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

Rubella virus-associated chronic inflammation in primary immunodeficiency diseases

PURPOSE OF THE REVIEW

The aim of this article is to summarize recent data on rubella virus (RuV) vaccine in chronic inflammation focusing on granulomas in individuals with primary immunodeficiencies (PIDs).

RECENT FINDINGS

The live attenuated RuV vaccine has been recently associated with cutaneous and visceral granulomas in children with various PIDs. RuV vaccine strain can persist for decades subclinically in currently unknown body site(s) before emerging in granulomas. Histologically, RuV is predominately localized in M2 macrophages in the granuloma centers. Multiple mutations accumulate during persistence resulting in emergence of immunodeficiency-related vaccine-derived rubella viruses (iVDRVs) with altered immunological, replication, and persistence properties. Viral RNA was detected in granuloma biopsies and nasopharyngeal secretions and infectious virus were isolated from the granuloma lesions. The risk of iVDRV transmissibility to contacts needs to be evaluated. Several broad-spectrum antiviral drugs have been tested recently but did not provide significant clinical improvement. Hematopoietic stem cell transplantation remains the only reliable option for curing chronic RuV-associated granulomas in PIDs.

SUMMARY

Persistence of vaccine-derived RuVs appears to be a crucial factor in a significant proportion of granulomatous disease in PIDs. RuV testing of granulomas in PID individuals might help with case management.

Infectious vaccine-derived rubella viruses emerge, persist, and evolve in cutaneous granulomas of children with primary immunodeficiencies

Rubella viruses (RV) have been found in an association with granulomas in children with primary immune deficiencies (PID). Here, we report the recovery and characterization of infectious immunodeficiency-related vaccine-derived rubella viruses (iVDRV) from diagnostic skin biopsies of four patients. Sequence evolution within PID hosts was studied by comparison of the complete genomic sequences of the iVDRVs with the genome of the vaccine virus RA27/3. The degree of divergence of each iVDRV correlated with the duration of persistence indicating continuous intrahost evolution. The evolution rates for synonymous and nonsynonymous substitutions were estimated to be 5.7 x 10-3 subs/site/year and 8.9 x 10-4 subs/site/year, respectively. Mutational spectra and signatures indicated a major role for APOBEC cytidine deaminases and a secondary role for ADAR adenosine deaminases in generating diversity of iVDRVs. The distributions of mutations across the genes and 3D hotspots for amino acid substitutions in the E1 glycoprotein identified regions that may be under positive selective pressure. Quasispecies diversity was higher in granulomas than in recovered infectious iVDRVs. Growth properties of iVDRVs were assessed in WI-38 fibroblast cultures. None of the iVDRV isolates showed complete reversion to wild type phenotype but the replicative and persistence characteristics of iVDRVs were different from those of the RA27/3 vaccine strain, making predictions of iVDRV transmissibility and teratogenicity difficult. However, detection of iVDRV RNA in nasopharyngeal specimen and poor neutralization of some iVDRV strains by sera from vaccinated persons suggests possible public health risks associated with iVDRV carriers. Detection of IgM antibody to RV in sera of two out of three patients may be a marker of virus persistence, potentially useful for identifying patients with iVDRV before development of lesions. Studies of the evolutionary dynamics of iVDRV during persistence will contribute to development of infection control strategies and antiviral therapies.

Maternal tetanus, diphtheria, and acellular pertussis (Tdap) and influenza immunization: an overview

BACKGROUND

Maternal tetanus, diphtheria, and acellular pertussis (Tdap) and influenza immunization for women during pregnancy (the so-called "maternal immunization") has been introduced in several countries, and recently also in Italy, to protect mother and fetus during pregnancy, infant in his first months of life and mother during postpartum period. However, very low vaccination coverage rates have been reached due to several variables.

METHODS

A literature search was conducted on PubMed and Embase, including any experimental or observational studies, to assesses existing evidence on the effectiveness, efficacy, safety and optimal timing of administration of Tdap and influenza immunization in pregnancy for mothers and their infants. The search was finalized in August 2019.

RESULTS

Reviewing the literature, we identified only a few studies that, among several maternal and infant outcomes, found sporadic significant associations with maternal influenza immunization and even less with Tdap immunization. Moreover, most of the authors of these studies explained these findings as a result of residual confounding effect. The effectiveness of maternal influenza immunization is more complicated to prove than the effectiveness of Tdap immunization because of several reasons. Not all nations recommend and offer vaccines in the same weeks of pregnancy and this one manifests the complexity in defining the best timing for Tdap or influenza immunization.

