Nasal immunoglobulin responses in acute rubella determined by the immunofluorescent technique

Post-exposure passive immunisation for preventing rubella and congenital rubella syndrome

BACKGROUND

Control of rubella is desired because infection in early pregnancy can result in miscarriage, foetal death or congenital abnormality. Primary studies examining the effectiveness of immunoglobulins for post-exposure prophylaxis of rubella have small sample sizes and varying results. National public health recommendations suggest a degree of effectiveness.

OBJECTIVES

To assess the effectiveness of intramuscular injection or intravenous infusion of polyclonal immunoglobulins of human sera or plasma origin for preventing rubella and congenital rubella syndrome when administered to exposed susceptible people before the onset of disease.

SEARCH METHODS

We searched CENTRAL (2014, Issue 7), MEDLINE (1946 to August week 2, 2014), EMBASE (1974 to August 2014), CINAHL (1981 to August 2014), LILACS (1982 to August 2014) and Web of Science (1955 to August 2014). We searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry on 16 October 2014. We searched the reference lists of relevant retrieved reviews and studies and identified national public health guidelines.

SELECTION CRITERIA

For the outcome 'preventing cases of rubella', we included randomised controlled trials (RCTs) and quasi-RCTs. We found several studies addressing this outcome where the design was a controlled clinical trial (CCT) (with exposure to rubella virus controlled by the investigators) but the method of allocation of participants to groups was not reported. We found an alternative report of one of these studies that indicated participants were assigned to groups randomly. We therefore included such studies as meeting criteria for RCTs or quasi-RCTs and undertook sensitivity analyses. For the outcomes, 'congenital rubella infection' and 'congenital rubella syndrome', we included RCTs, quasi-RCTs and prospective controlled (cohort) studies. Participants were necessarily susceptible and exposed to rubella. Polyclonal immunoglobulins derived from human sera or plasma must have been administered intramuscularly or intravenously as the only intervention in at least one group.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by The Cochrane Collaboration.

MAIN RESULTS

We included 12 studies (430 participants) in the review: seven RCTs and five CCTs where it was not clear whether participants were randomly allocated to groups. We did not include any unpublished studies. Participants included children and adults of both sexes. Only one study included pregnant women. All studies were conducted in high-income countries.The quality of the 11 studies in the initial meta-analysis was moderate, although we classified no study as having a low risk of bias on all criteria.We included 11 studies in the initial meta-analysis of gamma-globulin (concentrated polyclonal immunoglobulins) versus control (saline or no treatment) for rubella cases. The result favoured the intervention group (risk ratio (RR) 0.61, 95% confidence interval (CI) 0.45 to 0.83) but was heterogenous (Chi² test = 36.59, df = 10 (P value < 0.0001); I² statistic = 73%). Heterogeneity was explained by subgrouping studies according to the estimated volume of gamma-globulin administered per pound of bodyweight and then removing those studies where the intervention was administered more than five days after participant exposure to rubella (post hoc analysis). The test of subgroup differences demonstrated heterogeneity between subgroups according to our protocol definition (P value < 0.1; I² statistic > 60%) and there appeared to be greater effectiveness of the intervention when a greater volume of gamma-globulin was administered ('0.027 to 0.037 ml/lb' RR 1.60 (95% CI 0.57 to 4.52); '0.1 to 0.15 ml/lb' RR 0.53 (95% CI 0.29 to 0.99); '0.2 to 0.5 ml/lb' RR 0.20 (95% CI 0.04 to 1.00)).None of the studies reported the outcome 'congenital rubella infection'. One included study reported on congenital rubella syndrome, with no cases among participants who were fewer than nine weeks pregnant at enrolment and who were randomised to one of two gamma-globulin groups ('high' or 'low' rubella titre). However, the study did not report how congenital rubella syndrome was measured and did not report the length of follow-up according to intervention group. This study did not include a non-treatment group.No included study measured adverse events.

