Inoculation from measles, mumps and rubella

Measles, mumps and rubella - these 3 infections have both a similar epidemiology in many respects and the characteristics of vaccines that allow them to be combined, which justifies their joint presentation.

[1], [2], [3], [4]

Program for the elimination of measles

Under the elimination of measles is understood the achievement of such a state, when there is no transmission of infection and there is no secondary distribution from the imported case. The strategy for the first stage of measles elimination was to reduce the proportion of measles susceptible people to low levels by 2005 and maintain this level until 2007. In Russia, coverage with the first dose exceeded 95% in 2000, and the second - only in 2003. In 2005, only 454 cases of measles were registered (0.3 per 100 000 population); of 327 foci of measles 282 were not spread, and in 45 foci with the spread, there were 172 cases. In 2006, there was an increase in the incidence (1018 cases - 0.71 per 100,000). In 2007 - its decline (163 cases - 0.11 per 100 000, of which only 33 in children). At the second stage, WHO / Europe expects that "by 2010 or earlier, the incidence of measles in the region should not exceed 1 case per million population".

The importance of full vaccination coverage in maintaining the elimination status is evident from the experience of the United States, where in 2008 there were 131 cases of measles (at the end of July), of which only 8 were from non-residents. Of the 95 patients who were not vaccinated after 1 year, 63 were not vaccinated for "philosophical" or religious reasons - more often in states with more liberal approaches to immunization withdrawals. Preservation of a susceptible to infection layer among the adult population justifies the introduction of a "cleanup" in the Russian Calendar - vaccination of all persons under 35 years who received less than 2 vaccinations.

Now the role of laboratory verification of suspected measles cases is increasing, the organization of a serological examination of patients with all exanthemic diseases (the expected number of such cases is 2 per 100,000 population) and monitoring of antiepidemic measures in the outbreaks.

Genotyping of "wild" strains of measles virus showed that in Russia, measles type D viruses mainly circulate : Turkish (detected in Kazakhstan, Uzbekistan) and Ukrainian subtypes (found in Belarus and Azerbaijan). In the Far East, there are cases caused by the Chinese type of H1 virus. In Europe, morbidity declines, but there are still many cases in a number of CIS countries (except Belarus).

Parotitis

This considered easy infection can cause meningitis, pancreatitis, orchitis; it is believed that it is due to 1/4 of all cases of male infertility.

In Russia, due to the intensification of vaccination efforts, the incidence of mumps in recent years has declined from 98.9 per 100,000 children in 1998 to 14 in 2001> 2.12 in 2005 and 1, 31 in 2007. As in for measles, a significant proportion of all cases of mumps occur in persons over the age of 15 (39% in 2007), indicating that a significant pool of susceptible individuals who received fewer than 2 vaccinations remains. To overcome the shift in the incidence rate for adolescence (with a more severe course of infection), it is important to vaccinate all children and adolescents under 15 who are vaccinated less than 2 times. It is logical to "clean" the measles of people under 35 years of age to use divaxin mumps-mumps, since not vaccinated against measles, most likely, were not vaccinated against mumps. This would achieve the goal of WHO - to reduce the incidence of mumps by 2010 or earlier to a level of 1 or less per 100 000 population. Elimination of mumps was achieved in Finland in 1999, where twice vaccination with trivaccine was conducted since 1983. This allowed to prevent up to a thousand cases of meningitis and orchitis every year, while the incidence of children of 5-9 years of type 1 diabetes ceased to increase, which can also be associated with vaccination .

Intensification of the fight against rubella

Rubella in children is usually easy, but it is the leading cause of encephalitis. The contagiousness of rubella is lower than that of measles, but the patient with rubella secretes the virus within 7 days before and 7-10 days after the onset of the rash, as well as in asymptomatic rubella (25-50% of the total number of patients), which determines the difficulty of controlling it . Children with congenital rubella can secrete the virus for up to 1-2 years. Outbreaks of rubella occur with a share of susceptible persons in the population> 15%.

