Measles: not just another viral exanthem

The burden of viral skin diseases in the Middle East and North Africa region, 1990-2021

OBJECTIVE

To report the prevalence, incidence, and Years Lived with Disability (YLD) due to viral skin diseases (VSD) in the MENA region from 1990 to 2021, focusing on age, sex, and socio-demographic index (SDI) using GBD 2021 data.

METHODS

Data on the burden of VSD were sourced from the Global Burden of Disease (GBD) 2021 study, covering 21 countries in the MENA region. The results included the counts and age-standardised rates per 100,000 population, along with the associated 95 % uncertainty intervals (UIs).

RESULTS

In 2021, the MENA region exhibited an age-standardised prevalence rate of 1257.6 cases per 100,000 population for VSD and an incidence rate of 990.5 cases per 100,000. Prevalence rates peaked sharply in the 5-9 age group before declining with age for both sexes, indicating a higher burden in younger populations. A strong positive relationship existed between the YLD rate and SDI, suggesting an increased burden of VSD with higher SDIs.

CONCLUSION

This study highlights the increasing burden of viral skin diseases (VSD) in the MENA region, especially among younger populations, with males also experiencing a slightly higher burden than females. Given the influence of multiple factors, a comprehensive strategy focusing on data systems, healthcare delivery, and regional collaboration is vital. Addressing these areas will help mitigate VSD's impact and improve health outcomes.

Contagion comeback: unravelling the measles outbreak across the USA

Measles, a highly contagious respiratory illness caused by the measles virus (MeV), poses significant global and national public health challenges despite advancements in vaccination efforts. Though measles was declared eliminated in the United States in 2000, recent years have seen a resurgence of cases, particularly in under-vaccinated communities. This resurgence is compounded by factors such as vaccine hesitancy, the impact of the COVID-19 pandemic on immunization rates, and international travel introducing new cases from endemic regions. This paper examines the epidemiology and recent measles outbreaks in the United States, focusing on the significant rise in cases from 2020 to 2024. The analysis highlights the importance of maintaining high vaccination coverage, particularly in vulnerable populations, and explores the challenges of managing outbreaks. The study also reviews the pathophysiology, clinical presentation, diagnosis, and treatment of measles, emphasizing the role of prevention and control measures, including the MMR vaccine, public health interventions, and international cooperation in addressing this persistent threat.

Two-dose measles vaccine effectiveness remains high over time: A French observational study, 2017-2019

BACKGROUND

From 2008 to 2019, France has experienced a resurgence of measles epidemics. Surveillance data have shown that the proportion of cases vaccinated with two doses of measles-containing vaccine (MCV) increased with age, raising concerns about the duration of vaccine protection. Our objectives were to investigate age-stratified vaccine effectiveness (VE) for the second dose of MCV (MCV2) and to quantify protection levels over time.

METHODS

We analyzed data on measles cases aged 2-31 years, reported via mandatory notification to the French measles surveillance system from October 2017 to September 2019. We estimated an age-stratified VE for MCV2 using the screening method, which compares the vaccination status of cases with that of the general population. We improved this method by accounting for natural immunity, exploring four scenarios with four possible levels of natural immunity in the population. In addition, we quantified the decay rate of protection over time, by fitting an exponential decay model among individuals vaccinated in early life.

RESULTS

In the baseline analysis (absence of natural immunity), VE estimates were high in all age groups and decreased with age, from 99.6 % (95 % confidence interval: 99.3-99.8) in 2-5 years old to 91.4 % (85.1-95.0) in 26-31 years old. Accounting for natural immunity increased VE in the older age group to 93.2-99.2 % depending on the scenario. We estimated that VE was slowly decreasing over time, with an exponential decay rate of 0.0022/year (0.0017-0.0028), leading to VE of 96.7 % (96.0-97.4) 16 years after MCV2 vaccination. This decline was most compatible with scenario 2, a scenario of 4.4 % naturally immunized, non-vaccinated individuals in the 26-31 years old.

CONCLUSION

Our study confirms the continued high effectiveness of two doses of MCV with only slight degradation, decades after immunization. These findings support the importance of achieving a very high vaccination coverage with 2 doses of MCV.

Viral Infections of the Oral Cavity in Children

Various viral infections can affect the oral cavities of pediatric patients [...].

Assessing the Effects of Measles Virus Infections on Childhood Infectious Disease Mortality in Brazil

BACKGROUND

Measles virus infection induces acute immunosuppression for weeks following infection, and also impairs preexisting immunological memory, resulting in "immune amnesia" that can last for years. Both mechanisms predispose the host to severe outcomes of subsequent infections. Therefore, measles dynamics could potentially affect the epidemiology of other infectious diseases.

METHODS

To examine this hypothesis, we analyzed the annual mortality rates of children aged 1-9 years in Brazil from 1980 to 1995. We calculated the correlation between nonmeasles infectious disease mortality rates and measles mortality rates using linear and negative-binomial models, with 3 methods to control the confounding effects of time. We also estimated the duration of measles-induced immunomodulation.

