From the Center for Disease control: current status of measles in the United States, 1973--1977

MMR vaccination timing and long-term immunity among childhood cancer survivors

Long-term seroprotection against the measles and mumps viruses has not been reported in childhood cancer survivor (CCS) who received two-lifetime doses of the measles, mumps, and rubella (MMR) vaccine. We performed a retrospective study of measles and mumps titers among 55 CCS who received standard chemotherapy and two MMR vaccinations at any time. Over 75% of CCS who received at least one MMR prior to their cancer diagnosis had a negative or equivocal titer to measles or mumps. In contrast, all CCS who received the MMR series following their cancer treatment demonstrated long-term seroprotection to both viruses at a mean of 8.2 years after their last vaccination.

Innovations in vaccine delivery: increasing access, coverage, and equity and lessons learnt from measles and rubella elimination

Disease eradication and elimination programs drive innovations based on progress toward measurable objectives, evaluations of new strategies and methods, programmatic experiences, and lessons learned from the field. Following progress toward global measles elimination, reducing measles mortality, and increasing introductions of measles and rubella vaccines to national programs, the measles and rubella immunization program has faced setbacks in recent years. Currently available vaccine delivery methods have complicated logistics and drawbacks that create barriers to vaccination; innovations for easier, more efficient, and safer vaccine delivery are needed. Progress can be accelerated by new technologies like microarray patches (MAPs) that are now widely recognized as a potential new tool for enhancing global immunizations efforts. Clinical trials of measles-rubella vaccine MAPs have begun, and several other vaccine MAPs are in the pre-clinical development pathway. MAPs could significantly contribute to Immunization Agenda 2030 priorities, including reaching zero-dose children; increasing vaccine access, demand, coverage, and equity; and achieving measles and rubella elimination. With strong partnerships between public health agencies and biotechnology companies, translational novel vaccine delivery systems can be developed to help solve public health problems and achieve global health priorities.

A microneedle patch for measles and rubella vaccination: a game changer for achieving elimination

While morbidity and mortality associated with measles and rubella (MR) have dramatically decreased, there are still >100000 estimated deaths due to measles and an estimated 100000 infants born with congenital rubella syndrome annually. Given highly effective MR vaccines, the primary barrier to global elimination of these diseases is low vaccination coverage, especially among the most underserved populations in resource-limited settings. In contrast to conventional MR vaccination by hypodermic injection, microneedle patches are being developed to enable MR vaccination by minimally trained personnel. Simplified supply chain, reduced need for cold chain storage, elimination of vaccine reconstitution, no sharps waste, reduced vaccine wastage, and reduced total system cost of vaccination are advantages of this approach. Preclinical work to develop a MR vaccine patch has proceeded through successful immunization studies in rodents and non-human primates. On-going programs seek to make MR vaccine patches available to support MR elimination efforts around the world.

Use of a Diagonal Approach to Health System Strengthening and Measles Elimination after a Large Nationwide Outbreak in Mongolia

Measles is a highly transmissible infectious disease that causes serious illness and death worldwide. Efforts to eliminate measles through achieving high immunization coverage, well-performing surveillance systems, and rapid and effective outbreak response mechanisms while strategically engaging and strengthening health systems have been termed a diagonal approach. In March 2015, a large nationwide measles epidemic occurred in Mongolia, 1 year after verification of measles elimination in this country. A multidisciplinary team conducted an outbreak investigation that included a broad health system assessment, organized around the Global Health Security Agenda framework of Prevent-Detect-Respond, to provide recommendations for evidence-based interventions to interrupt the epidemic and strengthen the overall health system to prevent future outbreaks of measles and other epidemic-prone infectious threats. This investigation demonstrated the value of evaluating elements of the broader health system in investigating measles outbreaks and the need for using a diagonal approach to achieving sustainable measles elimination.

Reflections of a Vaccinologist: Lessons Learned About What We Can Do to Improve Trust in Vaccines and Vaccine Programsa

Public trust can be improved by learning from past mistakes, by establishing a standing forum for review of new concerns as they arise, and by maintaining a robust vaccine safety system. Developing standard guidelines for reporting causality assessment in case reports would help educate physicians and prevent future unnecessary concerns based on false assumptions of causal relationships.

African vaccination week as a vehicle for integrated health service delivery

Background

African Vaccination Week (AVW) is an initiative of the Member States of the African Region aimed at promoting vaccination and ensuring equity and access to its benefits. The initiative has proven to be particularly effective in reaching populations with limited access to regular health services as well as providing an opportunity to integrate other interventions with immunization services.

Methods

Using data available from the countries within the African Region, the effectiveness of AVW in creating awareness on vaccination as well as providing platform for integrated delivery of other interventions with immunization in the African Region were explored during the 2013 and 2014 campaigns of the AVW.

