A measles and rubella vaccine microneedle patch in The Gambia: a phase 1/2, double-blind, double-dummy, randomised, active-controlled, age de-escalation trial

BACKGROUND

Microneedle patches (MNPs) have been ranked as the highest global priority innovation for overcoming immunisation barriers in low-income and middle-income countries. This trial aimed to provide the first data on the tolerability, safety, and immunogenicity of a measles and rubella vaccine (MRV)-MNP in children.

METHODS

This single-centre, phase 1/2, double-blind, double-dummy, randomised, active-controlled, age de-escalation trial was conducted in The Gambia. To be eligible, all participants had to be healthy according to prespecified criteria, aged 18-40 years for the adult cohort, 15-18 months for toddlers, or 9-10 months for infants, and to be available for visits throughout the follow-up period. The three age cohorts were randomly assigned in a 2:1 ratio (adults) or 1:1 ratio (toddlers and infants) to receive either an MRV-MNP (Micron Biomedical, Atlanta, GA, USA) and a placebo (0·9% sodium chloride) subcutaneous injection, or a placebo-MNP and an MRV subcutaneous injection (MRV-SC; Serum Institute of India, Pune, India). Unmasked staff ransomly assigned the participants using an online application, and they prepared visually identical preparations of the MRV-MNP or placebo-MNP and MRV-SC or placebo-SC, but were not involved in collecting endpoint data. Staff administering the study interventions, participants, parents, and study staff assessing trial endpoints were masked to treatment allocation. The safety population consists of all vaccinated participants, and analysis was conducted according to route of MRV administration, irrespective of subsequent protocol deviations. The immunogenicity population consisted of all vaccinated participants who had a baseline and day 42 visit result available, and who had no protocol deviations considered to substantially affect the immunogenicity endpoints. Solicited local and systemic adverse events were collected for 14 days following vaccination. Unsolicited adverse events were collected to day 180. Age de-escalation between cohorts was based on the review of the safety data to day 14 by an independent data monitoring committee. Serum neutralising antibodies to measles and rubella were measured at baseline, day 42, and day 180. Analysis was descriptive and included safety events, seroprotection and seroconversion rates, and geometric mean antibody concentrations. The trial was registered with the Pan African Clinical Trials Registry PACTR202008836432905, and is complete.

FINDINGS

Recruitment took place between May 18, 2021, and May 27, 2022. 45 adults, 120 toddlers, and 120 infants were randomly allocated and vaccinated. There were no safety concerns in the first 14 days following vaccination in either adults or toddlers, and age de-escalation proceeded accordingly. In infants, 93% (52/56; 95% CI 83·0-97·2) seroconverted to measles and 100% (58/58; 93·8-100) seroconverted to rubella following MRV-MNP administration, while 90% (52/58; 79·2-95·2) and 100% (59/59; 93·9-100) seroconverted to measles and rubella respectively, following MRV-SC. Induration at the MRV-MNP application site was the most frequent local reaction occurring in 46 (77%) of 60 toddlers and 39 (65%) of 60 infants. Related unsolicited adverse events, most commonly discolouration at the application site, were reported in 35 (58%) of 60 toddlers and 57 (95%) of 60 infants that had received the MRV-MNP. All local reactions were mild. There were no related severe or serious adverse events.

INTERPRETATION

The safety and immunogenicity data support the accelerated development of the MRV-MNP.

FUNDING

Bill & Melinda Gates Foundation.

Congenital Rubella Syndrome Following Rubella Vaccination During Pregnancy

Rubella vaccine is usually given in combination with measles and mumps vaccines as a measles-mumps-rubella vaccination. Because it contains live attenuated virus, its use is contraindicated during pregnancy. However, since the introduction of rubella vaccine, no cases of congenital rubella syndrome have been reported following vaccination during pregnancy. We report a case of a female infant, born to a woman inadvertently vaccinated with measles-mumps-rubella vaccination early in pregnancy, who manifested a phenotype of cardiac and neurologic defects, neurodevelopmental delay, and lymphocytopenia consistent with congenital rubella syndrome.

Bilateral Deafness as a Complication of the Vaccination-A Case Report

The vaccination has much profit for an infectious disease. On the other hand, there is little frequency, side effects may appear. It includes severe complication. We reported the case that resulted in bilateral acute profound hearing loss after mumps alone and measles and rubella (MR) vaccination. The case was a 5 years old girl. She inoculated mumps alone and MR vaccine. After 18days later, both sides profound hearing loss occurred in her. The hearing loss was not improved by the intravenous feeding of the steroid. Three months later, cochlea implantation was carried out to her right ear. She got hearing again. As for the hearing loss, mumps vaccine was considered as a cause from a latency period until the onset. The bilateral profound hearing loss that was a very rare complication was occurred by vaccination. The care of the hearing is important, but the mental care of an affected child and the parent is important, too.