AUTHORS' CONCLUSIONS

Compared to no treatment, polyclonal immunoglobulins seem to be of benefit for preventing rubella. The available evidence suggests that this intervention may be of benefit up to five days after exposure, and that effectiveness is dependent on dose. Considering the attack rate for rubella cases in the control group of the highest volume gamma-globulin subgroup (333 per 1000), the absolute risk reduction (calculated from the RR) for this volume of gamma-globulin was 266 (95% CI 0 to 320) and the number needed to treat to benefit is four (95% CI 3 to incalculable).The included studies did not measure rubella-specific antibodies in the immunoglobulin products used in a standard way and thus estimation of the dose of rubella-specific antibodies in international units administered was not possible. As the concentration of rubella-specific antibodies in today's polyclonal immunoglobulin products may vary from those products used in the studies in the review, the volume required per pound of bodyweight to produce similar results may also vary.There is insufficient evidence to make direct conclusions about the effectiveness of polyclonal immunoglobulins for preventing congenital rubella syndrome. This is an area requiring further research.

Detection of immunoglobulin G and A antibodies to rubella virus in urine and antibody responses to vaccine-induced infection

Urine and serum samples from 89 healthy volunteers and three healthy individuals who underwent rubella vaccination were tested for immunoglobulin G (IgG), IgA, and IgM to rubella virus (RV) by enzyme-linked immunosorbent assay methods. Subjects with positive (n = 68) or negative (n = 21) results for serum IgG were exactly the same as those with the corresponding results for urinary IgG. Both urinary and serum IgG levels remained elevated from the 3rd or 4th week after vaccination until the end of the study. Both urinary IgA and serum IgM levels tended to increase rapidly between the 3rd and 5th week and then gradually decrease until the end of the study, but the levels of both remained positive except for one sample each at the end (26th week). On the other hand, the ratio of anti-RV IgA titer to anti-RV IgG titer in urine (urinary anti-RV IgA/IgG ratio) increased rapidly between the 3rd and 4th week after vaccination and then rapidly returned to the ratio levels of the subjects positive for serum IgG from among the healthy volunteers. In summary, detection of urinary anti-RV IgG should be useful for screening for previous RV infection, and measurement of urinary anti-RV IgA/IgG ratio might be useful for diagnosing recent infection.

Rubella in the developing world

Before Gregg's historic observation [1] rubella was not considered to have clinical or epidemiological importance in any country. In the western world epidemics occurred at varying intervals but with little morbidity and apparently only minor complications. Despite confirmation of Gregg's findings from many quarters, it was not until the worldwide outbreaks in the 1960s that the aftermath of rubella infection in pregnancy was fully realized. As a result of the 1964 outbreak in New York City, more than 1000 children were born with congenital rubella syndrome (CRS) and over 300 pregnancies either aborted spontaneously or were terminated for rubella infection [2]. The number of children affected represented 1% of births in the city; if extrapolated to the whole country this gave an estimated total of 30000 cases of CRS. No such disasters have so far been reported from the developing world.

Rubella and mumps vaccines

As a fetal infection occurring during early pregnancy, rubella's potential for teratogenicity is unparalleled. In the postnatal period it is a relatively benign disease. Mumps, on the other hand, causes moderate morbidity and occasional mortality. Both infections cause considerable morbidity and disruption in the lives of young people gathered for group activities. Widespread use of safe and effective live attenuated vaccines has dramatically reduced the incidence of rubella, congenital rubella, and mumps in the United States. Nevertheless, significant numbers of young children, especially in areas of urban and rural immigration and poverty, fail to be immunized in a timely fashion; and some adolescents and young adults remain susceptible either because they escaped immunization in childhood or are primary vaccine failures. These individuals remain the source of individual cases and small outbreaks of rubella and mumps. For total eradication of these infections, we need to intensify vaccine efforts and to maintain surveillance efforts for mumps, rubella, and congenital rubella syndrome.

Measles antibodies in the saliva of children with subacute sclerosing panencephalitis

Using the method of haemagglutination inhibition, the authors determined the levels of measles antibodies in the saliva of 14 children with subacute sclerosing panencephalitis. In 13 of them these antibodies were found in titres from 1:8 to 1:128. In the control groups, comprising 29 children, these antibodies were found in the saliva in only two cases and in low titres. There appears to be a correlation between the levels of these antibodies in the saliva and cerebrospinal fluid in patients with subacute sclerosing panencephalitis.

