial vaccine before administration to egg-allergic children. In children with positive skin tests, desensitization with the measles-mumps-rubella vaccine should be done in order to administer a full dose of the vaccine. Twelve egg-allergic children, aged 12 months to 5 years of age, were referred to our pediatric allergy clinic for MMR administration over a 20-month period. Three children had positive skin prick or intradermal tests to the MMR vaccine. Two of these three patients experienced systemic hypersensitivity reactions while undergoing desensitization to the MMR. All reactions occurred with injections of the undiluted vaccine. Based upon this experience, we recommend that egg-allergic children should continue to have cutaneous tests done to the MMR vaccine and careful observation during desensitization in those children with positive skin tests.

Decline of mumps antibodies in type 1 (insulin-dependent) diabetic children and a plateau in the rising incidence of type 1 diabetes after introduction of the mumps-measles-rubella vaccine in Finland. Childhood Diabetes in Finland Study Group

A nationwide mumps-measles-rubella vaccination was introduced in 1982 in Finland to children aged 1.5 to 6 years and since then mumps has virtually disappeared in the country. We investigated whether this rapid epidemiological change had any impact on antibody activity against mumps virus in Type 1 (insulin-dependent) diabetic children or on the incidence of Type 1 diabetes in Finland. Two case-control series were collected before (series I and II) and three series after (series III-V) the introduction of the vaccination. IgA class mumps antibody levels were significantly higher in Type 1 diabetic children than in matched control children in the first two but not in the three later series. IgG class antibody levels were similar in patients and control subjects in the first two series but significantly lower in patients than in control subjects in the three later series. The overall incidence of Type 1 diabetes in 0-14-year-old children increased until 1987 but remained about the same during 1988-1990. In 5-9-year-old children no further increase in Type 1 diabetes was seen since 1985, whereas in 0-4-year-old children the incidence continued to rise until 1990. The results suggest that the elimination of natural mumps by mumps-measles-rubella vaccination may have decreased the risk for Type 1 diabetes in Finland; a possible causal relationship is substantiated by the observed concomitant decrease in mumps antibody levels in diabetic children. However, further studies are required to determine if the vaccine virus, like natural mumps, could trigger the clinical onset of Type 1 diabetes in young children.

Illness after measles-mumps-rubella vaccination

OBJECTIVES

To provide accurate information on the common sequelae of measles-mumps-rubella (MMR) vaccination and to compare post-vaccine symptoms in children vaccinated at 13 and 15 months.

DESIGN

Prospective cluster randomized controlled trial.

SETTING

Twenty-two family practices in southwestern Ontario.

PATIENTS

All 376 infants who were due to receive MMR vaccine in the next year, 253 (67.3%) successfully completed the study.

INTERVENTION

MMR vaccine administered at 13 months by half of the family physicians and at 15 months by the remaining half.

OUTCOME MEASURES

Family physician's physical findings in children 7 days and 30 days after vaccine; reported illnesses by mothers in a daily diary in the month before and after vaccination and medical records of visits to family physicians and hospital admissions in the month before and after vaccination.

RESULTS

Compared with the incidence rates in the corresponding weeks before vaccination, the rates of lymphadenopathy (23.8%) and fever (16.8%) were higher 1 week afterward and the rate of rash (26.9%) was higher 7 to 14 days afterward. Fewer health problems were reported in the third and fourth weeks after vaccination than in the corresponding weeks beforehand. Hospital admissions after vaccination were no more frequent than those before once cause and time of admission were taken into account. The two age groups did not differ in any of the outcomes.

CONCLUSIONS

Mothers should be informed about the possibility of increased physical findings in the weeks after MMR vaccination, especially lymphadenopathy, nasal discharge and rash. Since the occurrence of sequelae does not seem to differ significantly between 13-month-old recipients and 15-month-old recipients, it should not influence the decision of when to administer the vaccine.