RESULTS

The mortality rates of nonmeasles infectious diseases and measles virus infection were highly correlated. This positive correlation remained significant after removing the time trends. We found no evidence of long-term measles immunomodulation beyond 1 year.

CONCLUSIONS

These results support that measles virus infection could increase the mortality of other infectious diseases. The short lag identified for measles effects (<1 year) implies that acute immunosuppression was potentially driving this effect in Brazil. Overall, our study indicates disproportionate contributions of measles to childhood infectious disease mortality, highlighting the importance of measles vaccination.

Health economic analyses of secondary vaccine effects: a systematic review and policy insights

INTRODUCTION

: Numerous analyses demonstrate substantial health economic impacts of primary vaccine effects (preventing or mitigating clinical manifestations of the diseases they target), but vaccines may also be associated with secondary effects, previously known as non-specific, heterologous, or off-target effects.

AREAS COVERED

: We define key concepts to distinguish primary and secondary vaccine effects for health economic analyses, summarized terminology used in different fields, and perform a systematic review of health economic analyses focused on secondary vaccine effects (SVEs).

EXPERT OPINION

: Health economists integrate evidence from multiple fields, which often use incomplete or inconsistent definitions. Like regulators and policy makers, health economists require high-quality evidence of specific effects. Consistent with the limited evidence on mechanisms of action for SVEs, the associated health economic literature remains highly limited, with 4 studies identified by our systematic review. The lack of specific and well-controlled evidence that supports quantification of specific SVEs limits the consideration of these effects in vaccine research, development, regulatory, and recommendation decisions and health economic analyses.

Antiviral Drug Targets of Single-Stranded RNA Viruses Causing Chronic Human Diseases

Ribonucleic acid (RNA) viruses associated with chronic diseases in humans are major threats to public health causing high mortality globally. The high mutation rate of RNA viruses helps them to escape the immune response and also is responsible for the development of drug resistance. Chronic infections caused by human immunodeficiency virus (HIV) and hepatitis viruses (HBV and HCV) lead to acquired immunodeficiency syndrome (AIDS) and hepatocellular carcinoma respectively, which are one of the major causes of human deaths. Effective preventative measures to limit chronic and re-emerging viral infections are absolutely necessary. Each class of antiviral agents targets a specific stage in the viral life cycle and inhibits them from its development and proliferation. Most often, antiviral drugs target a specific viral protein, therefore only a few broad-spectrum drugs are available. This review will be focused on the selected viral target proteins of pathogenic viruses containing single-stranded (ss) RNA genome that causes chronic infections in humans (e.g. HIV, HCV, Flaviviruses). In the recent past, an exponential increase in the number of available three-dimensional protein structures (>150000 in Protein Data Bank), allowed us to better understand the molecular mechanism of action of protein targets and antivirals. Advancements in the in silico approaches paved the way to design and develop several novels, highly specific small-molecule inhibitors targeting the viral proteins.

Positive Effect of Single-Dose Measles Vaccination in Reducing the Incidence of Pneumonia in Children with Measles

AIM

Measles is a worldwide common, highly infectious and vaccine-preventable contagious disease with high morbidity and mortality rates. We investigated the effects of administering single-dose measles vaccination in children with measles on the incidence of pneumonia and hospitalization.

MATERIALS AND METHODS

We retrospectively analysed the hospital records of children aged 0-18 years who were diagnosed with measles within a year before the study in a training and research hospital in Mogadishu, Somalia. We compared the measles vaccine ratios, hospitalization rates, hospitalization duration and pneumonia development rates.

RESULTS

We found that 34 (15.6%) patients had received measles vaccination, while 184 (84.4%) did not receive the vaccination. All the vaccinated patients received only a single dose of the vaccine. The proportion of those who had received pneumonia vaccine (14/34, 41.2%) was significantly lower than that of those who had never received a dose of measles containing vaccine (179/184, 97.3%) (p = 0.001). Moreover, patients who were immunized [n = 3 (3.1%)] had a significantly lower hospitalization rate than those who were not immunized [n = 94 (96.9%)] (p = 0.001).

CONCLUSION

The risk of pneumonia in children with measles vaccination, rate of hospitalization and length of hospital stay was significantly lower in children who had received even a single dose of the vaccine when compared with that in those who had not vaccinated. The results of this study reiterate the need for more effective global measles vaccination.

Severe Measles-Related Pneumonia in Children Treated with Steroid

Measles still remains one of the major causes of childhood morbidity and mortality in developing countries. It is a highly contagious viral illness with worldwide occurrence. In spite of a highly vaccinated population, a measles outbreak still occurred in Saudi Arabia in 2019, mainly in the northern regions. Measles-related pneumonia (MRP) is the commonest cause of death in children with measles. In this study, we described two cases of severe MRP in children, who were successfully treated with steroid during the 2019 outbreak.