Evaluation of a simplified sucrose gradient method for the detection of rubella-specific IgM in routine diagnostic practice

Rubella-specific IgM was measured in a single fraction of serum from a sucrose density gradient. Haemagglutination inhibition (HAI) tests were performed on paired aliquots of the fraction untreated and after treatment with 2- mercaptoethanol, dilutions of the aliquots being incubated over night with rubella antigen before the addition of red cells. Of 822 sera tested, specific IgM was found in 249, but not in 492. When first tested, the remaining 81 sera gave unsatisfactory results because of contamination of the IgM fraction with IgG (6.0%), probable aggregation of IgG (3.5%), or the persistence of chick red cell agglutinins (0.4%). Tests were performed on 134 patients with rubella confirmed by a rise of HAI antibodies. Rubella-specific IgM was found at a titre of more than eight in the sera taken from 62 of 64 patients between 10 and 29 days after the onset of the rash but in only one of the sera taken between 80 and 119 days, and in none taken later. However, specific IgM was still to be found at lower titre in the sera of 13 patients collected between 80 and 162 days after the onset of the illness. In routine diagnostic tests over three years on the serum from 479 patients with suspected acquired rubella, specific IgM was found at a titre of more than eight in 51 patients and in only 10 instances (2.1%) did a lower level pose a problem in interpretation.

Detection of rubella-specific serum IgG and IgA and nasopharyngeal IgA responses using a radioactive single radial immunodiffusion technique

A radioactive, single radial immunodiffusion technique (RSRID) employing 125I-labelled antiglobulins, was developed to determine rubella-specific serum IgG and IgA and nasopharyngeal IgA antibody responses following both naturally acquired rubella and vaccination with four attenuated vaccines. Rubella-specific IgG antibodies developed in parallel with haemagglutination inhibiting (HAI) antibodies and both persisted for at least a year in all cases of naturally acquired and vaccine induced infection. However, the RSRID test detected rises in titre in all of five volunteers challenged intranasally with RA27/3, whereas only one volunteer showed a rise by HAI. Serum IgA antibodies generally persisted for at least a year following naturally acquired infection but rubella vaccines induced variable responses. Thus, following administration of RA27/3 and To-336 vaccines, rubella-specific IgA usually persisted for a year, whereas Cendehill vaccine failed to induce a detectable response. Rubella-specific nasopharyngeal IgA was detected in all five patients following naturally acquired infection and was still present in the only two patients tested a year after infection. These antibodies were detected in fourteen of twenty-three vaccinees at 3 weeks, but persisted for a year in only two vaccinees, both of whom were given RA27/3 intranasally.

Persistence of rubellavirus-specific immunoglobulin M and immunoglobulin A antibodies: investigation of successive serum samples with lowered immunoglobulin G concentration

The persistence of rubellavirus-specific immunoglobulin (Ig) M and IgA antibodies has been studied in seven patients with primary postnatal rubella infections. Successive blood samples obtained over a period of several years after the onset of disease have been investigated, employing the fluorescent antibody technique and the sucrose gradient centrifugation method. IgM antibodies were found to persist for 4 to 5 weeks after the onset of disease, with only moderate variation being observed with respect to the different patients and the method of investigation being studied. The persistence of IgA antibodies (as examined by the fluorescent antibody technique) varied from a few weeks to several years after the onset of the disease. The detection of IgA antibodies cannot be considered as conclusive for the diagnosis of recent rubella infections.

