Prospective immunological assessment of arthritis induced by rubella vaccine

Lower temperatures reduce type I interferon activity and promote alphaviral arthritis

Chikungunya virus (CHIKV) belongs to a group of mosquito-borne alphaviruses associated with acute and chronic arthropathy, with peripheral and limb joints most commonly affected. Using a mouse model of CHIKV infection and arthritic disease, we show that CHIKV replication and the ensuing foot arthropathy were dramatically reduced when mice were housed at 30°C, rather than the conventional 22°C. The effect was not associated with a detectable fever, but was dependent on type I interferon responses. Bioinformatics analyses of RNA-Seq data after injection of poly(I:C)/jetPEI suggested the unfolded protein response and certain type I interferon responses are promoted when feet are slightly warmer. The ambient temperature thus appears able profoundly to effect anti-viral activity in the periphery, with clear consequences for alphaviral replication and the ensuing arthropathy. These observations may provide an explanation for why alphaviral arthropathies are largely restricted to joints of the limbs and the extremities.

Risk of rheumatoid arthritis following vaccination with tetanus, influenza and hepatitis B vaccines among persons 15-59 years of age

BACKGROUND

Associations between vaccinations, particularly hepatitis B, and onset of rheumatoid arthritis (RA) have been reported, but examined in few large-scale studies.

METHOD

Onset of RA cases and dates of vaccination against hepatitis B, tetanus, and influenza were identified in a retrospective chart review of approximately 1 million Kaiser Permanente Northern California members ages 15-59 years from 1997 through 1999. In a cohort analysis, rates of new-onset RA were compared between vaccinated and unvaccinated within 90, 180, and 365 days. In a case-control analysis, rates of vaccination during exposure intervals (90, 180, 365, and 730 days) were compared between cases and controls using conditional logistic regression.

RESULTS

378 RA cases were included in the cohort analysis; 37 additional cases were included in the case-control analysis. In the cohort analysis the relative risks of RA onset within 90, 180, or 365 days of hepatitis B vaccination were not significant (R.R.=1.44, p=0.53; R.R.=1.67, p=0.22; R.R.=1.23, p=0.59 respectively). We found a possible association between RA and influenza vaccine in the previous 180 and 365 days in the cohort analysis (R.R=1.36, p=0.03; R.R.=1.34, p=0.01 respectively), but in the case-control analysis, cases were no more likely than controls to have received any of the three vaccines.

CONCLUSIONS

In this large retrospective study we found no statistically significant association between exposure to hepatitis B vaccine and onset of RA. A possible association between RA and influenza vaccination in the cohort study was not borne out in the larger case-control analysis.

Rubella virus capsid protein: a small protein with big functions

Virus replication occurs in the midst of a life or death struggle between the virus and the infected host cell. To limit virus replication, host cells can activate a number of antiviral pathways, the most drastic of which is programmed cell death. Whereas large DNA viruses have the luxury of encoding accessory proteins whose main function is to interfere with host cell defences, the genomes of RNA viruses are not large enough to encode proteins of this type. Recent studies have revealed that proteins encoded by RNA viruses often play multiple roles in the battles between viruses and host cells. In this article, we discuss the many functions of the rubella virus capsid protein. This protein has well-defined roles in virus assembly, but recent research suggests that it also functions to modulate virus replication and block host cell defences.

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.

Generation of rubella virus-neutralising antibodies by vaccination with synthetic peptides

Four short peptides from rubella virus proteins E1 and E2, predicted to contain B cell epitopes, were used to vaccinate BALB/c mice. Sera from peptide-vaccinated animals reacted with viral antigens in ELISA and three of the four induced virus-neutralising antibody (nAb) responses. Peptide PY4, in contrast to the others, induced IgG2a responses upon vaccination and stimulated spleen cells in vitro produced IFN gamma in the absence of IL-5. It was reasoned that vaccination with PY4 caused Th1 subset activation, the appropriate type of response for anti-viral immunity and hence the efficient neutralising antibody response. Presentation of peptide for vaccination proved to be as important as the sequence. Similar profiles of IgG1 and IgG2a were detected in the sera of mice vaccinated with PY4 in Freund's complete adjuvant or alum; however nAb responses were not found when alum was used.

