The clinical significance of measles: a review

Vaccines in pediatric transplant recipients-Past, present, and future

Infections significantly impact outcomes for solid organ and hematopoietic stem cell transplantation in children. Vaccine-preventable diseases contribute to morbidity and mortality in both early and late posttransplant time periods. Several infectious diseases and transplantation societies have published recommendations and guidelines that address immunization in adult and pediatric transplant recipients. In many cases, pediatric-specific studies are limited in size or quality, leading to recommendations being based on adult data or mixed adult-pediatric studies. We therefore review the current state of evidence for selected immunizations in pediatric transplant recipients and highlight areas for future investigation. Specific attention is given to studies that enrolled only children.

Epidemiological and molecular investigation of a measles outbreak in Punjab, Pakistan, 2013-2015

Despite the availability of an effective vaccine, the measles virus continues to cause significant morbidity and mortality in children worldwide. Molecular characterization of wild-type measles strains is an invaluable component of epidemiological studies or surveillance systems that provides important information pertinent to outbreak linkages and transmission pathways. Serum samples and throat swabs were collected from suspected measles cases from the Punjab province of Pakistan (2013-2015) and further tested for measles immunoglobulin M (IgM) through enzyme-linked immunosorbent assay and reverse-transcriptase polymerase chain reaction for molecular characterization. Among the total of 5415 blood samples, 59% tested positive for measles IgM. Males had a higher infection rate (55%) than females (45%), and the highest frequency of positive cases (63%) was found in the age group of 0 to 5 years. Partial sequencing of the nucleoprotein gene showed that 27 strains belonged to the B3 genotype, whereas 2 viruses were identified as D4. On phylogenetic analysis, Pakistani B3 strains were found to be closely related to previously reported indigenous strains and those from neighboring countries of Iran and Qatar. This is the first report on the detection of the measles B3 genotype from Punjab, Pakistan. The current study shows a high burden of measles infections in Punjab province owing to poor routine immunization coverage in major cities. It is imperative that national health authorities adopt strategic steps on an urgent basis for improvement of routine immunization coverage. Molecular epidemiology of the measles viruses circulating in different parts of the country can provide useful data to manage future outbreaks.

Pulmonary measles disease: old and new imaging tools

BACKGROUND

Measles virus can cause lower respiratory tract infection, so that chest radiography is necessary to investigate lung involvement in patients with respiratory distress.

PURPOSE

To assess measles pneumonia imaging during the measles outbreak occurred in 2016-2017 in Italy.

MATERIAL AND METHODS

We retrospectively observed adult patients with a serological diagnosis of measles, who underwent chest-X rays for suspected pneumonia. If a normal radiography resulted, the patient underwent unenhanced CT. A CT post processing software package was used for an additional quantitative lung and airway involvement analysis .

RESULTS

Among 290 patients affected by measles, 150 underwent chest-X ray. Traditional imaging allowed the pneumonia diagnosis in 114 patients (76%). The most frequent abnormality at chest X-rays was bronchial wall thickening, observed in 88.5% of the cases; radiological findings are faint in the 25% of the cases (29/114 patients). In nine subjects with a normal chest X-ray, unenhanced CT with a quantitative analysis was performed, and depicted features consistent with constrictive bronchiolitis.

CONCLUSION

Measles may produce bronchiolitis and pneumonia. In the cases in which involvement of pulmonary parenchyma is not sufficient to result in radiological abnormalities, CT used with a dedicated postprocessing software package, provides an accurate lungs and airways analysis, also determining the percentage of lung involvement.

Effectiveness of Measles Vaccination and Immune Globulin Post-Exposure Prophylaxis in an Outbreak Setting-New York City, 2013

Background

Measles, mumps, and rubella vaccine (MMR) or immune globulin (IG) are routinely used for measles post-exposure prophylaxis (PEP). However, current literature on the effectiveness of measles PEP is limited and variable. Here, we examined the effectiveness of MMR and IG PEP among children exposed to measles during an outbreak in New York City (NYC) in 2013.

Methods

Contacts were identified by the NYC Department of Health and Mental Hygiene between 13 March 2013 and 30 June 2013. Immunity to measles and receipt of PEP was determined for contacts. PEP effectiveness [(1 - relative risk of developing measles) × 100] was calculated for MMR, IG, and any PEP (MMR or IG) for nonimmune contacts aged <19 years.

Results

A total of 3409 contacts were identified, of which 208 (6.1%), 274 (8.0%), and 318 (9.3%) met the inclusion criteria for analysis of MMR, IG, and any PEP effectiveness, respectively. Of the contacts included, 44 received MMR PEP and 77 received IG PEP. Effectiveness of MMR PEP was 83.4% (95% confidence interval [CI], 34.4%, 95.8%). No contact who received IG PEP developed measles; effectiveness of IG PEP was 100% (approximated 95% CI, 56.2%, 99.8%). Effectiveness of receiving any PEP (MMR or IG) was 92.9% (95% CI, 56.2%, 99.8%).

Conclusions

Contacts who received PEP were less likely to develop disease. Our findings support current recommendations for administration of PEP following exposure to measles. These results highlight the importance of a rapid public health outbreak response to limit measles transmission following case identification.

Analysing the characteristics of a measles outbreak in Houaphanh province to guide measles elimination in the Lao People's Democratic Republic

INTRODUCTION

In recent years, the incidence of measles has declined in the Lao People's Democratic Republic. However, an outbreak was reported in August 2014 in Houaphanh province, which was the biggest outbreak in the country since 2008. We describe the characteristics of this outbreak and outline critical interventions for the Lao People's Democratic Republic to achieve measles elimination.

