Live vaccinations in dermatology for immunosuppressed patients: a narrative review

Given the higher susceptibility to infectious disease in patients receiving immunosuppressive therapies for inflammatory dermatologic conditions, immunization is important in this population. While live vaccines protect against life-threatening diseases, they can be harmful in immunosuppressed patients given the risk of replication of the attenuated pathogen and adverse reactions. The utilization of live vaccines in immunosuppressed patients depends on multiple factors such as the vaccine and therapy regimen. To provide an overview of evidence-based recommendations for the use of live vaccines in patients receiving immunosuppressive therapies for dermatological conditions. A literature search of the PubMed database was performed using keywords live vaccine, live-attenuated vaccine, dermatology, immunosuppressed, and immunocompromised, and specific immunosuppressive therapies: corticosteroids, glucocorticoids, methotrexate, azathioprine, cyclosporine, mycophenolate mofetil, biologics. Relevant articles written in English were included. Using these keywords, 125 articles were reviewed, of which 28 were ultimately selected. Recommendations for live vaccines can be determined on a case-by-case basis. Measles, mumps, rubella, varicella (MMRV) vaccines may be safely administered to patients on low-dose immunosuppressive agents while the yellow fever vaccine is typically contraindicated. It may be safe to administer live MMRV boosters to children on immunosuppressive therapies and the live herpes zoster vaccine to patients on biologics. Given poor adherence to immunization guidelines in immunosuppressed patients, dermatologists have a critical role in educating patients and general practitioners regarding live vaccines. By reviewing a patient's vaccination history and following immunization guidelines prior to initiating immunosuppressive therapies, physicians can mitigate morbidity and mortality from vaccine-preventable diseases.

Impact of pregnancy vaccine uptake and socio-demographic determinants on subsequent childhood Measles, Mumps and Rubella vaccine uptake: A UK birth cohort study

BACKGROUND

We examined the association between socio-demographic determinants and uptake of childhood Measles, Mumps & Rubella (MMR) vaccines and the association between pregnant women's pertussis vaccine uptake and their children's MMR vaccine uptake.

METHODS

We used nationally-representative linked mother-baby electronic records from the United Kingdom's Clinical-Practice-Research-Datalink. We created a birth cohort of children born between 01.01.2000 and 12.12.2020. We estimated the proportion vaccinated with first MMR vaccine by age 2 years and first and second MMR vaccines by age 5 years. We used survival-analysis and Cox proportional hazard models to examine the association between deprivation, ethnicity and maternal age and pertussis vaccination in pregnancy and children's MMR uptake.

RESULTS

Overall, 89.4 % (710,797/795,497) of children had first MMR by age 2 years and 92.6 % (736,495/795,497) by age 5 years. Among children still in the cohort when second MMR was due, 85.9 % (478,480/557,050) had two MMRs by age 5 years. Children from the most-deprived areas, children of Black ethnicity and children of mothers aged < 20 years had increased risk of being unvaccinated compared with children from the least-deprived areas, White children and children of mothers aged 31-40 years: first MMR by 5 years, adjusted Hazard Ratios (HR):0.86 (CI:0.85-0.87), HR:0.87 (CI:0.85-0.88) & HR:0.89 (CI:0.88-0.90) respectively. Deprivation was the determinant associated with the greatest risk of missed second MMR: adjusted HR:0.82 (CI:0.81-0.83). Children of mothers vaccinated in pregnancy were more likely than children of unvaccinated mothers to have MMR vaccines after adjusting for ethnicity, deprivation, and maternal age (First and Second MMRs adjusted HRs:1.43 (CI:1.41-1.45), 1.49 (CI:1.45-1.53).

CONCLUSION

Children from most-deprived areas are less likely to have MMR vaccines compared with children from least-deprived areas. Mothers who take up pregnancy vaccines are more likely to have their children vaccinated with MMR. Healthcare services should promote and facilitate access to both maternal and childhood vaccines during pregnancy.

Immunity Rates of Live Viral Vaccines in Pediatric Renal Transplant Candidates: A Single-Center Experience

OBJECTIVES

Solid-organ transplant recipients are at an increased risk of severe infections due to their immunosuppressed state. Despite the recommendation of routine screening and vaccination before transplant to mitigate this danger, vaccination rates in these patients are still below desirable levels. We aimed to investigate the prevalence of positive antibody rates for measles, mumps, rubella, and varicella among children who are candidates for renal transplant.

MATERIALS AND METHODS

This retrospective study was conducted at a single center and included 144 pediatric kidney transplant patients for the past 7 years. We reviewed the medical records of all participants to evaluate their serologic status for measles, mumps, rubella, and varicella viruses before kidney transplant.

RESULTS

In this study, 144 pediatric kidney transplant candidates (mean age 11.5 years, 56.9% male) were enrolled, and the most frequent causes of the chronic renal disease were congenital anomalies of the kidney and urinary tract and glomerular diseases (32.6%). Seropositivity rates for measles, mumps, rubella, and varicella were 59.0%, 31.9%, 46.5%, and 43.6%, respectively, and all patients who tested negative for antibodies were vaccinated before transplant. Younger age at transplant (OR = 0.909, 95% CI = 0.840-0.923; P = .017) and congenital anomalies of the kidney and urinary tract (OR = 3.46, 95% CI = 1.1548-7.735; P = .002) were significantly associated with increased measles seropositivity, although no significant associations were observed for the other viruses.

CONCLUSIONS

We observed lower seropositivity rates for measles, mumps, rubella, and varicella in pediatric kidney transplant patients versus healthy children and other previous studies. It is essential to address these suboptimal rates to protect the health of these vulnerable patients. Future research should focus on targeted interventions to improve vaccination rates and outcomes in this population.

Measles, mumps, and rubella revaccination in children after completion of chemotherapy and hematopoietic stem cell transplantation: a single-center prospective efficacy and safety analysis

BACKGROUND

Chemotherapy and hematopoietic stem cell transplantation (HSCT) can damage the immune system, and may result in a loss of protection from infectious diseases. This study aimed to evaluate the impact of these treatments on the decrease in antibody titers of the measles, mumps, and rubella (MMR) vaccine and seroconversion post-revaccination of MMR.

METHODS

After completion of treatment for primary diseases, participants received an MMR revaccination. Antibody titers for MMR before revaccination were analyzed for all 110 children. After revaccination, 68 participants received a follow-up evaluation of  antibody titer and adverse reaction.

RESULTS

Multivariable analysis showed that therapeutic schedules were the only factor correlated with lack of antibody titers for measles after completing treatment (P = 0.008), while for mumps and rubella, no statistically significant difference was observed. Importantly, our study clearly demonstrated positive seroconversion rates for measles (97.5%), mumps (81.0%), and rubella (93.2%), with antibody levels rising across the board and peaking at around 6 months following revaccination. However, 6 months after revaccination, a downtrend of antibody titer levels was observed, which is comparatively earlier than the waning immunity observed in healthy children. Furthermore, we found MMR revaccination to be safe, with only a single adverse reaction (local pain at the injection site) reported.