Results

Countries that participated in the two campaigns of AVW have integrated other interventions with immunization during the AVW. The most common integrated intervention is vitamin A supplementation, followed by deworming. However, other interventions integrated, include public health educational activities, supplementation with vitamins and minerals, provision of other health services as well as introduction of new interventions. In 2013, more than 7,500,000 doses of different vaccine antigens were delivered in17 countries. Vitamin A administered to children under 5 years and women in post-partum in 13 countries with 31,500,000 tablets distributed. Polio eradication campaigns reaching young children in ten countries with 36,711,984 doses of oral polio vaccines (OPV) was the third most common intervention added onto the AVW activities. Over 21,190,000 deworming tablets were distributed to children <5 years and pregnant women in 9 countries. With respect to nutritional interventions, 6,377,222 children were screened for malnutrition in 3 countries while 3,814,680 water, sanitation and hygiene kits were distributed in 3 countries. In 2014, these results were even higher as many more countries integrated multiple interventions in the AVW.

Conclusion

Integration of other interventions with immunization during AVW, in the African Region is common and has shown potentials for improving immunization coverage, as this dedicated period is used both for catch-up campaigns and periodic intensified routine immunization. While its impact may call for further examination, it is a potential platform for integrated delivery of health interventions to people with limited access to regular health service.

Enhancing access to immunization services and exploiting the benefits of recent innovations in the African region

The African Regional Office of the World Health Organization (WHO AFRO) organized the annual regional conference on immunization (ARCI) from 10 to 12 December 2012 in Dar es Salaam, Tanzania, under the theme, "Innovations, access and the right of all to vaccines". The meeting reviewed the status of immunization in the region and identified all innovations, strategies and technologies available and how these could be fully utilized to enhance the access and the rights of all to vaccines. Over 50 oral presentations were made in plenary and parallel sessions of the conference which was attended by over 200 participants drawn from national immunization programs, academia, public health experts and immunization partners. In addition there were 40 poster presentations. This manuscript summarizes of the meeting, highlighting the innovations in immunization being piloted or scaled-up, their impact and suggesting ways to further improve immunization service delivery for the eradication, elimination and control of vaccine-preventable diseases in the region.

Highlights of historical events leading to national surveillance of vaccination coverage in the United States

The articles published in this special supplement of Public Health Reports provide examples of only some of the current efforts in the United States for evaluating vaccination coverage. So, how did we get here? The history of vaccination and assessment of vaccination coverage in the U.S. has its roots in the pre-Revolutionary War era. In many cases, development of vaccines, and attention devoted to the assessment of vaccination coverage, has grown from the impact of infectious disease on major world events such as wars. The purpose of this commentary is to provide a brief overview of the key historical events in the U.S. that influenced the development of vaccines and the efforts to track vaccination coverage, which laid the foundation for contemporary vaccination assessment efforts.

The immunization status of home-schooled children in America

The immunization of children against a vast number of life-threatening infectious agents has been hailed as one of the greatest public health interventions of the twentieth century. In America, the morbidity and mortality associated with many common childhood infectious diseases has all but vanished. State-based school entry vaccination laws play a significant role in achieving high immunization rates among children and adolescents. Alarmingly, there is no consistent regulation in place to monitor the immunization status of the ever-growing home-schooled population. It is widely unknown whether the nearly 2 million home-schooled children are adequately immunized. As the home schooling movement continues to gain ground in the United States, pediatric nurse practitioners in the primary care setting will play an important role in protecting the health of these children, as well as the public's health.

Immunization programs for infants, children, adolescents, and adults: clinical practice guidelines by the Infectious Diseases Society of America

Evidence-based guidelines for immunization of infants, children, adolescents, and adults have been prepared by an Expert Panel of the Infectious Diseases Society of America (IDSA). These updated guidelines replace the previous immunization guidelines published in 2002. These guidelines are prepared for health care professionals who care for either immunocompetent or immunocompromised people of all ages. Since 2002, the capacity to prevent more infectious diseases has increased markedly for several reasons: new vaccines have been licensed (human papillomavirus vaccine; live, attenuated influenza vaccine; meningococcal conjugate vaccine; rotavirus vaccine; tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis [Tdap] vaccine; and zoster vaccine), new combination vaccines have become available (measles, mumps, rubella and varicella vaccine; tetanus, diphtheria, and pertussis and inactivated polio vaccine; and tetanus, diphtheria, and pertussis and inactivated polio/Haemophilus influenzae type b vaccine), hepatitis A vaccines are now recommended universally for young children, influenza vaccines are recommended annually for all children aged 6 months through 18 years and for adults aged > or = 50 years, and a second dose of varicella vaccine has been added to the routine childhood and adolescent immunization schedule. Many of these changes have resulted in expansion of the adolescent and adult immunization schedules. In addition, increased emphasis has been placed on removing barriers to immunization, eliminating racial/ethnic disparities, addressing vaccine safety issues, financing recommended vaccines, and immunizing specific groups, including health care providers, immunocompromised people, pregnant women, international travelers, and internationally adopted children. This document includes 46 standards that, if followed, should lead to optimal disease prevention through vaccination in multiple population groups while maintaining high levels of safety.