A simplified method for the detection of rubella-specific IgM employing sucrose density fractionation and 2-mercaptoethanol

A simplified method for the detection of rubella-specific IgM in sera was developed involving HAI tests on only one fraction from a sucrose density gradient with and without treatment with 2-mercaptoethanol (2 ME). Slight trailing of IgG into the IgM fraction was shown to occur in patients with high titres of both IgG and IgM, but this could be detected by the 2ME treatment and did not affect the results.By this test, rubella-specific IgM was found in all of 54 patients with a rash and a rise of rubella HAI antibodies. When the antigen and serum were incubated for 1 hr. before adding the RBC, specific IgM was found in all 51 sera taken between 5 and 40 days after onset, and in about half the sera taken between 42 and 77 days, but in none of 16 people known to have possessed rubella antibodies at least a year previously. When antigen and serum were incubated for 18 hr. before adding the RBC, specific IgM was found in all of 21 sera taken between 2 and 49 days after onset, and in 6 of 11 sera taken between 50 and 117 days, but not in 9 people known to have possessed rubella antibodies at least a year before. The method has been found to be very useful in detecting recent rubella among patients in early pregnancy.

Specific immunoglobulin responses in serum and nasal secretions after the administration of attenuated rubella vaccine

The indirect immunofluorescent technique has been used to study the specific immunoglobulin responses in the sera of 63 non-immune adult women who received either Cendehill rubella vaccine subcutaneously, RA27/3 rubella vaccine subcutaneously, or RA27/3 vaccine intranasally. IgG, IgA and IgM antibodies increased virtually simultaneously, starting about 2 weeks after vaccination. IgG antibody appeared in all subjects and reached maximum titres 4-6 weeks after vaccination. The mean IgG titres elicited by the three different methods of vaccination did not differ significantly. IgA and IgM antibodies reached their highest titres between 21 and 28 days after vaccination and then declined to low or undetectable titres within about 9 weeks. The maximum IgA titres observed after intranasal administration of RA27/3 vaccine were significantly higher than those which occurred when the same vaccine was given subcutaneously, but no significant difference in IgM titres was observed. When unfractionated sera were examined IgA antibody was detected in 57 cases (91%) and IgM in 51 (81%). Fluorescent examination of fractions obtained by centrifugation on sucrose density gradients frequently revealed small amounts of IgA and IgM antibody which could not be detected by staining unfractionated serum, and with the inclusion of these results IgA antibody was detected in 61 cases (97%) and IgM in 59 (94%).When 39 adults with pre-existing serum antibody were challenged with vaccine a definite IgA response was detected in only one subject and in no case was there any evidence of the appearance of IgM antibody.Nasal antibody, consisting of IgG or IgA or both, was detected in 17 out of 23 non-immune subjects (74%) who received RA27/3 vaccine, either subcutaneously or intranasally. Titres were much lower than those which occur in the natural disease and there was no evidence that nasal antibody was elicited more readily by intranasal than by subcutaneous vaccination.

Comparison of immunofluorescence and isolation techniques in the diagnosis of respiratory viral infections of children

The immunoflourescent antibody technique (IFAT) and cell culture isolation procedures were compared for their efficiency in the etiological diagnosis of viral respiratory illness in children. Before the IFAT was incorporated as a routine procedure, antisera used in the test were carefully calibrated to insure specificity. A study was then conducted in which 375 nasopharyngeal suctions were investigated by both IFAT and isolation for the presence of parainfluenza virus types 1, 2, and 3, respiratory syncytial, influenza A, and influenza B viruses. Methods already established in our hospital for patient management and specimen collection were not altered for the purposes of the study. The IFAT, as conventionally practiced in the detection of respiratory virus antigens, requires adequate numbers of ciliated epithelial cells. There were 68.5% specimens which contained cells suitable for IFAT, whereas 31.5% had either an insufficient number or inappropriate types of cells and could be used only for virus isolation. Cell-associated immunoglobulins were detected in 16% of those specimens with adequate cells. When all specimens were considered regardless of their cell population, IFAT was inferior to isolation in diagnostic efficiency. However, isolation complemented by IFAT resulted in a statistically significant increase in number of positive virus identifications. Under routine working conditions in a large pediatric hospital, it was found that IFAT could not replace isolation techniques but could, if used in conjunction with isolation, provide a significant overall increase in number of positive diagnoses. The time that the specimen was taken in relation to first symptoms was found to be an important variable with respect to the method most likely to succeed in virus identification.