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Failure to Reach the Goal of Measles Elimination: Apparent Paradox of Measles Infections in Immunized Persons

Failure to Reach the Goal of Measles Elimination: Apparent Paradox of Measles Infections in... Abstract Background: Measles is the most transmissible disease known to man. During the 1980s, the number of measles cases in the United States rose dramatically. Surprisingly, 20% to 40% of these cases occurred in persons who had been appropriately immunized against measles. In response, the United States adopted a two--dose universal measles immunization program. We critically examine the effect of vaccine failure in measles occurring in immunized persons. Methods: We performed a computerized bibliographic literature search (National Library of Medicine) for all English-language articles dealing with measles outbreaks. We limited our search to reports of US and Canadian school-based outbreaks of measles, and we spoke with experts to get estimates of vaccine failure rates. In addition, we devised a hypothetical model of a school where measles immunization rates could be varied, vaccine failure rates could be calculated, and the percentage of measles cases occurring in immunized students could be determined. Results: We found 18 reports of measles outbreaks in very highly immunized school populations where 71% to 99.8% of students were immunized against measles. Despite these high rates of immunization, 30% to 100% (mean, 77%) of all measles cases in these outbreaks occurred in previously immunized students. In our hypothetical school model, after more than 95% of schoolchildren are immunized against measles, the majority of measles cases occur in appropriately immunized children. Conclusions: The apparent paradox is that as measles immunization rates rise to high levels in a population, measles becomes a disease of immunized persons. Because of the failure rate of the vaccine and the unique transmissibility of the measles virus, the currently available measles vaccine, used in a single-dose strategy, is unlikely to completely eliminate measles. The longterm success of a two-dose strategy to eliminate measles remains to be determined.(Arch Intern Med. 1994;154:1815-1820) References 1. Centers for Disease Control. Goal to eliminate measles from the United States . MMWR Morb Mortal Wkly Rep. 1978;27:391. 2. Centers for Disease Control. Measles prevention: recommendations of the Immunization Practices Advisory Committee (ACIP) . MMWR Morb Mortal Wkly Rep. 1989;38(suppl S-9):1-18. 3. Centers for Disease Control. Measles—United States, 1989 and first 20 weeks 1990 . MMWR Morb Mortal Wkly Rep. 1990;39:353-355, 361-363. 4. Centers for Disease Control. Measles—United States . MMWR Morb Mortal Wkly Rep. 1991;40:369-372. 5. Centers for Disease Control and Prevention. Public-sector vaccination efforts in response to the resurgence of measles among pre-school children—United States, 1989-1992 . MMWR Morb Mortal Wkly Rep. 1992;41:522-525. 6. Gindler JS, Atkinson WL, Markowitz LE, Hutchins SS. Epidemiology of measles in the United States in 1989 and 1990 . Pediatr Infect Dis J. 1992;11:841-846.Crossref 7. Centers for Disease Control and Prevention. Measles surveillance—United States, 1991 . MMWR Morb Mortal Wkly Rep. 1992;41( (suppl SS-6) ):1-12. 8. Aaby P, Bukh J, Lisse ID, Seim E, DeSilva MC. Increased perinatal mortality among children of mothers exposed to measles during pregnancy . Lancet . 1988; 1:516-519.Crossref 9. Jespersen CS, Littauer J, Sagild U. Measles as a cause of fetal defects: a retrospective study of ten measles epidemics in Greenland . Acta Pediatr Scand . 1977;66:367-372.Crossref 10. Shasby DM. Shope TC, Downs H, Herrmann KL, Polkowski J. Epidemic measles in a highly vaccinated population . N Engl J Med. 1977;296:585-589.Crossref 11. Hull HF, Montes JM, Hays PC, Lucero RL. Risk factors for measles vaccine failure among immunized students . Pediatrics . 1985;76:518-523. 12. Davis RM, Whitman ED, Orenstein WA, Preblud SR, Markowitz LE, Hinman AR. A persistent outbreak of measles despite appropriate prevention and control measures . Am J Epidemiol. 1987;126:438-449. 