A Measles Outbreak in a Local Children's Hospital in Korea, 2019

A measles outbreak with 20 confirmed cases occurred at a local children's hospital in Daejeon from March 28 to April 21, 2019. The index patient was a 7-month-old girl with a recent history of travel to Vietnam. Contact tracing, active surveillance, and post-exposure prophylaxis were conducted by health authorities. Among the 20 patients, 11 (55%) were infants (0-11 months of age), three (15%) were aged 1-3 years, one (5%) was aged 4 years, and five (25%) were adults. Fifteen (75%) patients did not have a history of measles vaccination, and five (25%) had received only one vaccine dose. This study described the importance of prompt application of infection control measures in susceptible environments, including hospitals. Age-appropriate vaccination and providing information on infectious diseases to international travelers and multicultural families in Korea is vital.

Are Boosters Necessary If Adult Patients Do Not Achieve Seroconversion After 2 Doses of the MMR Vaccine?

The Centers for Disease Control (CDC) recommend 2 documented doses of the MMR (measles-mumps-rubella) vaccine for adequate measles, mumps, and rubella immunity for all children and most adults. Sometimes, individuals are asked to provide serologic proof of immunity to measles, mumps, and/or rubella for educational or employment purposes. In other instances, serologic testing may be used to help clarify whether an individual has immunity to measles, mumps, and/or rubella. These serologic tests may sometimes show negative or equivocal antibody titers to measles, mumps and/or rubella, raising the question of adequate immunity. This report provides practical guidance for clinicians on when to use serologic testing to determine measles, mumps, and rubella immunity.

Immunogenicity after outbreak response immunization activities among young healthcare workers with secondary vaccine failure during the measles epidemic in Korea, 2019

BACKGROUND

Despite high vaccination coverage, measles outbreaks have been reported in measles elimination countries, especially among healthcare workers in their 20 and 30 s. This study was designed to identify measles-susceptible individuals and to evaluate whether primary or secondary vaccine failure occurred during measles outbreak response immunization (ORI) activities.

METHODS

The study population was divided into three groups as follows: natural immunity group (Group 1), vaccine-induced immunity group (Group 2), and vaccine failure group (Group 3). We evaluated the immunogenicity of measles among healthcare workers using three methods-enzyme-linked immunoassays, plaque reduction neutralization tests, and avidity assays. The results were assessed at baseline, 4 weeks after, and 6 months after the completion of measles-mumps-rubella (MMR) vaccination.

RESULTS

In total, 120 subjects were enrolled, with 40 subjects in each group. The median age of Group 3 was 29 years, which was significantly lower than that of the other groups. The baseline negative measles virus (MeV) IgG in Group 3 increased to a median value of 165 AU/mL at 4 weeks after ORI and was lower than that in Groups 1 and 2. The median neutralizing antibody titer was highest in Group 1, and this was significantly different from that in Group 2 or Group 3 at 4 weeks (944 vs. 405 vs. 482 mIU/mL, P = 0.001) and 6 months (826 vs. 401 vs. 470, P = 0.011) after ORI. The rates of high MeV avidity IgG were highest in Group 2, and these were significantly different from those in Groups 1 or 3 at 4 weeks (77.5 vs. 90% vs. 88.6%, P = 0.03) and 6 months (81 vs. 94.8 vs. 82.1%, P = 0.01) after ORI.

CONCLUSIONS

Considering the MeV-neutralizing antibodies and IgG avidity after MMR vaccination in measles-susceptible group, vaccine failure is inferred as secondary vaccine failure, and further data regarding the maintenance of immunogenicity are needed based on long-term data. The MeV-neutralizing antibody levels were highest in the natural immunity group, and the primary vaccine-induced immunity group showed the highest rates of high MeV IgG avidity.

Intralesional Immunotherapy with Measles-Mumps-Rubella Vaccine for Recalcitrant Facial Warts: A Report of Two Cases

Warts are common benign skin tumors caused by human papilloma viruses. Recalcitrant facial warts tend to be cosmetically embarrassing to patients and difficult to treat for doctors. Recently, intralesional immunotherapy by antigens like Bacille Calmette-Guerin vaccine, candida antigen, and measles, mumps, and rubella (MMR) vaccine has shown promising efficacy. Here, we report two cases of Omani men who presented with recalcitrant facial warts that resolved completely with a single intralesional injection of the MMR vaccine.