Sudden deafness and vertigo in children and juveniles

The 17 cases of sudden deafness in children and juveniles treated in the HNO-Universitäts-Klinik Erlangen between August 1977 and December 1980 are analyzed and correlations of symptoms and possible etiologies are discussed. There is no unique clinical picture. Vascular reasons do not play an important role contrary to adult patients. Unexpectedly viral infections are not of great importance. Young patients who had a sensorineural hearing loss prior to the sudden deafness seem to have a bad prognosis for therapy. Vestibular involvement seems to be of no meaning for a successful therapy in children and juveniles.

Safety and Immunogenicity of a Combination: Measles, Mumps, Rubella and Varicella Vaccine (ProQuad®)

BACKGROUND

A combination measles, mumps, rubella, and varicella vaccine (ProQuad, Merck & Co., Inc, West Point, PA) was evaluated in five clinical trials. Use of ProQuad would result in fewer injections for children and would facilitate universal immunization against all four diseases.

OBJECTIVE

To describe the combined results obtained from the studies conducted during the clinical development program for ProQuad.

METHODS

A total of 5833 healthy children, 12-23 months of age, and 399 healthy children, 4-6 years of age, received 1 or 2 doses of ProQuad in five controlled clinical trials. M-M-R II and VARIVAX were used as the control for most studies. Safety was evaluated for six weeks postvaccination and immunogenicity was assessed six weeks after each dose by a sensitive assay (ELISA or gpELISA).

RESULTS

A single dose of ProQuad in 12- to 23-month-old children was shown to be as immunogenic as a single dose of M-M-R II and VARIVAX and was generally well tolerated. ProQuad can be used concomitantly with other vaccines (hepatitis B and Hoemophilus influenzoe b). A higher rate of fever was reported after 1 dose of ProQuad compared to M-M-R II and VARIVAX, but fever episodes were transient without long-term sequelae. Both a 2-dose regimen of ProQuad in 12- to 23-month-olds and use of ProQuad in place of M-M-R II at 4-6 years were shown to be immunogenic and well tolerated. The incidence of adverse experiences following a second dose of ProQuad was lower than that following the initial dose.

CONCLUSIONS

A single dose of ProQuad is as immunogenic as M-M-R II and VARIVAX and is well tolerated in a 1- or 2-dose schedule. ProQuad should easily fit into the routine immunization schedule.

Balancing evidence and uncertainty when considering rubella vaccine introduction

BACKGROUND

Despite a safe and effective vaccine, rubella vaccination programs with inadequate coverage can raise the average age of rubella infection; thereby increasing rubella cases among pregnant women and the resulting congenital rubella syndrome (CRS) in their newborns. The vaccination coverage necessary to reduce CRS depends on the birthrate in a country and the reproductive number, R0, a measure of how efficiently a disease transmits. While the birthrate within a country can be known with some accuracy, R0 varies between settings and can be difficult to measure. Here we aim to provide guidance on the safe introduction of rubella vaccine into countries in the face of substantial uncertainty in R0.

METHODS

We estimated the distribution of R0 in African countries based on the age distribution of rubella infection using Bayesian hierarchical models. We developed an age specific model of rubella transmission to predict the level of R0 that would result in an increase in CRS burden for specific birth rates and coverage levels. Combining these results, we summarize the safety of introducing rubella vaccine across demographic and coverage contexts.

FINDINGS

The median R0 of rubella in the African region is 5.2, with 90% of countries expected to have an R0 between 4.0 and 6.7. Overall, we predict that countries maintaining routine vaccination coverage of 80% or higher are can be confident in seeing a reduction in CRS over a 30 year time horizon.

CONCLUSIONS

Under realistic assumptions about human contact, our results suggest that even in low birth rate settings high vaccine coverage must be maintained to avoid an increase in CRS. These results lend further support to the WHO recommendation that countries reach 80% coverage for measles vaccine before introducing rubella vaccination, and highlight the importance of maintaining high levels of vaccination coverage once the vaccine is introduced.