Chronic rubella vaccine-associated arthropathy

Rubella immunization or infection is an uncommonly recognized cause of acute, recurrent, or persistent musculoskeletal manifestations. After routine rubella immunization, two women presented with the onset of polyarthralgia, arthritis, maculopapular rash, fever, paresthesia, and malaise with persistent or recurrent manifestations lasting longer than 24 months after vaccination. The patients expressed rubella virus RNA in peripheral-blood leukocytes 10 and 8 months after vaccination, respectively, in contrast to repeated negative results in asymptomatic rubella-immunized controls. One patient developed significantly depressed antibody responses to rubella virus after vaccination and experienced a prolonged clinical improvement after a 3-month course of intravenous immune globulin. The second patient had normal antibody responses to rubella virus and underwent no clinical improvement during or after intravenous immune globulin therapy. Rubella immunization or infection should be considered as additional causative factors in evaluation of acute and continuing musculoskeletal syndromes.

Simultaneous administration of a diphtheria and tetanus toxoids and acellular pertussis vaccine with measles-mumps-rubella and oral poliovirus vaccines

OBJECTIVE

To compare the safety and immunogenicity of Lederle Laboratories' (Pearl River, NY) diphtheria and tetanus toxoids and acellular pertussis (DTaP) vaccine with diphtheria and tetanus toxoids and whole-cell pertussis (DTwP) vaccine when administered simultaneously with measles-mumps-rubella (MMR) vaccine and trivalent oral poliovirus (OPV) vaccine at 15 to 16 months of age.

DESIGN

Randomized and double-blind.

SETTING

Two general pediatric practices.

PARTICIPANTS

Ninety-seven infants, aged 15 to 16 months, who had received three previous DTwP immunizations. SELECTION PROCEDURES AND INTERVENTIONS: Healthy children received the DTaP or DTwP vaccine. Infants received the MMR vaccine at a separate site and the OPV vaccine concurrently. Blood was obtained on day 0 and at 6 weeks. Adverse events were recorded by parents at specified times after immunization.

MEASUREMENTS/RESULTS

Within 3 days of immunization, DTaP vaccine recipients had less fever, drowsiness, and irritability (P = .01, .04, .01, respectively). They also experienced less tenderness, erythema, and induration (.001, .001, and .002, respectively). There was no difference in the frequency of adverse reactions 6 to 14 days after immunization. Enzyme-linked immunosorbent assays were used to determine all antibody values. Antibody responses to filamentous hemagglutinin and pertussis toxoid were significantly greater in the DTaP group (P = .0001 and .02, respectively). Immune responses to the other measured antigens were similar.

CONCLUSIONS

Simultaneous administration of the Lederle DTaP with MMR and OPV vaccines did not interfere with antibody response to pertussis antigens measured or measles, mumps, or rubella viruses and was associated with fewer local and systemic adverse events during the first 3 days following immunization when compared with the simultaneous administration of the DTwP, OPV, and MMR vaccines. We conclude that the DTaP vaccine can be administered at 15 months of age concurrently with the MMR and OPV vaccines.

Reports of sensorineural deafness after measles, mumps, and rubella immunisation

There have been nine reports of sensorineural hearing loss after measles, mumps, and rubella (MMR) immunisation. In three cases the deafness was unrelated to MMR immunisation. In six cases the cause was unknown and MMR remained a possible aetiology. Any risk associated with attenuated viruses must be weighed against the risks of the natural diseases.

Viral infection including HIV and AIDS

Viruses have long been considered candidates for infectious etiologic agents or cofactors in the development of rheumatic diseases. The current epidemic of HIV infection has focused both scientific and lay interest on identifying such agents and understanding their role in precipitating and perpetuating disease. During 1992, the role of hepatitis C virus infection in cryoglobulinemia was further defined. Interest in members of the Herpesviridae family was raised. The potential for postvaccination rubella arthritis was popularized. Additional clinical presentations of parvovirus B19 infection were described. Studies in patients and in vitro continued to provide tantalizing clues to the possible role of retroviruses, both exogenous and endogenous, in rheumatic disease. This review highlights efforts made during the past year to elucidate the role of viral infection in rheumatologic disease.