Impact of an accelerated measles-mumps-rubella (MMR) vaccine schedule on vaccine coverage: An ecological study among London children, 2012-2018

BACKGROUND

Vaccination coverage of dose two of MMR (MMR2) at 5th birthday has been consistently low in London and measured 76.3% in 2018/19. Since the early 2000s seven boroughs in London started offering dose two earlier, from 15 to 18 months onwards instead of the recommended 3 years 4 months. In this study we investigate whether the accelerated schedule of MMR2 leads to a change in coverage of MMR2 and other childhood vaccines with an ecological study using childhood immunisation data from 2009 to 2018 in London.

METHODS

We modelled coverage used generalized estimating equations (GEE) adjusted for year and DTaP/IPV/Hib3 coverage measured at 2nd birthday as a proxy for baseline local vaccination programme performance to determine the percentage point difference in coverage of MMR2 and other childhood vaccines.

RESULTS

Average MMR2 coverage was higher among early implementing boroughs from 2012/13 onwards. Coverage difference was highest in 2017/18 (9.2 percentage points, 95% CI 4.8, 13.5, p < 0.001). On average over the 6 years, compared to London boroughs on the routine schedule, MMR2 coverage among early implementing boroughs was 3.3 percentage points higher (95% CI 1.3, 5.3, p = 0.01) after adjusting for DTaP/IPV/Hib3 coverage, IMD score and year.

CONCLUSION

Earlier vaccination of MMR2 is associated with significantly higher coverage at five years for this vaccine in London. Further research is needed to assess the association at a more granular level, but our findings underline a potential opportunity to increase MMR coverage.

Post Vaccine Rubella During a Measles Outbreak: Clinical Case

Rubella is a vaccine preventable infection, and congenital rubella the most feared complication of this disease. Although young adult women are at greatest risk of post-vaccine rubella, this is also the group who potentially benefits the most from vaccine protection. Since post-vaccine disease has a mild and self-limited course, the benefit clearly exceeds the risk. During a measles outbreak in the north of Portugal, a 38-year-old woman presented with cervical posterior lymphadenopathies, fever and a maculo-papular rash one week after the administration of the measles, mumps and rubella vaccine. Measles was discarded and rubella viremia was demonstrated. Symptoms of rubella are non-specific and laboratory confirmation is essential. This is particularly relevant during a measles outbreak.

Parental attitudes and decisions regarding MMR vaccination during an outbreak of measles among an undervaccinated Somali community in Minnesota

Incidence of measles is increasing in the US, largely due to transmission among growing unvaccinated communities. To elucidate predictors of parental decision to obtain measles, mumps, and rubella (MMR) vaccine for unvaccinated children during a measles outbreak, we surveyed families among a vaccine-hesitant Somali community in Minnesota. The survey assessed attitudes and beliefs about MMR vaccine, motivators for vaccinating, and intention to vaccinate future children on time. Among 300 families surveyed, 95% vaccinated their child with MMR due to fear of measles. The predominating parental concern about MMR vaccine (71%) was a fallacious presumed connection between vaccination and autism. Only 41% of parents intended to vaccinate future children on time with MMR; parents who received recommendations for MMR vaccination from multiple sources were more likely than other parents to intend to do so. These findings support the importance of diverse outreach efforts to increase vaccine coverage among undervaccinated communities.

Rubella virus-specific humoral immune responses and their interrelationships before and after a third dose of measles-mumps-rubella vaccine in women of childbearing age