Characterizing vaccine-associated risks using cubic smoothing splines

Estimating risks associated with the use of childhood vaccines is challenging. The authors propose a new approach for studying short-term vaccine-related risks. The method uses a cubic smoothing spline to flexibly estimate the daily risk of an event after vaccination. The predicted incidence rates from the spline regression are then compared with the expected rates under a log-linear trend that excludes the days surrounding vaccination. The 2 models are then used to estimate the excess cumulative incidence attributable to the vaccination during the 42-day period after vaccination. Confidence intervals are obtained using a model-based bootstrap procedure. The method is applied to a study of known effects (positive controls) and expected noneffects (negative controls) of the measles, mumps, and rubella and measles, mumps, rubella, and varicella vaccines among children who are 1 year of age. The splines revealed well-resolved spikes in fever, rash, and adenopathy diagnoses, with the maximum incidence occurring between 9 and 11 days after vaccination. For the negative control outcomes, the spline model yielded a predicted incidence more consistent with the modeled day-specific risks, although there was evidence of increased risk of diagnoses of congenital malformations after vaccination, possibly because of a "provider visit effect." The proposed approach may be useful for vaccine safety surveillance.

Rubella vaccination during the preconception period or in pregnancy and perinatal and fetal outcomes

The rubella vaccine is contraindicated in pregnancy. Between July and August 2009, the Turkish Republic Ministry of Health implemented a vaccine program to eradicate rubella in women in the reproductive period. In this program, many pregnant women were also vaccinated inadvertently. In this study, 62 pregnant women applied to our clinic who were vaccinated either during pregnancy or within one month before the last menstrual period. Seventeen of them were followed until the end of the pregnancy by fetal echocardiography and detailed ultrasonography. Rubella immunoglobulin (Ig) M and IgG antibodies were studied in the cord blood obtained at birth. All fetuses were examined by a pediatrician, an ophthalmologist and a pediatric cardiologist. A hearing test was also performed on all neonates. No signs of congenital rubella syndrome could be found.

[Combined or coadministred Measles, Mumps, Rubella and Varicella Vaccines? That is the question!]

In November 2011, the Medicine's Italian Agency published the Pediatric Working Group's recommendation; that is do not use the quadruple vaccine against measles, rubella, mumps and varicella as first dosage in children from 12 to 23 months, because it involves an increase of febrile convulsions risks. It caused a big discussion between international and national Scientific and Institutional Bodies. In Italy, varicella is the most common vaccine preventable disease and preventive measures are not uniform. Clear and universally accepted indication is needed.

Complex regional pain syndrome type-I after rubella vaccine

Complex regional pain syndrome type I (CRPS-I) is a complex disorder characterised by pain, autonomic dysfunction, and decreased range of motion. The syndrome was believed as a well-recognized disorder in adults but, less commonly recognized in children. CRPS-I after vaccination has been rarely reported. We reported an 11-year-old young girl with CRPS-I due to rubella vaccine.

Naive and Memory CD4+T-cells in the Cerebrospinal Fluid of Children with Aseptic Meningitis Following Measles-Mumps-Rubella Vaccination and Enteroviral Meningitis

We investigated the distribution of memory (CD45RO+) and naive (CD45RA+CD62L+) CD4+ T-cells as well as CD8+ T-cells and total T-cells in the CSF of children with aseptic meningitis following measles-mumps-rubella (MMW) vaccination and those with enteroviral meningitis. Flow cytometric analysis of CSF cells was performed in 12 children with MMR vaccine-associated meningitis and 11 children with enteroviral meningitis. Percentages of total T-cells, CD4+ and CD8+ T-cells and monocytes in CSF of patients from the two groups were not significantly different. The majority of CD4+ T-cells in the CSF of both patient groups were of memory phenotype. Percentages of CSF naive CD4+ T-cells were increased in children with aseptic meningitis following MMR vaccination. Further studies focused on the more detailed immunophenotyping of CSF cells are needed to fully establish the usefulness of flow cytometry in the diagnostic workup of inflammatory CNS diseases in children.

Distinguishing between primary infection and reinfection with rubella vaccine virus by IgG avidity assay in pregnant women

During the mass measles/rubella vaccination campaign in 2003 in Iran, many pregnant women were vaccinated mistakenly or became pregnant within 1 month of vaccination. To distinguish pregnant women who were affected by rubella vaccine as primary infection from those who had rubella reinfection from the vaccine, serum samples were collected 1-3 months after the campaign from 812 pregnant women. IgG avidity assay showed that 0.3% of the women had no rubella-specific IgG response; 14.4% had low-avidity anti-rubella IgG and were therefore not immune to rubella before vaccination; 85.3% had high-avidity anti-rubella IgG and were regarded as cases of reinfection.

Congenital rubella syndrome in infants of women vaccinated during or just before pregnancy with measles-rubella vaccine

BACKGROUND & OBJECTIVE

Measles and Rubella Control Campaign was conducted in Iran in December 2003 targeting both males and females 5 to 25 yr old using measles-rubella vaccine. During the campaign, some pregnant women received vaccine during the first trimester of pregnancy or some others became pregnant shortly thereafter. The goal of this study was to evaluate the risk of congenital rubella syndrome (CRS) among the infants born to the vaccinated mothers.