Syndrome of congenital rubella - CRS - occurs with the disease in the first trimester of pregnancy: in this case, about 3/4 of the children are born with congenital heart defects, central nervous system, sensory organs. The scale of the problem is evidenced by US figures: in 1960-1964. More than 50 000 pregnant women (half of them asymptomatic), more than 10 000 of them had miscarriages and stillbirths, more than 20 000 children with congenital rubella were born; in 2000, due to vaccination, there were only 4 cases of congenital rubella, 3 of them in non-vaccinated immigrants. In Russia, the accuracy of congenital rubella counts is low (in 2003 there were only 3 cases of congenital rubella), but according to data from a number of regions the incidence of congenital rubella syndrome is 3.5 per 1000 live births (at 16.5% of susceptible pregnant women), accounting for 15% of all congenital malformations, rubella accounts for 27-35% of intrauterine pathology.

The WHO Regional Committee for Europe in 1998 adopted as one of the objectives: "by 2010 or earlier the incidence of rubella in the region should not exceed 1 case per 1 million population".

In Russia, which began mass vaccination only in 2002-2003, a very high incidence of rubella (450,000 - 575,000 cases per year) began to decline: in 2005, there were 144,745 cases of rubella (100.12 per 100,000 population), in 2006 - 133 204 (92.62), in 2007 - 30 934 (21.61). Studies carried out in recent years have shown that only 50-65% of girls aged 12-15 have antibodies to rubella, which raises the question of the need for active prophylaxis. Especially great is the risk of illness for medical workers, medical students, employees of preschool institutions, teachers.

Elimination of rubella with the help of double vaccination MMR® II was achieved in 1999 in Finland, which prevented up to 50 cases of ICS annually. At the same time, the incidence of children with encephalitis decreased by one third.

In the new Russian Calendar, in addition to 2-fold vaccination, there is a "clean-up" - vaccination of all those who are not vaccinated (and who have only one inoculation) with children and adolescents under the age of 18 who are not infected with rubella, and women aged 18-25 years, which will sharply reduce the incidence of rubella and to eliminate congenital rubella. Only those who have serological confirmation of the diagnosis should be referred to rubella-sick people, since the term "rubella" often refers to various diseases.

Measles, mumps and rubella vaccines registered in Russia

Vaccines	The composition of vaccines is 1 dose
HCV - live measles vaccine, - Microgen, Russia	> 1000 TCD50 of the virus strain L16. Contains gentamycin sulfate (up to 10 U / dose) and traces of bovine serum.
Rueaks - measles, sanofi pasteur, France	1000 TCID50 attenuated measles virus.
HPV - parotitic Microgen Russia	> 20,000 TCD50 of strain L-3 virus, up to 25 μg gentamycin per sulphate and traces of bovine serum
Krasnushnaya - Institute of Immunology, INC, Croatia	> 1 000 TCID50 virus strain Wistar RA 27/3, not more than 0.25 μg neomycin sulfate.
Rubella, Serum Institut, India	> 1 000 TCID50 of the virus strain RA Wistar 27/3.
Rudivax - rubella sanofi pasteur, France	> 1 000 TCID50 of the strain Wistar RA 27 / 3M (author's strain of SA Plotkin), traces of neomycin
Diverticum parotitno-measles live dry, Microgen, Russia	20,000 TCD50 of L-3 virus and 1,000 TCD50 of L-16 virus, gentamycin sulfate up to 25 μg, traces of bovine serum
Root, parotitic, rubella - Serum Institut, India	1000 TSID50 viruses of the strain Edmonton-Zagreb and rubella strain Wistar RA 27/3, and 5000 TSSH 5 on mumps of the strain Leningrad-Zagreb.
M-M-R® P - measles, mumps, rubella - Merck, Sharpe, Dome, USA	> 10 TCID50 measles virus strain of Edmonston and rubella strain Wistar RA 27/3, as well as 2-2 10 TCID50 mumps virus strain Jeryl Lynn
Priority - measles, mumps, rubella GlaxoSmithKline, Belgium	> 10 TCID50 measles virus strain Schwarz, rubella strain Wistar RA 27/3, as well as 10 3 ' 7 TCID50 mumps strain RJT 43/85 (derived from Jeryl Lynn), up to 25 μg neomycin sulfate.