METHODS

Fever and rash cases in the Khouan and Samtai districts with an onset date from 1 September to 25 October 2014 were investigated. Active case finding and health facility record reviews were carried out. Appropriate samples from the individuals with suspected measles were tested to confirm the diagnosis.

RESULTS

A total of 265 suspected cases including 12 deaths were reported from eight villages in the Khouan and Samtai districts. Forty-five individuals tested positive for measles IgM. Most of the confirmed patients were male (n = 28, 62%), less than 5 years old (n = 23, 51%) and from the Hmong ethnic community (n = 44, 98%). The majority of the people with suspected measles (n = 213, 80%) and all the confirmed ones were unvaccinated. A measles vaccination campaign conducted in the eight affected villages resulted in 76% coverage of the targeted population.

DISCUSSION

Low routine coverage and measles occurrence among unvaccinated individuals indicate underimmunized areas. The geographical and sociodemographic characteristics of this outbreak highlight the need for tailored vaccination strategies to close the immunity gap. A sensitive surveillance system that is able to detect, notify, investigate and guide response measures, including a second measles dose in the routine immunization schedule, will be essential for the Lao People's Democratic Republic to attain its measles elimination status.

Sero-epidemiology and Risk Factor Analysis of Measles Among Children in Pakistan

Comparative cross sectional study was conducted on blood samples (n = 231) collected from children of 1 to 10 years of age in Punjab Pakistan through convenient sampling method. Indirect haemagglutination assay (IHA) was standardized and used for serodiagnosis and evaluation of humoral immunity against measles. Associated risk factors including age, gender, locale, and vaccination status were analyzed. Geometric mean titre (GMT) of vaccinated individuals was significantly higher (p < 0.001) than that of non-vaccinated individuals showing that IHA titre of vaccinated individuals was a measure of humoral immune response; whereas, in case of non-vaccinated individuals an indicative of exposure to the measles infection.

Raising Rates of Childhood Vaccination: The Trade-off Between Coercion and Trust

Vaccination is a highly effective public health strategy that provides protection to both individuals and communities from a range of infectious diseases. Governments monitor vaccination rates carefully, as widespread use of a vaccine within a population is required to extend protection to the general population through "herd immunity," which is important for protecting infants who are not yet fully vaccinated and others who are unable to undergo vaccination for medical or other reasons. Australia is unique in employing financial incentives to increase vaccination uptake, mainly in the form of various childcare payments and tax benefits linked to timely, age-appropriate vaccination. Despite relatively high compliance with the childhood vaccination schedule, however, the Australian government has determined that rates should be higher and has recently introduced policy that includes removing certain tax and childcare benefits for non-vaccinators and formally disallowing conscientious objection to vaccination ("No Jab No Pay"). In addition, it has raised the possibility of banning unvaccinated children from childcare centres ("No Jab No Play"). This article examines the impact of coercive approaches to childhood vaccination and raises the question of the ethical justification of health policy initiatives based on coercion. We consider the current evidence regarding childhood vaccination in Australia, the small but real risks associated with vaccination, the ethical requirement for consent for medical procedures, and the potential social harms of targeting non-vaccinators. We conclude that the evidence does not support a move to an increasingly mandatory approach that could only be delivered through paternalistic, coercive clinical practices.

How to hold an ethical pox party

Pox parties are a controversial alternative to vaccination for diseases such as chickenpox. Such parties involve parents infecting non-immune children by exposing them to a contagious child. If successful, infection will usually lead to immunity, thus preventing infection later in life, which, for several vaccine-preventable diseases, is more severe than childhood infection. Some may consider pox parties more morally objectionable than opting out of vaccination through non-medical exemptions. In this paper, I argue that this is not the case. Pox parties involve immediate risk of harm for children and reduce future harms, whereas opting out of vaccination places children at long-term risk of harms that increase with time, at least for some pathogens. Regarding harm to others through onward transmission of infection, this can be easily prevented in the case of pox parties-given the relatively controlled timing of infection-by quarantining attendees after the party, whereas opting out of vaccination involves risks to others that are more difficult to control. I defend three criteria for an ethical pox party: (1) that the disease is sufficiently low risk, (2) that parents consent to their child's attendance and (3) that children exposed to infection are quarantined and isolated appropriately. I argue that, if these criteria are met, pox parties are morally preferable to non-vaccination; such parties involve less risk to non-consenting others and, for some pathogens in some cases, even involve less risk for the children who participate. Thus, policies that permit non-medical exemption to vaccination should also permit ethical pox parties. Alternatively, if pox parties are not permitted, then vaccination should be mandated for those without medical contraindication.

Childhood measles contributes to post-bronchodilator airflow obstruction in middle-aged adults: A cohort study

BACKGROUND AND OBJECTIVE

Chronic obstructive pulmonary disease (COPD) has potential origins in childhood but an association between childhood measles and post-bronchodilator (BD) airflow obstruction (AO) has not yet been shown. We investigated whether childhood measles contributed to post-BD AO through interactions with asthma and/or smoking in a non-immunized middle-aged population.

METHODS

The population-based Tasmanian Longitudinal Health Study (TAHS) cohort born in 1961 (n = 8583) underwent spirometry in 1968 before immunization was introduced. A history of childhood measles infection was obtained from school medical records. During the fifth decade follow-up (n = 5729 responses), a subgroup underwent further lung function measurements (n = 1389). Relevant main associations and interactions by asthma and/or smoking on post-BD forced expiratory volume in 1 s/forced vital capacity (FEV₁ /FVC; continuous variable) and AO (FEV₁ /FVC < lower limit of normal) were estimated by multiple regression.