CONCLUSIONS

MMR revaccination is immunogenic for the population. We suggest periodic monitoring of antibody titers, in addition to a booster vaccination, although the optimal timing of booster vaccination remains to be investigated further.

Reduced antiviral seropositivity among patients with inflammatory bowel disease treated with immunosuppressive agents

BACKGROUND

Although live-attenuated vaccines are contraindicated under immunosuppression, the immune status of patients with inflammatory bowel disease (IBD) has not been fully assessed prior to immunosuppressive therapy.

AIMS

To investigate antiviral serostatus against viruses requiring live vaccines for prevention in IBD patients undergoing immunosuppressive therapy.

METHODS

This multicenter study included IBD patients who were aged <40 years and were treated with thiopurine monotherapy, molecular-targeted monotherapy, or combination therapy. Gender- and age-matched healthy subjects (HS) living in the same areas were included as control group. Antibody titers against measles, rubella, mumps, and varicella were measured by enzyme-linked immunosorbent assays.

RESULTS

A total of 437 IBD patients (163 ulcerative colitis [UC] and 274 Crohn's disease [CD]) and 225 HS were included in the final analysis. Compared with HS, IBD patients had lower seropositivity rates for measles (IBD vs. HS = 83.91% vs. 85.33%), rubella (77.55% vs. 84.89%), mumps (37.50% vs. 37.78%), and varicella (91.26% vs. 96.44%). Gender- and age-adjusted seropositivity rates were lower in UC patients than in both CD patients and HS for measles (UC, CD, and HS = 81.60%, 85.29%, and 85.33%), rubella (76.40%, 78.23%, and 84.89%), mumps (27.16%, 43.70%, and 37.78%), and varicella (90.80%, 91.54%, and 96.44%); the difference was significant for all viruses except measles. Divided by the degree of immunosuppression, there were no significant differences in seropositivity rates among IBD patients.

CONCLUSIONS

IBD patients, especially those with UC, exhibit reduced seropositivity rates and may benefit from screening prior to the initiation of immunosuppressive therapy.

Effectiveness of "Priorix" Against Measles and Mumps Diseases in Children Born After 2004 in the United Kingdom: A Retrospective Case-control Study Using the Clinical Practice Research Datalink GOLD Database

BACKGROUND

Evidence on vaccine effectiveness (VE) may encourage vaccination and help fight the reemergence of measles and mumps in Europe. However, limited data exist on real-life effectiveness of individual measles, mumps and rubella (MMR) vaccines. This study evaluated VE of GSK's MMR vaccine ("Priorix") against measles and mumps.

METHODS

This retrospective, case-control study used UK data from the Clinical Practice Research Datalink GOLD linked to the Hospital Episode Statistics database to identify children 1-13 years old diagnosed with measles or mumps from January 2006 to December 2018. Cases were matched to controls according to birth month/year and practice region. Cases were identified using clinical codes (without laboratory confirmation). "Priorix" exposure was identified using vaccine batch identifiers. Children exposed to other MMR vaccines were excluded. Adjusted VE was estimated for ≥1 vaccine dose in all children, and for 1 dose and ≥2 doses in children ≥4 years at diagnosis.

RESULTS

Overall, 299 measles cases matched with 1196 controls (87.6% <4 years old), and 243 mumps cases matched with 970 controls (74.2% <4 years old) were considered. VE for ≥1 dose in all children was 78.0% (97.5% confidence interval: 67.2%-85.3%) for measles and 66.7% (48.1%-78.6%) for mumps. In children ≥4 years old, VE after 1 dose was 74.6% (-21.7% to 94.7%) for measles and 82.3% (32.7%-95.3%) for mumps, and VE after ≥2 doses was 94.4% (79.7%-98.5%) for measles and 86.5% (64.0%-94.9%) for mumps.

CONCLUSIONS

"Priorix" is effective in preventing measles and mumps in real-life settings.

A large outbreak of measles in the West Midlands, England, 2017-2018: descriptive epidemiology, control measures and lessons learnt

In November 2017, eight confirmed measles cases were reported to Public Health England from a hospital in the West Midlands. A multidisciplinary Incident Management Team (IMT) was established to determine the extent of the problem and coordinate an outbreak response. Between 1 November 2017 and 4 June 2018, a total of 116 confirmed and 21 likely measles cases were linked to this outbreak; just under half (43%) were aged over 15 years of age. Fifty-five of the confirmed cases were hospitalised (48%) and no deaths were reported. At the start of the outbreak, cases were mostly individuals of Romanian origin; the outbreak subsequently spread to the wider population. Over the 8-month response, the IMT conducted the following control measures: extensive contact tracing, immediate provision of post-exposure prophylaxis, community engagement amongst specific high-risk groups, MMR awareness raising including catch-up campaigns and enhanced vaccination services at selected GP surgeries. Key challenges to the effective control measures included language difficulties limiting community engagement; delays in diagnosis, notification and appropriate isolation of cases; limited resources for contact tracing across multiple high-risk settings (including GPs and hospitals) and lack of timely data on vaccine coverage in sub-groups of the population to guide public health action.

Immunogenicity and safety of a quadrivalent meningococcal tetanus toxoid-conjugate vaccine administered concomitantly with other paediatric vaccines in toddlers: a phase III randomised study

Invasive meningococcal disease has high morbidity and mortality, with infants and young children among those at greatest risk. This phase III, open-label, randomised study in toddlers aged 12-23 months evaluated the immunogenicity and safety of meningococcal tetanus toxoid-conjugate vaccine (MenACYW-TT), a tetanus toxoid conjugated vaccine against meningococcal serogroups A, C, W and Y, when coadministered with paediatric vaccines (measles, mumps and rubella [MMR]; varicella [V]; 6-in-1 combination vaccine against diphtheria, tetanus, pertussis, polio, hepatitis B and Haemophilus influenzae type b [DTaP-IPV-HepB-Hib] and pneumococcal conjugate vaccine [PCV13])(NCT03205371). Immunogenicity to each meningococcal serogroup was assessed by serum bactericidal antibody assay using human complement (hSBA). Vaccine safety profiles were described up to 30 days post-vaccination. A total of 1183 participants were enrolled. The proportion with seroprotection (hSBA ≥1:8) to each meningococcal serogroup at Day 30 was comparable between the MenACYW-TT and MenACYW-TT + MMR + V groups (≥92 and ≥96%, respectively), between the MenACYW-TT and MenACYW-TT + DTaP-IPV-HepB-Hib groups (≥90% for both) and between the MenACYW-TT and MenACYW-TT + PCV13 groups (≥91 and ≥84%, respectively). The safety profiles of MenACYW-TT, and MMR + V, DTaP-IPV-HepB-Hib, and PCV13, with or without MenACYW-TT, were generally comparable. Coadministration of MenACYW-TT with paediatric vaccines in toddlers had no clinically relevant effect on the immunogenicity and safety of any of the vaccines.