Histopathological and Immunohistochemical Characteristics of Measles Exanthema: A Study of a Series of 13 Adult Cases and Review of the Literature

Despite available vaccination, measles is one of the leading causes of death among young children in developing countries. In clinical practice, the spectrum of differential diagnoses of morbilliform exanthemas associated with fever is wide, and it can be hard to differentiate from other infectious eruptions, especially in adults or in atypical courses in immunocompromised patients. The goal of our study was to identify characteristic histomorphological and immunohistochemical patterns of measles exanthema through the study of 13 skin biopsy specimens obtained from 13 patients with this disease and a review of cases in the literature. Histopathological features of measles exanthema are quite distinctive and characterized by a combination of multinucleated keratinocytes, and individual and clustered necrotic keratinocytes in the epidermis with pronounced folliculosebaceous as well as acrosyringeal involvement. Immunohistochemical staining of skin biopsies with anti-measles virus (MeV) nucleoprotein and anti-MeV phosphoprotein can be of great value in confirming the diagnosis of measles. Both methods can serve as quick additional diagnostic tools for prompt implementation of quarantine measures and for providing medical assistance, even in patients in whom the clinician did not consider measles as a differential diagnosis of the rash due to the rarity of the disease in a putatively vaccinated community.

Measles infection causing Bacillus Calmette-Guérin reactivation: a case report

Background

Reactivation of the Bacillus Calmette-Guérin (BCG), manifesting as erythema, induration, ulceration or crust formation at a previous BCG inoculation site, is a common and highly specific feature of Kawasaki disease (KD). We report the unusual finding of BCG reactivation in an infant with laboratory-confirmed measles.

Case presentation

A previously healthy 7-month old infant presented initially with fever, cough and coryza, and subsequently developed Koplik’s spots followed by a typical morbilliform skin rash. There was significant contact history with a household relative who had recently been diagnosed with measles. On examination, a 2.5 cm area of erythema and induration was seen at the previous BCG inoculation site, in addition to the widespread maculopapular rash. No other clinical features of KD were present. Measles virus was isolated from the throat swab and measles antibodies (IgM) were present in the serum. The patient recovered completely with oral vitamin A and supportive therapy, and had normal echocardiography examination on follow up.

Conclusions

This case report highlights the rare finding of BCG reactivation in a child with confirmed measles infection, and suggests that this clinical manifestation may occasionally occur in children with infections or conditions other than KD.

The tip of the iceberg: incompleteness of measles reporting during a large outbreak in The Netherlands in 2013-2014

Measles is a notifiable disease, but not everyone infected seeks care, nor is every consultation reported. We estimated the completeness of reporting during a measles outbreak in The Netherlands in 2013-2014. Children below 15 years of age in a low vaccination coverage community (n = 3422) received a questionnaire to identify measles cases. Cases found in the survey were matched with the register of notifiable diseases to estimate the completeness of reporting. Second, completeness of reporting was assessed by comparing the number of susceptible individuals prior to the outbreak with the number of reported cases in the surveyed community and on a national level.We found 307 (15%) self-identified measles cases among 2077 returned questionnaires (61%), of which 27 could be matched to a case reported to the national register; completeness of reporting was 8.8%. Based on the number of susceptible individuals and number of reported cases in the surveyed community and on national level, the completeness of reporting was estimated to be 9.1% and 8.6%, respectively. Estimating the completeness of reporting gave almost identical estimates, which lends support to the credibility and validity of both approaches. The size of the 2013-2014 outbreak approximated 31 400 measles infections.

Lung Infections

A review of pulmonary infections of all types with diagnostic and morphological features.

Effectiveness of Early Measles, Mumps, and Rubella Vaccination Among 6-14-Month-Old Infants During an Epidemic in the Netherlands: An Observational Cohort Study

Background

Routinely, the first measles, mumps, and rubella (MMR) vaccine dose is given at 14 months of age in the Netherlands. However, during a measles epidemic in 2013-2014, MMR vaccination was also offered to 6-14-month-olds in municipalities with <90% MMR vaccination coverage. We studied the effectiveness of the early MMR vaccination schedule.

Methods

Parents of all infants targeted for early MMR vaccination were asked to participate. When parent(s) suspected measles, their infant's saliva was tested for measles-specific antibodies. The vaccine effectiveness (VE) against laboratory-confirmed and self-reported measles was estimated using Cox regression, with VE calculated as 1 minus the hazard ratio.

Results

Three vaccinated and 10 unvaccinated laboratory-confirmed cases occurred over observation times of 106631 and 23769 days, respectively. The unadjusted VE against laboratory-confirmed measles was 94% (95% confidence interval [CI], 79%-98%). After adjustment for religion and sibling's vaccination status, the VE decreased to 71% (-72%-95%). For self-reported measles, the unadjusted and adjusted VE was 67% (40%-82%) and 43% (-12%-71%), respectively.

Conclusions

Infants vaccinated between 6 and 14 months of age had a lower risk of measles than unvaccinated infants. However, part of the effect was caused by herd immunity, since vaccinated infants were more likely to be surrounded by other vaccinated individuals.