Molecular biology of rubella virus

This chapter summarizes the present medical significance of rubella virus. Rubella virus infection is systemic in nature and the accompanying symptoms are generally benign, the most pronounced being a mild rash of short duration. The most common complication of rubella virus infection is transient joint involvement such as polyarthralgia and arthritis. The primary health impact of rubella virus is that it is a teratogenic agent. The vaccination strategy is aimed at elimination of rubella and includes both universal vaccination of infants at 15 months of age with the trivalent measles, mumps, rubella (MMR) vaccine and specific targeting with the rubella vaccine of seronegative women planning pregnancy and seronegative adults who could come in contact with women of childbearing age, although it is recommended that any individual over the age of 12 months without evidence of natural infection or vaccination be vaccinated. Medically, the current challenge posed by rubella virus is to achieve complete vaccination coverage to prevent resurgences.

Localization of the virus neutralizing and hemagglutinin epitopes of E1 glycoprotein of rubella virus

Current serological assays using whole rubella virus (RV) as a target antigen for detecting RV-specific antibodies fail to define specific RV proteins and antigenic determinants such as hemagglutinin (HA) and virus-neutralizing (VN) epitopes of rubella virus. A panel of E1 deletion mutants and a subset of E1-specific monoclonal antibodies (MAb) were used for the initial analysis of HA and VN epitopes of E1 glycoprotein. A peptide region (E1(193) to E1(269)) was found to contain HA and VN epitopes. Using both overlapping synthetic peptides and truncated fusion proteins within this region, the HA epitope defined by MAb 3D9F mapped to amino acid residues E1(214) to E1(240), while two VN epitopes defined by MAb 21B9H and MAb 16A10E mapped to amino acid residues E1(214) to E1(233) and E1(219) to E1(233), respectively. The epitopes defined in this study are recognized by antibody whether or not the epitopes are glycosylated.

Characterization of rubella virus-specific antibody responses by using a new synthetic peptide-based enzyme-linked immunosorbent assay

Rubella virus (RV)-specific immunoglobulin G antibodies were studied by enzyme-linked immunosorbent assay (ELISA) techniques in sera from RV (RA 27/3)-vaccinated individuals, patients experiencing natural RV infection, congenital rubella syndrome patients, and individuals failing to respond to repeated RV immunization. Results obtained by using whole-RV ELISAs (detergent-solubilized M33 strain or intact Gilchrist strain) and hemagglutination inhibition (HAI) and neutralization (NT) assays were compared with results obtained with the same sera by using ELISAs employing a synthetic peptide, BCH-178, representing a putative neutralization domain on the RV E1 protein. Murine RV E1-specific monoclonal antibodies with HAI and NT activities exhibited strong reactivity in ELISAs with BCH-178 peptide. In sera from RA 27/3-vaccinated individuals collected at 0 (prevaccine), 1, 2, 3, 4, 5, 6, 12, and 24 to 52 weeks postvaccine, the development of E1-peptide-reactive antibodies closely paralleled increases in RV-specific antibodies measured by whole-RV ELISAs and HAI and NT assays. Similarly, sequential serum samples obtained from patients during acute and convalescent phases of natural RV infection showed a coordinate increase in RV-specific antibodies as measured by whole-RV and peptide ELISAs. Conversely, congenital rubella syndrome patient sera, although exhibiting high levels of antibody in whole-RV ELISAs, had little or no antibody directed to the neutralization domain peptide. Sera from patients failing to respond to repeated RV immunization contained very low levels of RV-specific antibody in all ELISAs. Our results that the sequence represented by BCH-178 peptide may be a previously unidentified neutralization epitope for human antibodies on the RV E1 protein and may prove useful in determining effective RV immunity.