Compulsory vaccination and conscientious or philosophical exemptions: past, present, and future

Compulsory vaccination has contributed to the success of immunisation programmes in the USA and Australia, yet the benefits from compulsory vaccination are not universally recognised. Some people--experts and the public alike--believe that the benefits of compulsory vaccination are outweighed by the associated ethical problems. A review of vaccination legislation in the UK, Australia, and the USA raises four main points. First, compulsory vaccination may be effective in preventing disease outbreaks, reaching and sustaining high immunisation coverage rates, and expediting the introduction of new vaccines. Second, to be effective, compulsory programmes must have a reliable supply of safe and effective vaccines and most people must be willing to be vaccinated. Third, allowance of exemptions to compulsory vaccination may limit public backlash. Finally, compulsory vaccination may increase the burden on governments to ensure the safety of vaccines. Nevertheless, although compulsory immunisation can be very effective, it might not be acceptable in some countries where high coverage has been achieved through other approaches or efforts, such as in Sweden, Norway, Denmark, the Netherlands, and the UK. These factors should be considered when compulsory vaccinations are being introduced or immunisation laws refined. Lessons learned from compulsory vaccination could be useful to other public-health programmes.

Public health and the politics of school immunization requirements

Compulsory vaccination has contributed to the enormous success of US immunization programs. Movements to introduce broad "philosophical/personal beliefs" exemptions administered without adequate public health oversight threaten this success. Health professionals and child welfare advocates must address these developments in order to maintain the effectiveness of the nation's mandatory school vaccination programs. We review recent events regarding mandatory immunization in Arkansas and discuss a proposed nonmedical exemption designed to allow constitutionally permissible, reasonable, health-oriented administrative control over exemptions. The proposal may be useful in political environments that preclude the use of only medical exemptions. Our observations may assist states whose current nonmedical exemption provisions are constitutionally suspect as well as states lacking legally appropriate administrative controls on existing, broad non-medical exemptions.

Exemptions to school immunization requirements: the role of school-level requirements, policies, and procedures

OBJECTIVES

Our goal was to determine whether school-level variability in implementation of immunization requirements is associated with the likelihood of a child having received an exemption to school immunization requirements.

METHODS

We surveyed 1000 school immunization personnel in Colorado, Massachusetts, Missouri, and Washington. We explored associations between school implementation of immunization requirements and the likelihood of a child having an exemption using logistic regression models.

RESULTS

School policies associated with an increased likelihood of children having exemptions included lack of provision of written instructions for completing the school immunization requirement before enrollment, administrative procedures making it easier to claim an exemption, and granting of philosophical exemptions. In the 2 states we surveyed where philosophical exemptions are not authorized (Massachusetts and Missouri), 17.0% and 18.1% of schools reported permitting philosophical exemptions.

CONCLUSIONS

Inconsistencies in the interpretation and implementation of school immunization laws contribute to variability in rates of exemptions. School policies should be reviewed to ensure consistency with the intent of state laws.

Whole blood samples as an alternative to serum for detection of immunity to measles virus by ELISA

The aim of this study was to evaluate enzyme linked immunosorbent assay (ELISA) as a testing strategy for detection of antibodies against measles virus from microquantities of blood soaked onto filter paper. We studied 165 healthy children in the age group of 1 to 2 years, attending the outpatient department of pediatrics. Two sets of samples were collected from each child. One by venipuncture and the other on Whatman filter paper-3 discs of 20 mm size by finger or heel prick so that each strip is completely soaked with blood on both sides. These were tested for measles virus antibodies by ELISA using Melotest measles IgG commercial ELISA kit manufactured by Melotec S. A. (Barcelona, Spain). The resulting sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of the filter paper (FP) ELISA compared to serum ELISA was 100, 90, 97.8, and 100%, respectively. The correlation coefficient r = 0.93% (p < 0.001) and the agreement between the two techniques was 98% as calculated by the Kappa statistical method. The present study has found filter paper testing by ELISA to be a promising qualitative technique for detection of immunity against measles.

