Quality standard for assurance of measles immunity among health care workers. The Infectious Diseases Society of America

OBJECTIVE

The objective of this quality standard is to prevent nosocomial transmission of measles by assuring universal measles-mumps-rubella (MMR) vaccination of all health care workers who lack immunity to measles. Although the primary emphasis is on health care workers in hospitals, those at other sites, such as clinics, nursing homes, and schools, are also included. It will be the responsibility of designated individuals at these institutions to implement the standard.

OPTIONS

We considered advocating the use of measles vaccine rather than MMR but chose the latter because it also protects against mumps and rubella and because it is more readily available.

OUTCOMES

The desired outcome is a reduction in the nosocomial transmission of measles.

EVIDENCE

Although direct comparative studies are lacking, nosocomial outbreaks of measles have been reported (as recently as 1992) in institutions where measles immunization of nonimmune health care workers is not universal, whereas such outbreaks have not been reported in institutions with universal immunization. VALUES AND VALIDATION: We consulted more than 50 infectious-disease experts in epidemiology, government, medicine, nursing, obstetrics and gynecology, pediatrics, and surgery. In light of disagreement regarding the implementation of the standard, we used group discussions to reach a consensus.

BENEFITS, HARMS, AND COSTS

The consequences of the transmission of measles (and of mumps and rubella) in a health care institution include not only the morbidity and mortality attributable to the disease, but also the significant cost of evaluating and containing an outbreak and the serious disruption of regular hospital routines when control measures are instituted. The potential harm to health care workers after the implementation of the standard consists of untoward effects of MMR vaccine, although the reactions of vaccines should be minimal with adherence to recommended vaccination procedures. Implementation of the standard should entail no expense to health care workers; the precise cost to institutions is unknown, but the expense would be mitigated by prevention of measles outbreaks.

RECOMMENDATIONS

We recommend MMR vaccination of all health care workers who lack immunity to measles.

SPONSORS

The Quality Standards Subcommittee of the Clinical Affairs Committee of the Infectious Diseases Society of America (IDSA) developed the standard. The subcommittee was composed of representatives of the IDSA (Drs. Gross and McGowan), the Society for Hospital Epidemiology of America (Dr. Wenzel), the Surgical Infection Society (Dr. Dellinger), the Pediatric Infectious Diseases Society (Dr. Krause), the Centers for Disease Control and Prevention (Dr. Martone), the Obstetrics and Gynecology Infectious Diseases Society (Dr. Sweet), and the Association of Practitioners of Infection Control (Ms. Barrett). Funding was provided by the IDSA and the other cooperating organizations. The standard is endorsed by the IDSA.

Measles antibody: comparison of long-term vaccination titres, early vaccination titres and naturally acquired immunity to and booster effects on the measles virus

A two-dose vaccination programme, using a combined measles, mumps and rubella vaccine (MMR) and administration at the ages of 18 months and 12 years, was introduced into Sweden in 1982. Since the combined MMR vaccine was introduced, a yearly evaluation of the immunity patterns and seroconversion rates in 12-year-old children has been carried out. This study includes three study groups. All groups consisted of pre- and postvaccination samples from 12-year-old children taken in connection with the MMR immunization. There were 332 paired samples from children who 8-10 years previously had received live measles vaccine. Prevaccination sera from these children represent late postvaccination titres. The postvaccination sera of 49 children seronegative to measles before vaccination, obtained 2 months after vaccination, represent early postvaccination immunity. Ninety-five children who had not been vaccinated earlier and who were seropositive to measles represent naturally acquired immunity. All samples were studied by an enzyme-linked immunosorbent assay (ELISA). Sera from children with late postvaccination immunity had significantly lower titres than children in group 2, who represented early postvaccination sera (p < 0.001). Children with naturally acquired immunity had significantly higher titres than children with vaccine-induced immunity titres (p < 0.001). After revaccination of the previously vaccinated children, a significant booster rise was seen (p < 0.001). After revaccination of children with naturally acquired immunity, no significant booster effect was observed. Sixty-five children of the 332 (20%) previously vaccinated children had no or borderline measles titres prior to the booster. The study suggests that the vaccine-induced measles antibodies decline with time and may fall under the protective level.(ABSTRACT TRUNCATED AT 250 WORDS)

Measles vaccine failures: lack of sustained measles-specific immunoglobulin G responses in revaccinated adolescents and young adults

The measles-specific antibody responses of seronegative adolescents and young adults were evaluated after revaccination. Of 1650 previously vaccinated healthy volunteers between the ages of 10 and 30 years, 4.4% were found to be seronegative for measles antibodies and 9.9% had equivocal titers. Seronegative volunteers were revaccinated to measles and followed serially for development of measles-specific IgG. Of 43 subjects followed for at least 1 year, only 58% developed and maintained positive antibody titers; 12% never developed positive titers and 30% initially developed titers that fell below positive levels within 1 year. The peak titers achieved by those subjects who responded transiently were lower than those achieved by subjects who developed sustained responses. Thus even after the recommended two dose schedule of the current measles vaccine, some adolescents and young adults lack protective titers of measles-specific antibody.