METHODS

A total of 106 pregnant women, who had received vaccine during the first trimester of pregnancy or become pregnant less than three months after vaccination were included in the study for comparison 40 pregnant women without rubella vaccine were also included. The mothers' blood samples at the time of delivery, infants' cord blood and blood samples at the end of the second month of birth of sixty children whose parents agreed about blood sampling, were tested for rubella IgM and IgG antibodies using ELISA method.

RESULTS

There were 107 live births in the exposed group and 42 in the control group. Serological study showed no IgM rubella antibody in the maternal and infant cord blood; it was not found in the second blood specimens of 60 infants tested at 8 wk of age. IgG rubella antibody was positive in all infants' cord blood but it decreased in the second blood specimens of the infants. None of the children exhibited signs of congenital rubella syndrome.

INTERPRETATION & CONCLUSION

Finding of our study showed that none of the infants born to mothers vaccinated by MR vaccine during the first trimester of pregnancy or had become pregnant within three months after vaccination, had CRS.

Fetal risk associated with rubella vaccination during pregnancy

BACKGROUND

Costa Rica implemented a nationwide measles-rubella vaccination campaign among men and women (15-39 years old) in May 2001. A protocol was developed to follow-up the vaccinated women who were unknowingly pregnant, to determine the risk of congenital rubella syndrome (CRS) or congenital rubella infection only associated with the administration of the rubella vaccine RA27/3 during pregnancy.

METHODS

To classify the prevaccination maternal immune status, a serum sample was taken at the initial evaluation to detect IgM and IgG rubella antibodies (enzyme-linked immunosorbent assay). All pregnancies were followed up and all newborns were evaluated. A cord serum sample of their children was taken at birth. We calculated odds ratio, OR (95% confidence interval, 95% CI) associated with miscarriage, stillbirth, prematurity, low birth weight, and the presence of defects compatible with CRS.

RESULTS

The prevaccination immune status was established in 797 women and 1191 mother and child pairs were analyzed. Adjusted OR for miscarriage (OR = 0.60, 95% CI = 0.26-1.39), stillbirth (OR = 1.32, 95% CI = 0.10-16.81), prematurity (OR = 0.25, 95% CI = 0.03-2.39), low birth weight (OR = 0.25, 95% CI = 0.03-2.23) and defects compatible with CRS (OR = 1.09, 95% CI = 0.34-3.54) showed no association between immune and susceptible maternal status. There were no cases of CRS and no children were IgM positive.

CONCLUSIONS

No adverse pregnancy outcome such as miscarriages or CRS was documented in women who were vaccinated and unknowingly pregnant. These results support RA27/3 rubella vaccine safety.

Risk of serious neurologic disease after immunization of young children in Britain and Ireland

OBJECTIVE

We sought to investigate the risk of serious neurologic disease after immunization in early childhood.

METHODS

The results of a 3-year prospective study of children (2-35 months old) in Britain and Ireland with encephalitis and/or severe illness with convulsions and fever were linked to each child's vaccine history. Cases were reported via the British Paediatric Surveillance Unit's network. The self-controlled case-series method was used to investigate associations between immunization and acute potential adverse events. The risk periods investigated were 0 to 3 and 0 to 7 days post-diphtheria, tetanus, whole cell pertussis, Haemophilus influenzae type b or meningococcal C conjugate vaccine and 6 to 11 and 15 to 35 days post-measles, mumps, rubella vaccine.

RESULTS

A total of 157 disease episodes from 155 children met the analytical case definition. There were 11 cases of herpes simplex encephalitis and 23 cases of primary human herpesvirus 6 and/or 7 infection. There was no evidence of a raised relative incidence of serious neurologic disease in any of the specified risk periods with the exception of a raised relative incidence of 5.68 in the 6-11 days after measles, mumps, rubella vaccine. Based on this relative incidence, between 3 and 6 of the 6 cases in this period were estimated to be attributable to the vaccine with a best estimate of 5. The 6 cases all had fever with convulsions lasting >30 minutes; in all but 1, there was complete recovery by discharge from hospital. Of the 5 patients who recovered, 1 had a concurrent primary human herpesvirus 6 infection and one a primary human herpesvirus 7.

CONCLUSIONS

Six to 11 days after measles, mumps, rubella vaccine there is an increased risk of fever and convulsions lasting >30 minutes. All 6 of the episodes temporally related to immunization met the criteria for complex febrile convulsions. The estimated attributable risk of serious neurological disease was similar to that previously found for measles vaccine.