RESULTS

Sixty-nine percent (n = 950) had a history of childhood measles. Childhood measles augmented the combined adverse effect of current clinical asthma and smoking at least 10 pack-years on post-BD FEV₁ /FVC ratio in middle age (z-score: -0.70 (95% CI: -1.1 to -0.3) vs -1.36 (-1.6 to -1.1), three-way interaction: P = 0.009), especially for those with childhood-onset asthma. For never- and ever-smokers of <10 pack-years who had current asthma symptoms, compared with those without childhood measles, paradoxically, the odds for post-BD AO was not significant in the presence of childhood measles (OR: 12.0 (95% CI: 3.4-42) vs 2.17 (0.9-5.3)).

CONCLUSION

Childhood measles infection appears to compound the associations between smoking, current asthma and post-BD AO. Differences between asthma subgroups provide further insight into the complex aetiology of obstructive lung diseases for middle-aged adults.

A nosocomial measles outbreak in Italy, February-April 2017

We describe a nosocomial outbreak of measles that occurred in an Italian hospital during the first months of 2017, involving 35 persons and including healthcare workers, support personnel working in the hospital, visitors and community contacts. Late diagnosis of the first case, support personnel not being promptly recognised as hospital workers and diffusion of the infection in the emergency department had a major role in sustaining this outbreak.

Waning of measles maternal antibody in infants in measles elimination settings - A systematic literature review

INTRODUCTION

Most infants are born with immunity to measles through maternal antibodies transferred in pregnancy, which decay over time. However, in measles elimination settings, where measles does not circulate endemically and most immunity is from immunization rather than infection, maternal antibody levels are lower. This results in infant immunity that wanes earlier, and a wider susceptibility gap between maternal antibody decay and infant immunization than in non-eliminated settings. We aimed to systematically quantify the extent and duration of protection from measles in infants in settings that have sustained measles elimination.

METHODS

We conducted a systematic review of studies of measles maternal antibody waning in infants in measles elimination settings. We searched MEDLINE, Embase, CINAHL, Scopus, BIOSIS Previews, and Global Health databases for relevant studies. Studies were included if they were set in countries that had eliminated measles for ≥3 years, and if the study cohort included healthy, full-term, unvaccinated infants ≤12 months, born to healthy mothers, and reported a relevant measure of measles maternal antibody in infants. We assessed study quality using the MetaQAT tool.

RESULTS

We identified 4692 unique citations, eight of which met inclusion criteria. One study reported anti-measles antibody in cord blood, six reported antibody in infant sera, and one reported both. Two studies reported that 80 and 100% of infants were protected from measles at birth. One study reported no protection amongst 3-7 month old infants, and another reported limited protection in infants >4 months. The remaining studies reported the proportion of infants with detected antibody, but not the proportion immune.

CONCLUSION

Although limited, these data suggest that in settings that have sustained measles elimination, some infants are susceptible to measles well before the age of routine measles immunization. Setting-specific seroprevalence and vaccine effectiveness studies are required to evaluate this in different jurisdictions.

Quantitative Analysis of Cellular Proteome Alterations in CDV-Infected Mink Lung Epithelial Cells

Canine distemper virus (CDV), a paramyxovirus, causes a severe highly contagious lethal disease in carnivores, such as mink. Mink lung epithelial cells (Mv.1.Lu cells) are sensitive to CDV infection and are homologous to the natural host system of mink. The current study analyzed the response of Mv.1.Lu cells to CDV infection by iTRAQ combined with LC-MS/MS. In total, 151 and 369 differentially expressed proteins (DEPs) were markedly up-regulated or down-regulated, respectively. Thirteen DEPs were validated via real-time RT-PCR or western blot analysis. Network and KEGG pathway analyses revealed several regulated proteins associated with the NF-κB signaling pathway. Further validation was performed by western blot analysis and immunofluorescence assay, which demonstrated that different CDV strains induced NF-κB P65 phosphorylation and nuclear translocation. Moreover, the results provided interesting information that some identified DEPs possibly associated with the pathogenesis and the immune response upon CDV infection. This study is the first overview of the responses to CDV infection in Mv.1.Lu cells, and the findings will help to analyze further aspects of the molecular mechanisms involved in viral pathogenesis and the immune responses upon CDV infection.

Measles

Measles is a highly contagious disease that results from infection with measles virus and is still responsible for more than 100 000 deaths every year, down from more than 2 million deaths annually before the introduction and widespread use of measles vaccine. Measles virus is transmitted by the respiratory route and illness begins with fever, cough, coryza, and conjunctivitis followed by a characteristic rash. Complications of measles affect most organ systems, with pneumonia accounting for most measles-associated morbidity and mortality. The management of patients with measles includes provision of vitamin A. Measles is best prevented through vaccination, and the major reductions in measles incidence and mortality have renewed interest in regional elimination and global eradication. However, urgent efforts are needed to increase stagnating global coverage with two doses of measles vaccine through advocacy, education, and the strengthening of routine immunisation systems. Use of combined measles-rubella vaccines provides an opportunity to eliminate rubella and congenital rubella syndrome. Ongoing research efforts, including the development of point-of-care diagnostics and microneedle patches, will facilitate progress towards measles elimination and eradication.

Case report: Ribavirin and vitamin A in a severe case of measles

RATIONALE

Despite a vaccine being widely available, measles continues to occur frequently, with sometimes lethal consequences.

PATIENTS CONCERNS

The mortality rate reaches 35% and measles represents 44% of the 1.4 million deaths which are due to preventable diseases. Severe forms of measles are reported, mainly in young, unvaccinated adults, and in specific populations. The risk factors for severe measles include no or incomplete vaccination and vitamin A deficiency. Apart from secondary measles-related infections, severe measles is mainly represented by neurological, respiratory, and digestive symptoms.

DIAGNOSES

Strengthening the hypothesis that there is a link between vitamin A deficiency and severe measles in this paper we report the case of a 25-year-old unvaccinated man hospitalized for severe and complicated measles.

