Vaccine-modified measles in previously immunized children in Accra, Ghana: clinical, virological and serological parameters

Qualitative Variation among Commercial Immunoassays for Detection of Measles-Specific IgG

Measurement of measles virus-specific IgG is used to assess presumptive evidence of immunity among immunocompetent individuals with uncertain immune or vaccination status. False-negative test results may lead to unnecessary quarantine and exclusion from activities such as employment, education, and travel or result in unnecessary revaccination. In contrast, false-positive results may fail to identify susceptible individuals and promote spread of disease by those who are exposed and unprotected. To better understand the performance characteristics of tests to detect measles IgG, we compared five widely used, commercially available measles IgG test platforms using a set of 223 well-characterized serum samples. Measles virus neutralizing antibodies were also measured by in vitro plaque reduction neutralization, the gold standard method, and compared to IgG test results. Discrepant results were observed for samples in the low-positive ranges of the most sensitive tests, but there was good agreement across platforms for IgG-negative sera and for samples with intermediate to high levels of IgG. False-negative test results occurred in approximately 11% of sera, which had low levels of neutralizing antibody.

Are vaccinated measles cases protected against severe disease?

OBJECTIVES

We aimed to estimate vaccine effectiveness against severe measles based on the number of vaccine doses administered and the time since last vaccination.

PATIENTS AND METHODS

We included measles cases aged at least 2 years and born since 1980 who were notified in France between 2006 and mid-2019. We considered two severity levels (moderate, severe) and calculated adjusted relative risks (aRR) using multinomial logistic regression.

RESULTS

We included 10,399 cases. The risk of severe measles in two-dose vaccine recipients was 71% (aRR = 0.29 [95%CI 0.12-0.72]) and 83% (aRR = 0.17 [95%CI 0.04-0.70]) lower than in unvaccinated cases, if the time since last dose was less or more than 15 years, respectively. The risk of moderate disease followed a similar pattern.

CONCLUSIONS

Two-dose measles vaccination provided long-term protection against severe cases, even after vaccine failures. These findings underscore the need for compliance to the recommended measles vaccination schedule to prevent severe cases.

Outbreak of measles among persons with secondary vaccine failure, China, 2018

Although the incidence of measles has been dramatically reduced by the highly effective measles vaccine, cases of measles and outbreaks continue to occur in vaccinated population because of immunization failure. We report on an outbreak in which two cases had previous evidence of measles immunity and then one of them transmitted measles infection to an unvaccinated contact. The cases and contacts exposed during the outbreak were investigated. Clinical information and epidemiological information were obtained. Serum samples were collected for measles-specific immunoglobulin M (IgM), immunoglobulin G (IgG) and IgG avidity. Throat swabs were obtained to test for measles virus RNA. Two measles cases (case 1 and case 2) who have received one dose of MCV in past 5 years, and both working at a hospital in Beijing, occurred in 18th and 20nd of January, respectively. Out of the 102 contacts, one additional case (case 3) who had a close, long-term co-exposure with case 1 was reported subsequently. No additional cases of measles occurred among 15 contacts of case 3. The index case was not ascertained through the outbreak review. All three cases had laboratory confirmation of measles infection. Both case 1 and case 2 had high-avidity IgG antibody characteristic of a secondary immune response and developed a modified clinical presentation. This report confirms that a vaccinated individual with documented secondary vaccine failure (SVF) could transmit measles and is the second report since a New York City outbreak (the first report in China). The outbreak represented a series of rare events, so we can conclude that the SVF individuals in the transmission chain of measles are unlikely to threaten measles elimination. The importance of the herd immunity in preventing transmission and sensitive surveillance activities in case of misdiagnosis is emphasized.

Measles transmission in immunized and partially immunized air travellers

Most cases of measles in Australia are associated with travel or acquired from travellers from overseas. This study presents a series of three secondary cases of measles acquired through contact with a case of infectious measles acquired in China. Two of the cases were fully immunized siblings sitting eight rows behind the index case on a 4(1/2)-h flight from Singapore. The third case was acquired in the airport where the index case was in transit. The report highlights the travel-associated risk of measles and discusses the heredity of vaccine-induced measles immunity.