The effects of scientific messages and narratives about vaccination

A fundamental challenge complicates news decisions about covering vaccine side effects: although serious vaccine side effects are rare, less severe ones do occur occasionally. The study was designed to test whether a side effect message could induce vaccine hesitancy and whether that could be countered by pro-vaccine messages about vaccine safety. A large (N = 2,345), nationally representative experiment was conducted by randomly exposing participants to one of six videos about the measles, mumps, and rubella (MMR) vaccine edited from news programs produced during the 2019 measles outbreak in the United States. The design was a 2x3 factorial crossing the presence or absence of a hesitancy-inducing narrative message with a pro-vaccine science-supporting message (i.e., no message, science-supporting expert message, or pro-vaccine narrative message), leading to a total of six conditions. A general linear model was used to assess the effects of these videos on respondents’ (1) vaccine risk perceptions, (2) policy views on vaccination, (3) willingness to encourage others to vaccinate their children, and (4) intention to send a pro-vaccine letter to their state representative. Findings indicated that the science-supporting expert message about vaccine safety led to higher pro-vaccine evaluations relative to other conditions [e.g., b = -0.17, p < .001, a reduction in vaccine risk perceptions of 0.17 as compared to the control]. There was also suggestive evidence that the hesitancy-inducing narrative may limit the effectiveness of a science-supporting expert message, although this finding was not consistent across different outcomes. When shown alone the hesitancy-inducing narrative did not shift views and intentions, but more research is needed to ascertain whether exposure to such messages can undercut the pro-vaccine influence of science-supporting (expert) ones. All in all, however, it is clear that science-supporting messages are effective and therefore worthwhile in combating vaccine misinformation.

Post Vaccine Rubella During a Measles Outbreak: Clinical Case

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

Vaccination Coverage with Selected Vaccines and Exemption Rates Among Children in Kindergarten - United States, 2019-20 School Year

State and local school vaccination requirements serve to protect students against vaccine-preventable diseases (1). This report summarizes data collected by state and local immunization programs* on vaccination coverage among children in kindergarten (kindergartners) in 48 states, exemptions for kindergartners in 49 states, and provisional enrollment and grace period status for kindergartners in 28 states for the 2019-20 school year, which was more than halfway completed when most schools moved to virtual learning in the spring because of the coronavirus 2019 (COVID-19) pandemic. Nationally, vaccination coverage^† was 94.9% for the state-required number of doses of diphtheria and tetanus toxoids, and acellular pertussis vaccine (DTaP); 95.2% for 2 doses of measles, mumps, and rubella vaccine (MMR); and 94.8% for the state-required number of varicella vaccine doses. Although 2.5% of kindergartners had an exemption from at least one vaccine,^§ another 2.3% were not up to date for MMR and did not have a vaccine exemption. Schools and immunization programs can work together to ensure that undervaccinated students are caught up on vaccinations in preparation for returning to in-person learning. This follow-up is especially important in the current school year, in which undervaccination is likely higher because of disruptions in vaccination during the ongoing COVID-19 pandemic (2-4).

Short term impact of the COVID-19 pandemic on incidence of vaccine preventable diseases and participation in routine infant vaccinations in the Netherlands in the period March-September 2020

We aimed to assess the impact of the COVID-19 pandemic on the incidence of vaccine-preventable diseases (VPDs) and participation in the routine infant vaccination programme in the Netherlands. The incidence of various VPDs initially decreased by 75-97% after the implementation of the Dutch COVID-19 response measures. The participation in the first measles-mumps-rubella vaccination among children scheduled for vaccination in March-September 2020 initially dropped by 6-14% compared with the previous year. After catch-up vaccination, a difference in MMR1 participation of -1% to -2% still remained. Thus, the pandemic has reduced the incidence of several VPDs and has had a limited impact on the routine infant vaccination programme.

Association between season of vaccination and antibody levels against infectious diseases

Vaccination has reduced the disease burden of vaccine-preventable diseases. However, the extent to which seasonal cycles of immunity could influence vaccine-induced immunity is not well understood. A national cross-sectional serosurveillance study performed in the Netherlands (Pienter-2) yielded data to investigate whether season of vaccination was associated with antibody responses induced by DT-IPV (diphtheria, tetanus and poliomyelitis), MMR (measles, mumps and rubella) and meningococcus C (MenC) vaccines in children. In total, 434 children met the inclusion criteria to study DT-IPV immunity, 811 for MMR and 311 for MenC. Differences in log(antibody levels) by season of vaccination were investigated with linear multivariable regression analyses. Seroconversion rates varied according to season of vaccination for rubella (90% of autumn-vaccinated children vs. 99% of winter-vaccinated had concentrations above cut-off levels). Summer-vaccinated boys showed a slower decline of tetanus antibodies (6% per month), in comparison with winter-vaccinated boys. In conclusion, season of vaccination showed little association with immunological protection. However, a number of associations were seen with a P-value of about 0.03; and adding data from a just-completed nationwide serological study might add more power to the current study. Further immunological and longitudinal investigations could help understand the mechanisms of seasonal influence in vaccine-induced responses.

[MMR vaccination at UNIL and EPFL : Lausanne medical students get involved]

In recent years, several cases of measles have appeared on the campuses of the University of Lausanne (UNIL) and the Swiss Federal Institute of Technology in Lausanne (EPFL). In response to this, several medical students have mobilized in collaboration with various cantonal authorities in order to set up a free measles, mumps and rubella vaccination campaign on the UNIL/EPFL campuses, in 2019. This first edition was a success and will be repeated in the future. Such an approach having shown its feasibility, it could be applied to other public health issues. The involvement of medical students could thus be extremely valuable if a generalized vaccination against SARS-CoV-2 were to take place.

Effects of a measles outbreak on vaccination uptake

This paper explores the effects of a measles outbreak on vaccination uptake in Austria, using administrative data with individual-level information on childhood vaccinations. I define a treatment group of children affected by the outbreak, and compare them with a control group of earlier-born children who are unaffected. Twelve months after the outbreak, the vaccination rate of the treatment group is 2.5 (first dose of the measles, mumps and rubella vaccine) and 4 (second dose) percentage points higher than the corresponding rates of the control group. The results do not indicate that families at increased risk respond more strongly, suggesting that the outbreak changed the perceived value of vaccinations across the whole population. Findings also reveal heterogeneity in the response of families based on the parents' level of education, indicating that parents with higher education levels absorb new information more rapidly.

Mumps Cases Disproportionately Affecting Persons Living with HIV Infection and Men Who Have Sex with Men - Chicago, Illinois, 2018

During January 1-March 2, 2018, the number of mumps cases among adults reported to the Chicago Department of Public Health (CDPH) doubled compared with the same period in 2017. In response, CDPH created a supplementary questionnaire to collect additional information on populations affected and potential transmission routes. An epidemiologic analysis of routine and supplementary data, including spatiotemporal analysis, was performed to describe mumps cases reported to CDPH during 2018. A fourfold increase in mumps cases was reported during 2018 compared with 2017, with men who have sex with men (MSM) and persons living with human immunodeficiency virus (HIV) infection disproportionately represented among cases. A spatiotemporal, residential cluster was identified in a 9-square-mile area within six adjacent communities. The majority of persons affected were MSM, and this area was visited by many other persons with mumps diagnoses. Spatiotemporal analyses could be used in real time to identify case clusters to target public health response efforts, including to guide recommendations for additional measles, mumps, and rubella (MMR) vaccine and to identify specific transmission venues.