CONCLUSIONS

The safety of maternal Tdap or influenza immunization is supported by the evidence so far, however, regular surveillance should be maintained, especially with regard to the influenza vaccine that changes in formulation each year. There is a need to optimize the timing of vaccination in pregnancy and to have a national system of detection of maternal immunization in each country.

Effects of sex and birth weight on non-specific health services use following whole-cell pertussis vaccination: a self-controlled case series analysis

Previous studies from low-resource countries have highlighted concerns surrounding non-specific effects of whole-cell pertussis vaccination, particularly in females. We sought to examine the effects of sex and birth weight on health services utilization following first exposure to whole-cell pertussis vaccine. Using a self-controlled case series design and by calculating relative incidence ratios (RIRs), we compared the relative incidence of emergency department visits and/or hospital admissions between sexes and between birth weight quintiles. Females had a higher relative incidence of events following vaccination compared to males (RIR = 1.13, 95% CI: 0.99, 1.30), which persisted after adjustment for birth weight (RIR = 1.12, 95% CI: 0.97, 1.28). We also observed a trend of increasing relative incidence of events over decreasing quintiles of birth weight; infants in the lowest quintile had a 26% higher relative event rate compared to the highest quintile, which was robust to adjustment for sex (Unadjusted RIR = 1.26, 95% CI: 1.01, 1.56; Adjusted RIR = 1.23, 95% CI: 0.99, 1.53). The risk of all-cause health services utilization immediately following vaccination, was elevated in female infants and infants having lower birth weight. Further study is warranted to determine if vaccine dosing should take infant weight into account.

Immunizations in Athletes

Context:

Immunizations are a cornerstone of preventive care and an important consideration for team physicians caring for athletes.

Evidence Acquisition:

A PubMed search was performed from August 2016 through May 2017 as well as a website review of the Centers for Disease Control and Prevention, World Health Organization, and Immunization Action Coalition.

Study Design:

Clinical review.

Level of Evidence:

Level 4.

Results:

By keeping abreast of diseases endemic to nations to which athletes may be traveling as well as the vaccination status of the athletes, team physicians can provide appropriate advice regarding immunization and prevention of disease.

Conclusion:

There are a host of regularly updated reliable websites to assist the team physician in these recommendations.

How to determine protective immunity in the post-vaccine era

The ability to determine an individual's susceptibility to infection relies heavily on the assay used, and the ability to correlate results of the assay to a clinical interpretation. Current rubella immunity screening methods identify total rubella IgG antibodies circulating in the serum, however both humoral and cell mediated immune responses have been shown to contribute to protection from infection. Therefore, antibody screening assays may under-estimate immunity in some populations. In fact, waning antibody titers over time in a large prenatal population were recently documented in North America, and the trend has been echoed in other countries that have achieved elimination through universal rubella vaccination. Despite decreasing antibody titers, the number of acute rubella cases has not increased in these populations, suggesting that the lower antibody levels may still be protective. Based on the changing epidemiology in universally vaccinated populations, it may be time to reassess the level of antibody that indicates immunity to rubella infection.

Safety and immunogenicity of rVSVΔG-ZEBOV-GP Ebola vaccine in adults and children in Lambaréné, Gabon: A phase I randomised trial

BACKGROUND

The rVSVΔG-ZEBOV-GP vaccine prevented Ebola virus disease when used at 2 × 107 plaque-forming units (PFU) in a trial in Guinea. This study provides further safety and immunogenicity data.