OUTCOMES

The evolution was good after administration of intramuscular vitamin A as well as intravenous ribavirin.

LESSONS

Measles remains a fatal and serious disease. The early use of ribavirin and vitamin A shows significant improvements regarding morbimortality and should be systematic in severe cases.

Facebook and Twitter vaccine sentiment in response to measles outbreaks

Social media posts regarding measles vaccination were classified as pro-vaccination, expressing vaccine hesitancy, uncertain, or irrelevant. Spearman correlations with Centers for Disease Control and Prevention-reported measles cases and differenced smoothed cumulative case counts over this period were reported (using time series bootstrap confidence intervals). A total of 58,078 Facebook posts and 82,993 tweets were identified from 4 January 2009 to 27 August 2016. Pro-vaccination posts were correlated with the US weekly reported cases (Facebook: Spearman correlation 0.22 (95% confidence interval: 0.09 to 0.34), Twitter: 0.21 (95% confidence interval: 0.06 to 0.34)). Vaccine-hesitant posts, however, were uncorrelated with measles cases in the United States (Facebook: 0.01 (95% confidence interval: -0.13 to 0.14), Twitter: 0.0011 (95% confidence interval: -0.12 to 0.12)). These findings may result from more consistent social media engagement by individuals expressing vaccine hesitancy, contrasted with media- or event-driven episodic interest on the part of individuals favoring current policy.

Measles lessons in an anti-vaccination era: public health is a social duty, not a political option

BACKGROUND

Measles virus, member of the genus Morbillivirus in the family Paramyxoviridae, is a highly contagious human pathogen. An effective live-attenuated vaccine is available and its use has the potential to eradicate the disease from the human population. Although the vaccine was introduced in national vaccination schedules, several measles outbreaks have occurred because of insufficient vaccination coverage. Since early January 2017, a new outbreak of measles in Italy has been observed.

METHODS

We analyzed all the patients admitted to the Emergency Department of Bambino Gesù Children Hospital of Rome from the 1st of January 2017 to the end of May 2017 and discharged with diagnosis of suspected or confirmed measles or admitted to the Pediatric and Infectious Disease Unit. For each confirmed case, demographic data, vaccination history, exposure to source case, clinical presentation, date of onset of symptoms, hospitalization, laboratory test results, complications and therapy were collected.

RESULTS

From the 1st of January 2017 to the 31st of May 2017, we enrolled 139 patients who were conducted to the Emergency Department of Bambino Gesù Children's Hospital because of measles: 33 patients were discharged with the diagnosis of suspected measles by clinical manifestations; 33 discharged with the diagnosis of confirmed measles by laboratory tests and 73 were admitted to the Pediatric and Infectious Disease Unit. Seven patients, who were exposed to mothers with measles, were admitted to receive treatment with Measles Immune Globulin intravenously. Among the 66 patients admitted to the hospital with measles, 31 cases (47%) occurred in unvaccinated individuals who were age-eligible for measles vaccination; 29 (44%) were infants too young to be vaccinated; only five patients (8%) received one dose of measles-containing vaccine. Out of the 66 patients, 35 (53%) developed complications. Acute respiratory failure was the most reported complications (20%). Death, due to multiorgan failure by measles, occurred in one 9-girl-year-age patient with genetic disorders who was unvaccinated.

CONCLUSIONS

Measles still represents a serious public health problem worldwide. Vaccination against measles is safe, effective, and cost-effective. High vaccination coverage (>95%) with two doses of measles vaccine is crucial to elimination. Health care professionals play an important role in vaccination uptake and prevention of measles spread during an outbreak.

The importance of immunization in cancer prevention, treatment, and survivorship

Answer questions and earn CME/CNE A measles outbreak originating in California during 2014 and 2015 called attention to the potential for infectious disease outbreaks related to underimmunized populations in the United States and the potential risk to pediatric patients with cancer attending school when such outbreaks occur. Compliance with vaccine recommendations is important for the prevention of hepatitis B-related and human papillomavirus-related cancers and for protecting immunocompromised patients with cancer, and these points are often overlooked, resulting in the continued occurrence of vaccine-preventable neoplastic and infectious diseases and complications. This article provides an overview of the importance of vaccines in the context of cancer and encourages clinician, health system, and public policy efforts to promote adherence to immunization recommendations in the United States. CA Cancer J Clin 2017;67:398-410. © 2017 American Cancer Society.

Measles in Pakistan: Time to make steps towards eradication

World Health Organization (WHO) measles surveillance data report a reduction in cases of measles globally from 67,524 cases in 2015 to 16,846 in 2016, and a reduction in deaths from 546,800 to 114,900 during period of 2000-14. Pakistan is among the five nations where almost a million children did not receive their first dose of measles vaccination, and outbreaks of the disease resulted in 4386 cases in 2011, 14,687 cases in 2012 with 310 deaths. In 2013, about 25,401 cases of measles were reported and 321 affected children died. The measles vaccination coverage is very low in Pakistan for both 1st dose and booster dose. To prevent outbreaks of measles in Pakistan a national vaccination program should be launched side by side with a polio eradication program in each district and township and a campaign should be launched to educate parents on measles vaccination for childrens to reduce the measles case fatality rate.