Vaccines for measles, mumps, rubella, and varicella in children

BACKGROUND

Measles, mumps, rubella, and varicella (chickenpox) are serious diseases that can lead to serious complications, disability, and death. However, public debate over the safety of the trivalent MMR vaccine and the resultant drop in vaccination coverage in several countries persists, despite its almost universal use and accepted effectiveness. This is an update of a review published in 2005 and updated in 2012.

OBJECTIVES

To assess the effectiveness, safety, and long- and short-term adverse effects associated with the trivalent vaccine, containing measles, rubella, mumps strains (MMR), or concurrent administration of MMR vaccine and varicella vaccine (MMR+V), or tetravalent vaccine containing measles, rubella, mumps, and varicella strains (MMRV), given to children aged up to 15 years.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library 2019, Issue 5), which includes the Cochrane Acute Respiratory Infections Group's Specialised Register, MEDLINE (1966 to 2 May 2019), Embase (1974 to 2 May 2019), the WHO International Clinical Trials Registry Platform (2 May 2019), and ClinicalTrials.gov (2 May 2019).

SELECTION CRITERIA

We included randomised controlled trials (RCTs), controlled clinical trials (CCTs), prospective and retrospective cohort studies (PCS/RCS), case-control studies (CCS), interrupted time-series (ITS) studies, case cross-over (CCO) studies, case-only ecological method (COEM) studies, self-controlled case series (SCCS) studies, person-time cohort (PTC) studies, and case-coverage design/screening methods (CCD/SM) studies, assessing any combined MMR or MMRV / MMR+V vaccine given in any dose, preparation or time schedule compared with no intervention or placebo, on healthy children up to 15 years of age.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed the methodological quality of the included studies. We grouped studies for quantitative analysis according to study design, vaccine type (MMR, MMRV, MMR+V), virus strain, and study settings. Outcomes of interest were cases of measles, mumps, rubella, and varicella, and harms. Certainty of evidence of was rated using GRADE.

MAIN RESULTS

We included 138 studies (23,480,668 participants). Fifty-one studies (10,248,159 children) assessed vaccine effectiveness and 87 studies (13,232,509 children) assessed the association between vaccines and a variety of harms. We included 74 new studies to this 2019 version of the review. Effectiveness Vaccine effectiveness in preventing measles was 95% after one dose (relative risk (RR) 0.05, 95% CI 0.02 to 0.13; 7 cohort studies; 12,039 children; moderate certainty evidence) and 96% after two doses (RR 0.04, 95% CI 0.01 to 0.28; 5 cohort studies; 21,604 children; moderate certainty evidence). The effectiveness in preventing cases among household contacts or preventing transmission to others the children were in contact with after one dose was 81% (RR 0.19, 95% CI 0.04 to 0.89; 3 cohort studies; 151 children; low certainty evidence), after two doses 85% (RR 0.15, 95% CI 0.03 to 0.75; 3 cohort studies; 378 children; low certainty evidence), and after three doses was 96% (RR 0.04, 95% CI 0.01 to 0.23; 2 cohort studies; 151 children; low certainty evidence). The effectiveness (at least one dose) in preventing measles after exposure (post-exposure prophylaxis) was 74% (RR 0.26, 95% CI 0.14 to 0.50; 2 cohort studies; 283 children; low certainty evidence). The effectiveness of Jeryl Lynn containing MMR vaccine in preventing mumps was 72% after one dose (RR 0.24, 95% CI 0.08 to 0.76; 6 cohort studies; 9915 children; moderate certainty evidence), 86% after two doses (RR 0.12, 95% CI 0.04 to 0.35; 5 cohort studies; 7792 children; moderate certainty evidence). Effectiveness in preventing cases among household contacts was 74% (RR 0.26, 95% CI 0.13 to 0.49; 3 cohort studies; 1036 children; moderate certainty evidence). Vaccine effectiveness against rubella is 89% (RR 0.11, 95% CI 0.03 to 0.42; 1 cohort study; 1621 children; moderate certainty evidence). Vaccine effectiveness against varicella (any severity) after two doses in children aged 11 to 22 months is 95% in a 10 years follow-up (rate ratio (rr) 0.05, 95% CI 0.03 to 0.08; 1 RCT; 2279 children; high certainty evidence). Safety There is evidence supporting an association between aseptic meningitis and MMR vaccines containing Urabe and Leningrad-Zagreb mumps strains, but no evidence supporting this association for MMR vaccines containing Jeryl Lynn mumps strains (rr 1.30, 95% CI 0.66 to 2.56; low certainty evidence). The analyses provide evidence supporting an association between MMR/MMR+V/MMRV vaccines (Jeryl Lynn strain) and febrile seizures. Febrile seizures normally occur in 2% to 4% of healthy children at least once before the age of 5. The attributable risk febrile seizures vaccine-induced is estimated to be from 1 per 1700 to 1 per 1150 administered doses. The analyses provide evidence supporting an association between MMR vaccination and idiopathic thrombocytopaenic purpura (ITP). However, the risk of ITP after vaccination is smaller than after natural infection with these viruses. Natural infection of ITP occur in 5 cases per 100,000 (1 case per 20,000) per year. The attributable risk is estimated about 1 case of ITP per 40,000 administered MMR doses. There is no evidence of an association between MMR immunisation and encephalitis or encephalopathy (rate ratio 0.90, 95% CI 0.50 to 1.61; 2 observational studies; 1,071,088 children; low certainty evidence), and autistic spectrum disorders (rate ratio 0.93, 95% CI 0.85 to 1.01; 2 observational studies; 1,194,764 children; moderate certainty). There is insufficient evidence to determine the association between MMR immunisation and inflammatory bowel disease (odds ratio 1.42, 95% CI 0.93 to 2.16; 3 observational studies; 409 cases and 1416 controls; moderate certainty evidence). Additionally, there is no evidence supporting an association between MMR immunisation and cognitive delay, type 1 diabetes, asthma, dermatitis/eczema, hay fever, leukaemia, multiple sclerosis, gait disturbance, and bacterial or viral infections.

AUTHORS' CONCLUSIONS

Existing evidence on the safety and effectiveness of MMR/MMRV vaccines support their use for mass immunisation. Campaigns aimed at global eradication should assess epidemiological and socioeconomic situations of the countries as well as the capacity to achieve high vaccination coverage. More evidence is needed to assess whether the protective effect of MMR/MMRV could wane with time since immunisation.