Measles cases in highly vaccinated population of Novosibirsk, Russia, 2000-2005

While the proportion of measles cases in vaccinees is expected to increase as vaccine coverage increases, such cases must be carefully investigated. The present study was conducted to examine possible contributions to vaccine failures (VFs) and to genetically characterize measles virus (MV) strains circulating in Novosibirsk, Russia during 2000-2005. Totally, 27 adult measles patients admitted to a regional hospital were prospectively enrolled in our study. Genetic characterization of the MV strains revealed circulation of genotypes A, D4 and D6 between 2000 and 2003 years; a genotype D6 MV was associated with the 2005 measles outbreak. Based on IgG avidity testing, half of the vaccinated patients demonstrated evidence of secondary vaccine failure (SVF). Patients, representing both levels of vaccine failure in our study were characterized by the lack of protective titers of neutralizing antibodies against circulating MVs, despite high IgG levels in many cases and high IgG avidity in SVF cases.

High CD4/CD45RO+ and CD8/CD45RO+ frequencies in children with vaccine-modified measles

BACKGROUND

Despite availability and wide vaccine coverage, measles infections still occur especially in developing countries. An outbreak of measles occurred among previously immunized older Ghanaian children who had milder clinical symptoms with measles-specific IgG antibodies that could have been attributed to secondary vaccine failure, suggesting that the infection was vaccine-modified measles (VMM).

METHODS

Two-color immunophenotyping of the peripheral blood mononuclear cells was performed at acute, recovery and convalescence phases for 19 VMM patients (mean age 6.2 +/- 3.5 years) using flow cytometry, and compared with that of 20 healthy, sex- and age-matched controls.

RESULTS

The results showed a significantly higher memory helper (CD4(+)/CD45RO(+)) cell frequency and increased suppressor cell (CD8(+)/CD45R0(+)) frequency in VMM patients compared to healthy controls. There were no complications and all the patients recovered completely.

CONCLUSIONS

These findings show that the mild symptoms in patients with VMM may have correlated with the increase of memory T cells, which is in sharp contrast with previous reports on acute measles infection. This may suggest that the intact immunologic memory cells could have been crucial for the resolution of VMM.

Measles in Minsk, Belarus, 2001–2003: Clinical, virological and serological parameters

BACKGROUND

A number of cases of measles have been reported in the Republic of Belarus despite vaccine coverage of 98%. The absence of information on measles virus genotypes circulating in the Republic of Belarus has made it difficult to asses the situation.

OBJECTIVES

The purpose of this study was to isolate and sequence measles virus strains from clinical cases in Minsk, Belarus, and to estimate the role of vaccine failure in those cases.

STUDY DESIGN

Between 2001 and 2003 years, 14 measles cases admitted to the Hospital of Infectious Diseases of Minsk were enrolled in our study. Clinical, routine laboratory, as well as serological and virological examinations were carried out. Detection of measles antibodies and IgG avidity testing was performed using commercial test kits. All measles cases were confirmed by RT-PCR and phylogenetically characterized.

RESULTS

Only 42.9% of the cases met the WHO laboratory criteria for measles, however, all cases were confirmed by RT-PCR. Most of the measles cases were attributed to secondary vaccine failure (SVF). Phylogenetic analysis revealed the presence of genotype A virus strains in 2001 and 2002 with D6 and D7 genotypes in 2003.

CONCLUSIONS

For the first time, MVs were genetically characterized in Belarus. Our results suggest that in a highly vaccinated population, most of measles cases represent vaccine failures and are vaccine-modified. Our results also indicate that confirmation of a clinical diagnosis of vaccine-modified measles requires a combination of serological and virological tests.