[An intranasal method of revaccination against mumps]

The effectiveness of revaccination against mumps was studied using different routes for administration of a live mumps vaccine from L-3 strain. Poor reactogenicity of the vaccine was observed after intranasal administration. The highest rise in titres of virus-neutralizing antibody was demonstrated in volunteers given the vaccine by the intranasal route. Revaccination of adults by both intranasal and subcutaneous routes induced production of antigen-specific memory cells. The results of the study attest to the usefulness of the intranasal route of vaccine administration in revaccinations against epidemic parotitis.

Illness after measles-mumps-rubella vaccination

OBJECTIVES

To provide accurate information on the common sequelae of measles-mumps-rubella (MMR) vaccination and to compare post-vaccine symptoms in children vaccinated at 13 and 15 months.

DESIGN

Prospective cluster randomized controlled trial.

SETTING

Twenty-two family practices in southwestern Ontario.

PATIENTS

All 376 infants who were due to receive MMR vaccine in the next year, 253 (67.3%) successfully completed the study.

INTERVENTION

MMR vaccine administered at 13 months by half of the family physicians and at 15 months by the remaining half.

OUTCOME MEASURES

Family physician's physical findings in children 7 days and 30 days after vaccine; reported illnesses by mothers in a daily diary in the month before and after vaccination and medical records of visits to family physicians and hospital admissions in the month before and after vaccination.

RESULTS

Compared with the incidence rates in the corresponding weeks before vaccination, the rates of lymphadenopathy (23.8%) and fever (16.8%) were higher 1 week afterward and the rate of rash (26.9%) was higher 7 to 14 days afterward. Fewer health problems were reported in the third and fourth weeks after vaccination than in the corresponding weeks beforehand. Hospital admissions after vaccination were no more frequent than those before once cause and time of admission were taken into account. The two age groups did not differ in any of the outcomes.

CONCLUSIONS

Mothers should be informed about the possibility of increased physical findings in the weeks after MMR vaccination, especially lymphadenopathy, nasal discharge and rash. Since the occurrence of sequelae does not seem to differ significantly between 13-month-old recipients and 15-month-old recipients, it should not influence the decision of when to administer the vaccine.

Antibody response to measles and rubella vaccine by children with HIV infection

To determine the immunogenicity of the measles and rubella components of the measles, mumps, and rubella virus (MMR) vaccine in human immunodeficiency virus (HIV)-infected children, we compared their response to that of uninfected controls. Sera were collected from HIV-infected patients and HIV seroreverters followed in our clinic and tested as close to 2 months post-MMR vaccination as possible. Specific IgG to both rubella and measles were measured by enzyme-linked immunosorbent assay. Of 20 children with HIV, 11 responded with adequate levels of antibody to measles. In the seroreverters, 12 of 13 responded. Of the measles responders, the median antibody level was significantly lower in the HIV-infected group than in the seroreverter group. In addition, HIV-infected responders tested at 9-15 months after vaccination demonstrated a significant decline in measles antibody levels. Although there was not a difference between the two cohorts in the proportion of patients who responded to the rubella component of the vaccine, there was a significant difference in the median antibody level of the responders of the two groups. We did not find a statistical difference in CD4 counts between responders and nonresponders. Alternate strategies will need to be established to prevent measles in HIV-infected children.

Surveillance of measles in Scotland 1983-1991; a comparison of statutory notification and laboratory reporting

The epidemiology of measles in Scotland for the period 1983-1991, based on statutory notification and laboratory reporting, is described. There were 34,823 notifications compared to only 690 laboratory reports. This suggests that for less than 1 in 50 notifications of measles was the clinical diagnosis confirmed by laboratory testing. Both sets of data show a declining incidence of measles (in keeping with rising rates of immunisation) but a statistically significant shift in the age distribution of cases towards the over 15 years age group. There were differences, however, between the two sets of data in the sex ratio within various age groups. In particular, among notified cases, there was a highly significant but unexplained preponderance of males in the over 15 years age group (59.7% vs. 40.3%, P < 0.001). Discrepancies between the two sets of data were also evident from comparisons among Health Boards. Possible sources of bias are suggested for each set of data. The relevance of this surveillance to the current debate about the need for a two stage Measles/Mumps/Rubella (MMR) immunisation policy is briefly discussed. In order that this debate be reliably informed, it is highly desirable that the clinical diagnosis in each case of apparent vaccine failure is confirmed by laboratory testing.

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.