Impact of vaccination on measles, mumps, and rubella antibody titers in Japanese healthcare workers: An observational study

Given the complicated history of Japan’s National Immunization Program, a significant proportion of Japanese people including healthcare workers (HCWs) still lack adequate immunity against measles, mumps, and rubella (MMR), resulting in occasional outbreaks. In 2014, the Japanese Society of Infection Prevention and Control (JSIPC) published vaccination guidelines for HCWs. We evaluated antibody titers before and after MMR vaccination in HCWs at the Nara Medical University Hospital, the attainment rate of the target antibody titers defined by the JSIPC guidelines, and the safety of vaccines. We measured MMR antibody titers in HCWs, followed by inoculation with the respective monovalent vaccines and/or trivalent MMR (tMMR) vaccine according to the JSIPC guidelines. Among 467 HCWs evaluated, antibody titers against measles and mumps measured using the IgG-enzyme immunoassay increased from 11.0 [interquartile range (IQR): 8.0–13.6] to 13.7 (IQR: 11.3–16.9; P < 0.001) and from 2.8 (IQR: 2.1–3.5) to 4.8 (IQR: 3.7–5.7; P < 0.001), respectively. By evaluating a logarithmic value of log₂(X + 1) converted from an antibody titer X, antibody titers against rubella measured using the hemagglutination assay increased from 3.2 (IQR: 0–4.1) to 6.0 (IQR: 4.6–8.0; P < 0.001). Antibody titer elevated following tMMR vaccination was lower than that following monovalent vaccination in a single dose of the measles-containing, a single dose of the mumps-containing, and two doses of rubella-containing vaccine groups (P = 0.01, 0.01, and <0.001, respectively). After vaccination, 20.0%, 61.5%, and 46.2% of HCWs attained target antibody titers specified by the JSIPC guidelines for measles, rubella, and mumps, respectively. The systemic response in female HCWs who underwent monovalent mumps vaccination was statistically higher than that in others. Although the vaccination program for HCWs according to the JSIPC guidelines caused increased MMR antibody titers, the rates of attaining the target criteria were low.

Consequences of Undervaccination - Measles Outbreak, New York City, 2018-2019

BACKGROUND

Measles was declared eliminated in the United States in 2000, but the risk of outbreaks owing to international importations remains. An outbreak of measles in New York City began when one unvaccinated child returned home from Israel with measles; onset of rash occurred on September 30, 2018, 9 days after the child returned home.

METHODS

We investigated suspected cases of measles by conducting interviews, reviewing medical and immunization records, identifying exposed persons, and performing diagnostic testing. Measles-mumps-rubella (MMR) vaccine (given as either MMR or measles-mumps-rubella-varicella vaccine and collectively referred to as MMR vaccine) uptake was monitored with the use of the Citywide Immunization Registry. The total direct cost to the New York City Department of Health and Mental Hygiene was calculated.

RESULTS

A total of 649 cases of measles were confirmed, with onsets of rash occurring between September 30, 2018, and July 15, 2019. A majority of the patients (93.4%) were part of the Orthodox Jewish community, and 473 of the patients (72.9%) resided in the Williamsburg area of Brooklyn, New York. The median age was 3 years; 81.2% of the patients were 18 years of age or younger, and 85.8% of the patients with a known vaccination history were unvaccinated. Serious complications included pneumonia (in 37 patients [5.7%]) and hospitalization (in 49 patients [7.6%]); among the patients who were hospitalized, 20 (40.8%) were admitted to an intensive care unit. As a result of efforts to promote vaccination, the percentage of children in Williamsburg who received at least one dose of MMR vaccine increased from 79.5% to 91.1% among children 12 to 59 months of age. As of September 9, 2019, a total of 559 staff members at the Department of Health and Mental Hygiene (7% of the agency) had been involved in the measles response. The cost of the Department of Health and Mental Hygiene response was $8.4 million.

CONCLUSIONS

Importation of measles and vaccination delays among young children led to an outbreak of measles in New York City. The outbreak response was resource intensive and caused serious illness, particularly among unvaccinated children.

A review of the safety of vaccines used in routine immunization in Africa

BACKGROUND

Despite the significant role played by vaccines in global health, concerns over vaccine safety have increased tremendously over the years. There have been occasions where vaccines have caused rare, adverse reactions some of which have led to hospitalizations and even death. It is therefore important to establish the safety profile of routinely used vaccines in order to allay fears pertaining to their use.

OBJECTIVES

This review was aimed at pooling together the safety data of selected vaccines used for routine immunization in Africa, a region of the world with paucity of vaccine safety data.

METHODS

Adverse Events Following Immunization safety data was searched for rotavirus, yellow fever, measles, rubella, tuberculosis (Bacillus Calmette Guerin-BCG), pneumococcal, Haemophilus Influenza type b, polio, meningococcal and the influenza A (H1N1) vaccines in PUBMED, Google Scholar, Clinical trials.gov and Cochrane controlled register of trials databases.

RESULTS

A total of twenty-four serious AEFIs and twenty-three minor AEFIs were identified from the review. The strength of association between AEFIs and vaccine was high for tuberculosis vaccine and moderate for all other vaccines.

CONCLUSION

Even though AEFIs (including mild and severe) were identified in the review, all the vaccines studied were generally well tolerated.

Application of a fast and cost-effective 'three-in-one' MMR ELISA as a tool for surveying anti-MMR humoral immunity: the Hungarian experience

In Hungary, between February 2017 and July 2019, 70 confirmed measles cases were reported, raising questions about the adequacy of population-level immunity. Although the assumed vaccination coverage is ≥99%, in a recent study, we detected potential gaps in the anti-measles humoral immunity. In Hungary, according to a decree by the Ministry of Public Welfare, beginning from 2021, the healthcare provider should conduct a serosurvey of anti-measles protection levels of healthcare professionals. To facilitate the compliance with this requirement, we developed a quick 'three-in-one' or 'triple' MMR (measles, mumps and rubella) indirect ELISA (IgG); an assay format that is currently not available commercially. High throughput applicability of the 'three-in-one' ELISA was verified using 1736 sera from routine laboratory residual samples, using an automated platform (Siemens BEP 2000 Advance). Assay verification was performed by comparing the full antigen repertoire-based 'target' assay with in-house 'control' assays using recombinant viral antigen coatings, and by validated commercially available kits. Indirect immunofluorescence was used as an independent reference method. Data were analysed using OriginLab, IBM SPSS, RStudio and MedCalc. In case of measles, we combined our current results with previously published data (Ntotal measles = 3523). Evaluation of anti-mumps and anti-rubella humoral antibody levels was based on the measurement of 1736 samples. The lowest anti-measles seropositivity (79.3%) was detected in sera of individuals vaccinated between 1978 and 1987. Considering the antigen-specific seropositivity ratios of all samples measured, anti-measles, -mumps and -rubella IgG antibody titres were adequate in 89.84%, 91.82% and 92.28%, respectively. Based on the virus-specific herd immunity threshold (HIT) values (HITMeasles = 92-95%, HITMumps = 75-86%, HITRubella = 83-86), it can be stated that regarding anti-measles immunity, certain age clusters of the population may have inadequate levels of humoral immunity. Despite the potential gaps in herd immunity, the use of MMR vaccine remains an effective and low-cost approach for the prevention of measles, mumps and rubella infections.