Vaccines to prevent pneumonia in children - a developing country perspective

Pneumonia accounted for 15% of the 6.3 million deaths among children younger than five years in 2013, a total of approximately 935,000 deaths worldwide. Routine vaccination against common childhood illnesses has been identified as one of the most cost-effective strategies to prevent death from pneumonia. Vaccine-preventable or potentially preventable diseases commonly linked with respiratory tract infections include Streptococcus pneumoniae, Haemophilus influenza type-b (Hib), pertussis, influenza, measles, and tuberculosis. Although here have been great strides in the development and administration of effective vaccines, the countries that carry the largest disease burdens still struggle to vaccinate their children and newer conjugated vaccines remain out of reach for many. The Global Vaccine Action Plan (GVAP) has identified priority areas for innovation in research in all aspects of immunisation development and delivery to ensure equitable access to vaccines for all.

Child pneumonia - focus on the Western Pacific Region

Worldwide, pneumonia is the leading cause of death in infants and young children (aged <5 years). We provide an overview of the global pneumonia disease burden, as well as the aetiology and management practices in different parts of the world, with a specific focus on the WHO Western Pacific Region. In 2011, the Western Pacific region had an estimated 0.11 pneumonia episodes per child-year with 61,900 pneumonia-related deaths in children less than 5 years of age. The majority (>75%) of pneumonia deaths occurred in six countries; Cambodia, China, Laos, Papua New Guinea, the Philippines and Viet Nam. Historically Streptococcus pneumoniae and Haemophilus influenzae were the commonest causes of severe pneumonia and pneumonia-related deaths in young children, but this is changing with the introduction of highly effective conjugate vaccines and socio-economic development. The relative contribution of viruses and atypical bacteria appear to be increasing and traditional case management approaches may require revision to accommodate increased uptake of conjugated vaccines in the Western Pacific region. Careful consideration should be given to risk reduction strategies, enhanced vaccination coverage, improved management of hypoxaemia and antibiotic stewardship.

Severe pneumococcal pneumonia following Measles- Mumps- Rubella vaccination / Pneumonie pneumococică severă dezvoltată ca urmare a vaccinării Rujeolă-Oreion-Rubeolă

Hereby, we report a case of severe multi-lobular pneumococcal pneumonia with gangrene requiring pneumonectomy and accompanying septic shock that developed 1 day after a live-attenuated measles-mumps-rubella vaccination in a 58-year old kindergarten teacher.

Oncolytic viruses: From bench to bedside with a focus on safety

Oncolytic viruses are a relatively new class of anti-cancer immunotherapy agents. Several viruses have undergone evaluation in clinical trials in the last decades, and the first agent is about to be approved to be used as a novel cancer therapy modality. In the current review, an overview is presented on recent (pre)clinical developments in the field of oncolytic viruses that have previously been or currently are being evaluated in clinical trials. Special attention is given to possible safety issues like toxicity, environmental shedding, mutation and reversion to wildtype virus.

Measles Outbreak among Previously Immunized Adult Healthcare Workers, China, 2015

Measles is caused by measles virus belonging to genus Morbillivirus of the family Paramyxoviridae. Vaccination has played a critical role in controlling measles infection worldwide. However, in the recent years, outbreaks of measles infection still occur in many developing countries. Here, we report an outbreak of measles among healthcare workers and among the 60 measles infected patients 50 were healthcare workers including doctors, nurses, staff, and medics. Fifty-one patients (85%) tested positive for IgM antibodies against the measles virus and 50 patients (83.3%) tested positive for measles virus RNA. Surprisingly, 73.3% of the infected individuals had been previously immunized against measles. Since there is no infection division in our hospital, the fever clinics are located in the Emergency Division. In addition, the fever and rash were not recognized as measles symptoms at the beginning of the outbreak. These factors result in delay in isolation and early confirmation of the suspected patients and eventually a measles outbreak in the hospital. Our report highlights the importance of following a two-dose measles vaccine program in people including the healthcare workers. In addition, vigilant attention should be paid to medical staff with clinical fever and rash symptoms to avoid a possible nosocomial transmission of measles infection.

The Association between Invasive Group A Streptococcal Diseases and Viral Respiratory Tract Infections

Viral infections of the upper respiratory tract are associated with a variety of invasive diseases caused by Streptococcus pyogenes, the group A streptococcus, including pneumonia, necrotizing fasciitis, toxic shock syndrome, and bacteremia. While these polymicrobial infections, or superinfections, are complex, progress has been made in understanding the molecular basis of disease. Areas of investigation have included the characterization of virus-induced changes in innate immunity, differences in bacterial adherence and internalization following viral infection, and the efficacy of vaccines in mitigating the morbidity and mortality of superinfections. Here, we briefly summarize viral-S. pyogenes superinfections with an emphasis on those affiliated with influenza viruses.

Potentially Modifiable Factors Associated with Death of Infants and Children with Severe Pneumonia Routinely Managed in District Hospitals in Malawi

OBJECTIVE

To investigate recognised co-morbidities and clinical management associated with inpatient pneumonia mortality in Malawian district hospitals.