The History of Rubella and Rubella Vaccination Leading to Elimination

Congenital rubella syndrome (CRS) was discovered in the 1940s, rubella virus was isolated in the early 1960s, and rubella vaccines became available by the end of the same decade. Systematic vaccination against rubella, usually in combination with measles, has eliminated both the congenital and acquired infection from some developed countries, most recently the United States, as is confirmed by the articles in this supplement. The present article summarizes the clinical syndrome of CRS, the process by which the vaccine was developed, and the history leading up to elimination, as well as the possible extension of elimination on a wider scale.

Inadvertent rubella vaccination of pregnant women: Evaluation of possible transplacental infection with rubella vaccine

During mass campaign for measles/rubella vaccination on December 2003 in Iran, many pregnant women have vaccinated mistakenly. These women were grouped to susceptible and immune against rubella before vaccination by the status of IgG avidity response to rubella vaccine, then susceptible women were followed up to delivery time and their neonates were followed up to one year. In five neonates that were born from susceptible women, rubella-specific IgM has detected in cord blood sera, but they have not shown signs compatible to congenital rubella syndrome.

[Antibody development and frequency of events temporarily associated with measles and rubella vaccines among university health personnel in Jalisco]

OBJECTIVE

To evaluate the seroprevalence, seroconversion, anamnesic response and events temporally associated with immune status pre and post immunization with measles and rubella vaccine in health personnel from a public University in Guadalajara, Mexico.

MATERIAL AND METHODS

We carried out a prospective, longitudinal and comparative study from May to June 2000 among 120 healthy volunteers. Informed consent was obtained from all participants. We administered measles (Schwarz) and rubella (RA 27/3) vaccines. Weekly phone calls during six weeks were recorded from each volunteer to assess local and systemic events temporally associated with immunization non attributable to any other disease. Serum samples were obtained before and after vaccination in 75 volunteers. Antibodies against measles and rubella were measured by an enzyme immunoassay kit (Behring) with cut-off points of 300mUI/mL 8UI/mL respectively. Statistical analysis included mean, standard deviation and paired Student's t-test (P < 0.05).

RESULTS

105/120 participants (87.5%) were followed during 6 weeks. 87.4% were health personnel and 44.6% were males. The age range was 17-71 years (median = 21). We found a prior history of measles in 57.1%. Local events included pain, heat, redness and induration and were reported by 4/105. Systemic events such as fever, exanthema, pain in joints and arthritis was reported by 9/105. The proportion of study subjects with protective antibodies against measles and rubella prior to vaccination was 90.7 and 94.7% respectively. Both groups reached 100% after vaccination.

CONCLUSIONS

The proportion of non-immune health personnel was low and similar to other reports. However, the potential spread of measles and rubella virus from a non-immunized infected health care provider could be amplified by the number of patients seen daily during the peak period of 3-5 days. The vaccination of health personnel should be encouraged.

[Characterization of antirubella vaccine in an epidemiological trial]

The work was aimed at the evaluation of the antigenic activity and reactogenicity of antirubella vaccine, manufactured by the Serum Institute of India, on the basis of the active observation of 373 children. Vaccinal reactions were registered in 8.8% of the vaccinees. Seroconversion after the injection of the vaccine was 100%. The results of the epidemiological trial demonstrated that the Indian antirubella vaccine was faintly reactogenic and had high antigenic activity.

Infant immunization and the occurrence of atopic disease in Dutch and German children: a nested case-control study

Our goal was to assess the role of early childhood vaccination in the occurrence of respiratory symptoms and allergic sensitization in 7-8-year-old Dutch and German children. A nested case-control study was conducted among children participating in a large longitudinal study on respiratory health, to study the relationship between vaccination (bacille Calmette-Guérin (BCG), pertussis, measles/mumps, rubella, and Haemophilus influenza type b (Hib)) and respiratory symptoms and allergic sensitization. Parents of 510 7-8-year-old children with respiratory complaints and an equal number of randomly selected children without respiratory complaints were asked to complete a questionnaire. Blood samples were collected for specific serum IgE analysis. Vaccination status was assessed through the records of the participating Municipal Health Services. No association between vaccination against pertussis, measles, rubella, or Hib and respiratory symptoms or allergic sensitization was found. For sensitization against house dust mite, BCG vaccination resulted in an increased risk (OR, 2.28; 95% CI, 1.05-4.96). Birth order was inversely associated with allergic sensitization, but was not related to respiratory symptoms. We found an association between BCG vaccination and the subsequent risk for sensitization against house dust mite. No evidence was found for an association between vaccination and respiratory symptoms. Earlier reports of an association of birth order with atopic disease were supported by the results of the present study.