Characteristics of vaccines

Lyophilized live attenuated vaccines, including combined ones, are used to actively prevent measles, mumps and rubella. Domestic measles and mumps vaccine strains are cultivated on fibroblasts of Japanese quail embryos, foreign chicken embryos, and rubella on diploid cells. Vaccines are released with the applied solvent (1 dose of 0.5 ml), they are stored at a temperature of 2-8 ° or in a freezer, the solvent is stored at a temperature of 2-25 °, freezing of the solvent is not allowed.

Human immunoglobulin is used for passive measles prevention. It does not contain HBsAg, as well as antibodies to HIV and HCV.

[5], [6], [7], [8],

Timing and methods of administering vaccines against measles, mumps and rubella

All vaccines are injected in the volume of 0.5 ml subcutaneously under the scapula or in the outer region of the shoulder, monovacins are administered simultaneously in different parts of the body; the use of di- and trivaxin reduces the number of injections. Since vaccine viruses are inactivated by ether, alcohol and detergents, it is necessary to prevent the drug from contacting these substances, allowing them to dry before injection.

Vaccination against measles in 116 countries with high incidence occurs at the age of 9 and even 6 months. In order to protect infants in whom it is particularly difficult. In many children immunity may not develop due to neutralization of the vaccine virus with maternal antibodies, so the children are re-vaccinated in the second year.

Since the 2nd vaccination against these infections, strictly speaking, is not a revaccination, but aims to protect children who did not give seroconversion after the 1st vaccination, in principle, the interval between 2 vaccinations can be any more than 1 month. Although, of course, at these times there is a high probability that the factor that reduced the immune response does not cease to exist in these terms. Therefore, the 2nd vaccine before the school should be given to all children, even if the 1st vaccination was carried out at the age of 2-5 years, practically, as indicated in JV 3.1.2. 1176-02, between 2 vaccinations the interval should be at least 6 months. In different countries, the 2nd vaccine is done at the age of 3-12 years.

When carrying out "mop-up" vaccination, it makes perfect sense to vaccinate all children who received the 1st vaccine at the age of 6 (mainly in 2002-2006), as well as girls vaccinated in these years at the age of 13 years. When teenagers are vaccinated against rubella with trivaccine, twice immunized against measles schoolchildren will receive a third dose of measles and mumps vaccines; this should not be embarrassing, since it is immediately neutralized by the antibodies of the vaccinated.

Compatibility

In case of a violation of the vaccination schedule, simultaneous vaccination with live vaccines with any other vaccine, the introduction of which is indicated at this time, including with DTP, ADS or HBV, should be carried out. Vaccinated vaccines can be re-immunized with another mono- or combination vaccine and vice versa. If a tuberculin test is required, it should be performed prior to measles vaccination (in extreme cases, simultaneously with it) or 6 weeks after it, as a measles (and possibly mumps) vaccination process can cause a temporary decrease in sensitivity to tuberculin, which will give false -negative result.

[9], [10], [11], [12],

The effectiveness of vaccination against measles, mumps and rubella

The protective titer of anticorrosive antibodies is determined in 95-98% vaccinated already from the beginning of the second week, which allows the vaccine to be administered to the contacts (up to 72 hours). Immune to measles is kept, according to the most long-term observations, for more than 25 years, only a very small number of vaccinated people can die out.

Immunity to mumps after successful vaccination lasts for a long time, more than 10 years for the majority, perhaps for life. A recent outbreak of mumps in England made it possible to clarify the effectiveness of vaccinations: in children who received 1 dose, it was 96% at the age of 2 years, decreasing to 66% at the age of 11-12 years; in those who received 2 inoculations, the effectiveness in 5-6 years was 99%, decreasing to 85% by 11-12 years. The use of mumps vaccination against contact is less reliable (70%) than in the case of measles.

Specific immunity to rubella develops later - after 15-20 days, which does not allow to enter it by contact; the seroconversion rate is almost 100% and lasts more than 20 years (Rudivax - 21 years). Reintroduction of live vaccines is carried out for the purpose of immunization of persons who did not give an immune response to the first vaccination.

