Comment: Thorough review includes clinical principles, pathogenesis, immunity and includes prevention/eradication discussion.
Comment: Report summarizes all recommendations since 1998. New recommendations in this version include:
1) For acceptable evidence of immunity, removing documentation of physician diagnosed disease as an acceptable criterion for evidence of immunity for measles and mumps, and including laboratory confirmation of disease as a criterion for acceptable evidence of immunity for measles, rubella, and mumps.
2) For persons with human immunodeficiency virus (HIV) infection, expanding recommendations for vaccination to all persons aged ≥12 months with HIV infection who do not have evidence of current severe immunosuppression; recommending revaccination of persons with perinatal HIV infection who were vaccinated before establishment of effective antiretroviral therapy (ART) with 2 appropriately spaced doses of MMR vaccine once effective ART has been established; and changing the recommended timing of the 2 doses of MMR vaccine for HIV-infected persons to age 12 through 15 months and 4 through 6 years.
3) For measles postexposure prophylaxis, expanding recommendations for use of immune globulin administered intramuscularly (IGIM) to include infants aged birth to 6 months exposed to measles; increasing the recommended dose of IGIM for immunocompetent persons; and recommending use of immune globulin administered intravenously (IGIV) for severely immunocompromised persons and pregnant women without evidence of measles immunity who are exposed to measles.
Comment: Guidelines based on studies suggesting treatment for very sick children or those suffering from malnutrition, immunodeficiency, or complication of infection all do better with measles infection. Note high dose of Vitamin A may cause temporary headache or nausea.
Comment: The study used banked sera from Vietnamese cohorts suggest that routine serosurviellance in populations may be useful to help understand when to institute preventative immunization measures beyond the routine to prevent outbreaks.
Comment: Somewhat surprisingly, this study from Italy did not find an age relationship but rather CRP as a risk factor for complications. This may well contrast from what is seen in children in low resource settings, especially if malnourished.
Comment: Update with barriers including children infected with HIV, cold-chain issues for vaccine, high contagiousness and dynamic travel along with the fact that much MV eradication has been tied to polio elimination and those grant dollars (Gates, others) may decline soon. Potential breakthrough would be new vaccine delivery system not requiring refrigeration and ability to safely immunize effectively at younger ages.
Comment: Eight studies of antibody levels in cord blood and then followed in infants suggest that insufficient maternal immunization is present in some infants well before customary immunization age.
Comment: Report from California of 17 SSPE cases, particularly in unvaccinated children who acquired native infection in infancy. Median age of diagnosis = 12 years, with latency period estimated at 9.5 years (range 2.5 to 34 years). Authors argue to not allow infants especially prior to immunization travel to regions endemic for measles or consider early immunization during months of 6-11.
Comment: Report of cases traced to unvaccinated people (65 total cases) many in a Somali-American community with the misunderstanding that autism was tied to MMR immunization. Though multiple studies have shown no such link, this linkage continues to persist as factual in some communities.
Comment: Fourteen year old sucumbed to SSPE who was thought to have been vaccinated at age 8 mos in the Phillipines (probably too young to engender good immunity), and acquired native measles at age 1 year. Thought to be an extraordinary rare complicated (due to defective structural protein in virus), analysis of SSPE among persons who had measles during the 1989–1991 U.S. measles resurgence indicated an incidence of 4–11 SSPE cases per 100,000 measles cases, approximately 10 times higher than earlier estimates.
Comment: Helpful survey article reviewing the four major types of encephalitis related ot measles virus.
Comment: Imported cases continue to trigger outbreaks in the US, especially in populations where parents have not had their children immunized at fairly high rates such as California. Over 80% of US-based measles are in those unvaccinated or had unknown vaccination status. Four outbreaks described this year, but 70% accounted for by one larger outbreak. These circumstances certainly highlight why continued immunization rates should be high and universal.
Comment: Measles cases globally slowly decreasing, but difficult to reach eradication goals. Currently 63% of countries have > 90% vaccine coverage.
Comment: Story of intentionally non-immunized 17yr who acquired measles in UK, led to largest outbreak in US since 2000 with 58 cases. Over 3500 contacts had to be assessed receiving post-exposure MMR or IVIG. THis points to two key facts: the highly infectious nature without protective immunity and the significant costs driven by a single case.