Emerging Infections and Pertinent Infections Related to Travel for Patients with Primary Immunodeficiencies

In today's global economy and affordable vacation travel, it is increasingly important that visitors to another country and their physician be familiar with emerging infections, infections unique to a specific geographic region, and risks related to the process of travel. This is never more important than for patients with primary immunodeficiency disorders (PIDD). A recent review addressing common causes of fever in travelers provides important information for the general population Thwaites and Day (N Engl J Med 376:548-560, 2017). This review covers critical infectious and management concerns specifically related to travel for patients with PIDD. This review will discuss the context of the changing landscape of infections, highlight specific infections of concern, and profile distinct infection phenotypes in patients who are immune compromised. The organization of this review will address the environment driving emerging infections and several concerns unique to patients with PIDD. The first section addresses general considerations, the second section profiles specific infections organized according to mechanism of transmission, and the third section focuses on unique phenotypes and unique susceptibilities in patients with PIDDs. This review does not address most parasitic diseases. Reference tables provide easily accessible information on a broader range of infections than is described in the text.

Viral posterior uveitis

The causes of posterior uveitis can be divided into infectious, autoimmune, or masquerade syndromes. Viral infections, a significant cause of sight-threatening ocular diseases in the posterior segment, include human herpesviruses, measles, rubella, and arboviruses such as dengue, West Nile, and chikungunya virus. Viral posterior uveitis may occur as an isolated ocular disease in congenital or acquired infections or as part of a systemic viral illness. Many viruses remain latent in the infected host with a risk of reactivation that depends on various factors, including virulence and host immunity, age, and comorbidities. Although some viral illnesses are self-limiting and have a good visual prognosis, others, such as cytomegalovirus retinitis or acute retinal necrosis, may result in serious complications and profound vision loss. Since some of these infections may respond well to antiviral therapy, it is important to work up all cases of posterior uveitis to rule out an infectious etiology. We review the clinical features, diagnostic tools, treatment regimens, and long-term outcomes for each of these viral posterior uveitides.

Zinc supplementation for the treatment of measles in children

BACKGROUND

Measles is an important cause of childhood morbidity and mortality globally, despite increasing vaccine coverage. Zinc plays a significant role in the maintenance of normal immunological functions, therefore supplements given to zinc-deficient children will increase the availability of zinc and could reduce measles-related morbidity and mortality. This is an update of a review first published in 2015.

OBJECTIVES

To assess the effects of zinc supplementation in reducing morbidity and mortality in children with measles.

SEARCH METHODS

We searched CENTRAL (03 February 2017, Issue 2), MEDLINE (1946 to 03 February 2017), Embase (1974 to 03 February 2017), CINAHL (1981 to 03 February 2017), LILACS (1982 to 03 February 2017), Web of Science (1985 to 03 February 2017), and BIOSIS Previews (1985 to 27 June 2014). We also searched ClinicalTrials.gov, the Australian New Zealand Clinical Trials Registry and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) on 03 February 2017 to identify unpublished and ongoing studies.

SELECTION CRITERIA

Randomised controlled trials (RCTs) and quasi-RCTs evaluating the effects of zinc in reducing morbidity and mortality in children with measles.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the studies for inclusion and extracted data on outcomes, details of the interventions, and other study characteristics using a standardised data extraction form. We used risk ratio (RR) and hazard ratio (HR) as measures of effect with 95% confidence intervals (CI). We included only one study, and did not conduct meta-analysis.

MAIN RESULTS

We did not identify any new studies for inclusion in this update. One RCT met our inclusion criteria. The study was conducted in India and included 85 children diagnosed with measles and pneumonia. The trial showed no significant difference in mortality between children with measles and pneumonia who received zinc supplements and those who received placebo (RR 0.34, 95% CI 0.01 to 8.14). There was no significant difference in time to absence of fever between children who received zinc supplements and those who did not (HR 1.08, 95% CI 0.67 to 1.74). No treatment-related side effects were reported in either group. We assessed the overall quality of the evidence as very low.

AUTHORS' CONCLUSIONS

We could not draw any definitive conclusions from this review about the effects of zinc supplementation on clinical outcomes of children with measles due to the very low quality of the evidence available. There is insufficient evidence to confirm or refute the effect of zinc supplementation in children with measles.

Forgotten but Not Gone: Update on Measles Infection for Hospitalists

Measles (rubeola) continues to be endemic and epidemic in many regions of the world. Measles is primarily a disease of childhood, but it can also affect adult populations, and therefore it is important that both adult and pediatric hospitalist physicians be able to recognize it. Although the disease is rarely encountered in the United States, measles infection can spread rapidly across vulnerable populations. In addition, infected adults can develop complications that may require hospitalization for treatment. This review summarizes the typical clinical course and complications of measles infection, along with recommendations for diagnosis and management for both adult and pediatric hospitalists. Journal of Hospital Medicine 2017;12:472-476.

Infectious encephalitis: Management without etiological diagnosis 48hours after onset

Introduction

The etiological diagnosis of infectious encephalitis is often not established 48 hours after onset. We aimed to review existing literature data before providing management guidelines.

Method

We performed a literature search on PubMed using filters such as “since 01/01/2000”, “human”, “adults”, “English or French”, and “clinical trial/review/guidelines”. We also used the Mesh search terms “encephalitis/therapy” and “encephalitis/diagnosis”.

Results

With Mesh search terms “encephalitis/therapy” and “encephalitis/diagnosis”, we retrieved 223 and 258 articles, respectively. With search terms “encephalitis and corticosteroid”, we identified 38 articles, and with “encephalitis and doxycycline” without the above-mentioned filters we identified 85 articles. A total of 210 articles were included in the analysis.

Discussion

Etiological investigations must focus on recent travels, animal exposures, age, immunodeficiency, neurological damage characteristics, and potential extra-neurological signs. The interest of a diagnosis of encephalitis for which there is no specific treatment is also to discontinue any empirical treatments initially prescribed. Physicians must consider and search for autoimmune encephalitis.

Trends in childhood measles vaccination highlight socioeconomic inequalities in Vietnam

OBJECTIVES

To describe trends in measles vaccine coverage rates and their association with socioeconomic characteristics among children from age 12 to 23 months in Vietnam from the year 2000 to 2014.