In the U.S., measles, mumps, and rubella vaccination is recommended as two vaccine doses. A third dose of measles-mumps-rubella (MMR) vaccine is being administered in certain situations (e.g., identified seronegativity and during outbreaks). We studied rubella-specific humoral immunity (neutralizing antibody, enzyme-linked immunosorbent assay/ELISA IgG titer and antibody avidity) and the frequencies of antigen-specific memory B cells before and after a third dose of MMR-II in 109 female participants of childbearing age (median age, 34.5 years old) from Olmsted County, MN, with two documented prior MMR vaccine doses. The participants were selected from a cohort of 1117 individuals if they represented the high and the low ends of the rubella-specific antibody response spectrum. Of the 109 participants, we identified four individuals (3.67% of all study participants; 7.14% of the low-responder group) that were seronegative at Baseline (rubella-specific ELISA IgG titers <10 IU/mL), suggesting a lack of protection against rubella before receipt of a third MMR vaccine dose. The peak geometric mean neutralizing antibody titer one month following the third dose of MMR vaccine for the cohort was 243 NT₅₀ (CI; 241, 245), which is expected for a cohort with two doses of MMR, and the peak geometric mean IgG titer was 150 IU/mL (CI; 148, 152) with no seronegative individuals at Day 28. One-third of all subjects (31.8% for the neutralizing antibody; 30.8% for the IgG titer) experienced a significant boost (≥4-fold) of antibody titers one month following vaccination. Antibody titers and other tested immune-response variables were significantly higher in the high-responder group compared to the low-responder group. The frequencies of rubella-specific memory B cells were modestly associated with the antibody titers. Our study suggests the importance of yet unknown inherent biologic and immune factors for the generation and maintenance of rubella-vaccine-induced humoral immune responses.

[Letter to the Editor: When Judas Got Measles]

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Evaluation of the measles, mumps and rubella vaccination catch-up campaign in England in 2013

In January-March 2013 in England, confirmed measles cases increased in children aged 10-16 years. In April-September 2013, the National Health System and Public Health England launched a national measles-mumps-rubella (MMR) campaign based on data from Child Health Information Systems (CHIS) estimating that approximately 8% in this age group were unvaccinated. We estimated coverage at baseline, and, of those unvaccinated (target), the proportion vaccinated up to 20/08/2013 (mid-point) to inform further public health action. We selected a sample of 6644 children aged 10-16 years using multistage sampling from those reported unvaccinated in CHIS at baseline and validated their records against GP records. We adjusted the CHIS MMR vaccine coverage estimates correcting by the proportion of vaccinated children obtained through sample validation. We validated 5179/6644 (78%) of the sample records. Coverage at baseline was estimated as 94.7% (95% confidence intervals, CI: 93.5-96.0%), lower in London (86.9%, 95%CI: 83.0-90.9%) than outside (96.1%, 95%CI 95.5-96.8%). The campaign reached 10.8% (95%CI: 7.0-14.6%) of the target population, lower in London (7.1%, 95%CI: 4.9-9.3) than in the rest of England (11.4%, 95%CI: 7.0-15.9%). Coverage increased by 0.5% up to 95.3% (95% CI: 94.1-96.4%) but an estimated 210,000 10-16 year old children remained unvaccinated nationally. Baseline MMR coverage was higher than previously reported and was estimated to have reached the 95% campaign objective at midpoint. Eleven per cent of the target population were vaccinated during the campaign, and may be underestimated, especially in London. No further national campaigns are needed but targeted local vaccination activities should be considered.

Measles Outbreak Associated With International Travel, Indiana, 2011

BACKGROUND

Endemic measles was declared eliminated in the United States in 2000, but imported measles cases continue to cause outbreaks. On June 20, 2011, 5 epidemiologically linked measles cases were reported to the Indiana State Department of Health. We investigated to identify additional cases and to prevent further spread.

METHODS

Case findings and contact investigations during the June 3, 2011-August 13, 2011 outbreak identified measles cases, exposed persons, and exposure settings. Laboratory confirmation included measles serology and reverse-transcription polymerase chain reaction. Control measures included evaluating measles immune status and providing post-exposure prophylaxis, isolation, and quarantine.

RESULTS

Fourteen confirmed measles illnesses were identified (10 [71%] females; median age, 11.5 years [range, 15 months-27 years]). The source patient was an unvaccinated US resident who recently traveled from Indonesia. Twelve patients were unvaccinated members of the source patient's extended family. Two hospitalizations and no deaths were reported. Among 868 exposed persons identified through contact investigation, 644 (74%) had documented measles immunity, 153 (18%) were lost to follow-up, and 71 (8%) lacked evidence of immunity.

CONCLUSIONS

Misdiagnosis of measles in an unvaccinated patient with recent travel history to a measles-endemic region resulted in the second largest measles outbreak in the United States during 2011. Clinicians should consider measles among patients presenting with febrile rash illness and history of recent travel, and clinicians should promptly report suspected illnesses. Early identification of infectious patients, rapid public health investigation, and maintenance of high vaccine coverage are critical for the prevention and control of measles outbreaks.