13. Gustavson TL, Brunell PA, Lievens AW, et al. Measles outbreak in a 'fully immunized' secondary school population . N Engl J Med. 1987;316:771-774.Crossref 14. Nkowane BM, Bart SW, Orenstein WA, Baltier M. Measles outbreak in a vaccinated school population: epidemiology, chains of transmission and the role of vaccine failures . Am J Public Health. 1987;77:434-438.Crossref 15. Chen RT, Goldbaum GM, Wassilak SGF, Markowitz LE, Orenstein WA. An explosive point-source measles outbreak in a highly vaccinated population: modes of transmission and risk factors for disease . Am J Epidemiol. 1989;129:173-182. 16. Edmonson MB, Addis DG, McPherson JT, Berg JL, Circo SR, Davis JP. Mild measles and secondary vaccine failure during a sustained outbreak in a highly vaccinated population . JAMA. 1990:263:2467-2471. 17. Hutchins SS, Markowitz LE, Mead P, et al. A school-based measles outbreak: the effect of a selective revaccination policy and risk factors for vaccine failure . Am J Epidemiol. 1990;132:157-168. 18. Hersh BS, Markowitz LE, Hoffman RE, et al. A measles outbreak at a college with a prematriculation immunization requirement . Am J Public Health. 1991; 81:360-364.Crossref 19. McCombie SC, Worrell RD, Porter BW, Browning JA, Ray CG. Risk for measles related to immunization status in two Tucson high schools . Public Health Rep. 1988:103:162-166. 20. Guasparini R, Sheps SB, Mathias RB, Glick N. Measles outbreak in a Vancouver school population: relative risk and vaccine efficacy . Can J Public Health. 1988;79:26-30. 21. Mast EE, Berg JL, Hanrahan LP, Wassell JT, Davis JP. Risk factors for measles in a previously vaccinated population and cost-effectiveness of revaccination strategies . JAMA. 1990;264:2529-2533.Crossref 22. Birkhead GS, Morse DL, Mills IJ, Novick LF. New York State's two-dose schedule for measles immunization . Public Health Rep. 1991;106:338-344. 23. Veit BC, Schydlower M, McIntyre S, et al. Serological response to measles revaccination in a highly immunized military dependent adolescent population . J Adolesc Health. 1991;12:273-278.Crossref 24. Judelsohn RG, Fleissner ML, O'Mara DJ. School-based measles outbreaks: correlation of age at immunization with risk of disease . Am J Public Health. 1980; 70:1162-1165.Crossref 25. Centers for Disease Control. Measles in an immunized school-aged population— New Mexico . MMWR Morb Mortal Wkly Rep. 1985:34:52-54, 59. 26. Narian JP, Farrell JB. Measles in schools: age at vaccination vs risk of disease . J Ark Med Soc. 1989;85:383-385. 27. Osterman JW, Melnychuk D. Revaccination of children during school-based measles outbreaks: potential impact of a new policy recommendation . Can Med Assoc J. 1992;146:929-936. 28. Hicks NR. Misplaced loss of confidence in measles vaccination: an investigation in a primary school . J R Coll Gen Pract. 1989;39:151-152. 29. Kenya PR. Measles and mathematics: 'control or eradication?' East Afr Med J. 1990;67:856-863. 30. Thacker SB, Millar JD. Mathematical modeling and attempts to eliminate measles: a tribute to the late professor George Macdonald . Am J Epidemiol. 1991;133: 517-525. 31. Levy DL. The future of measles in highly immunized population: a modeling approach . Am J Epidemiol. 1984;120:39-48. 32. Hethcote HW. Measles and rubella in the United States . Am J Epidemiol. 1983; 117:2-13. 33. Fine PEM, Clarkson JA. Measles in England and Wales, II: the impact of the measles vaccination programme on the distribution of immunity in the population . Int J Epidemiol. 1982;11:15-25.Crossref 34. Nokes DJ, Anderson RM. The use of mathematical models in the epidemiological study of infectious diseases and in the design of mass immunization programmes . Epidemiol Infect. 1988;101:1-20.Crossref 35. Fox JP, Elveback L, Scott W, Gatewood L, Ackerman E. Herd immunity: basic concept and relevance to public health immunization practices . Am J Epidemiol . 1971;94:179-189. 36. Bailey NTJ. The Mathematical Theory of Epidemics . Darien, Conn: Hafner Publishing Co; 1957. 37. Preblud SR, Katz SL. Measles vaccine . In: Plotkin SA, Mortimer EA, eds. Vaccines . Philadelphia, Pa: WB Saunders Co; 1988:182-222. 38. Measles Vaccines Committee. Vaccination against measles: clinical trial of live measles vaccine given alone and live vaccine preceded by killed vaccine: second report to Medical Research Council . BMJ . 1968:2:449-452.Crossref 39. Cherry JD, Feigin RD, Lobes LA. Urban measles in the vaccine era: a clinical, epidemiologic and serologic study . J Pediatr. 