METHODS

Data were drawn from the Vietnam Multiple Indicator Cluster Surveys in years 2000, 2006, 2011, and 2014. Concentration indices were used to determine the magnitude of socioeconomic inequalities in measles vaccine coverage. Associations between measles vaccine coverage and relevant social factors were assessed using logistic regression.

RESULTS

Socioeconomic inequalities in measles vaccine coverage rates decreased during 2000-2014. Children belonging to ethnic minority groups, having mothers with lower education, and belonging to the poorest group were less likely to receive measles vaccine; although, their vaccine coverage rates did increase with time. Measles vaccine coverage declined among children of mothers with more education and belonging to the wealthiest socioeconomic group.

CONCLUSIONS

Understanding the social factors influencing adherence to recommend childhood vaccination protocols is essential. Attempts to regain and retain herd immunity must be guided by an understanding of these social factors if they are to succeed.

Viral co-infections among children with confirmed measles at hospitals in Hanoi, Vietnam, 2014

OBJECTIVE

To characterize viral co-infections among representative hospitalized measles cases during the 2014 Hanoi outbreak.

METHODS

Throat swabs were collected from 54 pediatric patients with confirmed measles, and molecular diagnostics performed for 10 additional viral respiratory pathogens (Influenza A/H1N1pdm09; A/H3N2 and influenza B; Parainfluenza 1, 2, 3; Respiratory Synctial Virus, RSV; human Metapneumovirus, hMPV; Adenovirus and Picornavirus).

RESULTS

Twenty-one cases (38.9%) showed evidence of infection with other respiratory viruses: 15 samples contained measles plus one additional virus, and 6 samples contained measles plus 2 additional viruses. Adenovirus was detected as a predominant cause of co-infections (13 cases; 24.1%), followed by RSV (6 cases; 11.1%), A/H1N1pdm09 (3 cases; 5.6%), PIV3 (3 cases; 3.7%), Rhinovirus (3 cases; 3.7%) and hMPV (1 case; 1.96%).

CONCLUSIONS

Viral co-infections identified from pediatric measles cases may have contributed to increased disease severity and high rate of fatal outcomes. Optimal treatment of measles cases may require control of multiple viral respiratory pathogens.

Does Measles Vaccination Reduce the Risk of Acute Respiratory Infection (ARI) and Diarrhea in Children: A Multi-Country Study?

BACKGROUND

Pneumonia and diarrhea occur either as complications or secondary infections in measles affected children. So, the integrated Global Action Plan for Pneumonia and Diarrhea (GAPPD) by WHO and UNICEF includes measles vaccination as preventive measure in children. The objective of the study is to examine the effect of measles vaccination on Acute Respiratory Infection (ARI) and diarrhea in children in the Democratic Republic of Congo, Ethiopia, India, Nigeria, and Pakistan.

METHODS

We analyzed data from the most recent rounds of Demographic and Health Surveys (DHS) in the selected countries. We included children age 12-59 months in the analysis. We used multivariable binary logistic regression to examine the effect of measles vaccination on ARI and diarrhea in children. We also estimated Vaccination Effectiveness (VE).

FINDINGS

More than 60 percent of the children age 12-59 months were given measles vaccine before the survey in the Democratic Republic of Congo, Ethiopia, India and Pakistan. Children who were given the measles vaccine were less likely to suffer from ARI than unvaccinated children in India and Pakistan. Children who were given the measles vaccine had a lower risk of diarrhea than those who did not receive it in all the selected countries except Ethiopia. Measles vaccination was associated with reduction in ARI cases by 15-30 percent in India and Pakistan, and diarrhea cases by 12-22 percent in the Democratic Republic of Congo, India, Nigeria and Pakistan.

CONCLUSION

The receipt of the measles vaccine was associated with decrease in ARI and diarrhea in children. The immunization program must ensure that each child gets the recommended doses of measles vaccine at the appropriate age. The measles vaccination should be given more attention as a preventive intervention under the Global Action Plan for Pneumonia and Diarrhea (GAPPD) in all low and middle-income countries.

Detection of Measles Virus Genotypes B3, D4, D5, D8, and H1 in the Surveillance System in Hokkaido, Japan, 2006-2015, the Last Decade toward the Elimination

Measles is an acute and highly contagious disease caused by measles virus (MeV). The government of Japan, following the last epidemic in 2007 and 2008, which was caused by genotype D5 strains, introduced a catch-up-vaccination program for teenagers during Japan fiscal years 2008-2012 and a mandatory case-based reporting system for the nationwide elimination. Furthermore, laboratory confirmation of measles cases by genotyping of isolates has been performed to clarify the source of infection and support the interruption of measles cases. Owing to these preventive measures, the number of measles cases has been steadily decreasing after the last epidemic. In March 2015, Japan was internationally verified as having achieved measles elimination by the World Health Organization Regional Office for the Western Pacific. The continuous elimination of measles and high levels of vaccination coverage for MeV have been maintained nationally. However, imported or import-associated cases of measles have sporadically occurred during this time. After the last nationwide epidemic, 17 imported or import-associated measles cases (MeV strains identified as genotypes H1, D4, D8, and B3) were reported in Hokkaido, the northern islands of Japan. In this study, we present the occurrence of measles and surveillance activities in Hokkaido during 2006-2015.

Adenovirus Type 7 Pneumonia in Children Who Died from Measles-Associated Pneumonia, Hanoi, Vietnam, 2014

During a 2014 measles outbreak in Vietnam, postmortem pathologic examination of hospitalized children who died showed that adenovirus type 7 pneumonia was a contributory cause of death in children with measles-associated immune suppression. Adenovirus type 7 pneumonia should be recognized as a major cause of secondary infection after measles.