Season of death and birth predict patterns of mortality in Burkina Faso

BACKGROUND

Mortality in developing countries has multiple causes. Some of these causes are linked to climatic conditions that differ over the year. Data on season-specific mortality are sparse.

METHODS

We analysed longitudinal data from a population of approximately 35,000 individuals in Burkina Faso. During the observation period 1993-2001, a total number of 4,098 deaths were recorded. The effect of season on mortality was investigated separately by age group as (i) date of death and (ii) date of birth. For (i), age-specific death rates by month of death were calculated. The relative effect of each month was assessed using the floating relative risk method and modelled continuously. For (ii), age-specific death rates by month of birth were calculated and the mean date of birth among deaths and survivors was compared.

RESULTS

Overall mortality was found to be consistently higher during the dry season (November to May). The pattern was seen in all age groups except in infants where a peak was seen around the end of the rainy season. In infants we found a strong association between high mortality and being born during the time period September to February. No effect was seen for the other age groups.

CONCLUSIONS

The observed excess mortality in young children at or around the end of the rainy season can be explained by the effects of infectious diseases and, in particular, malaria during this time period. In contrast, the excess mortality seen in older children and adults during the early dry season remains largely unexplained although specific infectious diseases such as meningitis and pneumonia are possible main causes. The association between high infant mortality and being born at around the end of the rainy season is probably explained by most of the malaria deaths in areas of high transmission intensity occurring in the second half of infancy.

The development of a plant-based vaccine for measles

Plant-based vaccination strategies have the potential to overcome the limitations of the current measles vaccine. The measles virus hemagglutinin (MV-H) protein has been expressed in tobacco. Oral immunisation of mice with plant-derived MV-H protein resulted in MV-specific antibodies and secretory IgA, indicative of humoral and mucosal immune responses. In addition, boosting with oral plant-derived MV-H protein following a MV-H DNA prime, resulted in a greater response than could be induced with either vaccine alone. Collectively, this research represents a significant step towards an effective oral measles vaccine that would be temperature-stable, easy to administer and amenable to inexpensive manufacture.

Acute infectious mononucleosis and coincidental measles virus infection

BACKGROUND

Both Epstein-Barr and measles viruses (MV) cause immune suppression, and the association of the two viruses is evaluated as life threatening. The cell immune impairment caused by simultaneous Epstein-Barr and measles viral infections was responsible for the complicated course of the disease in all described previously reports and for unfavorable outcomes in most of the cases. Timely diagnosis of coincidental viral infections could be a useful predictor for the clinical course and complications. Diagnosis must be based on an accurate assessment of clinical, hematologic, serologic manifestations and supported by appropriate laboratory methods. Recognizing the infectious etiology of concomitant infections is important for both clinicians and epidemiologists.

OBJECTIVE

To describe a case report of a 20-year-old woman previously vaccinated against measles infected with acute mononucleosis and coincidental measles virus infection.

STUDY DESIGN

The clinical, routine laboratory, as well as serological and virologic findings of this patient were scrutinized. Special emphasis was placed on the use of RT-PCR/PCR for confirming the involvement of both measles virus and Epstein-Barr virus (EBV) in this patient's illness.

RESULTS

Infectious mononucleosis was not suspected at admission to the hospital. The final diagnosis of a concomitant measles virus infection and acute infectious mononucleosis was facilitated using viral serology to detect virus-specific IgG and IgM antibodies and by RT-PCR for the detection of measles virus RNA and EBV DNA from peripheral blood monocyte cells (PBMC).

CONCLUSION

The present report highlights the difficulty of diagnosing two coincidental virus infections on clinical grounds. Serological and molecular laboratory methods, specifically the PCR (RT-PCR) analysis, are found to be useful for confirming the concomitant viral infections and proper identification of the infecting pathogens.

