Meningitis aguda posterior a vacuna tresvírica / Acute meningitis following mumps vaccine

Resumen En Chile, la cepa del virus parotídeo utilizada en la vacuna es Leningrad-Zagreb (L-Z). Aunque la relación entre meningitis y la cepa L-Z sigue siendo controvertida, la mayoría de los casos reportados han presentado un cuadro de curso benigno y sin secuelas neurológicas. Presentamos el caso de una paciente que tres semanas post-inmunización con la vacuna tresvírica evolucionó con una meningitis aséptica de predominio mononuclear, con serología para IgM positiva contra el virus parotídeo. En este caso clínico, existió una relación temporal entre la vacunación, el inicio del cuadro parotídeo y posteriormente el meníngeo; la curva de inmunoglobulinas demostró una infección aguda posterior a la vacuna. Si bien no se logró aislar el virus en LCR, es razonable atribuir el cuadro a una infección post-vacunal.

In Chile, the strain of the mumps virus used in the vaccine is Leningrad-Zagreb (L-Z). Although the relationship between meningitis and the L-Z strain remains controversial, most of the reported cases have shown a benign course without permanent neurological sequelae. We present a case of a patient who presented an aseptic meningitis three weeks after immunization with a mumps vaccine; and laboratory confirmation showed positive serum mumps IgM antibody. In this clinical case, there was a temporal relationship between vaccination and the onset of the mumps and subsequently the meningeal involvement; the immunoglobulin curve demonstrates acute infection after vaccination. Although it was not possible to isolate the virus in CSF, it is reasonable to attribute the picture to a post-vaccinal infection.

[Acute meningitis following mumps vaccine]. / Meningitis aguda posterior a vacuna tresvírica.

In Chile, the strain of the mumps virus used in the vaccine is Leningrad-Zagreb (L-Z). Although the relationship between meningitis and the L-Z strain remains controversial, most of the reported cases have shown a benign course without permanent neurological sequelae. We present a case of a patient who presented an aseptic meningitis three weeks after immunization with a mumps vaccine; and laboratory confirmation showed positive serum mumps IgM antibody. In this clinical case, there was a temporal relationship between vaccination and the onset of the mumps and subsequently the meningeal involvement; the immunoglobulin curve demonstrates acute infection after vaccination. Although it was not possible to isolate the virus in CSF, it is reasonable to attribute the picture to a post-vaccinal infection.

No definitive evidence for L-Zagreb mumps strain associated aseptic meningitis: a review with special reference to the da Cunha study.

The study by da Cunha et al. published in 2002 reported that MMR vaccine containing L-Zagreb mumps strain manufactured by Serum Institute of India Ltd. caused a high incidence of aseptic meningitis (AM) from routine surveillance during two mass immunization campaigns (MIC) conducted in 1998 in two states in Brazil. Since the results were contrary to those in India, Egypt and Bahamas, a critical analysis of the study was done. Several inconsistencies were found in the study, which undermined the conclusions drawn. Two similar studies from Brazil reported similar results. Review of these studies and those done on the vaccine from Zagreb, Croatia showed that in no study the L-Zagreb mumps virus has been isolated from cerebrospinal fluid (CSF) of an AM case. Isolation of the vaccine virus is necessary for definite causal association of AM with the vaccine. There is no such evidence to causally link MMR vaccine containing L-Zagreb mumps strain with AM.

Frequency of lymphocytic meningitis associated with mumps before and after a mass campaign for mumps vaccination in children from Salvador, Northeast Brazil.

OBJECTIVE: To describe the frequency of lymphocytic meningitis(LM) concomitant with mumps, before and after the mumps mass immunization campaign in 1997. METHOD: Demographic, clinical and cerebrospinal fluid(CSF) information was collected from the chart of all patients aged from 2 to 59 months, whose CSF exam was performed at the CSF Lab/FJS, between 1989 and 2001. LM was defined as pleocytosis composed by lymphomononuclear cells and negative exams for bacterial or mycologic infection. RESULTS: Of 1,519 patients, 894(58.9%) had normal exams. LM was present in 301(19.8%) patients, out of which 22(7.3%) had concomitant mumps. The frequency of LM ranged from 15.8% in 1989 to 19.7% in 2001 and of LM with concomitant Mumps ranged from 10.5% in 1989 to 4.7% in 1995, when the last cases were registered. CONCLUSION: It is probable that the mumps vaccine campaign has influenced the absence of LM with concomitant Mumps, from 1996 to 2001.

The risk of aseptic meningitis associated with the Leningrad-Zagreb mumps vaccine strain following mass vaccination with measles-mumps-rubella vaccine, Rio Grande do Sul, Brazil, 1997.