METHODS AND FINDINGS

A randomised, open-label phase I trial in Lambaréné, Gabon, studied 5 single intramuscular vaccine doses of 3 × 103, 3 × 104, 3 × 105, 3 × 106, or 2 × 107 PFU in 115 adults and a dose of 2 × 107 PFU in 20 adolescents and 20 children. The primary objective was safety and tolerability 28 days post-injection. Immunogenicity, viraemia, and shedding post-vaccination were evaluated as secondary objectives. In adults, mild-to-moderate adverse events were frequent, but there were no serious or severe adverse events related to vaccination. Before vaccination, Zaire Ebola virus (ZEBOV)-glycoprotein (GP)-specific and ZEBOV antibodies were detected in 11% and 27% of adults, respectively. In adults, 74%-100% of individuals who received a dose 3 × 104, 3 × 105, 3 × 106, or 2 × 107 PFU had a ≥4.0-fold increase in geometric mean titres (GMTs) of ZEBOV-GP-specific antibodies at day 28, reaching GMTs of 489 (95% CI: 264-908), 556 (95% CI: 280-1,101), 1,245 (95% CI: 899-1,724), and 1,503 (95% CI: 931-2,426), respectively. Twenty-two percent of adults had a ≥4-fold increase of ZEBOV antibodies, with GMTs at day 28 of 1,015 (647-1,591), 1,887 (1,154-3,085), 1,445 (1,013-2,062), and 3,958 (2,249-6,967) for the same doses, respectively. These antibodies persisted up to day 180 for doses ≥3 × 105 PFU. Adults with antibodies before vaccination had higher GMTs throughout. Neutralising antibodies were detected in more than 50% of participants at doses ≥3 × 105 PFU. As in adults, no serious or severe adverse events related to vaccine occurred in adolescents or children. At day 2, vaccine RNA titres were higher for adolescents and children than adults. At day 7, 78% of adolescents and 35% of children had recombinant vesicular stomatitis virus RNA detectable in saliva. The vaccine induced high GMTs of ZEBOV-GP-specific antibodies at day 28 in adolescents, 1,428 (95% CI: 1,025-1,989), and children, 1,620 (95% CI: 806-3,259), and in both groups antibody titres increased up to day 180. The absence of a control group, lack of stratification for baseline antibody status, and imbalances in male/female ratio are the main limitations of this study.

CONCLUSIONS

Our data confirm the acceptable safety and immunogenicity profile of the 2 × 107 PFU dose in adults and support consideration of lower doses for paediatric populations and those who request boosting.

TRIAL REGISTRATION

Pan African Clinical Trials Registry PACTR201411000919191.

Vaccination and autoimmune diseases: is prevention of adverse health effects on the horizon?

Autoimmune diseases, including multiple sclerosis and type 1 diabetes mellitus, affect about 5% of the worldwide population. In the last decade, reports have accumulated on various autoimmune disorders, such as idiopathic thrombocytopenia purpura, myopericarditis, primary ovarian failure, and systemic lupus erythematosus (SLE), following vaccination. In this review, we discuss the possible underlying mechanisms of autoimmune reactions following vaccinations and review cases of autoimmune diseases that have been correlated with vaccination. Molecular mimicry and bystander activation are reported as possible mechanisms by which vaccines can cause autoimmune reactions. The individuals who might be susceptible to develop these reactions could be especially not only those with previous post-vaccination phenomena and those with allergies but also in individuals who are prone to develop autoimmune diseases, such as those with a family history of autoimmunity or with known autoantibodies, and the genetic predisposed individuals. Further research is encouraged into the direct associations between vaccines and autoimmune conditions, and the biological mechanisms behind them.

Adverse Events After MMR or MMRV Vaccine in Infants Under Nine Months Old

BACKGROUND

In the United States, measles is resurging, with more than 700 confirmed cases since January 2014. During measles outbreaks, vaccination as early as at 6 months of age is sometimes recommended for infants who are at risk for exposure.

METHODS

We searched the Vaccine Adverse Event Reporting System for reports of measles, mumps and rubella vaccine combined or measles, mumps, rubella and varicella vaccine combined vaccination in children less than 9 months of age. We performed a clinical assessment of each report and summarized the frequency, range, onset time and severity of adverse events.

RESULTS

After excluding 346 reports because they were duplicates or because they contained insufficient information about the child's age or vaccine(s), we retained 204 reports in the analysis, including 35 (17%) that were serious. Among the 169 nonserious reports, more than half (88; 52%) described a vaccination error without any adverse event per se. Other nonserious reports described fever, injection reactions and gastrointestinal symptoms. Serious adverse events included developmental disorders, fever and fussiness. There were 44 reports of fever, but only 4 cases began 5-12 days after immunization, the peak risk window. The vast majority of fever reports listed concomitant vaccines, such as diphtheria and tetanus toxoids, acellular or whole-cell pertussis vaccine.

CONCLUSIONS

This review did not identify any major safety concerns. These findings may facilitate discussions about the risks and benefits of vaccinating infants who are potentially exposed to this life-threatening disease.

The key role of rubella virus glycoproteins in the formation of immune response, and perspectives on their use in the development of new recombinant vaccines

Rubella is a highly contagious viral disease which is mostly threatens to women of reproductive age. Existent live attenuated vaccines are effective enough, but have some drawbacks and are unusable for a certain group of people, including pregnant women and people with AIDS and other immunodeficiency. Thereby the development of alternative non-replicating, recombinant vaccines undoubtedly is needed. This review discusses the protein E1 and E2 role in formation of immune response and perspectives in development of new generation recombinant vaccines using them.

