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Rubella vaccine
EDITOR'S COLUMN
Rubella vacc&e
IN MAN'S attempt at prevention of viral diseases, vaccine has stood out among the most effective and practical means for interruption of the host-pathogen relationship. This method has been especially satisfactory if the vaccine mimicked the pathogenic infection itself in all respects, save production of the disease. Live virus vaccines against yellow fever, poliomyelitis, and measles are excellent examples of just such an accomplishment. It is not surprising, therefore, that appearance of these vaccines had been hailed by the health authorities and lay people alike. Isolation of rubella virus provided basis for the selection of an attenuated strain of the virus that could serve as vaccine; the 1964 epidemic created the right emotional climate for the development of such a vaccine. By 1970 several virus strains were introduced with claims that they could serve as vaccines. As had happened in the case of polio vaccine, this was followed by active controversy and lively debate. However, there was an important difference. Whereas the community, aware of the ravages of poliomyelitis, had been ready to accept the vaccine, the lay constituency in 1970 was not especially receptive to the vaccine against rubella. This could be attributed to the relatively benign nature of the disease and the fact that the 1964 epidemic, with the large numbers of deformed infants in its wake, was largely forgotten. Therefore community acceptance of the vaccine had to be created by intense propaganda and administration of the vaccine itself had to be assured by legislation. Moreover, unlike poliovirus and yellow fever vaccines, which were essentially free of side effects, or measles vaccine, of which side effects were limited to transient fever, rubella vaccine-induced arthralgia or even arthritis developed in some recepients. 1, 2 In addition, again unlike the other live virus vaccines, which were designed to protect the vaccinated individual against the consequences of a serious infection, the intent of rubella vaccine administered to children was to prevent disease in third parties once r e m o v e d - - t h e as yet unborn human fetuses. In devising a program of vaccination against rubella, society demanded, and indeed enforced, personal sacrifice of each individual for the benefit of o t h e r s - - a concept in some disagreement with the Helsinki Convention.
None of these arguments against rubella vaccine would bear great weight, if its effectiveness in mass vaccination programs were not in question. It is true that recipients of the available vaccines develop circulating rubella antibodies but, in parallel with those who are immune after natural infection, they are not fully protected against reinfection. 3,4 Although there is no clear-cut evidence that reinfected women can transmit rubella virus to the embryo, the probability that this may be so has been suggested, s' 6 We must therefore face the issue that the available rubella vaccines as currently administered to one segm e n t of the population for the protection of another in fact are only partly effective.
See related article, p. 474. Elsewhere in this issue Rachelefsky and Herrmann argue t h a t a c o m m u n i t y - w i d e rubella v a c c i n a t i o n program in Casper, Wyo., "probably reduced the occurrence of fetal infection and congenital malformations." If one assumes that the risk of development of congenital rubella in individual infants born to mothers who were infected during pregnancy is determined by factors unrelated to the total number of pregnant women inf e c t e d - s u r e l y a valid a s s u m p t i o n - - t h e n a mere reduction in half of rubella infection in pregnant women is less than one has a right to expect of a vaccine. If one takes into account the possibility of rubella embryopathy in infants of reinfected preimmune women, the complication of arthritis, and the unique demand for "third party protection," then one may reasonably question the appropriateness of the currently recommended rubella vaccination program. It would be far better to concentrate our efforts on the development of a vaccine that would prevent the disease and reinfection and direct it against nonimmune, prepubertal women and nonimmune women in the immediate postpartum period. A claim has been made that the R A 27/3 rubella vaccine, not yet licensed in this country, but now available abroad, does in fact prevent reinfection. If this claim is valid, then efforts to introduce the use of this or a similar vaccine should be made. The moral issue whether all
Vol. 84, No. 4, PP. 615-616
616
Editor's column
children should be vaccinated, or only the n o n i m m u n e w o m e n at risk, remains unanswered. H o w e v e r , it would be easier to argue for the universal administration of the vaccine if its effectiveness and safety could be assured. Michael Katz, M.D. Professor of Tropical Medicine and of Pediatrics Columbia University College of Physicians ~ Surgeons 630 14/. 168 St. New York, N.Y. 10032 REFERENCES 1. Cooper, L. Z., Ziring, P. R., Weiss, H. J., et al.: Transient arthritis after rubella vaccination, Am. J. Dis. Child. 118: 218, 1969.
The Journal of Pediatrics April 1974
2.
Deinard, A. S., Hoban, T. W., and Venters, H. D.: Clinical reactions in children after rubella vaccination, Health Serv. Rep. 88: 459, 1973. 3. Horstmann, D. M., Pajot, T. G., and Liebhaber, H.: Epidemiology of rubella; subclinical infection and occurrence of reinfection, Am. J. Dis. Child. 118: 133, 1969. 4. Chang, T. W., DeRossier, S., and Weinstein, L.: Booster immunization against rubella in adult women, Arch. Intern. Med. 131: 530, 1973. 5. Elland, T.: Rubella reinfection in pregnancy followed by transmission to the fetus, Abst. 97, 13th Interscience Conference on Antimicrobial Agents and Chemotherapy, 1971. 6. Northrop, R. L., Gardner, W. M., and Geittmann, W. F.: Rubella reinfection during early pregnancy, Obstet, Gynecol. 33: 524, 1972.