METHODS

Prospective cohort study, of patient records, carried out in Malawi between 1st October 2000 and 30th June 2003. The study included all children aged 0-59 months admitted to the paediatric wards in sixteen district hospitals throughout Malawi with severe and very severe pneumonia. We compared individual factors between those that survived (n = 14 076) and those that died (n = 1 633).

RESULTS

From logistic regression analysis, predictors of death in hospital, adjusted for age, sex and severity grade included comorbid conditions of meningitis (OR =2.49, 95% CI 1.50-4.15), malnutrition (OR =2.37, 95% CI 1.94-2.88) and severe anaemia (OR =1.41, 95% CI 1.03-1.92). Requiring supplementary oxygen (OR =2.16, 95% CI 1.85-2.51) and intravenous fluids (OR =3.02, 95% CI 2.13-4.28) were associated with death while blood transfusion was no longer significant (OR =1.10, 95% CI 0.77-1.57) when the model included severe anaemia.

CONCLUSIONS

This study identified a number of challenges to improve outcome for Malawian infants and children hospitalised with pneumonia. These included improved assessment of co-morbidities and more rigorous application of standard case management.

Tuberculosis as a cause or comorbidity of childhood pneumonia in tuberculosis-endemic areas: a systematic review

Pneumonia is a major cause of morbidity and mortality in infants and children worldwide, with most cases occurring in tuberculosis-endemic settings. Studies have emphasised the potential importance of Mycobacterium tuberculosis in acute severe pneumonia in children as a primary cause or underlying comorbidity, further emphasised by the changing aetiological range with rollout of bacterial conjugate vaccines in high mortality settings. We systematically reviewed clinical and autopsy studies done in tuberculosis-endemic settings that enrolled at least 100 children aged younger than 5 years with severe pneumonia, and that prospectively included a diagnostic approach to tuberculosis in all study participants. We noted substantial heterogeneity between studies in terms of study population and diagnostic methods. Of the 3644 patients who had culture of respiratory specimens for M tuberculosis undertaken, 275 (7·5%) were culture positive, and an acute presentation was common. Inpatient case-fatality rate for pneumonia associated with tuberculosis ranged from 4% to 21% in the four clinical studies that reported pathogen-related outcomes. Prospective studies are needed in high tuberculosis-burden settings to address whether tuberculosis is a cause or comorbidity of childhood acute severe pneumonia.

Spotlight on measles in Italy: why outbreaks of a vaccine-preventable infection continue in the 21st century

Measles is a serious infectious disease that can lead to significant morbidity and mortality. Remarkable progress has been made through measles vaccination in reducing the number of people dying from measles. In the last years, concerns about the safety of vaccines have led to decline in immunization coverage rates and new outbreaks of measles in many European countries, including Italy. We believe that it is important to reinforce the message that measles vaccine is safe and highly effective through appropriate information campaigns and public awareness.

[An update on measles]

Measles is a highly contagious infectious disease, which needs more than 95% worldwide vaccination coverage of 2 doses to be eradicated. Despite an important involvement of the WHO for massive immunization, goals have not bean reached, and outbreaks can occur at any time in many countries, including Western Europe. In France, 22,000 cases were identified between 2009 and 2011, mainly in infants and young adults, which are not or not enough vaccinated (one dose). In 2012, even though the number of cases has drastically decreased, the outbreak is still going on, especially in South of France. That is why every clinician needs to be concerned about the clinical manifestations of the disease, and its complications. Besides a febrile rash, measles is often responsible of pneumonia and biologic hepatitis in adults. Hepatitis does not seem frequent in children. Clinicians need to be aware of specific complications, like encephalitis in case of cellular immunodepression, high risk of pneumonia in pregnant women. In patients previously vaccinated, incidence of complications is the same but patients are not contagious. Even if measles diagnosis is clinical, blood confirmation by serology is recommended in France when possible. Outcome is mainly favourable, but measles is not well-tolerated with high levels of hospitalisation even without any complication. Vaccination is the only way to protect against it.

A comparison of adult and pediatric measles patients admitted to emergency departments during the 2008-2011 outbreak in the Midi-Pyrénées region of France

The present French and European measles outbreaks show a bimodal distribution: the two most affected populations are infants aged less than 1 year and adults older than 20 years. The purpose of this study was to determine wether there were differences in the clinical presentation and evolution of measles between adult and pediatric patients. We performed a retrospective study of adult and pediatric measles patients admitted to three tertiary-level university hospitals between January 2008 and May 2011. Data were extracted from medical charts and positive laboratory results. Collected data were age, sex, geographical origin, vaccination status, source of exposure, overseas travel before symptom onset, clinical symptoms, risk factors for complications, severity criteria on admission, type of diagnosis, biological abnormalities, complications, and treatments. A total of 305 patients (171 children and 134 adults) were included in the study. The mean age was 4.6 ± 4.4 years in children and 26.7 ± 8.1 years in adults. Children were less often hospitalized than adults (29% vs. 66%). A comparison between hospitalized pediatric (n = 49) and adult (n = 89) patients revealed that the former had a higher incidence of complications (P < 0.0001), more otorhinolaryngological complications (24% vs. 1%; P < 0.0001), and a higher incidence of severe criteria on admission (P = 0.02). Hospitalized pediatric patients differed from adults in terms of disease severity and complications.