Vaccination in elite athletes

Public health vaccination guidelines cannot be easily transferred to elite athletes. An enhanced benefit from preventing even mild diseases is obvious but stronger interference from otherwise minor side effects has to be considered as well. Thus, special vaccination guidelines for adult elite athletes are required. In most of them, protection should be strived for against tetanus, diphtheria, pertussis, influenza, hepatitis A, hepatitis B, measles, mumps and varicella. When living or traveling to endemic areas, the athletes should be immune against tick-borne encephalitis, yellow fever, Japanese encephalitis, poliomyelitis, typhoid fever, and meningococcal disease. Vaccination against pneumococci and Haemophilus influenzae type b is only relevant in athletes with certain underlying disorders. Rubella and papillomavirus vaccination might be considered after an individual risk–benefit analysis. Other vaccinations such as cholera, rabies, herpes zoster, and Bacille Calmette–Guérin (BCG) cannot be universally recommended for athletes at present. Only for a very few diseases, a determination of antibody titers is reasonable to avoid unnecessary vaccinations or to control efficacy of an individual’s vaccination (especially for measles, mumps, rubella, varicella, hepatitis B and, partly, hepatitis A). Vaccinations should be scheduled in a way that possible side effects are least likely to occur in periods of competition. Typically, vaccinations are well tolerated by elite athletes, and resulting antibody titers are not different from the general population. Side effects might be reduced by an optimal selection of vaccines and an appropriate technique of administration. Very few discipline-specific considerations apply to an athlete’s vaccination schedule mainly from the competition and training pattern as well as from the typical geographical distribution of competitive sites.

Rubella and pregnancy: diagnosis, management and outcomes

Rubella is a mild viral disease that typically occurs in childhood. Rubella infection during pregnancy causes congenital rubella syndrome, including the classic triad of cataracts, cardiac abnormalities and sensorineural deafness. Highly effective vaccines have been developed since 1969, and vaccination campaigns have been established in many countries. Although there has been progress, the prevention and diagnosis of rubella remain problematic. This article reviews the implications and management of rubella during pregnancy.

Increased emergency room visits or hospital admissions in females after 12-month MMR vaccination, but no difference after vaccinations given at a younger age

BACKGROUND

Previous studies have suggested that a child's sex may be a predictor of vaccine reactions.

METHODS

We used a self-controlled case series design, an extension of retrospective cohort methodology which controls for fixed confounders using a conditional Poisson modeling approach. We compared a risk period immediately following vaccination to a control period farther removed from vaccination in each child and estimated the relative incidence of emergency room visits and/or hospital admissions following the 2-, 4-, 6-, and 12-month vaccinations to investigate the effect of sex on relative incidence. All infants born in Ontario, Canada between April 1, 2002 and March 31, 2009 were eligible for study inclusion.

RESULTS

In analyses combining immunizations at 2, 4 and 6 months and examining these vaccinations separately, there was no significant relationship between the relative incidence of an event and sex of the child. At 12 months, we observed a significant effect of sex, with female sex being associated with a significantly higher relative incidence of events (P=0.0027). The relative incidence ratio (95% CI) comparing females to males following the 12-month vaccination was 1.08 (1.03 to 1.14), which translates to 192 excess events per 100,000 females vaccinated compared to the number of events that would have occurred in 100,000 males vaccinated.

CONCLUSIONS

As the MMR vaccine is given at 12 months of age in Ontario, our findings suggest that girls may have an increased reactogenicity to the MMR vaccine which may be indicative of general sex differences in the responses to the measles virus.

A guide to utilization of the microbiology laboratory for diagnosis of infectious diseases: 2013 recommendations by the Infectious Diseases Society of America (IDSA) and the American Society for Microbiology (ASM)(a)

The critical role of the microbiology laboratory in infectious disease diagnosis calls for a close, positive working relationship between the physician and the microbiologists who provide enormous value to the health care team. This document, developed by both laboratory and clinical experts, provides information on which tests are valuable and in which contexts, and on tests that add little or no value for diagnostic decisions. Sections are divided into anatomic systems, including Bloodstream Infections and Infections of the Cardiovascular System, Central Nervous System Infections, Ocular Infections, Soft Tissue Infections of the Head and Neck, Upper Respiratory Infections, Lower Respiratory Tract infections, Infections of the Gastrointestinal Tract, Intraabdominal Infections, Bone and Joint Infections, Urinary Tract Infections, Genital Infections, and Skin and Soft Tissue Infections; or into etiologic agent groups, including Tickborne Infections, Viral Syndromes, and Blood and Tissue Parasite Infections. Each section contains introductory concepts, a summary of key points, and detailed tables that list suspected agents; the most reliable tests to order; the samples (and volumes) to collect in order of preference; specimen transport devices, procedures, times, and temperatures; and detailed notes on specific issues regarding the test methods, such as when tests are likely to require a specialized laboratory or have prolonged turnaround times. There is redundancy among the tables and sections, as many agents and assay choices overlap. The document is intended to serve as a reference to guide physicians in choosing tests that will aid them to diagnose infectious diseases in their patients.