BACKGROUND: Few data are available on the risk of aseptic meningitis following vaccination with the Leningrad-Zagreb (L-Z) strain of mumps vaccine. In 1997 the mumps vaccine was introduced into the state of Rio Grande do Sul in Brazil through mass vaccination with mumps-measles-rubella (MMR), targeting children aged 1-11 years. Five municipalities used exclusively MMR vaccine containing the L-Z strain of mumps. An outbreak of aseptic meningitis was observed shortly after the mass campaign. METHODS: To estimate the risk of aseptic meningitis associated with this strain, we analysed vaccination and meningitis case surveillance data from the selected municipalities. A case of vaccine-associated aseptic meningitis was defined as one with a pleocytosis of 10-1,500 leukocytes/ml and occurring within 15-35 days after vaccine receipt. RESULTS: We estimated a risk of 2.9 cases per 10,000 doses of L-Z administered, equivalent to 1 case per 3,390 doses administered. The overall risk of aseptic meningitis following the campaign was increased 12.2-fold (95% CI: 6.0-24.7) compared with the same period in 1995-1996. Following the mass campaign, the incidence of mumps declined 93% during 1998-2000. CONCLUSIONS: Vaccination with the L-Z strain of mumps vaccine as part of a mass campaign was associated with a significantly increased risk of aseptic meningitis. Decisions about type of mumps vaccine and mumps vaccination strategies must consider vaccine safety issues in addition to other criteria.

Tipos de vacunas pediátricas / Types of pediatric vaccines

La autora describe las vacunas pediátricas de uso obligatorio en nuestro país en la actualidad. Se menciona su acción, vía de administración, efectos adversos y contraindicaciones (AU)

Immunization still saves lives

Under the immunization regulations, parents and guardians have equal responsibility to take their children for vaccination "within one year of child's birth or soon after". (AU)

Lidocaine-prilocaine patch decreases the pain associated with the subcutaneous administration of measles-mumps-rubella vaccine but does not adversely affect the antibody response.

BACKGROUND: Topical lidocaine 2.5% and prilocaine 2.5% (EMLA) is effective in decreasing the pain associated with minor procedures including immunization, although the effect on the antibody response to vaccine constituents has not been assessed. OBJECTIVE: To measure the antibody response to measles-mumps-rubella (MMR) vaccine, as well as pain reduction associated with the use of the EMLA patch. PARTICIPANTS AND SETTING: One hundred sixty healthy infants at least 12 months old undergoing their first MM immunization in an ambulatory setting. DESIGN AND INTERVENTIONS: Randomized, double-blind, controlled trial of EMLA patch (5%-1 g) or placebo before MMR immunization. Blood sampling before and 28 to 35 days after immunization. OUTCOME MEASURES: The primary outcome measure was the antibody response to measles by plaque reduction neutralization and to mumps and rubella by enzyme immunoassay. The secondary outcomes were pain scores by the Modified Behavioral Pain Scale and drug- and vaccine-associated adverse events. RESULTS: There was no difference in the antibody response between the EMLA- and placebo-treated groups. The response rates in the EMLA group were 89.7%, 88.3%, and 92.3% to measles, mumps, and rubella, respectively, compared with rates of 91.1%, 94.9%, and 93.7% in the placebo group (P >.05 for all comparisons). EMLA recipients had less pain after immunization (mean Modified Behavioral Pain Scale score increase 3.1 compared with 3.8; P =.043) and less irritability (16% compared with 31%; P =.040) than did placebo recipients. CONCLUSIONS: The EMLA patch has no adverse effect on the antibody response to MMR vaccine and significantly reduces the pain associated with the subcutaneous administration of the vaccine.

Outbreak of aseptic meningitis associated with mass vaccination with a urabe-containing measles-mumps-rubella vaccine: implications for immunization programs.

A mass immunization campaign with a Urabe-containing measles-mumps-rubella vaccine was carried out in 1997 in the city of Salvador, northeastern Brazil, with a target population of children aged 1-11 years. There was an outbreak of aseptic meningitis following the mass campaign. Cases of aseptic meningitis were ascertained through data collected from the records of children admitted to the local referral hospital for infectious diseases between March and October of 1997, using previously defined eligibility criteria. Vaccination histories were obtained through home visits or telephone calls. Eighty-seven cases fulfilled the study criteria. Of those, 58 cases were diagnosed after the vaccination campaign. An elevated risk of aseptic meningitis was observed 3 weeks after Brazil's national vaccination day compared with the risk in the prevaccination period (relative risk = 14.3; 95% confidence interval: 7.9, 25.7). This result was confirmed by a case series analysis (relative risk = 30.4; 95% confidence interval: 11.5, 80.8). The estimated risk of aseptic meningitis was 1 in 14,000 doses. This study confirms a link between measles-mumps-rubella vaccination and aseptic meningitis. The authors discuss the implications of this for the organization and planning of mass immunization campaigns.