Rubella vacc&e
IN MAN'S attempt at prevention of viral diseases, vaccine has stood out among the most effective and practical means for interruption of the host-pathogen relationship. This method has been especially satisfactory if the vaccine mimicked the pathogenic infection itself in all respects, save production of the disease. Live virus vaccines against yellow fever, poliomyelitis, and measles are excellent examples of just such an accomplishment. It is not surprising, therefore, that appearance of these vaccines had been hailed by the health authorities and lay people alike. Isolation of rubella virus provided basis for the selection of an attenuated strain of the virus that could serve as vaccine; the 1964 epidemic created the right emotional climate for the development of such a vaccine. By 1970 several virus strains were introduced with claims that they could serve as vaccines. As had happened in the case of polio vaccine, this was followed by active controversy and lively debate. However, there was an important difference. Whereas the community, aware of the ravages of poliomyelitis, had been ready to accept the vaccine, the lay constituency in 1970 was not especially receptive to the vaccine against rubella. This could be attributed to the relatively benign nature of the disease and the fact that the 1964 epidemic, with the large numbers of deformed infants in its wake, was largely forgotten. Therefore community acceptance of the vaccine had to be created by intense propaganda and administration of the vaccine itself had to be assured by legislation. Moreover, unlike poliovirus and yellow fever vaccines, which were essentially free of side effects, or measles vaccine, of which side effects were limited to transient fever, rubella vaccine-induced arthralgia or even arthritis developed in some recepients. 1, 2 In addition, again unlike the other live virus vaccines, which were designed to protect the vaccinated individual against the consequences of a serious infection, the intent of rubella vaccine administered to children was to prevent disease in third parties once r e m o v e d - - t h e as yet unborn human fetuses. In devising a program of vaccination against rubella, society demanded, and indeed enforced, personal sacrifice of each individual for the benefit of o t h e r s - - a concept in some disagreement with the Helsinki Convention.
None of these arguments against rubella vaccine would bear great weight, if its effectiveness in mass vaccination programs were not in question. It is true that recipients of the available vaccines develop circulating rubella antibodies but, in parallel with those who are immune after natural infection, they are not fully protected against reinfection. 3,4 Although there is no clear-cut evidence that reinfected women can transmit rubella virus to the embryo, the probability that this may be so has been suggested, s' 6 We must therefore face the issue that the available rubella vaccines as currently administered to one segm e n t of the population for the protection of another in fact are only partly effective.
See related article, p. 474. Elsewhere in this issue Rachelefsky and Herrmann argue t h a t a c o m m u n i t y - w i d e rubella v a c c i n a t i o n program in Casper, Wyo., "probably reduced the occurrence of fetal infection and congenital malformations." If one assumes that the risk of development of congenital rubella in individual infants born to mothers who were infected during pregnancy is determined by factors unrelated to the total number of pregnant women inf e c t e d - s u r e l y a valid a s s u m p t i o n - - t h e n a mere reduction in half of rubella infection in pregnant women is less than one has a right to expect of a vaccine. If one takes into account the possibility of rubella embryopathy in infants of reinfected preimmune women, the complication of arthritis, and the unique demand for "third party protection," then one may reasonably question the appropriateness of the currently recommended rubella vaccination program. It would be far better to concentrate our efforts on the development of a vaccine that would prevent the disease and reinfection and direct it against nonimmune, prepubertal women and nonimmune women in the immediate postpartum period. A claim has been made that the R A 27/3 rubella vaccine, not yet licensed in this country, but now available abroad, does in fact prevent reinfection. If this claim is valid, then efforts to introduce the use of this or a similar vaccine should be made. The moral issue whether all
Vol. 84, No. 4, PP. 615-616
616
Editor's column
children should be vaccinated, or only the n o n i m m u n e w o m e n at risk, remains unanswered. H o w e v e r , it would be easier to argue for the universal administration of the vaccine if its effectiveness and safety could be assured. Michael Katz, M.D. Professor of Tropical Medicine and of Pediatrics Columbia University College of Physicians ~ Surgeons 630 14/. 168 St. New York, N.Y. 10032 REFERENCES 1. Cooper, L. Z., Ziring, P. R., Weiss, H. J., et al.: Transient arthritis after rubella vaccination, Am. J. Dis. Child. 118: 218, 1969.
The Journal of Pediatrics April 1974
2.
Deinard, A. S., Hoban, T. W., and Venters, H. D.: Clinical reactions in children after rubella vaccination, Health Serv. Rep. 88: 459, 1973. 3. Horstmann, D. M., Pajot, T. G., and Liebhaber, H.: Epidemiology of rubella; subclinical infection and occurrence of reinfection, Am. J. Dis. Child. 118: 133, 1969. 4. Chang, T. W., DeRossier, S., and Weinstein, L.: Booster immunization against rubella in adult women, Arch. Intern. Med. 131: 530, 1973. 5. Elland, T.: Rubella reinfection in pregnancy followed by transmission to the fetus, Abst. 97, 13th Interscience Conference on Antimicrobial Agents and Chemotherapy, 1971. 6. Northrop, R. L., Gardner, W. M., and Geittmann, W. F.: Rubella reinfection during early pregnancy, Obstet, Gynecol. 33: 524, 1972.