Seroepidemiological study of rubella in Vojvodina, Serbia: 24 years after the introduction of the MMR vaccine in the national immunization programme

Although rubella is usually a mild childhood disease, this infection in early pregnancy poses a serious problem due to its teratogenic effect. The goal of interrupted circulation and elimination of rubella virus was achieved in many countries in the world. The aim of this study was to determine the status of rubella immunity in Vojvodina and evaluate Serbia's progress toward this goal. A total of 3404 residual serum samples from patients of all ages (1 to 84 years) were included in the study. Samples were collected between May 2015 and December 2017 in Vojvodina. Rubella IgG antibodies were determined using an indirect chemiluminescent immunoassay. Percentage of participants seropositive for rubella antibodies was 92.9% in the entire sample. The highest number of seronegatives was in the youngest (1 year) age group (44.7%), followed by the group aged 24-49 (6.4%) and 2-11 years (6.2%). The absence of a higher percentage of children with protective anti-rubella antibodies in the group aged 2-11 can be explained by a lower immunization coverage during certain years. Participants in the group aged 24-49 were born during the pre-vaccination period with lower rubella incidence, leading to the conclusion that not all individuals of that age came into a contact with the virus. Comparing levels of anti-rubella IgG antibodies of seropositive males and females of different ages reveals that the immunity after a contact with the virus and a previously acquired infection is stronger than the immunity after the vaccination. Although the incidence rate of rubella in Vojvodina has been low for the last ten years, there is still a risk of an outbreak due to a decrease in immunization coverage. This study shows that the percentage of susceptible individuals is high, especially considering women aged 24-49, and that additional ("catch-up") immunization is required.

Frequency and cost of live vaccines administered too soon after prior live vaccine in children aged 12 months through 6 years, 2014-2017

OBJECTIVE

To identify number of children who received live vaccines outside recommended intervals between doses and calculate corrective revaccination costs.

METHODS

We analyzed >1.6 million vaccination records for children aged 12 months through 6 years from six immunization information system (IIS) Sentinel Sites from 2014-15 when live attenuated influenza vaccine (LAIV, FluMist® Quadrivalent) was recommended for use, and from 2016-17, when not recommended for use. Depending on the vaccine, insufficient intervals between live vaccine doses are less than 24 or 28 days from a preceding live vaccine dose. Private and public purchase costs of vaccines were used to determine revaccination costs of live vaccine doses administered during the live vaccine conflict interval. Measles, mumps, rubella (MMR), varicella, combined MMRV, and LAIV were live vaccines evaluated in this study.

RESULTS

Among 946,659 children who received at least one live vaccine dose from 2014-15, 4,873 (0.5%) received at least one dose too soon after a prior live vaccine (revaccination cost, $786,413) with a median conflict interval of 16 days. Among 704,591 children who received at least one live vaccine dose from 2016-17, 1,001 (0.1%) received at least one dose too soon after a prior live vaccine (revaccination cost, $181,565) with a median conflict interval of 14 days. The live vaccine most frequently administered outside of the recommended intervals was LAIV from 2014-15, and varicella from 2016-17.

CONCLUSIONS

Live vaccine interval errors were rare (0.5%), indicating an adherence to recommendations. If all invalid doses were corrected by revaccination over the two time periods, the cost within the IIS Sentinel Sites would be nearly one million dollars. Provider awareness about live vaccine conflicts, especially with LAIV, could prevent errors, and utilization of clinical decision support functionality within IISs and Electronic Health Record Systems can facilitate better vaccination practices.

Vaccination Coverage with Selected Vaccines and Exemption Rates Among Children in Kindergarten - United States, 2018-19 School Year

State and local school vaccination requirements exist to ensure that students are protected against vaccine-preventable diseases (1). This report summarizes data collected by state and local immunization programs* on vaccination coverage among children in kindergarten in 49 states, exemptions for kindergartners in 50 states, and provisional enrollment and grace period status for kindergartners in 30 states. Nationally, vaccination coverage^† was 94.9% for the state-required number of doses of diphtheria and tetanus toxoids, and acellular pertussis vaccine (DTaP); 94.7% for 2 doses of measles, mumps, and rubella vaccine (MMR); and 94.8% for the state-required doses of varicella vaccine. Whereas 2.5% of kindergartners had an exemption from at least one vaccine,^§ 2.8% of kindergartners were not up to date for MMR and did not have a vaccine exemption. Nearly all states could achieve the recommended ≥95% MMR coverage if all nonexempt kindergartners were vaccinated in accordance with local and state vaccination policies.

National Update on Measles Cases and Outbreaks - United States, January 1-October 1, 2019

During January 1-October 1, 2019, a total of 1,249 measles cases and 22 measles outbreaks were reported in the United States. This represents the most U.S. cases reported in a single year since 1992 (1), and the second highest number of reported outbreaks annually since measles was declared eliminated* in the United States in 2000 (2). Measles is an acute febrile rash illness with an attack rate of approximately 90% in susceptible household contacts (3). Domestic outbreaks can occur when travelers contract measles outside the United States and subsequently transmit infection to unvaccinated persons they expose in the United States. Among the 1,249 measles cases reported in 2019, 1,163 (93%) were associated with the 22 outbreaks, 1,107 (89%) were in patients who were unvaccinated or had an unknown vaccination status, and 119 (10%) measles patients were hospitalized. Closely related outbreaks in New York City (NYC) and New York State (NYS; excluding NYC), with ongoing transmission for nearly 1 year in large and close-knit Orthodox Jewish communities, accounted for 934 (75%) cases during 2019 and threatened the elimination status of measles in the United States. Robust responses in NYC and NYS were effective in controlling transmission before the 1-year mark; however, continued vigilance for additional cases within these communities is essential to determine whether elimination has been sustained. Collaboration between public health authorities and undervaccinated communities is important for preventing outbreaks and limiting transmission. The combination of maintenance of high national vaccination coverage with measles, mumps, and rubella vaccine (MMR) and rapid implementation of measles control measures remains the cornerstone for preventing widespread measles transmission (4).

National, Regional, State, and Selected Local Area Vaccination Coverage Among Adolescents Aged 13-17 Years - United States, 2018

The Advisory Committee on Immunization Practices (ACIP) recommends routine vaccination of persons aged 11-12 years to protect against certain diseases, including human papillomavirus (HPV)-associated cancers, meningococcal disease, and pertussis (1). A booster dose of quadrivalent meningococcal conjugate vaccine (MenACWY) is recommended at age 16 years, and serogroup B meningococcal vaccine (MenB) may be administered to persons aged 16-23 years (1). To estimate vaccination coverage among adolescents in the United States, CDC analyzed data from the 2018 National Immunization Survey-Teen (NIS-Teen) which included 18,700 adolescents aged 13-17 years.* During 2017-2018, coverage with ≥1 dose of HPV vaccine increased from 65.5% to 68.1%, and the percentage of adolescents up-to-date^† with the HPV vaccine series increased from 48.6% to 51.1%, although the increases were only observed among males. Vaccination coverage increases were also observed for ≥1 MenACWY dose (from 85.1% to 86.6%) and ≥2 MenACWY doses (from 44.3% to 50.8%). Coverage with tetanus and reduced diphtheria toxoids and acellular pertussis vaccine (Tdap) remained stable at 89%. Disparities in coverage by metropolitan statistical area (MSA)^§ and health insurance status identified in previous years persisted (2). Coverage with ≥1 dose of HPV vaccine was higher among adolescents whose parents reported receiving a provider recommendation; however, prevalence of parents reporting receiving a recommendation for adolescent HPV vaccination varied by state (range = 60%-91%). Supporting providers to give strong recommendations and effectively address parental concerns remains a priority, especially in states and rural areas where provider recommendations were less commonly reported.