[The EMLA cream versus placebo in MMR vaccination of older children in general practice]

We investigated the effect of EMLA cream (active ingredients: 25 mg lidocaine and 25 mg prilocaine per gram of cream) on subjective experience of pain in connection with vaccination. The study was conducted as a double-blind, randomized, placebocontrolled trial in a general practice setting. The subjects were ten to fifteen year-olds, who were due to be inoculated with measles-mumps-rubella vaccine. Of the 118 children entering the trial, 117 completed the treatment (EMLA 58, placebo 59). Treatment time was at least 60 minutes for all children. The children reported similar degrees of pain immediately after vaccination in both groups, one third of both treatment and placebo groups reporting medium to strong pain (not significant). On the day after vaccination, more than half the families (59%) said that they would use the cream again in connection with future vaccinations; again, there was no statistically significant difference between the two groups in this respect. Based on these results, we conclude that use of EMLA cream as a topical local anaesthetic does not reduce the experience of pain in connection with the administration of measles-mumps-rubella vaccine to older children.

Duration of the immune response to MMR vaccine in children of two age-different groups

A combined vaccine against measles, mumps and rubella (MMR) was administered to both a group of children aged 10-12 months simultaneously with booster doses of compulsory diphtheria-tetanus toxoids and oral poliovirus vaccine and a group of children aged 15-24 months who had previously received booster doses of the compulsory vaccines. Apart from one subject belonging to the second group who was non responder and one from the same group who did not seroconvert against the mumps virus alone, 5 to 6 weeks after MMR vaccine administration we found protective levels of antibodies against measles, mumps and rubella viruses in all children. The follow up of both groups at 3 years did not reveal difference between the two groups. Protective levels of serum antibodies against measles and mumps were found in the two groups, although a significant decline of rubella antibodies was shown (p < 0.05). Since the immunogenicity of the vaccines in the two groups did not differ, we recommend that the scientific community reconsider the vaccination schedule until now recommended. In our opinion the MMR vaccine should be administered simultaneously with booster doses of diphtheria-tetanus toxoids and oral poliovirus vaccine at 10-12 months of age because this policy improves parents' compliance, markedly reduces community costs and simplifies routine immunization schedule.

Immunity to measles in young adults in Israel

The likelihood of an epidemic of measles in 1990-92 in Israel prompted us to study the immune status against measles in a random sample of 454 recruits aged 18-19 years in order to obtain data that might be used in determining vaccination policy. This cohort had received one dose of measles vaccine at 12 months of age. The measles immunity status was studied by determination of antibody values that were measured by means of an enzyme-linked immunosorbent (ELISA) IgG antibody test. Of the recruits, 84.6% were found to have positive sera for anti-measles IgG antibodies, while 13.7% had negative sera. Eight (1.7%) subjects had borderline results. The results of this study indicate the need to administer a second dose of measles vaccine at an older age in addition to the MMR (measles, mumps, rubella) vaccine that is now given in Israel at 12 months of age. This step will help achieve the World Health Organization's target of complete eradication of measles.

[The MMR vaccination: no effect of feedback of vaccination scores in general practice]

The purpose of this study was to assess the effect of graphic feed-back of vaccination scores (VS) for vaccination against measles, mumps and rubella (MMR) at the age of 15 months among practices in a Danish county. The study was designed as an intervention study, comparing VS for each practice with VS for the other practices in the county. The feed-back was evaluated qualitatively by use of a postal questionnaire. A majority of the 73 responding practices welcomed the graphic feed-back, regarded it as easily understood and requested similar information on an annual basis in the future. In 13 (18%) of the practices, the calculated VS was lower than the doctors had expected. The most frequent explanation for this discrepancy, given by 4 practices, was incorrect registration of the vaccination. Twenty-one percent of the practices had taken action to improve their performance after receiving the feed-back, but there was no significant improvement in VS in this group. In practices with low VS (< 70%) before intervention, there was no significant change in VS. The total VS for all practices in the county was 89% before and 88% after intervention. In conclusion, the feed-back had no observable effect on VS. Registration errors may explain why some practices had low VS. Feed-back with performance indicators may have better quantitative effect if accompanied by qualitative measures.

[Experience with preventive measles, mumps and rubella vaccination in unified Germany]

Considerable immunity gaps in respect of mumps and rubella (German measles) of up to 30% among pupils of the prepuberty age are the requisite arguments in favour of the need for vaccination measures. Combined protective vaccination with live attenuated measles-mumps-rubella vaccine without preceding laboratory tests is recommended for practical reasons and economy. No side effects have been seen on renewed protective vaccination with live attenuated measles vaccine in case of already existent natural immunity. A booster effect can be demonstrated in vaccinated persons with low or borderline antibody levels. Revaccination from the 6th year of life onwards is recommended and advocated to close existing vaccination and immunity gaps.