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.

Positive rates for rubella antibody in pregnant women and benefit of post-partum vaccination in a Japanese perinatal center

AIM

This study of pregnant women was undertaken to clarify their immune status for rubella and to evaluate the efficacy of, and adverse reaction to, post-partum rubella vaccination.

METHODS

We determined the levels of both rubella antibody by hemagglutination inhibition test and IgM antibody by enzyme-linked immunosorbent assay in the first gestational trimester and surveyed the positive rates for rubella antibody in pregnant women at our perinatal center; we recommended post-partum vaccination for women with poor immune status. We also evaluated the effectiveness of the vaccine and any adverse reaction.

RESULTS

Among 2741 pregnant women, 185 cases (6.7%) were seronegative for rubella virus. This rate was especially high (12.4%) in the population who had opted out of the vaccination because of a change in Japanese government policy. A total of 30 cases (1.1%) were positive or false-positive for IgM antibody, but no congenital rubella syndrome (CRS) developed. The seropositive rate was 93.3% in total, but this figure includes those who required post-partum vaccination (558 cases or 20.3%) because their titers were 16x or lower. Among 145 cases who received post-partum rubella vaccine, no severe adverse reaction was detected, and in all 37 cases with hemagglutination inhibition antibody titers of 8x or lower, the efficacy rate was 100%.

CONCLUSIONS

It is necessary to appropriately evaluate the CRS risk. Also, we need to emphasize the importance and safety of post-partum rubella vaccination in Japan.

Drug-Induced Musculoskeletal Disorders

Drug-induced musculoskeletal disorders represent a broad clinical spectrum, from asymptomatic biological abnormalities to severe and even life-threatening diseases. Since an increasing number of drugs have been implicated in inducing rheumatic symptoms and/or syndromes, this review is not meant to be exhaustive, bearing in mind that the development of any musculoskeletal disorder should be considered as possibly related to a medication. The purpose of this article is to provide an overview of the more frequent drug-induced musculoskeletal disorders. These include: (i) arthralgias and arthropathies, including chondropathies and inflammatory arthritis; (ii) connective tissue diseases, especially lupus-like syndromes; (iii) periarticular disorders, including tendinopathies, enthesopathies and frozen shoulder; (iii) bone diseases, such as osteoporosis, osteomalacia and osteonecrosis; and (iv) myopathies. Although virtually all drug classes may induce musculoskeletal disorders, a significant part of them are related to corticosteroids, vaccines, antibacterials and lipid-lowering agents. Knowledge of drug-induced musculoskeletal disorders avoids carrying out unnecessary investigations, and allows optimal management of the patients, i.e. early discontinuation of the offending agent, adequate treatment monitoring and/or intervention with appropriate preventive actions.

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.

Vaccination-related adverse events

Vaccine-related adverse events are uncommon and typically mild. Children may experience conditions such as rashes, fevers, syncope, protracted crying, or seizures shortly after receiving their routine immunizations. When children are brought to the emergency department or clinic to be evaluated for one of these conditions, the health care provider may be called upon to determine the likelihood that it was caused by a recently administered set of vaccines. This determination has substantial implications for medical care, including the safety of administering future vaccines. This article reviews the current understanding of vaccine-related adverse events. Using this information, clinicians should be able to identify those events likely to be related to vaccine administration and those that are not. The appropriate management of vaccine-related adverse events is also discussed.

Systematic review of the literature on postpartum care: selected contraception methods, postpartum Papanicolaou test, and rubella immunization

BACKGROUND

The postpartum period is a time when many routine interventions are provided to mothers. This review examined the published evidence for the effectiveness of selected contraceptive methods, Papanicolaou (Pap) tests, and rubella immunization.

METHODS

MEDLINE, Cinahl, PsycINFO, and the Cochrane Library were searched for randomized controlled trials of interventions initiated from immediately after birth to 1 year in postnatal women. The initial literature search was done in 1999, and was enhanced in 2003. Studies were categorized and reviewed by topic areas. Data were extracted in a systematic method, and the quality of each study was reviewed.