Reaçöes adversas a vacina MMR em pacientes alergicos a ovo: revisao da literatura / Adverse reactions to MMR vaccine in patients with egg allergy: review

Reacoes adversas agudas apos a administracao da vacina MMR podem ocorrer em pacientes com hipersensibilidade a ovo. Essas reacoes podem decorrer da presenca de proteinas originadas do tecido embrionario da galinha, incluindo substancias antigenicamente similares ao ovo. Os autores deste relato discutem o risco da administracao da vacina MMR em criancas alergicas a ovo, concluindo que se trata de...

Seroconversion of a trivalent measles, mumps, and rubella vaccine in children aged 9 and 15 months.

The serological response to MMR vaccine was evaluated in 109 9-month-old infants having no history of measles vaccination, and in 98 15-month-old children who had received monocomponent measles immunisation at 9 months. The combined vaccine contained Schwarz, Urabe Am9, and Wistar RA 27/3 live attenuated virus strains. Preimmunisation antibody levels were extremely low for the 9-month-old children, indicating that maternally-transmitted antibodies do not persist at this age. In the case of mumps, preimmunisation antibody levels were significantly higher in the 15-month-old than in the 9-month-old group. A difference between groups in terms of postimmunisation antibody titres was observed only for rubella, with titres being significantly higher in the older group. Seroconversion rates were high in both groups and no serious events attributable to vaccination were observed. The MMR vaccine can thus be administered to children as young as 9 months of age. Evidence for the efficacy of a two-dose schedule, i.e. at 9 and 15 months, is presented.

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

OBJECTIVE: To compare the safety and immunogenicity of Lederle Laboratories' (Pearl River, NY) diphtheria and tetanus toxoids and acellular pertussis (DTaP) vaccine with diphtheria and tetanus toxoids and whole-cell pertussis (DTwP) vaccine when administered simultaneously with measles-mumps-rubella (MMR) vaccine and trivalent oral poliovirus (OPV) vaccine at 15 to 16 months of age. DESIGN: Randomized and double-blind. SETTING: Two general pediatric practices. PARTICIPANTS: Ninety-seven infants, aged 15 to 16 months, who had received three previous DTwP immunizations. SELECTION PROCEDURES AND INTERVENTIONS: Healthy children received the DTaP or DTwP vaccine. Infants received the MMR vaccine at a separate site and the OPV vaccine concurrently. Blood was obtained on day 0 and at 6 weeks. Adverse events were recorded by parents at specified times after immunization. MEASUREMENTS/RESULTS: Within 3 days of immunization, DTaP vaccine recipients had less fever, drowsiness, and irritability (P = .01, .04, .01, respectively). They also experienced less tenderness, erythema, and induration (.001, .001, and .002, respectively). There was no difference in the frequency of adverse reactions 6 to 14 days after immunization. Enzyme-linked immunosorbent assays were used to determine all antibody values. Antibody responses to filamentous hemagglutinin and pertussis toxoid were significantly greater in the DTaP group (P = .0001 and .02, respectively). Immune responses to the other measured antigens were similar. CONCLUSIONS: Simultaneous administration of the Lederle DTaP with MMR and OPV vaccines did not interfere with antibody response to pertussis antigens measured or measles, mumps, or rubella viruses and was associated with fewer local and systemic adverse events during the first 3 days following immunization when compared with the simultaneous administration of the DTwP, OPV, and MMR vaccines. We conclude that the DTaP vaccine can be administered at 15 months of age concurrently with the MMR and OPV vaccines.

Egg hypersensitivity and adverse reactions to measles, mumps, and rubella vaccine.

We evaluated the safety of the measles-mumps-rubella (MMR) combination vaccine in 140 children with egg hypersensitivity. All children, regardless of vaccine skin test results or severity of egg hypersensitivity, were safely immunized with the MMR vaccine. Systemic reactions to MMR vaccine in two nonallergic children were documented, indicating that reactions unrelated to egg protein can occur. With the use of a competitive enzyme-linked immunosorbent assay, the standard MMR injection was found to contain approximately 37 pg of ovalbumin-like material. This study provides 95% confidence that at least 97.5% of egg-allergic children will tolerate MMR vaccine without significant difficulty. Skin testing was not found to be helpful in predicting an adverse reaction. We recommend that the American Academy of Pediatrics consider revising its current policy regarding skin test response to MMR vaccine and administration of MMR vaccine to egg-allergic children.