With the introduction of combined vaccines (measles-mumps, MM-RII and Prioriks) antibodies to measles virus were detected in 95-98%, for mumps virus in 96% and for the rubella virus in 99% of the vaccinated. With MMR® II in the United States, measles incidence fell by 99.94% compared to the peak and measles transmission was interrupted for 16 weeks, and in Finland, by the end of the 12-year period, all three infections were eliminated.

Vaccination reactions and complications

All live vaccines - both combined and monovaccines are not very reactogenic. Vaccination against measles is accompanied in 5-15% of children by a specific reaction from 5-6 to 15 days: temperature (rarely up to 39 °), catarrh ( cough, minor conjunctivitis, runny nose ), 2-5% - neoblichnaya pale pink korepobodnaya rash between 7 and 12 days.

Reactions to mumps vaccine are also rare, sometimes in the period from 4 to 12 days, temperature and catarrh rise within 1-2 days. Very rarely there is an increase in parotid salivary glands (up to 42 days).

Reactions to rubella vaccine of children are not very serious and are rare - short-term subfebrile condition, hyperemia at the injection site, less often lymphadenitis. In 2% of adolescents, 6% of persons under 25 and 25% of women over 25 years from 5 to 12 days after inoculation, there is an increase in occipital, cervical and behind-the-back lymph nodes, short-term rashes, joint pain and arthritis (often knee and wrist joints ), which take place within 2-4 weeks. After vaccination in the puerperium, and also after 7 days from the beginning of the menstrual cycle, complications are observed less often.

Data on rubella vaccination of pregnant women (more than 1,000 women who did not know about its presence) showed that infection of the fetus occurs quite often (up to 10%), but there were no violations of the fetus development.

Allergic reactions

Children with allergies, both in the first days after vaccination, and during the height of the vaccine reaction, allergic rashes may occur; their frequency does not exceed 1:30 000, less often there is hives, Quincke's edema, lymphadenopathy, hemorrhagic vasculitis. They are associated with an allergy to neomycin or other components of the vaccine. Foreign vaccines produced on the chicken embryo cell culture are practically devoid of ovalbumin, so they carry a minimal risk of developing the reaction, and only in children reacting to it in an immediate manner. Therefore, the allergy to chicken protein is not a contraindication to vaccination with trivaccines. Conducting skin tests before vaccination is also not required. Reactions are even less common with the use of LCV and HPV, which are prepared on the culture of fibroblasts of Japanese quail embryos, although cross reactions are possible.

[13], [14], [15], [16], [17],

Convulsions

When the temperature is higher than 39.5 ° (more than 4 days - 1:14 000), predisposed children may develop febrile convulsions, usually 1-2 min (single or repeated). Their prognosis is favorable, in children with the appropriate anamnesis should be appointed paracetamol from the 5th day after vaccination. The risk of developing seizures in children who have had afebrile convulsions in a personal, and even more so in a family history, is extremely low, so that they are a contraindication.

[18], [19], [20], [21], [22], [23], [24], [25], [26], [27], [28], [29], [30],

CNS lesions

Violation of gait or nystagmus for several days is observed after a trivaccine with a frequency of 1:17 000. Persistent severe CNS lesions after measles vaccination are very rare (1: 1 000 000); the incidence of encephalitis in vaccinated people is even lower than among the general population. Inoculation against measles reduces the incidence of subacute sclerosing panencephalitis (PSPE), so eliminating measles will obviously also eliminate SSPE.

With the use of mumps vaccines from strain L-3, as well as Jeryl Lynn and RIT 4385, serous meningitis is rarely recorded (1: 150,000 -1: 1,000,000). Although the strain Urabe and Leningrad-Zagreb are more likely to give meningitis, experts and WHO consider it possible to continue their use; in Russia the strain Urabe is not registered.

[31], [32], [33], [34], [35], [36], [37], [38], [39],

Stomach ache

Abdominal pain (pancreatitis) develops extremely rarely after the mumps vaccine. Orchitis rarely (1: 200 000) occurs up to 42 days after vaccination with a favorable outcome.