Victims, vectors and villains: are those who opt out of vaccination morally responsible for the deaths of others?

Mass vaccination has been a successful public health strategy for many contagious diseases. The immunity of the vaccinated also protects others who cannot be safely or effectively vaccinated-including infants and the immunosuppressed. When vaccination rates fall, diseases like measles can rapidly resurge in a population. Those who cannot be vaccinated for medical reasons are at the highest risk of severe disease and death. They thus may bear the burden of others' freedom to opt out of vaccination. It is often asked whether it is legitimate for states to adopt and enforce mandatory universal vaccination. Yet this neglects a related question: are those who opt out, where it is permitted, morally responsible when others are harmed or die as a result of their decision? In this article, we argue that individuals who opt out of vaccination are morally responsible for resultant harms to others. Using measles as our main example, we demonstrate the ways in which opting out of vaccination can result in a significant risk of harm and death to others, especially infants and the immunosuppressed. We argue that imposing these risks without good justification is blameworthy and examine ways of reaching a coherent understanding of individual moral responsibility for harms in the context of the collective action required for disease transmission. Finally, we consider several objections to this view, provide counterarguments and suggest morally permissible alternatives to mandatory universal vaccination including controlled infection, self-imposed social isolation and financial penalties for refusal to vaccinate.

Host-Pathogen Interactions in Measles Virus Replication and Anti-Viral Immunity

The measles virus (MeV) is a contagious pathogenic RNA virus of the family Paramyxoviridae, genus Morbillivirus, that can cause serious symptoms and even fetal complications. Here, we summarize current molecular advances in MeV research, and emphasize the connection between host cells and MeV replication. Although measles has reemerged recently, the potential for its eradication is promising with significant progress in our understanding of the molecular mechanisms of its replication and host-pathogen interactions.

Organization, Function, and Therapeutic Targeting of the Morbillivirus RNA-Dependent RNA Polymerase Complex

The morbillivirus genus comprises major human and animal pathogens, including the highly contagious measles virus. Morbilliviruses feature single stranded negative sense RNA genomes that are wrapped by a plasma membrane-derived lipid envelope. Genomes are encapsidated by the viral nucleocapsid protein forming ribonucleoprotein complexes, and only the encapsidated RNA is transcribed and replicated by the viral RNA-dependent RNA polymerase (RdRp). In this review, we discuss recent breakthroughs towards the structural and functional understanding of the morbillivirus polymerase complex. Considering the clinical burden imposed by members of the morbillivirus genus, the development of novel antiviral therapeutics is urgently needed. The viral polymerase complex presents unique structural and enzymatic properties that can serve as attractive candidates for druggable targets. We evaluate distinct strategies for therapeutic intervention and examine how high-resolution insight into the organization of the polymerase complex may pave the path towards the structure-based design and optimization of next-generation RdRp inhibitors.

Resurgence of Vaccine-Preventable Diseases in the United States: Anesthetic and Critical Care Implications

Vaccine-preventable diseases (VPDs) such as measles and pertussis are becoming more common in the United States. This disturbing trend is driven by several factors, including the antivaccination movement, waning efficacy of certain vaccines, pathogen adaptation, and travel of individuals to and from areas where disease is endemic. The anesthesia-related manifestations of many VPDs involve airway complications, cardiovascular and respiratory compromise, and unusual neurologic and neuromuscular symptoms. In this article, we will review the presentation and management of 9 VPDs most relevant to anesthesiologists, intensivists, and other hospital-based clinicians: measles, mumps, rubella, pertussis, diphtheria, influenza, meningococcal disease, varicella, and poliomyelitis. Because many of the pathogens causing these diseases are spread by respiratory droplets and aerosols, appropriate transmission precautions, personal protective equipment, and immunizations necessary to protect clinicians and prevent nosocomial outbreaks are described.

Measles Virus Host Invasion and Pathogenesis

Measles virus is a highly contagious negative strand RNA virus that is transmitted via the respiratory route and causes systemic disease in previously unexposed humans and non-human primates. Measles is characterised by fever and skin rash and usually associated with cough, coryza and conjunctivitis. A hallmark of measles is the transient immune suppression, leading to increased susceptibility to opportunistic infections. At the same time, the disease is paradoxically associated with induction of a robust virus-specific immune response, resulting in lifelong immunity to measles. Identification of CD150 and nectin-4 as cellular receptors for measles virus has led to new perspectives on tropism and pathogenesis. In vivo studies in non-human primates have shown that the virus initially infects CD150⁺ lymphocytes and dendritic cells, both in circulation and in lymphoid tissues, followed by virus transmission to nectin-4 expressing epithelial cells. The abilities of the virus to cause systemic infection, to transmit to numerous new hosts via droplets or aerosols and to suppress the host immune response for several months or even years after infection make measles a remarkable disease. This review briefly highlights current topics in studies of measles virus host invasion and pathogenesis.

Estimating the Number of Measles-Susceptible Children and Adolescents in the United States Using Data From the National Immunization Survey-Teen (NIS-Teen)

Despite high measles vaccination rates in the United States, imported measles cases have led to outbreaks in the United States. These outbreaks have not led to sustained measles transmission; however, with each birth cohort of children not fully vaccinated against measles, measles-susceptible individuals accumulate in the population. The total number of measles-susceptible children and adolescents in the United States is unknown. We used age-specific measles vaccination data from the National Immunization Survey-Teen (2008-2013) to estimate the number of measles-susceptible children aged 17 years or younger, accounting for vaccine effectiveness, infant protection from maternal antibodies, and loss of immunity following childhood cancer treatment. Approximately 12.5% of US children and adolescents are susceptible to measles, with the highest levels of susceptibility being observed in children aged 3 years or younger (24.7% are susceptible to measles). In sensitivity analyses, we found that a sustained decrease in measles vaccination coverage from 91.9% (2013 level) to 90.0% (2009 level) would add nearly 1.2 million susceptible children and adolescents (thus making 14.2% of those aged 17 years or younger susceptible to measles). This reemphasizes the need for high measles vaccination coverage to support population-level immunity and prevent reestablishment of indigenous measles transmission in the United States.