1972;81:217-237.Crossref 40. Bottiger M, Christenson B. Romanus V, Taranger J, Strandell A. Swedish experience of two dose vaccination programme aiming at eliminating measles, mumps, and rubella . BMJ. 1987;295:1264-1267.Crossref 41. Hanna JN, Macintyre AB, Worswick DA, Burrell LJ. Seroconversion after administration of measles vaccine to central Australian aboriginal children at nine months of age . Med J Aust. 1989:150:188-192. 42. Halsey NA, Boulos R, Mode F, et al. Response to measles vaccine in Haitian infants 6 to 12 months old: influence of maternal antibodies, malnutrition, and concurrent illnesses . N Engl J Med. 1985;313:544-549.Crossref 43. Kakakios AM, Burgess MA, Bransby RD, Quinn AA, Allars HM. Optimal age for measles and mumps vaccination in Australia . Med J Aust. 1990;152: 472-474. 44. Brunell PA, Weigle K, Murphy D, Shehab Z, Cobb E. Antibody response following measles-mumps-rubella vaccine under conditions of customary use . JAMA. 1983;250:1409-1412.Crossref 45. Mathias RG, Meekison WG, Arcand TA, Schechter MT. The role of secondary vaccine failures in measles outbreaks . Am J Public Health. 1989;79:475-478.Crossref 46. Orenstein WA, Herrmann KL, Bernier R, et al. Immunity against measles and rubella in Massachusetts school children . Dev Biol Stand. 1986:65:75-83. 47. Christenson B, Bottiger M, Heller L. Mass vaccination programme aimed at eradicating measles, mumps and rubella in Sweden: first experience . BMJ . 1983; 287:289-291.Crossref 48. Miller C. Live measles vaccine: a 21 year follow-up . BMJ . 1987;295:22-24.Crossref 49. Rabo E, Taranger J. Scandinavian model for eliminating measles, mumps and rubella . BMJ . 1984:289:1402-1404.Crossref 50. US Dept of Health and Human Services. Healthy People 2000: National Health Promotion and Disease Prevention Objectives . Washington, DC: US Dept of Health and Human Services; 1991. Publication PHS 91-50213. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Internal Medicine American Medical Association

Failure to Reach the Goal of Measles Elimination: Apparent Paradox of Measles Infections in Immunized Persons

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Publisher
American Medical Association
Copyright
Copyright © 1994 American Medical Association. All Rights Reserved.
ISSN
0003-9926
eISSN
1538-3679
DOI
10.1001/archinte.1994.00420160048006
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Abstract

Abstract Background: Measles is the most transmissible disease known to man. During the 1980s, the number of measles cases in the United States rose dramatically. Surprisingly, 20% to 40% of these cases occurred in persons who had been appropriately immunized against measles. In response, the United States adopted a two--dose universal measles immunization program. We critically examine the effect of vaccine failure in measles occurring in immunized persons. Methods: We performed a computerized bibliographic literature search (National Library of Medicine) for all English-language articles dealing with measles outbreaks. We limited our search to reports of US and Canadian school-based outbreaks of measles, and we spoke with experts to get estimates of vaccine failure rates. In addition, we devised a hypothetical model of a school where measles immunization rates could be varied, vaccine failure rates could be calculated, and the percentage of measles cases occurring in immunized students could be determined. Results: We found 18 reports of measles outbreaks in very highly immunized school populations where 71% to 99.8% of students were immunized against measles. Despite these high rates of immunization, 30% to 100% (mean, 77%) of all measles cases in these outbreaks occurred in previously immunized students. In our hypothetical school model, after more than 95% of schoolchildren are immunized against measles, the majority of measles cases occur in appropriately immunized children. Conclusions: The apparent paradox is that as measles immunization rates rise to high levels in a population, measles becomes a disease of immunized persons. Because of the failure rate of the vaccine and the unique transmissibility of the measles virus, the currently available measles vaccine, used in a single-dose strategy, is unlikely to completely eliminate measles. The longterm success of a two-dose strategy to eliminate measles remains to be determined.