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To the Editor: Because vaccination of children and members of the armed forces was not mandatory in Italy until 1998, measles, mumps, and rubella (MMR) diseases have imposed a significant burden on the Italian military. The recent (April 1998) introduction of mandatory vaccination of military recruits provided an opportunity to examine the effectiveness and adverse effects of MMR vaccine (containing Schwarz measles, Urabe Am9 mumps, and Wistar RA 27/3 rubella strains) in a military setting.

Methods
In the Italian military, MMR diseases are generally diagnosed on the basis of clinical criteria. These cases are reported to the Director General for Military Health, in the context of the military surveillance system for communicable diseases. Vaccination status is ascertained by chart reviews, in which date of vaccination, type, and lot of vaccine as well as possible adverse effects are reported. To assess the efficacy of the MMR vaccine and the Urabe Am9–related reactogenicity, the incidence rates of MMR diagnosed in the Italian armed forces during 1999 (postvaccine period) were compared with those diagnosed during 1997 (prevaccine period). Furthermore, the incidence rates of aseptic meningitis (the most common neurological reaction to mumps-containing live vaccines¹) occurring in the same time periods were computed.

Results
During 1999 all new arriving recruits should have been vaccinated with MMR vaccine. However, only 75% were actually vaccinated because of contraindications or logistical difficulties. As expected, the incidence rates for measles and rubella decreased dramatically in 1999. By contrast, the incidence rate for mumps increased after the introduction of MMR immunization (Table 1). All but 2 mumps cases reported in those who received the vaccine, however, occurred within 1 month of vaccination (Table 2). The incidence rate of aseptic meningitis in 1999 was lower than in 1997 (3.3 per 100,000 vs 5.5 per 100,000, respectively). Of the 4 cases occurring during 1999, in only 2 cases were the time period between vaccination and onset of aseptic meningitis consistent with vaccination-induced disease.

View this table: [in this window] [in a new window] Table 1. Incidence Rates (Cases per 100,000) of Measles, Mumps, and Rubella in the Italian Armed Forces in the Prevaccine (1997) and Postvaccine (1999) Periods

View this table: [in this window] [in a new window] Table 2. Efficacy of Measles-Mumps-Rubella Vaccine Among 119,891 Italian Military Recruits, 1999

Comment
The Schwarz measles and Wistar RA 27/3 rubella strains seem to be highly effective in this population. The efficacy of the Urabe Am9 mumps strain could not be determined because of difficulties in defining new mumps cases in the vaccinees, but it is at least 70% effective, which is consistent with other recent data.² However, the close temporal association between the vaccination and onset of mumps suggests a mumps-like disease due to some residual virulence of vaccine strain. However, in the absence of molecular analysis to identify the mumps virus genotype, this conclusion is not definitive. Moreover, from these preliminary observations, the Urabe Am9 mumps strain does not seem to have a high risk of inducing aseptic meningitis in adults. Even if the 2 cases were actually due to adverse effects from vaccine, the incidence of aseptic meningitis would be 2.2 per 100,000 vaccine recipients, similar to the lowest reported values (0.82 per 100,000),³ but much lower than 3 per 1000,⁴ 1 per 11,000,⁵ or 1 per 14,000 described⁶ in other population samples.

Raffaele D'Amelio, MD; Roberto Biselli, MD; Giovanni Fascia, MD; Sergio Natalicchio, MD
Ministero della Difesa
Direzione Generale Sanità Militare
Rome, Italy

1. Mumps meningitis and MMR vaccination. Lancet. 1989;2:1015-1016. PUBMED 2. Chamot E, Toscani L, Egger P, Germann D, Bourquin C. Estimation of the efficacy of three strains of mumps vaccines during an epidemic of mumps in the Geneva canton. Rev Epidemiol Santé Publique. 1998;46:100-107. WEB OF SCIENCE | PUBMED 3. Autret E, Jonville-Bera AP, Galy-Eyraud C, Hessel L. Aseptic meningitis after mumps vaccination. Therapie. 1996;51:681-683. WEB OF SCIENCE | PUBMED 4. Fujinaga T, Motegi Y, Tamura H, Kuroume T. A prefecture-wide survey of mumps meningitis associated with measles, mumps and rubella vaccine. Pediatr Infect Dis J. 1991;10:204-209. WEB OF SCIENCE | PUBMED 5. Miller E, Goldacre M, Pugh S, et al. Risk of aseptic meningitis after measles, mumps, and rubella vaccine in UK children. Lancet. 1993;341:979-982. FULL TEXT | WEB OF SCIENCE | PUBMED 6. Dourado I, Cunha S, Texeira M, et al. Outbreak of aseptic meningitis associated with mass vaccination with a Urabe-containing measles-mumps-rubella vaccine. Am J Epidemiol. 2000;151:524-530. FREE FULL TEXT

Letters Section Editors: Stephen J. Lurie, MD, PhD, Senior Editor; Phil B. Fontanarosa, MD, Executive Deputy Editor.

JAMA. 2000;284:2059.

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RELATED LETTER

Molecular Analysis of Early Postvaccine Mumps-like Disease in Italian Military Recruits
Florigio Lista, Giovanni Faggioni, Mario Stefano Peragallo, Francesco Tontoli, Antonio Stella, Piero Salvatori, Michele Pusino, Marlo Alberto Germani, Vito Contreas, and Raffaele D'Amelio
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Molecular Analysis of Early Postvaccine Mumps-like Disease in Italian Military Recruits
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