Thrombocytopenia

Thrombocytopenia after the use of trivaccine for 17-20 days is rare (1:22 300, according to one study), it is usually associated with the influence of the rubella component. However, individual cases of thrombocytopenia with complete recovery and after the use of measles monovaccine are described.

Contraindications to vaccination against measles, rubella and mumps

Contraindications to vaccination against measles, rubella and mumps are as follows:

• immunodeficiency states (primary and consequent immunosuppression), leukemias, lymphomas, other malignant diseases, accompanied by a decrease in cellular immunity;
• severe forms of allergic reactions to aminoglycosides, egg white;
• for mumps vaccine - anaphylactic reaction to measles vaccine and vice versa (general substrate of cultivation);
• pregnancy (in view of the theoretical risk to the fetus).

Vaccinations are carried out at the end of an acute illness or exacerbation of a chronic one. Vaccinated women should be warned about the need to avoid pregnancy within 3 months. (in case of Rudivax application - 2 months); the occurrence of pregnancy in this period, however, does not require its interruption. Breastfeeding is not a contraindication to vaccination.

[40], [41], [42], [43], [44],

Vaccination of children against measles, rubella and mumps with chronic pathology

Immunodeficiencies

Live vaccines for children with primary forms are contraindicated Infected with HIV children (with symptoms and asymptomatic course), but without severe immunosuppression (according to CD4-lymphocyte count) vaccinated at the age of more than 12 months. After drug or radiation immunosuppression, live vaccines are administered no earlier than 3 months after high-dose corticosteroids (more than 2 mg / kg / day or 20 mg / day for 14 days or more) - not earlier than 1 month. After the end of the course of treatment.

Tuberculosis

Although measles often provokes an exacerbation of tuberculosis infection, this effect of vaccination has not been noted; The introduction of SLE and other vaccines does not require the preliminary setting of a tuberculin test.

Patients receiving blood products

Patients receiving blood products are vaccinated against measles, rubella and mumps in not earlier than 3 months. When injecting blood products less than 2 weeks after the administration of these vaccines, vaccination should be repeated.

Post-exposure prevention of measles, rubella and mumps

Contact persons on measles older than 12 months, who are not ill with measles and who are not vaccinated, are injected with HCV in the first 3 days from the moment of contact. Children aged 6-12 months. Postexposure vaccine prevention is also possible. An alternative to it, as well as for persons with contraindications to vaccination, is the administration of 1 or 2 doses (1.5 or 3.0 ml) of human immunoglobulin depending on the time elapsed from the moment of contact (most effective when administered before the 6th day ).

Postexposure prophylaxis of mumps is less effective, but the introduction of HPV is regulated for persons who had contact in the outbreaks of mumps that had not previously been vaccinated and not infected with this infection no later than the 7th day after the first patient was identified in the outbreak. At the same time, it is obvious that some children will be vaccinated within 72 hours after infection, the most favorable. To prevent the disease, the introduction of human immunoglobulin at contact does not guarantee the prevention of the disease.

Inoculations against rubella in the focus of rubella infection are all non-immune rubella, with the exception of pregnant women, since vaccination in the first three days from the onset of contact reduces the risk of developing clinically expressed forms of the disease. However, given the early contagiousness of patients (see above), this recommendation is unlikely to be effective.

In case of contact of a pregnant woman with a sick rubella, her susceptibility should be determined serologically. In the case of IgG antibodies, a woman is considered immune. In the absence of antibodies, the analysis is repeated after 4-5 weeks: if a positive result is offered, termination of pregnancy, if the second sample does not contain antibodies, take an analysis after 1 month. - The interpretation is the same.

The use of human immunoglobulin for the purpose of post-exposure rubella prevention in pregnancy is not recommended, it is administered only in cases where a woman does not want to terminate pregnancy. Limited observations suggest that the administration of a 16% immunoglobulin solution at a dose of 0.55 ml / kg can prevent infection or change the course of the disease. However, some of the pregnant women who received the drug may remain unprotected, and the children born to them - have a congenital rubella syndrome.