Measles

Measles is an infectious disease in humans caused by the measles virus (MeV). Before the introduction of an effective measles vaccine, virtually everyone experienced measles during childhood. Symptoms of measles include fever and maculopapular skin rash accompanied by cough, coryza and/or conjunctivitis. MeV causes immunosuppression, and severe sequelae of measles include pneumonia, gastroenteritis, blindness, measles inclusion body encephalitis and subacute sclerosing panencephalitis. Case confirmation depends on clinical presentation and results of laboratory tests, including the detection of anti-MeV IgM antibodies and/or viral RNA. All current measles vaccines contain a live attenuated strain of MeV, and great progress has been made to increase global vaccination coverage to drive down the incidence of measles. However, endemic transmission continues in many parts of the world. Measles remains a considerable cause of childhood mortality worldwide, with estimates that >100,000 fatal cases occur each year. Case fatality ratio estimates vary from <0.01% in industrialized countries to >5% in developing countries. All six WHO regions have set goals to eliminate endemic transmission of MeV by achieving and maintaining high levels of vaccination coverage accompanied by a sensitive surveillance system. Because of the availability of a highly effective and relatively inexpensive vaccine, the monotypic nature of the virus and the lack of an animal reservoir, measles is considered a candidate for eradication.

The Costs and Valuation of Health Impacts of Measles and Rubella Risk Management Policies

National and global health policymakers require good information about the costs and benefits of their investments in measles and rubella immunization programs. Building on our review of the existing measles and rubella health economics literature, we develop inputs for use in regional and global models of the expected future benefits and costs of vaccination, treatment, surveillance, and other global coordination activities. Given diversity in the world and limited data, we characterize the costs for countries according to the 2013 World Bank income levels using 2013 U.S. dollars (2013$US). We estimate that routine immunization and supplemental immunization activities will cost governments and donors over 2013$US 2.3 billion per year for the foreseeable future, with high-income countries accounting for 55% of the costs, to vaccinate global birth cohorts of approximately 134 million surviving infants and to protect the global population of over 7 billion people. We find significantly higher costs and health consequences of measles or rubella disease than with vaccine use, with the expected disability-adjusted life year (DALY) loss for case of disease generally at least 100 times the loss per vaccine dose. To support estimates of the economic benefits of investments in measles and/or rubella elimination or control, we characterize the probabilities of various sequelae of measles and rubella infections and vaccine adverse events, the DALY inputs for health outcomes, and the associated treatment costs. Managing measles and rubella to achieve the existing and future regional measles and rubella goals and the objectives of the Global Vaccine Action Plan will require an ongoing commitment of financial resources that will prevent adverse health outcomes and save the associated treatment costs.

Economic Costs of Measles Outbreak in the Netherlands, 2013-2014

In 2013 and 2014, the Netherlands experienced a measles outbreak in orthodox Protestant communities with low measles–mumps–rubella vaccination coverage. Assessing total outbreak costs is needed for public health outbreak preparedness and control. Total costs of this outbreak were an estimated $4.7 million.

Molecular detection and genetic characterization of circulating measles virus in northern Italy

BACKGROUND

Laboratory diagnosis of measles virus (MV) infection and genetic characterization of circulating MV play an essential role in measles surveillance, allowing proper interventions to interrupt endemic transmission.

OBJECTIVES

We describe results obtained using serological and molecular methods to confirm MV infection among suspected cases reported in a large region in the north of Italy during 2010-2014 and the genotyping of the MV strains detected.

STUDY DESIGN

Three hundred seventy-two samples (361 urine and 11 oral fluids) were tested for MV-RNA detection. In 281 cases, the serological results for MV-IgM detection were also available.

RESULTS

A total of 276 cases were classified as confirmed measles and MV-RNA detection resulted positive for 239/276 cases. Nucleotide sequence analysis revealed sporadic cases of genotypes D9 and different circulations of endemic MV strains (D8, D4 and B3).

CONCLUSIONS

This data suggests that there is still an unvaccinated part of the population maintaining the endemic circulation of MV in Italy.

Clinical and immunological analysis of measles patients admitted to a Beijing hospital in 2014 during an outbreak in China

At the end of 2013, China reported a countrywide outbreak of measles. From January to May 2014, we investigated the clinical and immunological features of the cases of the outbreak admitted to our hospital. In this study, all 112 inpatients with clinically diagnosed measles were recruited from the 302 Military Hospital of China. The virus was isolated from throat swabs from these patients, and cytokine profiles were examined. By detecting the measles virus of 30 of the 112 patients, we found that this measles outbreak was of the H1 genotype, which is the major strain in China. The rates of complications, specifically pneumonia and liver injury, differed significantly in patients aged 18 years: pneumonia was more common in children, while liver injury was more common in adults. Pneumonia was a significant independent risk factor affecting measles duration. Compared to healthy subjects, measles patients had fewer CD4+IL-17+, CD4+IFN-γ +, and CD8+IFN-γ + cells in both the acute and recovery phases. In contrast, measles patients in the acute phase had more CD8+IL-22+ cells than those in recovery or healthy subjects. We recommend that future studies focus on the age-related distribution of pneumonia and liver injury as measles-related complications as well as the association between immunological markers and measles prognosis.