Transverse myelitis after measles and rubella vaccination

The incidence of severe neurological complications associated with measles or rubella vaccination is low. A 9-year-old girl developed urinary retention and lower limb paralysis 16 days after measles and rubella vaccination. Her illness was diagnosed as transverse myelitis. Clinical, laboratory and magnetic resonance image findings were consistent with her diagnosis. She was treated with steroids and discharged with only mild lower limb weakness.

The first rapid onset optic neuritis after measles–rubella vaccination: case report

During the largest mass campaign for measles-rubella (MR) vaccination 33,000,000 people with an age range of 5-25 years were vaccinated in Iran. Some complications were encountered, including a rare case of optic neuritis. In the past 30 years of medical literature, five cases of optic neuritis have been reported but all of them were developed at least 8 days after vaccination. We are supposed to report the first case of rapid onset optic neuritis in which the complication came out just in few hours in a 16 years old boy.

Pregnancy outcome following rubella vaccination: A prospective controlled study

The rubella virus is a potent human teratogen. Because the rubella vaccine is prepared with live virus, a high level of anxiety surrounds exposure in pregnancy. There is relatively scarce data on fetal risk following vaccination in pregnancy, and all of the available data were collected retrospectively. Our objective was to examine whether periconceptional exposure to rubella vaccine can cause the congenital rubella syndrome, and to compare the rate of major malformations and developmental milestones among offspring of women who received rubella vaccine 3 months pre- or post-conception to an unexposed comparison group. We collected prospectively and followed up 94 women who received rubella vaccination 3 months pre- or post-conception and a comparison group that consisted of 94 women who were counseled during pregnancy in a similar manner but were not exposed to known teratogens. The controls were matched for age, smoking, alcohol, and drug use. Not any of the women exposed to the vaccine gave birth to a child with congenital rubella syndrome. Rates of major malformations were similar in both groups as were birth weights and developmental milestones. In contrast, the rate of therapeutic abortions was higher in the exposed group (7.4% vs. 0%) (P < 0.05), due to fears of teratogenicity. We conclude that rubella vaccination in pregnancy does not appear to affect pregnancy outcome in general or cause congenital rubella syndrome in particular.

Vaccines, viruses, and voodoo

Vaccinations are invaluable in protection from a wide variety of diseases that can cause substantial morbidity and mortality. Although a rare complication of vaccination, autoimmune disorders represent one of these morbidities. Recently, widespread public concern has arisen from case reports suggesting that--similar to what has been observed after natural viral infections--there might be an association between specific immunizations and autoimmune diseases. Herein we address the biological plausibility of such a connection, focusing particularly on the examples of hepatitis B, rubella, and measles-mumps-rubella (MMR) vaccinations, and the autoimmune diseases they are potentially associated with. Our review of the available data suggests that, for the general population, the risk: benefit ratio is overwhelmingly in favor of vaccinations. However, the possibility cannot be ruled out that, in genetically susceptible individuals, vaccination can result in the unmasking of an autoimmune disease triggered by the immunization. We also critically examine the existing data suggesting a link between immunization against MMR and autism, and briefly discuss the controversial evidence pointing to a possible relationship between mercury exposure from vaccines and autistic disorders. There is a continued urgent need for rigorously designed and executed studies addressing these potential associations, although the use of vaccinations remains a critical public health tool for protection against infectious disease.

Vaccinations and risk of central nervous system demyelinating diseases in adults

BACKGROUND

Several case reports of the onset or exacerbation of multiple sclerosis or other demyelinating conditions shortly after vaccination have suggested that vaccines may increase the risk of demyelinating diseases.

OBJECTIVE

To evaluate the association between vaccination and onset of multiple sclerosis or optic neuritis.

DESIGN

Case-control study involving cases of multiple sclerosis or optic neuritis among adults 18 to 49 years of age. Data on vaccinations and other risk factors were obtained from computerized and paper medical records and from telephone interviews.

SETTING

Three health maintenance organizations.

PARTICIPANTS

Four hundred forty case subjects and 950 control subjects matched on health maintenance organization, sex, and date of birth.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Onset of first symptoms of demyelinating disease at any time after vaccination and during specified intervals after vaccination (<1 year, 1-5 years, and >5 years).

RESULTS

Cases and controls had similar vaccination histories. The odds ratios (95% confidence intervals), adjusted for potential confounding variables, of the associations between ever having been vaccinated and risk of demyelinating disease (multiple sclerosis and optic neuritis combined) were 0.9 (0.6-1.5) for hepatitis B vaccine; 0.6 (0.4-0.8) for tetanus vaccination; 0.8 (0.6-1.2) for influenza vaccine; 0.8 (0.5-1.5) for measles, mumps, rubella vaccine; 0.9 (0.5-1.4) for measles vaccine; and 0.7 (0.4-1.0) for rubella vaccine. The results were similar when multiple sclerosis and optic neuritis were analyzed separately. There was no increased risk according to timing of vaccination.