(Arch Intern Med. 1994;154:1815-1820) References 1. Centers for Disease Control. Goal to eliminate measles from the United States . MMWR Morb Mortal Wkly Rep. 1978;27:391. 2. Centers for Disease Control. Measles prevention: recommendations of the Immunization Practices Advisory Committee (ACIP) . MMWR Morb Mortal Wkly Rep. 1989;38(suppl S-9):1-18. 3. Centers for Disease Control. Measles—United States, 1989 and first 20 weeks 1990 . MMWR Morb Mortal Wkly Rep. 1990;39:353-355, 361-363. 4. Centers for Disease Control. Measles—United States . MMWR Morb Mortal Wkly Rep. 1991;40:369-372. 5. Centers for Disease Control and Prevention. Public-sector vaccination efforts in response to the resurgence of measles among pre-school children—United States, 1989-1992 . MMWR Morb Mortal Wkly Rep. 1992;41:522-525. 6. Gindler JS, Atkinson WL, Markowitz LE, Hutchins SS. Epidemiology of measles in the United States in 1989 and 1990 . Pediatr Infect Dis J. 1992;11:841-846.Crossref 7. Centers for Disease Control and Prevention. Measles surveillance—United States, 1991 . MMWR Morb Mortal Wkly Rep. 1992;41( (suppl SS-6) ):1-12. 8. Aaby P, Bukh J, Lisse ID, Seim E, DeSilva MC. Increased perinatal mortality among children of mothers exposed to measles during pregnancy . Lancet . 1988; 1:516-519.Crossref 9. Jespersen CS, Littauer J, Sagild U. Measles as a cause of fetal defects: a retrospective study of ten measles epidemics in Greenland . Acta Pediatr Scand . 1977;66:367-372.Crossref 10. Shasby DM. Shope TC, Downs H, Herrmann KL, Polkowski J. Epidemic measles in a highly vaccinated population . N Engl J Med. 1977;296:585-589.Crossref 11. Hull HF, Montes JM, Hays PC, Lucero RL. Risk factors for measles vaccine failure among immunized students . Pediatrics . 1985;76:518-523. 12. Davis RM, Whitman ED, Orenstein WA, Preblud SR, Markowitz LE, Hinman AR. A persistent outbreak of measles despite appropriate prevention and control measures . Am J Epidemiol. 1987;126:438-449. 13. Gustavson TL, Brunell PA, Lievens AW, et al. Measles outbreak in a 'fully immunized' secondary school population . N Engl J Med. 1987;316:771-774.Crossref 14. Nkowane BM, Bart SW, Orenstein WA, Baltier M. Measles outbreak in a vaccinated school population: epidemiology, chains of transmission and the role of vaccine failures . Am J Public Health. 1987;77:434-438.Crossref 15. Chen RT, Goldbaum GM, Wassilak SGF, Markowitz LE, Orenstein WA. An explosive point-source measles outbreak in a highly vaccinated population: modes of transmission and risk factors for disease . Am J Epidemiol. 1989;129:173-182. 16. Edmonson MB, Addis DG, McPherson JT, Berg JL, Circo SR, Davis JP. Mild measles and secondary vaccine failure during a sustained outbreak in a highly vaccinated population . JAMA. 1990:263:2467-2471. 17. Hutchins SS, Markowitz LE, Mead P, et al. A school-based measles outbreak: the effect of a selective revaccination policy and risk factors for vaccine failure . Am J Epidemiol. 1990;132:157-168. 18. Hersh BS, Markowitz LE, Hoffman RE, et al. A measles outbreak at a college with a prematriculation immunization requirement . Am J Public Health. 1991; 81:360-364.Crossref 19. McCombie SC, Worrell RD, Porter BW, Browning JA, Ray CG. Risk for measles related to immunization status in two Tucson high schools . Public Health Rep. 1988:103:162-166. 20. Guasparini R, Sheps SB, Mathias RB, Glick N. Measles outbreak in a Vancouver school population: relative risk and vaccine efficacy . Can J Public Health. 1988;79:26-30. 21. Mast EE, Berg JL, Hanrahan LP, Wassell JT, Davis JP. Risk factors for measles in a previously vaccinated population and cost-effectiveness of revaccination strategies . JAMA. 1990;264:2529-2533.Crossref 22. Birkhead GS, Morse DL, Mills IJ, Novick LF. New York State's two-dose schedule for measles immunization . Public Health Rep. 1991;106:338-344. 23. Veit BC, Schydlower M, McIntyre S, et al. Serological response to measles revaccination in a highly immunized military dependent adolescent population . J Adolesc Health. 1991;12:273-278.Crossref 24. Judelsohn RG, Fleissner ML, O'Mara DJ. School-based measles outbreaks: correlation of age at immunization with risk of disease . Am J Public Health. 