[Live Vaccine in Children with DiGeorge/22q11.2 Deletion Syndrome]

INTRODUCTION

Children with DiGeorge syndrome/chromosome 22q11.2 deletion syndrome might have a variable degree of immunodeficiency, which may limit the use of live vaccines. The aim of this study was to review the adverse effects of live vaccines and possible relation with immune status in patients with DiGeorge Syndrome/partial 22q11.2 deletion syndrome.

MATERIAL AND METHODS

Retrospective study with analysis of the clinical records of children with chromosome 22q11.2 deletion syndrome and DiGeorge syndrome phenotype, followed in a Primary Immunodeficiency center. Data were collected on: demographic characteristics; medical and vaccination history with live vaccines; T-CD4+ lymphocyte counts and lymphocyte proliferative responses to antigens and mitogens; adverse reactions; vaccine failure.

RESULTS

Twenty three children with DiGeorge syndrome/22q11.2 deletion syndrome were included, 65.2% male, with average age at diagnosis of 11.3 months. Eighteen children (78%) received bacillus Calmette-Guérin vaccine: all with evidence of thymic activity; three presented moderate T-CD4+ lymphopenia and abnormal lymphocyte proliferative responses; one had abnormal lymphocyte proliferative responses for mitogens, four for purified protein derivative and one for tetanus toxoid. Measles, mumps and rubella vaccine was administered to 15 children, three of them with moderate immunosuppression and abnormal lymphocyte proliferative responses. Live attenuated polio vaccine was administered to 4 children without immunosuppression and the rotavirus vaccine to three children, one with moderate immunosuppression. No significant adverse reactions were reported.

DISCUSSION

These data are in line with the findings of other international studies.

CONCLUSION

In our sample, live vaccines were well-tolerated, even in children with moderate T-CD4+ lymphopenia and abnormal lymphocyte proliferative responses to antigens/mitogens.

Sero-epidemiological study in prediction of the risk groups for measles outbreaks in Vojvodina, Serbia

Background

Age-stratified serologic surveys provide insight into the gaps of measles-specific immunity as well as estimates of the age-specific seroprevalence. The aim of this study was to describe the measles sero-epidemiology in Vojvodina before the occurrence of outbreak in 2017/18 and to discuss preventive measures for potential future epidemics.

Methods

A seroprevalence study was conducted from April 2015 to June 2017 on serum bank of 3199 residual samples. Study was performed prior to the last measles outbreak in Vojvodina that occurred between 12th November 2017 and 30th June 2018. Measles-specific IgG antibodies were determined using an indirect chemiluminescent immunoassay (CLIA).

Results

Median age of enrolled participants was 20 years (IQR 11–37). Overall, 86.9% serum samples were seropositive. The highest proportion of measles seronegativity was observed in children aged 12–23 months of age and in adults aged 20–39 years (56.1% and 18.5%, respectively). Prevalence of measles seronegativity above WHO target levels susceptibility was observed in the following age groups: 2, 7, 13, 15, and among all adults aged between 20 and 49 years. Out of total measles outbreak cases (177), there were 91 (51.4%) participants aged 20–39 years. A significant positive correlation was observed between measles seronegativity and the number of reported measles cases aged ≥ 12 months (r = 0.4675, p = 0.0213).

Conclusions

In order to prevent new outbreaks and achieve the elimination of measles in Vojvodina, the vaccination coverage of both measles-mumps-rubella (MMR1 and MMR2) vaccines needs to be improved and sustained. Educational campaigns for the improvement of acceptance and timely vaccination with vaccine against measles among doctors and the general population are crucial. Our results indicate possible gap in measles protection in adults born during implementation of one dose of measles vaccine and prioritize supplementary immunization activities targeting adults in Vojvodina, Serbia.

Increase in Measles Cases - United States, January 1-April 26, 2019

As of April 26, 2019, CDC had reported 704 cases of measles in the United States since the beginning of 2019, representing the largest number of cases reported in the country in a single year since 1994, when 963 cases occurred, and since measles was declared eliminated* in 2000 (1,2). Measles is a highly contagious, acute viral illness characterized by fever and a maculopapular rash; complications include pneumonia, encephalitis, and death. Among the 704 cases, 503 (71%) were in unvaccinated persons and 689 (98%) occurred in U.S. residents. Overall, 66 (9%) patients were hospitalized. Thirteen outbreaks have been reported in 2019, accounting for 663 cases, 94% of all reported cases. Six of the 13 outbreaks were associated with underimmunized close-knit communities and accounted for 88% of all cases. High 2-dose measles vaccination coverage in the United States has been critical to limiting transmission (3). However, increased global measles activity poses a risk to U.S. elimination, particularly when unvaccinated travelers acquire measles abroad and return to communities with low vaccination rates (4). Health care providers should ensure persons are up to date with measles, mumps, rubella (MMR) vaccine, including before international travel, and rapidly report all suspected cases of measles to public health authorities.

Completeness and timeliness of diphtheria-tetanus-pertussis, measles-mumps-rubella, and polio vaccines in young children with chronic health conditions: A systematic review

OBJECTIVE

To systematically review literature on uptake and timeliness of diphtheria-tetanus-pertussis, measles-mumps-rubella, and/or polio-containing vaccines ininfants who were born preterm, with a low birth weight, and/or with chronic health conditions that were diagnosed within the first 6 months of life.

METHODS

Using a standardized search strategy developed by a medical librarian, records were extracted from MEDLINE, Embase, Database of Abstracts of Reviews of Effects, and CINAHL up to May 8, 2018.

RESULTS

Out of the 1997 records that were screened, we identified 21 studies that met inclusion criteria. Eleven studies assessed vaccine coverage and/or timeliness in preterm infants, 6 in low birth weight infants, and 7 in children with chronic health conditions. Estimates of coverage in these populations were highly variable, ranging from 40% to 100% across the vaccines and population groups.

CONCLUSIONS

There is a lack of studies reporting coverage and timeliness of routine immunizations in special populations of children.

POLICY IMPLICATIONS

Our review suggests a need for improved surveillance of immunization status in special populations of infants, as wellas aneed for standardization of reporting practices.

Four Italian experiences on vaccination policies: results and lessons

INTRODUCTION

In 2018 the Council of Europe adopted a Recommendation on strengthened cooperation against vaccine preventable diseases. Among EU Member States, Italy has a long-lasting tradition of immunization policies implemented in the context of the National Health Service over the last forty years.

METHODS

We identify, report and critically appraise four immunization strategies implemented in Italy in recent years and quantitatively assess their impact on coverage rates and other selected indicators.