RESULTS

In the 1999 search, 140 studies were randomized controlled trials that met the selection criteria: 5 related to postpartum contraception, 1 to timing of the postpartum Pap test, and 2 to postpartum rubella immunization. In the 2003 searches, 1 additional study related to postpartum contraception was identified. From the published literature on selected contraceptive methods, the intrauterine devices examined were effective in preventing pregnancy and had comparable side effect profiles. No clear recommendation can be made because insertion timing was not randomized in the included trials. Although delaying the postpartum Pap smear until 8 weeks reduces the proportion of inflammatory smears, it is uncertain whether a Pap smear is of benefit to postpartum women. The RA 27/3 postpartum rubella vaccine appears to be more effective than the Cendehill vaccine, but a small proportion of women may develop acute and chronic joint manifestations.

CONCLUSIONS

Some evidence is available to support selected postpartum contraceptive methods and the postpartum rubella vaccine, but data are lacking on the effectiveness and optimal timing of the postpartum Pap smear.

Systematic review of the literature on postpartum care: methodology and literature search results

BACKGROUND

The postpartum period is a time for multiple clinical interventions. To date, no critical review of these interventions exists. This systematic review examined evidence for the effectiveness of postpartum interventions that have been reported in the literature.

METHODS

MEDLINE, Cinahl, PsycINFO, and the Cochrane Library were searched for randomized controlled trials of interventions initiated from immediately after birth to 1 year in postnatal women that were conducted in North America, Europe, Australia, or New Zealand. The initial literature search was done in 1999, using postpartum content search terms, and was enhanced in 2003. In both years, bibliographic databases were searched from their inception. Studies were categorized into key topic areas. Data extraction forms were developed and completed for each study, and the quality of each study was systematically reviewed. Groups of studies in a topic area were reviewed together, and clinically relevant questions emanating from the studies were identified to determine whether the studies, alone or together, provided evidence to support the clinical intervention.

RESULTS

In the 1999 search, of 671 studies identified, 140 studies were randomized controlled trials that met the selection criteria: 41 studies related to breastfeeding, 33 to postpartum perineal pain management, and 63 to 11 other key topic areas (Papanicolaou test, rubella immunization, contraception, postpartum support, early discharge, postpartum depression and anxiety, postpartum medical disorders, smoking cessation, nutrition supplements other than breastfeeding, effects of pelvic floor exercise, and effects of early newborn contact). The results of the systematic review of each topic will be summarized in separate papers as they are completed.

CONCLUSIONS

This systematic search has identified key topic areas in postpartum care for which randomized controlled trials have been conducted. Our ultimate goal is to provide evidence-based guidelines on the use of routine postpartum interventions.

Controversies in immunization practices: vaccine safety and implications for midwifery practice

Adverse events occur only rarely after vaccine exposure. Yet, given the high vaccine coverage rates in the United States, the public is increasingly becoming concerned that vaccines may be causing immediate or long-term health problems and less concerned about the possibility of becoming infected. More than 10,000 reports of possible vaccine-related adverse events are reported every year to VAERS, the passive surveillance system that monitors vaccine safety after licensure. As providers of primary health care services to women, midwives are ideally positioned to answer women's questions about vaccine safety. This article provides the background midwives need to be able to help their clients make informed vaccine decisions. It discusses the incidence and risks of infection, the efficacy and risks of vaccines, issues complicating the evaluation of vaccine safety, the state of vaccine safety monitoring systems, and approaches consumers use in vaccine decision making.

Rubella seropositivity in the United States, 1988-1994

Data obtained in the third National Health and Nutrition Examination Survey (NHANES III), conducted during 1988-1994, were analyzed to determine the epidemiology of rubella seropositivity in the United States, including risk factors for low rubella seropositivity. Serological samples obtained from NHANES III study participants > or =6 years of age were tested for rubella IgG antibodies. "Rubella seropositivity" was defined as serum rubella IgG antibody level > or =10 IU by enzyme immunoassay. Overall, rubella seropositivity rates in the United States were 92% in persons aged 6-11 years, 83% in persons aged 12-19 years, 85% in persons aged 20-29 years, 89% in persons aged 30-39 years, and >or =93% in persons aged > or =40 years. The lowest rate (78%) of any United States birth cohort of the 20th century occurred among persons born from 1970-1974. Eliminating rubella and chronic rubella syndrome in the United States will require international efforts, including vaccination of preschool- and school-age children and all susceptible young adults.