1980; 70:1162-1165.Crossref 25. Centers for Disease Control. Measles in an immunized school-aged population— New Mexico . MMWR Morb Mortal Wkly Rep. 1985:34:52-54, 59. 26. Narian JP, Farrell JB. Measles in schools: age at vaccination vs risk of disease . J Ark Med Soc. 1989;85:383-385. 27. Osterman JW, Melnychuk D. Revaccination of children during school-based measles outbreaks: potential impact of a new policy recommendation . Can Med Assoc J. 1992;146:929-936. 28. Hicks NR. Misplaced loss of confidence in measles vaccination: an investigation in a primary school . J R Coll Gen Pract. 1989;39:151-152. 29. Kenya PR. Measles and mathematics: 'control or eradication?' East Afr Med J. 1990;67:856-863. 30. Thacker SB, Millar JD. Mathematical modeling and attempts to eliminate measles: a tribute to the late professor George Macdonald . Am J Epidemiol. 1991;133: 517-525. 31. Levy DL. The future of measles in highly immunized population: a modeling approach . Am J Epidemiol. 1984;120:39-48. 32. Hethcote HW. Measles and rubella in the United States . Am J Epidemiol. 1983; 117:2-13. 33. Fine PEM, Clarkson JA. Measles in England and Wales, II: the impact of the measles vaccination programme on the distribution of immunity in the population . Int J Epidemiol. 1982;11:15-25.Crossref 34. Nokes DJ, Anderson RM. The use of mathematical models in the epidemiological study of infectious diseases and in the design of mass immunization programmes . Epidemiol Infect. 1988;101:1-20.Crossref 35. Fox JP, Elveback L, Scott W, Gatewood L, Ackerman E. Herd immunity: basic concept and relevance to public health immunization practices . Am J Epidemiol . 1971;94:179-189. 36. Bailey NTJ. The Mathematical Theory of Epidemics . Darien, Conn: Hafner Publishing Co; 1957. 37. Preblud SR, Katz SL. Measles vaccine . In: Plotkin SA, Mortimer EA, eds. Vaccines . Philadelphia, Pa: WB Saunders Co; 1988:182-222. 38. Measles Vaccines Committee. Vaccination against measles: clinical trial of live measles vaccine given alone and live vaccine preceded by killed vaccine: second report to Medical Research Council . BMJ . 1968:2:449-452.Crossref 39. Cherry JD, Feigin RD, Lobes LA. Urban measles in the vaccine era: a clinical, epidemiologic and serologic study . J Pediatr. 1972;81:217-237.Crossref 40. Bottiger M, Christenson B. Romanus V, Taranger J, Strandell A. Swedish experience of two dose vaccination programme aiming at eliminating measles, mumps, and rubella . BMJ. 1987;295:1264-1267.Crossref 41. Hanna JN, Macintyre AB, Worswick DA, Burrell LJ. Seroconversion after administration of measles vaccine to central Australian aboriginal children at nine months of age . Med J Aust. 1989:150:188-192. 42. Halsey NA, Boulos R, Mode F, et al. Response to measles vaccine in Haitian infants 6 to 12 months old: influence of maternal antibodies, malnutrition, and concurrent illnesses . N Engl J Med. 1985;313:544-549.Crossref 43. Kakakios AM, Burgess MA, Bransby RD, Quinn AA, Allars HM. Optimal age for measles and mumps vaccination in Australia . Med J Aust. 1990;152: 472-474. 44. Brunell PA, Weigle K, Murphy D, Shehab Z, Cobb E. Antibody response following measles-mumps-rubella vaccine under conditions of customary use . JAMA. 1983;250:1409-1412.Crossref 45. Mathias RG, Meekison WG, Arcand TA, Schechter MT. The role of secondary vaccine failures in measles outbreaks . Am J Public Health. 1989;79:475-478.Crossref 46. Orenstein WA, Herrmann KL, Bernier R, et al. Immunity against measles and rubella in Massachusetts school children . Dev Biol Stand. 1986:65:75-83. 47. Christenson B, Bottiger M, Heller L. Mass vaccination programme aimed at eradicating measles, mumps and rubella in Sweden: first experience . BMJ . 1983; 287:289-291.Crossref 48. Miller C. Live measles vaccine: a 21 year follow-up . BMJ . 1987;295:22-24.Crossref 49. Rabo E, Taranger J. Scandinavian model for eliminating measles, mumps and rubella . BMJ . 1984:289:1402-1404.Crossref 50. US Dept of Health and Human Services. Healthy People 2000: National Health Promotion and Disease Prevention Objectives . Washington, DC: US Dept of Health and Human Services; 1991. Publication PHS 91-50213.

Journal

Archives of Internal MedicineAmerican Medical Association

Published: Aug 22, 1994

References