Rubella in the United States: toward a strategy for disease control and elimination

More than 25 years have passed since the last rubella epidemic in the United States. The rubella pandemic of 1964–5 demonstrated clearly the extraordinary teratogenic potential of the rubella virus. In the United States alone, it is estimated that more than 12500000 cases of rubella occurred during the winter and spring of 1964–5. Congenital rubella infection occurred in an estimated 30000 pregnancies, 10000 resulting in fetal death or therapeutic abortion and 20000 resulting in infants born with congenital rubella syndrome (CRS) [1]. In contrast, during 1988, only 225 cases of rubella were reported to the Centers for Disease Control (CDC) in Atlanta, the lowest annual total since rubella became a nationally notifiable disease in 1966 [2]. However, in 1989, this downward trend of reported cases was interrupted, with the number of reported rubella cases in the United States increasing nearly twofold, and in 1990, the total increased another threefold (to more than 1000 cases) [3]. Although the 1990 reports represent the highest total since 1982, the overall incidence of rubella in the United States has still declined by more than 98% since 1969, the year rubella vaccine was licensed (Fig. 1).

Congenital rubella syndrome associated with calcific epiphyseal stippling and peroxisomal dysfunction

An infant girl had the clinical and immunologic findings of congenital rubella syndrome but also had arthrogryposis multiplex and calcific epiphyseal stippling. Spastic quadriparesis developed, and both physical and behavioral development were slow. Increased spasticity of the legs at 5 1/2 years was related not to progressive rubella encephalomyelopathy but to spinal cord compression by abnormal cartilaginous tissue. The presence of a peroxisomal disorder was demonstrated by a greatly increased level of phytanic acid and slightly increased levels of hexacosanoate in serum and by reduced activity of peroxisomal dihydroxyacetone phosphate acyltransferase and a slightly increased ratio of cytosolic to peroxisomal catalase activity in cultured fibroblasts. A reduction in the number and size of peroxisomes was demonstrated in cultured fibroblasts, and a needle biopsy specimen of the liver also showed the peroxisomes to have a smaller diameter than usual. We recommend that any child with epiphyseal stippling be assessed for peroxisomal disease and that the potential for spinal cord compression by dysplastic bone or cartilage be recognized. The association of peroxisomal dysfunction with congenital rubella has not been described previously. The interaction between rubella virus infection and peroxisomal function may need further investigation.

Kinetics of isotype-specific humoral immunity in rubella vaccine-associated arthropathy

The present study documents the relationship between the development of rubella vaccine-associated arthropathy and isotype-specific rubella antibody responses in a prospectively studied population of 44 adult rubella hemagglutination inhibition (HAI) seronegative females undergoing rubella immunization. Rubella-specific IgM, IgG, and IgA antibody responses were evaluated prior to and at 1, 2, 3, 4, 5, 6, 12, and 24 weeks postvaccine. Detectable preimmunization rubella antibody of the IgG or IgA class was present using ELISA techniques in 6 of 6 individuals developing acute arthritis, 13 of 17 developing acute arthralgia, and in 15 of 21 with no joint manifestations postvaccine. Significantly elevated HAI IgM responses were noted 3 and 4 weeks postvaccine in the acute arthritis group but no significant differences were found in IgG and IgA rubella antibody levels postvaccine in relation to the presence or absence of joint manifestations at any time period postvaccine. The data support rubella reinfection as an important feature of rubella vaccine-associated arthropathy but do not support a role for quantitative differences in rubella IgG and IgA antibody in the pathogenesis of this syndrome.