Respiratory failure complicating rubeola

We reviewed the charts of 19 patients with the diagnosis of measles who were admitted to the pediatric intensive care unit for respiratory failure requiring intubation and mechanical ventilation. Patients studied were admitted during the period June 1989 to June 1990. The mean age was 19 months (range, 3 to 51 months). The cause for respiratory failure fell into two groups: 47 percent developed pneumonitis and refractory hypoxemia. Patients with pneumonitis and hypoxemic respiratory failure had a 56 percent mortality. An oxygenation index of greater than 40 for 4 h separated survivors from nonsurvivors (oxygenation index = [mean airway pressure x FIo2/PaO2 x 100]). Patients with tracheitis alone all survived. In these patients the organism primarily responsible was Staphylococcus aureus (70 percent). Two of the seven patients with S aureus tracheitis had signs and symptoms of toxic shock syndrome and we subsequently demonstrated toxic shock syndrome toxin 1 in both patients.

Surveillance. Information for action

Success in immunization requires success in developing an adequate information base. While special studies are important, there is no substitute for surveillance systems. Such systems help evaluate health impact, monitor trends in reported disease and adverse events, and identify areas for more intense investigation. Surveillance data alone have played major roles in immunization strategy changes. Successful surveillance relies on cooperation by health care providers and health departments. While filling out forms and reporting cases may be viewed as a burden by some, such information in the aggregate becomes an important part of the knowledge base used to refocus implementation efforts and potentially to change strategies. Reporting by all physicians is particularly important when reported cases lead to aggressive control actions such as outbreak control. Rapid reporting even when cases are not confirmed can help health departments ensure that needed laboratory specimens are collected and allow control measures to be undertaken before disease containment becomes difficult. In conclusion, any immunization program worth instituting is worth monitoring. Surveillance represents constant vigilance to ensure effective control or elimination of disease.

Distribuição etária do sarampo e vacinação: considerações sobre alguns dados do município do Rio de Janeiro

São apresentados alguns dados sobre a distribuição etária dos casos notificados de sarampo no Município do Rio de Janeiro entre 1964 e 1982, observando-se a modificação ocorrida nesta distribuição entre o período pré-vacinação e o período pós-vacinação. Estes dados são comparados com dados de alguns outros países e é feita uma breve discussão sobre a influência da vacinação na epidemiologia do sarampo.

Antibody assay for measles virus: comparisons of immune-adherence haemagglutination, single radial haemolysis, enzyme immunoassay and haemagglutination inhibition

Immune-adherence haemagglutination (IAHA); single radial haemolysis and enzyme immunoassay (ELISA) versus haemagglutination inhibition (HAI) for detecting antibodies to measles virus were evaluated. The rank correlation computed according to Spearman for the sera of healthy individuals gave values of 0.66, 0.73, 0.72, respectively, for HAI-IAHA, HAI-single radial haemolysis (SRH) and HAI-ELISA. High percentages of accordance were observed as regards sera from both healthy and vaccinated individuals. In the case of vaccinated individuals the discordance analysis showed significant differences between HAI and IAHA, HAI and SRH, SRH and ELISA. The discordances indicate higher sensitivity of HAI and ELISA for the detection of seroconversion.

Epidemiology of prenatal infections: an extension of the congenital rubella model

The properties of prenatal infections are studied through the development of a theoretical model. The responses of such epidemic systems to natural changes in transmission rates, age at maternity, social stratification, geographical heterogeneity, epidemic instability and the introduction of vaccination, are examined. The effects of age-at-vaccination, efficacy of vaccination, wild virus interaction, and vaccine-immunity decay rates, are also examined in some detail. Several powerful putative influences upon the evolution of prenatally determined infective diseases are identified. They provide scientific tools for detecting processes of this kind.

Low measles incidence: association with enforcement of school immunization laws

Of 54 federal immunization project areas in the United States, 13 areas with low measles incidence rates in 1977 and 1978 and 10 with high measles incidence rates were compared for differences in surveillance systems, demography, vaccine utilization, school immunization laws, and immunity levels. There was no significant difference between the low incidence and high incidence group for any examined parameter of demographic characteristics, vaccine utilization, or surveillance systems. However, in the low incidence group, school immunization laws were found to be more comprehensive and more strictly enforced with a statewide policy of exclusion from school of noncompliant students. Furthermore, immunization levels were similar for two-year-olds in both groups but were significantly higher for school entrants in the low incidence group. In all public health efforts to control or eliminate measles, priority should be given to establishing and strictly enforcing comprehensive school immunization laws.

Measles mortality in the United States 1971-1975

During 1971-75, an average of 35.4 measles-related deaths were recorded each year; one death for every 1,000 measles cases reported. Measles mortality rate was highest in children under 1 year of age, as was the death-to-case ratio. Mortality rates were higher in non-metropolitan than in metropolitan counties. Measles mortality rates were inversely related to median family income.