Drug-induced rheumatic disorders: incidence, prevention and management

The purpose of this article is to review the causes, the clinical manifestations and the management of the more frequent drug-induced rheumatic disorders. These include: (i) articular and periarticular manifestations induced by fluoroquinolones, nonsteroidal anti-inflammatory drugs, injections of corticosteroids, and retinoids; (ii) multisystemic manifestations such as drug-induced lupus and arthritis induced by vaccination, Bacillus Calmette-Guerin therapy and cytokines; (iii) drug-induced disorders of bone metabolism (corticosteroid-induced osteoporosis, drug-induced osteomalacia and osteonecrosis); and (iv) iatrogenic complex regional pain syndromes. Disorders caused by nonpharmacological and rarely used treatments have been deliberately excluded. Knowledge of these drug-induced clinical symptoms or syndromes allows an earlier diagnosis and treatment, and earlier drug withdrawal if necessary. With the introduction of new medications such as the recombinant cytokines and antiretroviral treatments, the number of drug-induced rheumatic disorders is likely to increase.

Safety of routine childhood vaccinations. An epidemiological review

Immunisations have been one of the most cost-effective public health interventions in human history. Despite remarkable progress, several challenges face immunisation programs worldwide. Paradoxically, despite vaccines' clear effectiveness in reducing risks of diseases that were previously widely prevalent and caused substantial morbidity and mortality, current vaccination policies have become increasingly controversial due to concerns about vaccine safety. Vaccines, like other pharmaceutical products, are not entirely risk-free. While most known adverse effects are minor and self-limited, some vaccines have been associated with very rare but serious adverse effects. Because such rare effects are often not evident until vaccines come into widespread use, ongoing surveillance programs to monitor vaccine safety are needed. Such monitoring will be essential if the public is to accept the increasing number of new vaccines made possible by biotechnology. The interpretation of data from vaccine safety research is complex and is associated with some uncertainty. Effectively communicating this uncertainty and continuing to improve understanding of rare risks and risk factors are essential for "mature" immunisation programs to maintain public confidence in immunisations.

Mapping of genetic determinants of rubella virus associated with growth in joint tissue

Rubella virus (RV) strains vary in their abilities to replicate and persist in cell cultures derived from human joint tissue (synovial cells [SC]), and this arthrotropism appears to be linked to their association with joint symptoms in vivo. In order to map the genetic determinants of arthrotropism, an infectious clone of the Cendehill vaccine strain of RV was constructed, as well as two chimeric clones containing cDNAs from both Cendehill and Therien (wild-type) strains. Replacement of the entire structural gene region of Therien in the infectious clone pROBO302 with the corresponding region of Cendehill did not affect growth in SC. A further observation that Cendehill bound equally well to SC and the permissive Vero cell line indicated that restriction was not at the level of receptor binding, a function of the envelope proteins. Mutations that affected growth in joint cells were mapped to two locations in the nonstructural gene region. The first of these (nucleotides 2803 and 6416) resulted in a 10-fold decrease in yield of progeny virus from SC. This region contained five mutations, at nucleotides 2829, 3060, 3164, and 3528 (near the carboxy terminus of P150 where the protease domain is located) and at nucleotide 4350 in p90. Further substitution of the sequence representing nucleotides 1 to 2803 to give a complete Cendehill infectious clone restricted growth in SC by a further 100-fold to less than 10 PFU/ml. This region contains three mutations, at nucleotides 34, 37, and 55, within the 5' stem-loop structure. In conclusion, the Cendehill-specific mutations believed to be determinants of joint cell growth are located in two regions, the 5' nontranslated region and in a sequence that encodes the carboxy-terminal region of p150 extending into the helicase domain of p90.

Viral arthritis

Identifying viral infections related to rheumatic syndromes and understanding the pathophysiologic mechanisms by which they cause disease are crucial steps to furthering our understanding of the pathogenesis of rheumatic disease. Many common viral infections can induce autoantibody formation. Parvovirus B19 (B19) can cause acute arthritis, and occasionally chronic arthropathy, in infected adults. Persistent B19 infection can be found in synovium of some patients. Antibodies reactive with B19 epitopes can cross react with some autoantigens. Studies of rheumatic syndromes associated with other viral infections, including alphaviruses, rubella, hepatitis C, and retroviruses, suggest differing mechanisms of host interaction with the infectious agents to cause disease.