Antibodies to Epstein-Barr viral antigens in familial rheumatoid arthritis

Serum antibodies to Epstein-Barr virus (EBV) were measured in members of twenty-nine families in which two or more first degree relatives had rheumatoid arthritis (RA). These patients were assessed clinically for activity of disease and their treatment recorded. A higher proportion of seropositive individuals was found among patients and affected kindred than among the non-affected groups. Antibody titres to Viral Capsid Antigen (VCA) tended to be higher in patients and affected kindred. In those individuals in whom antibody to Early Antigen (EA) was present there was a lower titre of antibody to Epstein-Barr Nuclear Antigen (ENBA). The results suggest that an immunoregulatory defect may exist in some patients with RA which allows for enhanced expression of EBV.

Immune responses to wild and vaccine rubella viruses after rubella vaccination

Antibody responses to individual structural proteins (E1, E2, and C) of the M33 wild rubella virus and the RA 27/3 live attenuated rubella strain were assayed by immunoblotting in 11 girls, following immunization with RA 27/3 rubella vaccine. Serum samples were drawn before immunization and at 10 days, 1 month, 1 year, 2 years, and 3 years afterwards. All the subjects showed antibodies to E1 glycoprotein of both the virus strains up to three years after immunization, indicating the importance of E1 in immunity. Antibodies to E1 were always present when with neutralizing activity was observed. Antibodies to E2 protein of both the viruses and to the C protein of the M33 virus gradually disappeared with time in some samples, while antibodies to C protein of the RA 27/3 virus strain were found persistently in all the sera.

Is RA27/3 rubella immunization a cause of chronic fatigue?

Patients with chronic fatigue syndromes (primary fibrositis syndrome, major affective disorder, etc.) have elevated IgG serum antibodies to multiple common viruses. Only IgG rubella antibodies are positively correlated with the intensity of symptoms and have a height that is clearly significant compared to healthy controls. The lymphotropic properties of the rubella virus could account for the multiple elevated antibodies. Adult women are over-represented in the population of patients with chronic fatigue, and are especially susceptible to developing such symptoms following exposure to attenuated rubella virus. A new more potent strain of live rubella vaccine (strain RA27/3) was introduced in 1979. Within three years reports of patients with chronic fatigue began surfacing in the literature. Considering all this, the possible role of rubella immunization in the etiology of chronic fatigue syndromes deserves further study.

Factors associated with clinical reactions to rubella vaccination in women

Two types of rubella vaccine were given to 272 seronegative healthy Japanese adult women. Clinical and laboratory studies on clinical reaction after vaccination were carried out on HI antibody response, HLA types, basal body temperature (BBT), menstrual cycles and serum progesterone levels of vaccinees. Clinical reactions were not associated with HLA types of vaccinees, but arthropathy occurred significantly more often in women vaccinated at the progestational stage than in women vaccinated at the estrogenic stage.

Rubella-associated arthritis. II. Relationship between circulating immune complex levels and joint manifestations

The role played by raised circulating immune complex (CIC) levels in the pathogenesis of rubella-associated joint reactions has been assessed during the course of RA 27/3 rubella immunisation and epidemic wild rubella infection. CIC levels were evaluated by C1q microplate enzyme-linked immunosorbent assay (ELISA) and Raji cell ELISA techniques. Mean CIC levels were generally higher both before and after immunisation among individuals developing vaccine-associated arthritis than among those developing arthralgia or no joint symptoms. However, these differences reached statistical significance only with CIC (Raji) techniques at six and 12 weeks postimmunisation. The proportion of individuals within each group having raised CIC levels (greater than or equal to 2SD above normal control values) was also higher in the postvaccine arthritis group, though statistically significant differences were not found with either Raji or C1q techniques. These data do not support a direct role for raised CIC levels in the pathogenesis of rubella-associated arthritis or arthralgia.