Risk for tuberculosis in child contacts. Development and validation of a predictive score

RATIONALE

Contact investigation of persons exposed to tuberculosis (TB) is resource intensive. To date, no clinical prediction rule for TB risk exists for use as a guide during contact investigation.

OBJECTIVES

We sought to develop and validate a simple and easy-to-use predictive score for TB risk, using data routinely available during contact investigation.

METHODS

The derivation cohort consisted of 9,411 children aged 0 to 12 years from 2008 to 2009 national contacts cohort. We used a multivariate Cox proportional hazards model to predict the risk of developing active TB. The validation cohort consisted of 2,405 children from the 2005 national contacts cohort. We calculated area under the receiver operating characteristic curves of the model as well as the predicted risk of TB for contacts with different scores.

MEASUREMENTS AND MAIN RESULTS

An 8-point scoring system was developed, including reaction to tuberculin skin test of the contacts, as well as smear-positivity, residence in high-incidence areas, and sex of the index cases. Area under the receiver operating characteristic curve was 0.872 (95% confidence interval, 0.810-0.935) for the derivation cohort and 0.900 (95% confidence interval, 0.830-0.969) for the validation cohort. The risk of developing active TB within 3 years is 100, 7.8, 4.3, 1.0, 0.7, and 0.2% for contacts with risk scores of 7, 6, 5, 4, 3, and 2, respectively.

CONCLUSIONS

A risk predictive score was developed and validated to identify child contacts aged 0 to 12 years at increased risk for active TB. This predictive score can help to prioritize active case finding or isoniazid preventive therapy among children exposed to TB.

Measles epidemic from 1951 to 2012 and vaccine effectiveness in Guangzhou, southern China

BACKGROUND

Since the National Expanded Program on Immunization was implemented in China, considerable progress has been made in reducing the incidence of measles. However, the incidence of measles increased again in 2004. Few post-marketing studies on measles vaccine effectiveness were reported in China. In this study, we aimed to describe the measles epidemic and to evaluate the effectiveness of the measles vaccine in Guangzhou, southern China.

METHODS

Based on the surveillance data for measles, we investigated the epidemiology during different periods between 1951 and 2012. We analyzed the clinical characteristics of laboratory-confirmed cases of measles between 2009 and 2012 and conducted a case-control study using test-negative cases as controls. We determined the protective effect of measles vaccine.

RESULTS

The highest annual incidence in Guangzhou was 2187.15/100,000 in 1964, and the lowest was 0.32/100,000 in 2011. The average incidence of measles from 1951 to 2012 was 306.27/100,000. There was a significant tendency of decline in recent years. From 2009 to 2012, there are 700 laboratory-confirmed cases were reported with an average onset age of 2.5 (median) years. The non-vaccinated target population (age<8 months and ≥ 15 years) accounted for 56.7% of the cases. The transient (non-resident) population accounted for 51.3% of the cases. Fewer cases were observed in the population targeted for measles vaccine (aged 8 months to 14 years). The effectiveness of a single dose of the measles vaccine was 89.1% (95% confidence interval (CI), 44.5-97.9), and the effectiveness of ≥ 2 doses of the measles vaccine was 97.8% (95% CI, 88.3-99.6) in children aged 8 months to 14 years old.

CONCLUSIONS

There is a significant overall decline in the incidence of measles (including clinical and laboratory confirmed cases) in the measles vaccine targeted population in Guangzhou. Two doses of measles vaccine are more effective than one dose in preventing measles in China. In order to accelerate the elimination of measles, vaccination should also be given to the transient and the non-vaccine targeted population.

Measles Virus

Name of Virus: Measles virus

Measles outbreak in a pediatric oncology unit and the role of ribavirin in prevention of complications and containment of the outbreak

The role of oral ribavirin in treatment and containment of a measles outbreak in 15 children in an oncology unit is presented. Measles was diagnosed on clinical features and history of contact. Measles specific IgM ELISA and RNA were positive in 7 of 15 and 2 of 7 tested children, respectively. Duration of illness was longer in unimmunized as compared to immunized children (P = 0.02). Complications were higher in hematological malignancies (P = 0.025). Delay in starting ribavirin was associated with fatal complications (2 of 2 vs. 0 of 13, P = 0.009). Ribavirin prevented measles in all (21 of 21) patients exposed to the cases.