Identification of rubella virus T-cell epitopes recognized in anamnestic response to RA27/3 vaccine: associations with boost in neutralizing antibody titer

Rubella virus (RV)-specific cell-mediated immunity (CMI) and antibodies were measured in healthy adolescents reimmunized with measles-mumps-rubella (MMR) vaccine. Lymphocyte proliferation to RV synthetic peptides was determined before and at 2, 4 and 10 weeks after, MMR. After MMR, increased CMI was observed with 16 peptides, including six containing antibody neutralization (NT) domains. Positive CMI (stimulation index > or =2.0) to E1(254-285) and C(1-29) before vaccination was significantly associated with a boost in NT titers, while positive CMI at weeks 2 or 4 to E1(254-285), E1(301-314), E1(389-408), E1(462-481), E2(134-150), E2(140-156), E2(168-179), C(1-29) and C(88-111) showed the same association.

Measles vaccines: a review of adverse events

A great deal of controversy has recently been generated over the publication of several articles implicating measles vaccine in the induction of Crohn's disease and autism. The publication of this work has already had a negative impact on measles vaccine acceptance in the UK. These allegations are particularly troubling because they arise in the context of increased use of measles vaccine as global control of measles nears and the international community considers strategies for a drive towards eradication. In 1994, the US Institute of Medicine reviewed the world literature and published a comprehensive review of adverse events associated with measles-containing vaccines. Reviewing the literature published between 1994 and the present day, reveals that there is considerable new data suggesting that modified gelatin rather than egg proteins is responsible for most episodes of anaphylaxis following measles vaccination. New work weakens the possible links between measles vaccine and subacute sclerosing panencephalitis and Guillain-Barré syndrome, but strengthens the rare association of measles-containing vaccines with post infectious encephalomyelitis. The alleged associations between measles vaccination and Crohn's disease and autism are based upon weak science and have largely been refuted by a large volume of stronger work. A review of the data generated in the last 4 years amply demonstrates the continued efforts of the scientific community to monitor and understand true measles vaccine-associated adverse events. The rapidity and clarity of this same community's debunking of the spurious associations with Crohn's disease and autism suggests that those charged with vaccination programmes have learned from past mistakes. During 30 years of worldwide use, measles vaccination has proven to be one of the safest and most successful health interventions in the history of mankind. It is not a 'perfect' vaccine, but the benefits of measles vaccination far outweigh the risks even in countries with low incidence of measles and high rates of measles vaccine coverage.

Rubella virus and chronic joint disease: is there an association?

Synovial fluid samples and/or biopsies from 79 patients with various chronic inflammatory joint diseases or traumatic joint injury were tested for rubella virus (RV) in order to confirm or refute results from other studies that suggested RV as a cause of chronic inflammatory joint disease. Sixty-eight of the 72 patients tested had RV antibodies. RV RNA was detected by reverse transcription-PCR in the synovial fluid cells from two patients. RV was also isolated by cell culture from the synovial fluid of one of these two patients. This patient was a 42-year-old female with common variable immune deficiency and Mycoplasma hominis arthritis, while the other was a 68-year-old female with rheumatoid arthritis. While these results fail to confirm that RV is associated with chronic inflammatory joint disease, they suggest that RV may persist within a joint and be reactivated when cell-mediated immunity is suppressed.

Characterization of an overlapping CD8+ and CD4+ T-cell epitope on rubella capsid protein

A synthetic peptide corresponding to rubella virus capsid protein residues 263 to 275 which contains an epitope recognized by a cloned CD4+ cytotoxic T-lymphocyte (CTL) line was used to induce CD8+ T-cell lines specific to this peptide. A peptide-specific CD8+ CTL clone was derived and characterized. This peptide-specific CD8+ CTL clone exhibited cytotoxicity against target cells infected by a vaccinia recombinant virus expressing rubella virus capsid protein, but not by target cells infected by vaccinia recombinant virus expressing rubella virus E1 or E2 envelope proteins. Analysis of HLA class I restriction of the CD8+ CTL clone revealed that A11 and A3 were restrictive elements. Fine mapping with truncated and overlapping peptide analogs revealed a nonamer sequence, C(264-272), as the T-cell epitope eliciting stronger cytotoxicity. Two anchor residues for binding to HLA A11 and A3 were identified at position 2 (isoleucine) and at position 9 (histidine) or at position 8 (arginine) of the epitope sequence. The identification of overlapping CD4+ and CD8+ T-cell epitopes within the capsid protein sequence C(263-275) implicates a strategy for using such epitopes in a candidate peptide-based rubella vaccine.