Evaluation of the measles clinical case definition

An accurate system of identifying and classifying suspected measles cases is critical for the measles surveillance system in the United States. To examine the performance of the clinical case definition in predicting laboratory confirmation of suspected cases of measles, we reviewed 4 studies conducted between 1981 and 1994. A clinical case definition was examined that included a generalized maculopapular rash, fever (>or=38.3 degrees C, if measured), and either a cough, coryza, or conjunctivitis. Serological confirmation of measles was done either by hemagglutination inhibition assay, complement fixation assay, or enzyme immunoassays. The positive predictive value of the clinical case definition decreased from 74% to 1% as incidence decreased from 171 cases/100000 population to 1.3 cases/100000 population. Sensitivity was high, and for the larger studies with the most precise estimates, sensitivity was 76%-88%. The low positive predictive value of the clinical case definition in settings of low incidence demonstrates that serological confirmation is essential to ensure an accurate diagnosis of measles when measles is rare.

Progress in the control of measles in Ghana, 1980-2000

By review of available literature, routine surveillance data, coverage surveys, and hospital records, measles control in Ghana was assessed since vaccinations began in 1978. Nationally, measles vaccination coverage increased from 24% in 1980 to 84% in 2000. This achievement is attributed to health sector reforms that included a higher district share of the total recurrent health budget from 20% in 1996 to 42% in 1999. The budget reallocation resulted in improved access to immunization services, supply procurement, transport management, staff motivation, and information flow. On the client side, the age of the child, socioeconomic status of parents, and type of prenatal care were associated with vaccination coverage. Routine vaccination coverage of >80% has resulted in lower measles incidence, a longer interepidemic interval, and a shift in cases to older children. Ghana recently developed a strategic plan to reduce measles deaths to near zero.

The challenge of improving the efficacy of measles vaccine

Despite a safe and effective measles vaccine, measles still claims an estimated 800,000 lives per year mostly among children in developing countries. This paper deals with strategies to improve vaccine efficacy and prevent unnecessary deaths, including considerations of one dose at 9 months strategy for developing countries, strain of vaccine, potency and number of doses of measles vaccine. After more than 20 years of measles immunisation in the developing world, the epidemiology of measles is radically changed, and the absence of measles epidemics might lead to waning immunity due to less clinical and subclinical infections boosting the antibody level. An increasing proportion of mothers are vaccinated, thus transferring a lower maternal antibody level to their infants who will be susceptible to measles at a younger age. The strategies to limit nosocomial measles infection and spread of measles epidemics are reviewed. Though the measles elimination programmes have been very effective in the Americas, it seems unlikely that they will be equally effective in the rest of the world. Even if eradication should be possible, it might be unwise to stop measles vaccination because the vaccine apparently has beneficial effects and because it would make measles a likely weapon for bio-terrorism. If we are unlikely to get rid of measles and measles vaccine, it might be wise to study further some of the many unanswered questions regarding the long-term effects of measles and measles vaccination.

Multiplexed immunoassays by flow cytometry for diagnosis and surveillance of infectious diseases in resource-poor settings

An accurate, rapid and cost-effective diagnosis is the cornerstone of efficient clinical and epidemiological management of infections. Here we discuss the relevance of an emerging technology, multiplexed immunoassays read by flow cytometry, for the diagnosis of infectious diseases. In these assays, multiple fluorescent microspheres, conjugated to different antigens or antibodies, constitute the solid phase for detecting antibodies or antigens in biological samples. These assays seem to be more sensitive than traditional immunoassays, have a high throughput capacity, and provide a wide analytical dynamic range. Additionally, they have multiplexing ability-ie, they are capable of measuring multiple antibodies or antigens simultaneously. We discuss four different areas where this technology could make an impact in resource-poor settings: (i) infections causing rash and fever in children; (ii) sero-epidemiological studies on vaccine-preventable diseases; (iii) management of genital ulcers and vaginal discharge; and (iv) screening of infections in blood banking. We predict a widespread use for a new breed of small, affordable, practical flow cytometers as field instruments for replacing ELISA and RIA tests, which will also be capable of doing cellular immunological tests such as CD4+ T-cell enumeration and Plasmodium falciparum detection in whole blood.