Comment: Review from France where recent measles outbreaks have been more common. In this case series, none of the patients had received two doses of MMR--hence at risk. Measles pneumonitis was the primary driver to ICU care, although the viral infection had protean manifestations. Post-infectious encephalomyelitis also seen, but less commonly.
Comment: Attempts at eradicating measles have not been achieved, authors review that success likely lies in societal factors in a few endemic countries compared to biological factors. Current estimates place costs of measles eradication at $5-8 billion, but factors such as concurrent polio eradication, anti-vaccine lobbyists, civil wars/terrorism and lack of perceived problem in industrialized countries as reasons slowing or preventing progress.
Comment: Immunization appears generally safe in HIV-infected children upon review of 39 studies, but authors cite the data is limited.
Comment: Safety and efficacy of immunization as early as 4 and 1/2 months compared to usual approach at 9 months during a measles outbreak in Guinea-Bissau. Infants had 92% seroconversion, and only 0.7% of immunized infants at this earlier timeframe developed measles. There was a trend toward lower mortality but this was not significant.
Comment: Immigrants to Canada, found that about one-third (36%) were non-immune to either measles, mumps or rubella.
Comment: View of Koplik spots.
Comment: Large outbreak of measles in US attributed to case imported from Romania that spread in a population of children in whom routine vaccination was refused. Epidemic reinforces the need to maintain high rates of immunization.
Comment: Addressing concerns about the longevity of measles immunization protection, 56 participants (77% were 2-dose recipients), all had antibodies detected by the plaque reduction neutralization (PRN) antibody assay an average of 26-33 years after the first or second dose of measles vaccine; 92% had a PRN titer considered protective (>1 : 120). These data support routine two dose immunization.
Comment: Large outbreak in industrialized country, with 3292 reported cases; 94% of affected patients unvaccinated. Only 1 patient had received 2 doses of vaccine. Three patients died, and 16% had complications. Herd immunity outside unvaccinated clusters was high enough to prevent further transmission. This jives with measles-associated mortality rate in the United States generally quoted as 0.3%. By contrast in some developing countries, the mortality rate of measles is as high as 10%
Comment: Report of case of child aged 10 months adopted from orphanage A in China who was taken to a Texas hospital with fever, conjunctivitis, coryza, Koplik spots, and a maculopapular rash. Measles was confirmed by serologic testing. Public health authorities in Texas notified CDC, which then collaborated with health officials in other states to contact other recently adopted children from China and their adoptive families. Contact investigations that identified 14 U.S. measles cases. Most cases in US arise from importation.
Comment: Small series from Cornell of six patients with severe measles pneumonitis. One pt. died, however, the other five were thought to improve significantly in respiratory status with early administration of parenteral ribavirin.
Comment: Report of one HIV-infected adult who developed fever, rash, coryza and conjunctivitis 12 days after measles immunization. A retrospective survey conducted by the New York City Department of Health found no complications following measles immunization of HIV-infected children.
Comment: Disease is more severe in patients with HIV, cancer or immunosuppression. Characteristic rash may be absent (27-40%) and hence delay consideration of diagnosis. These patients most commonly have fever and pneumonitis (58-80%) as most common features. Giant-cell (Hecht's Giant Cell) pneumonia with syncytia may be tip off with culture or IFA confirming since antibody production may be not reliable in this patient population.
Comment: Large study suggesting that prevention of vitamin A deficiency decreased mortality, probably by reducing diarrheal and pulmonary disease as a consequence of childhood illnesses such as measles.
Comment: Atypical measles occurred in recipients of formalin-inactivated measles vaccine [1963-1967] and subsequently exposed to wild-type measles virus. Sx severity worse in atypical measles. Instead of starting at the head and spreading down the body, rash of atypical measles spreads centripetally not only maculopapular, but also hemorrhagic, vesicular, or urticarial. Coryza, conjunctivitis, and Koplik spots unusual in atypical measles. However, interstitial pneumonia prominent feature of atypical measles as well as pleural effusions, extremity edema, hepatitis, hyperesthesia. Has been confused w/RMSF
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