Severe Measles Infection: The Spectrum of Disease in 36 Critically Ill Adult Patients

France has recently witnessed a nationwide outbreak of measles. Data on severe forms of measles in adults are lacking. We sought to describe the epidemiologic, clinical, treatment, and prognostic aspects of the disease in adult patients who required admission to an intensive care unit (ICU). We performed a retrospective analysis of a cohort of 36 adults admitted to a total of 64 ICUs throughout France for complications of measles from January 1, 2009, to December 31, 2011. All cases of measles were confirmed by serologic testing and/or reverse transcription polymerase chain reaction.The cohort consisted of 21 male and 15 female patients, with a median age of 29.2 years (25th-75th interquartile range [IQR], 27.2-34.2 yr) and a median Simplified Acute Physiology Score (SAPS II) of 13 (IQR, 9-18). Among the 26 patients whose measles vaccination status was documented, none had received 2 injections. One patient had developed measles during childhood. Underlying comorbid conditions included chronic respiratory disease in 9 patients, immunosuppression in 7 patients, and obesity in 3 patients, while measles affected 5 pregnant women.Respiratory complications induced by measles infection led to ICU admission in 32 cases, and measles-related neurologic complications led to ICU admission in 2 cases. Two patients were admitted due to concurrent respiratory and neurologic complications.Bacterial superinfection of measles-related airway infection was suspected in 28 patients and was documented in 8. Four cases of community-acquired pneumonia, 6 cases of ventilator-associated pneumonia, 1 case of tracheobronchitis, and 2 cases of sinusitis were microbiologically substantiated.Of 11 patients who required mechanical ventilation, 9 developed acute respiratory distress syndrome (ARDS). Among the patients with ARDS, extraalveolar air leak complications occurred in 4 cases. Five patients died, all of whom were severely immunocompromised.On follow-up, 1 patient had severe chronic respiratory failure related to lung fibrosis, and 2 patients had mild lower limb paraparesis along with bladder dysfunction, both of which were ascribable to measles-induced encephalitis and myelitis. Among the 5 pregnant patients, the course of measles infection was uneventful, albeit 1 patient underwent emergent cesarean delivery because of fetal growth restriction.Measles is a disease with protean and potentially deceptive clinical manifestations, especially in the immunocompromised patient. Measles-associated pneumonitis and its complications, and less commonly postinfectious encephalomyelitis, are the main source of morbidity and mortality. In contrast with the usually benign course of the disease in immunocompetent patients, measles occurring in immunocompromised patients gives rise to lethal complications including ARDS, with or without bacterial superinfection. Other patients potentially at high risk for severe measles are young adults and pregnant women. Measles pneumonitis may predispose to air leak disease in patients using mechanical ventilation. To date, vaccination remains the most potent tool to control measles infection.

Global burden of childhood pneumonia and diarrhoea

Diarrhoea and pneumonia are the leading infectious causes of childhood morbidity and mortality. We comprehensively reviewed the epidemiology of childhood diarrhoea and pneumonia in 2010-11 to inform the planning of integrated control programmes for both illnesses. We estimated that, in 2010, there were 1·731 billion episodes of diarrhoea (36 million of which progressed to severe episodes) and 120 million episodes of pneumonia (14 million of which progressed to severe episodes) in children younger than 5 years. We estimated that, in 2011, 700,000 episodes of diarrhoea and 1·3 million of pneumonia led to death. A high proportion of deaths occurs in the first 2 years of life in both diseases--72% for diarrhoea and 81% for pneumonia. The epidemiology of childhood diarrhoea and that of pneumonia overlap, which might be partly because of shared risk factors, such as undernutrition, suboptimum breastfeeding, and zinc deficiency. Rotavirus is the most common cause of vaccine-preventable severe diarrhoea (associated with 28% of cases), and Streptococcus pneumoniae (18·3%) of vaccine-preventable severe pneumonia. Morbidity and mortality from childhood pneumonia and diarrhoea are falling, but action is needed globally and at country level to accelerate the reduction.

Approach to common bacterial infections: community-acquired pneumonia

Community-acquired pneumonia (CAP) occurs more often in early childhood than at almost any other age. Many microorganisms are associated with pneumonia, but individual pathogens are difficult to identify, which poses problems in antibiotic management. This article reviews the common as well as new, emerging pathogens, as well as the guidelines for management of pediatric CAP. Current guidelines for pediatric CAP continue to recommend the use of high-dose amoxicillin for bacterial CAP and azithromycin for suspected atypical CAP (usually caused by Mycoplasma pneumoniae) in children.

The receptor-binding site of the measles virus hemagglutinin protein itself constitutes a conserved neutralizing epitope

Here, we provide direct evidence that the receptor-binding site of measles virus (MV) hemagglutinin protein itself forms an effective conserved neutralizing epitope (CNE). Several receptor-interacting residues constitute the CNE. Thus, viral escape from neutralization has to be associated with loss of receptor-binding activity. Since interactions with both the signaling lymphocyte activation molecule (SLAM) and nectin4 are critical for MV pathogenesis, its escape, which results from loss of receptor-binding activity, should not occur in nature.