RESULTS

First: the regional law that suspended mandatory vaccination in the Veneto Region in 2007 to stimulate a proactive approach to vaccine uptake was not successful. Second: a strengthened political commitment started in 2014 brought to the release of an innovative and updated National Immunization Prevention Plan and to encouraging increase in vaccine confidence and vaccination uptake. Third: the success of social media influencers is exemplified by the case of Roberto Burioni, professor of microbiology, who in 2015 started a personal social media campaign to contrast anti-vaccinists. Fourth: The new 2017 Italian law extending mandatory vaccinations has successfully impacted on vaccine coverage which increased by more than 1% and 4% for polio and MMR vaccines, respectively, in the first six months since its entering into force, and has continued to raise in 2018.

CONCLUSION

Our data and real-life case studies offer to the broader European public health community a solid basis for discussion and ground to evaluate similar polices implemented in different European settings, with the common goal to share best practices and promote the culture of immunization.

Talk to Patients About: Mumps

More than 2,000 U.S. mumps cases occurred in 2018. That's down from 6,000-plus cases CDC reported in both 2016 and 2017, but a far cry from the hundreds reported in 2012. Texas is not immune. In 2018, mumps outbreaks occurred at Texas Christian University in Fort Worth, Texas State University in San Marcos, and a national cheerleading competition in Dallas. Mumps still spreads much faster and more dangerously among unvaccinated groups, and immunization remains the best protection.

[Vaccination Controversies: An Adult Case of Post-Vaccinal Acute Disseminated Encephalomyelitis]

Acute disseminated encephalomyelitis is a rare inflammatory demyelinating multifocal disease of the central nervous system that typically occurs in children following vaccination or exanthematous viral infections and conveys an elevated risk of neurological sequelae unless promptly recognized and treated. We describe an adult case of acute disseminated encephalomyelitis following vaccination against Mumps, Measles and Rubella, presenting with fever and progressive neurological deficits which improved under systemic corticosteroid therapy. Considering the ongoing public debate regarding universal vaccination and the surge of previously controlled infectious diseases, we aim not only to underline the need for a rigorous assessment of vaccination safety on adult patients in order to prevent misguidance of public opinion, but also to alert clinicians for an early diagnosis of acute disseminated encephalomyelitis in these patients, the incidence of which we speculate may be rising.

Austerity, measles and mandatory vaccination: cross-regional analysis of vaccination in Italy 2000-14

Background

Italy has experienced a resurgence in measles since 2015. Although much emphasis has been placed on the role of individuals opting out of vaccination, here we test the hypothesis that large budget reductions in public health spending were also a contributing factor.

Methods

Multi-variate statistical models were used to assess the relationship between measles, mumps and rubella (MMR) coverage and real public health expenditure per-capita across Italy's 20 regions covering the period 2000-14.

Results

Between 2010 and 2014 Italy's public health expenditure fell by over 2%, although varying among regions. Fixed effects models estimate that each 1% reduction in per-capita public health expenditure was associated with a decrease of 0.5 percentage points (95% CI: 0.36-0.65 percentage points) in MMR coverage, after adjusting for time and regional-specific time trends. The consequences can be illustrated by comparing two regions, Lazio, where public health spending fell by 5% and MMR coverage by over 3 percentage points, and Sardinia, a historically deprived region, where public health spending partly rose and MMR rates remained approximately steady.

Conclusion

Adoption of austerity policies in the Italian health system was found to be significantly associated with declining vaccination rates for MMR. However, the recent introduction of mandatory vaccination for Italian children may help counteract this trend.

School-based educational and on-site vaccination intervention among adolescents: study protocol of a cluster randomised controlled trial

INTRODUCTION

Childhood vaccination programmes have been established in all Organisation for Economic Co-operation and Development (OECD) countries; however, measles, mumps and rubella (MMR) as well as diphtheria, tetanus, pertussis and polio (Tdap-IPV) vaccination rates are not optimal in adolescents. Education in combination with easy access vaccination may be a promising approach to improve vaccination rates. We aim at improving MMR and Tdap-IPV rates in a school setting in the context of a planned cluster randomised controlled trial (cRCT), the present paper describes the detailed protocol of this trial.

METHODS AND ANALYSIS

We will conduct a school-based cRCT, where schools will be randomised to either an educational condition addressing knowledge, risk communication and enhancing self-efficacy regarding vaccination or a low-intensity information condition. In both conditions, a bus equipped with medical staff and materials, will be delivering MMR and Tdap-IPV vaccine directly after the intervention. Schools in the city centre of Berlin, Germany, will be stratified by percentage of migration and type of school. Primary outcome is the number of students who receive vaccination in the bus. Secondary outcomes are knowledge and self-efficacy. An estimated sample size of 355 school classes with approximately 25 students per class is required. The planned analyses will take the nested structure of students, classes and schools into account.

ETHICS AND DISSEMINATION

The study will be performed according to the principles of Good Clinical Practice and the Declaration of Helsinki. Approval was obtained by the local ethics committee. Parents of all students will be informed in advance. Their written consent will be obtained, in case students are underage. For dissemination, we will engage with governmental organisations to create potential of our educational unit to be included in future public health prevention schemes.

TRIAL REGISTRATION NUMBER

ISRCTN18026662;Pre-results.

Immunosuppression Does Not Affect Antibody Concentrations to Measles, Mumps, and Rubella in Patients with Inflammatory Bowel Disease

BACKGROUND

The Advisory Committee on Immunization Practices (ACIP) recommends using the immunization record and not serologic testing to determine immunity against measles and rubella in the general population, due to potential false negatives. However, it is unknown whether the immune response is less durable among patients who are immunosuppressed.

AIMS

The primary aim of this study was to evaluate sustained vaccine-induced measles, mumps, and rubella (MMR) antibody concentrations in immunosuppressed patients with inflammatory bowel disease (IBD).

METHODS

We performed a cross-sectional study to compare antibody concentrations following the two-dose (MMR) vaccine among 46 patients with IBD and 20 healthy controls (HC). Three IBD groups stratified by the immunosuppressive regimen that preceded study entry for at least 3 months: (1) thiopurine monotherapy, (2) anti-TNF monotherapy, or (3) combination therapy (anti-TNF agent combined with an immunomodulator) were enrolled.

RESULTS

All subjects had measurable antibody concentrations to the three vaccine viruses. Age and time since receipt of MMR series were similar in both groups. There were no difference in the antibody concentration of measles (IBD 667 mIU/ml vs HC 744 mIU/ml; p = 0.45), mumps (IBD 339 EU/ml vs HC 402 EU/ml; p = 0.62), or rubella (IBD 25 mIU/ml vs HC 62 mIU/ml; p = 0.11) among the groups. No differences in antibody concentrations were found among the IBD treatment groups.

CONCLUSION

Immunosuppressed patients with IBD have sustained antibody concentrations comparable to healthy controls. Thus, gastroenterologist should follow the ACIP recommendations and use the immunization record when available to determine immunity to measles and rubella in patients with IBD. Clinical Trials Registry # NCT02434133.