CONCLUSION

Vaccination against hepatitis B, influenza, tetanus, measles, or rubella is not associated with an increased risk of multiple sclerosis or optic neuritis.

Measles, mumps and rubella vaccine, autism and inflammatory bowel disease: advising concerned parents

Measles, mumps and rubella (MMR) vaccine has been used for almost 30 years in the US, 20 years in Sweden and Finland, and over 10 years in most of the rest of Europe. During this time, it has brought about a dramatic reduction in the morbidity and mortality due to measles and mumps, as well as a considerable reduction in the number of babies with the congenital rubella syndrome. In spite of extensive evidence confirming the efficacy and safety of the vaccine, concerns have recently been raised about a possible link with autism and bowel problems. These arose principally from a research group in the UK, but have now spread to other countries. In the UK this has caused a fall in the uptake of the vaccine with fears of possible outbreaks of measles and mumps in some groups of children. Over the last 3 years a number of studies have addressed this possible link between MMR and autism and inflammatory bowel disease. Studies from the US, UK, Sweden, and Finland have all failed to demonstrate a link. Amongst others, the American Academy of Pediatrics, the Royal College of Paediatrics and Child Health, the Institute of Medicine, and the World Health Organization have all considered the evidence and endorsed the continuing use of the vaccine. No regulatory body in the world has changed its policy as a result of this hypothesized link. Professionals and parents can be assured that MMR is well tried and tested and one of the most successful interventions in healthcare.

A one year followup of chronic arthritis following rubella and hepatitis B vaccination based upon analysis of the Vaccine Adverse Events Reporting System (VAERS) database

OBJECTIVES

This analysis examined the incidence rate of chronic arthritis adverse reactions reported following adult rubella and hepatitis B vaccinations. In this analysis, etiologic mechanisms for chronic arthritis following adult rubella and hepatitis B vaccines were also explored.

METHODS

The Vaccine Adverse Events Reporting System (VAERS) database was analyzed for the incidence rate of reported cases of chronic arthritis in comparison to Tetanus-diphtheria (Td) and tetanus toxoid adult vaccine control groups.

RESULTS

Chronic arthritis adverse reactions following adult rubella vaccination were primarily reported in females (female/male ratio = 3.0), at about 45 years-old, and at a mean onset time of 10-11 days following vaccination. Chronic arthritis adverse reactions following adult hepatitis B vaccination were also primarily reported in females(female/male ratio = 3.5), at about 33 years-old, and with a mean onset time of 16 days following vaccination. The incidence rates of chronic arthritis following adult rubella and adult hepatitis B vaccinations were statistically significantly increased, by chi 2 analysis, in comparison to the adult vaccine control groups. The attributable risk of chronic arthritis following adult rubella vaccine ranged from 32 to 53 and from 5.1 to 9.0 following adult hepatitis B vaccine in comparison to the adult vaccine control groups.

CONCLUSION

This study revealed that adult rubella and adult hepatitis B vaccines were statistically associated with chronic arthritis which persisted for at least one year. The etiology for these adverse reactions may involve autoimmune mechanisms. Furthermore, potential biases in the reporting rates of adverse reactions to VAERS were not observed.

A randomized trial demonstrating successful boosting responses following simultaneous aerosols of measles and rubella (MR) vaccines in school age children

The reactogenicity and immunogenicity of combined measles and rubella (MR) booster vaccination, via aerosol and subcutaneous routes, was assessed in 562 healthy children. Rates of rubella seroconversion and geometric mean titers (GMT) were similar for both routes. Rates of measles PN seroconversion, GMT and measles ELISA post-vaccination seropositivity and seroconversion rate were each higher for aerosol vaccine (54%, 3928 IU/l, 99.6 and 98.8%), than for subcutaneous vaccine (7%, 866 IU/l, 92.2 and 82.4%) (P<0.01). Reactogenicity was higher for subcutaneous vaccine (P<0.05). This study demonstrates that aerosol vaccine was more immunogenic for measles antibodies, and equally immunogenic for rubella antibodies. Aerosol vaccine was less reactogenic.

Aerosolized measles and measles-rubella vaccines induce better measles antibody booster responses than injected vaccines: randomized trials in Mexican schoolchildren

OBJECTIVE

To compare antibody responses and side-effects of aerosolized and injected measles vaccines after revaccination of children enrolling in elementary schools.