Rubella-associated arthritis. I. Comparative study of joint manifestations associated with natural rubella infection and RA 27/3 rubella immunisation

Joint manifestations observed during the course of a prospective RA 27/3 rubella immunisation trial were compared with those observed during an intercurrent wild rubella epidemic in an outlying community. Among 44 rubella haemagglutination inhibition (HAI) negative females ranging in age from 17 to 33 years who received rubella vaccine, six (13.6%) developed acute polyarticular arthritis within two to four weeks postvaccine and two (4.5%) had continuing or recurrent arthropathy lasting longer than 18 months. In contrast, among 23 females ranging in age from 11 to 39 years undergoing wild rubella infection, 12 (52.2%) developed acute polyarticular arthritis and seven (30.4%) had recurrent arthropathy 18 months postinfection. Among 23 males ranging in age from 13 to 54 years undergoing wild rubella infection, only two (8.7%) developed acute arthritis and both individuals had continuing joint manifestations 18 months postinfection. Wild rubella infection in adult populations is associated with a higher incidence, increased severity, and more prolonged duration of joint manifestations than is seen after RA 27/3 rubella immunisation.

Rubella in teenagers: epidemiology and prophylaxis in Siena, Italy

Six hundred and fifty-three teenagers (aged 11-13 year) living in Siena and its surroundings (Tuscany, Italy) were the sample for serological screening intended to ascertain immunity to rubella. It was found that 324 of the teenagers (49.62%) lacked antibodies and, hence, were unprotected against the infection. Out of the 324 girls, 196 (around 3/5) were vaccinated using live vaccine. Post-vaccinal complications, with clinical signs of rubella infection, were recorded in almost one third of the vaccinees. Virus isolation from the blood was, in every case, not possible after either 10 or 30 days from vaccination. The serological findings, expressed in hemagglutination inhibition antibodies, could be summarized in the following way: (i) antibodies at low titre were found in only eight out of 184 girls (4.35%) ten days after vaccination; (ii) serological conversion was recorded in 187 out of 188 girls (99.47%) 30 days after vaccination; (iii) the titres were moderately high but much lower than those recorded for the natural infection. The results are discussed in the context of their implications for the strategies of rubella vaccination as far as the safety and the effectiveness of the vaccine are concerned, with emphasis on the duration of the protective immunity.

Sequential studies on synovial lymphocyte stimulation by rubella antigen, and rubella virus isolation in an adult with persistent arthritis

The response of synovial lymphocytes from a 65-year-old lady with persistent polyarthritis, to rubella antigen and a number of other microbial agents was studied over a period of 11 months by [3H]thymidine incorporation. The results were correlated with the ability to isolate rubella virus from both peripheral blood and synovial fluid during the same period. The patient showed initially a maximal stimulation index to rubella antigen assayed on five occasions over a five-month period. Rubella virus was detected in both peripheral blood and synovial fluid samples on three occasions during this period. Five months later the lymphoproliferative response of her synovial lymphocytes to rubella antigen had dropped to low levels, and virus could no longer be isolated from synovial exudates. At this time the patient's arthritis had become much less active, indicating that a good correlation existed between the presence of rubella virus, local lymphocyte sensitisation, and the inflammatory reaction.

Subclass distribution of rubella virus-specific immunoglobulin G

An enzyme-linked immunosorbent assay was used to study the subclass distribution of rubella virus-specific immunoglobulin G (IgG) in 97 serum samples from healthy donors and from patients with recent or remote rubella infections. Plastic beads coated with rubella antigen were incubated with test serum and then with monoclonal antibodies to the four human subclass of IgG. Rubella virus-specific IgG1 was present in all serum samples containing rubella virus-specific IgG antibodies. Rubella virus-specific IgG2 was present in 1 of 35 samples from healthy donors that also contained specific IgG1. Rubella virus-specific IgG3 was found in serum samples from patients with recent rubella infections but had disappeared by 6 months after the onset of symptoms. Rubella virus-specific IgG4 was found in low amounts in 7 of 35 samples from healthy immune donors. Of 20 serum samples that were negative by other serological techniques, 8 gave absorbances above cutoff levels in the assays for rubella virus-specific total IgG and IgG1. In 1 of 20 serum samples, the assays for total IgG and IgG2 were positive. High absorbance in the assay for rubella virus-specific IgG4 was found in one serum. This serum was negative in all other assays for rubella virus-specific antibodies.