DHEA inhibits measles virus through a mechanism independent of its ability to modulate the Raf/MEK/ERK signaling pathway

Aim: Despite the existence of an effective vaccine, measles infection is still frequent in many developing countries with reduced health infrastructure, and it is one of the major causes of child death globally. In the past decade numerous outbreaks have occurred in developed countries, giving a fresh impetus to antiviral research against measles virus. The aim of this study was to investigate the antiviral activity of the natural steroid hormone DHEA against measles virus and the role of the Raf/MEK/ERK signaling pathway in viral multiplication and DHEA’s antiviral activity. Materials & methods: The antiviral activity of DHEA and two ERK modulators, UO126 and anisomycin, was determined using a virus yield reduction assay. Furthermore, we studied DHEA’s virucidal activity and the viral multiplication step affected by the compound. The effect of virus infection on the Raf/MEK/ERK pathway and the activity of those compounds against measles virus spread and induced cytopathic effect were studied using western blot and indirect immunofluorescence. Results & conclusion: We found that DHEA and UO126 are active against measles virus and that they are able to diminish virus-induced cytopathic effects. Also, our study showed that early events in the viral multiplication cycle trigger ERK activation, suggesting that DHEA, a Raf/MEK/ERK modulator, may not exert its antiviral activity through the modulation of this pathway. Our results may provide a first step in the development of new antiviral agents against measles virus.

Functional and structural characterization of neutralizing epitopes of measles virus hemagglutinin protein

Effective vaccination programs have dramatically reduced the number of measles-related deaths globally. Although all the available data suggest that measles eradication is biologically feasible, a structural and biochemical basis for the single serotype nature of measles virus (MV) remains to be provided. The hemagglutinin (H) protein, which binds to two discrete proteinaceous receptors, is the major neutralizing target. Monoclonal antibodies (MAbs) recognizing distinct epitopes on the H protein were characterized using recombinant MVs encoding the H gene from different MV genotypes. The effects of various mutations on neutralization by MAbs and virus fitness were also analyzed, identifying the location of five epitopes on the H protein structure. Our data in the present study demonstrated that the H protein of MV possesses at least two conserved effective neutralizing epitopes. One, which is a previously recognized epitope, is located near the receptor-binding site (RBS), and thus MAbs that recognize this epitope blocked the receptor binding of the H protein, whereas the other epitope is located at the position distant from the RBS. Thus, a MAb that recognizes this epitope did not inhibit the receptor binding of the H protein, rather interfered with the hemagglutinin-fusion (H-F) interaction. This epitope was suggested to play a key role for formation of a higher order of an H-F protein oligomeric structure. Our data also identified one nonconserved effective neutralizing epitope. The epitope has been masked by an N-linked sugar modification in some genotype MV strains. These data would contribute to our understanding of the antigenicity of MV and support the global elimination program of measles.

Do income inequality and social capital associate with measles-containing vaccine coverage rate?

OBJECTIVE

We investigated the association between income inequality and social capital with measles-containing vaccine (MCV) coverage rates in Japan.

METHODS

MCV coverage data for all 1750 municipalities were collected from statistics publicized by the Ministry of Health, Labour and Welfare of Japan in 2010. Prefectural Gini coefficients in 2009 (an indicator of income inequality) and social capital indicators (including voting rates, volunteer rates at the prefectural level, and move-in ratios at the municipal level) were linked to MCV coverage using a multilevel analysis adjusting for covariates (population, age distribution, average income, average number of household members).

RESULTS

Coverage of the first dose of MCV (MCV1), and second dose (MCV2), decreased by 3.98% (95% confidence interval [CI]: 0.26-7.71) and 4.28% (95% CI: 0.60-7.60) per each 0.1-unit increase in Gini coefficients within large municipalities (with a population 50,000 or more), respectively. Conversely, coverage of MCV2 increased by 0.26% (95% CI: 0.08-0.45) per 1% increase in voting rate within large municipalities. Volunteer rates were inversely associated with MCV2 coverage within large municipalities. Move-in ratios at the municipal level were inversely associated with MCV2 coverage within medium-sized municipalities (with a population between 10,000 and 50,000).

CONCLUSIONS

While higher income inequality at a prefectural level was associated with lower MCV coverage rates, higher social capital was associated with higher coverage in large municipalities. To enhance MCV coverage in Japan, we recommend that income inequality be addressed and social capital boosted at the prefectural level.

Measles

Measles is a highly contagious disease caused by measles virus and is one of the most devastating infectious diseases of man--measles was responsible for millions of deaths annually worldwide before the introduction of the measles vaccines. Remarkable progress in reducing the number of people dying from measles has been made through measles vaccination, with an estimated 164,000 deaths attributed to measles in 2008. This achievement attests to the enormous importance of measles vaccination to public health. However, this progress is threatened by failure to maintain high levels of measles vaccine coverage. Recent measles outbreaks in sub-Saharan Africa, Europe, and the USA show the ease with which measles virus can re-enter communities if high levels of population immunity are not sustained. The major challenges for continued measles control and eventual eradication will be logistical, financial, and the garnering of sufficient political will. These challenges need to be met to ensure that future generations of children do not die of measles.