METHODS

Vaccines for measles (Edmonston-Zagreb) or measles-rubella (Edmonston-Zagreb with RA27/3) were given by aerosol or injection to four groups of children. An additional group received Schwarz measles vaccine by injection. These five groups received vaccines in usual standard titre doses. A sixth group received only 1000 plaque-forming units of Edmonston-Zagreb vaccine by aerosol. The groups were randomized by school. Concentrations of neutralizing antibodies were determined in blood specimens taken at baseline and four months after vaccination from randomized subgroups (n = 28-31) of children in each group.

FINDINGS

After baseline antibody titres were controlled for, the frequencies of fourfold or greater increases in neutralizing antibodies did not differ significantly between the three groups that received vaccine by aerosol (range 52%-64%), but they were significantly higher than those for the three groups that received injected vaccine (range 4%-23%). Mean increases in titres and post-vaccination geometric mean titres paralleled these findings. Fewer side-effects were noted after aerosol than injection administration of vaccine.

CONCLUSION

Immunogenicity of measles vaccine when administered by aerosol is superior to that when the vaccine is given by injection. This advantage persists with aerosolized doses less than or equal to one-fifth of usual injected doses. The efficacy and cost-effectiveness of measles vaccination by aerosol should be further evaluated in mass campaigns.

Rubella vaccine and arthritic adverse reactions: an analysis of the Vaccine Adverse Events Reporting System (VAERS) database from 1991 through 1998

OBJECTIVE

The United States Academy of Sciences, Institute of Medicine (IOM) reported in 1991 that the evidence indicates a causal relationship between the currently used rubella vaccine and acute and chronic arthritis. The purpose of this study was to analyze the associated arthritic reactions reported following rubella immunization from 1991 through 1998 to the Vaccine Adverse Events Reporting System (VAERS) database.

METHODS

A certified copy of the VAERS database was obtained from the CDC. Microsoft Access was used to analyze the database.

RESULTS

The results show that rubella vaccine is associated with a number of arthritic reactions reported to the VAERS database.

CONCLUSION

Adult female patients need to make informed decisions on whether or not rubella vaccination is right for them. Doctors and patients must together make an informed consent decision about the risk verses the benefit to the patient in their particular life situation. Additionally, those patients who have had an adverse reaction to rubella vaccination should be informed that they may seek compensation under the no-fault Vaccine Compensation Act, which is administered by the US Claims Court.

The Vaccine Safety Datalink project

The Vaccine Safety Datalink (VSD) is a collaborative project between the National Immunization Program of the Centers for Disease Control and Prevention (CDC) and several large health maintenance organizations (HMOs) in the United States. The project began in 1990 with the primary purpose of rigorously evaluating concerns about the safety of vaccines. Computerized data on vaccination, medical outcome (e.g. hospital discharge, outpatient visits, emergency room visits, and deaths), and covariate data (e.g. birth certificates and census) are prospectively collected at multiple HMOs (initially four) and linked under joint protocol for analyses. Approximately 6 million people (2% of the US population) are members of HMOs participating in the VSD. The VSD has proven to be a valuable resource that has provided important information on a number of vaccine safety issues. The databases and infrastructure created for the VSD have also provided opportunities to address other immunization questions including vaccination coverage and cost-effectiveness. In a recent investigation of intussusception following rotavirus vaccination, the VSD methodology was expanded to include 10 managed care organizations. A cohort study was conducted that allowed estimation of incidence rates of intussusception and attributable risks associated with rotavirus vaccine.

Minimum estimated incidence in Japan of anaphylaxis to live virus vaccines including gelatin

We have previously found that most occurrences of anaphylaxis to live virus vaccines are caused by gelatin present in the vaccines as a stabilizer. After we published the evidence for the role of gelatin in anaphylaxis, vaccine manufacturers in Japan began to eliminate gelatin from live virus vaccines. In the present study, we tried to estimate its incidence before the gelatin elimination was started. Physicians and vaccine manufacturers submitted serum samples from children with anaphylaxis to measles, mumps, rubella or varicella vaccine to National Institute of Infectious Diseases (NIID) for 3 years from April 1994 to March 1997. Specific IgE to gelatin was assayed at NIID or two manufacturers by the CAP and ELISA methods. There were 44 children with life-threatening severe anaphylaxis (airway obstruction or anaphylactic shock) during the 3-year period, 41 of whom had anti-gelatin IgE. There were 64 children with mild anaphylaxis (without airway obstruction); 62 had anti-gelatin IgE. There were 100 children with only systemic cutaneous signs; 81 had anti-gelatin IgE. The estimates for the incidence of the severe anaphylaxis in 1994-1996 are: 6.84, 7.31, 4. 36, and 10.3 cases per million doses of gelatin-containing measles, rubella, mumps, and varicella vaccines, respectively.