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Why we should vaccinate early for measles
Since the measles outbreak in the Pacific Northwest (where I did my training and remain in touch with colleagues and patients), parents with infants ages 6 to 11 months are requesting vaccinations before 12 months—the standard age to start immunizations.1 But physicians decline to provide inoculation, citing institutional policy on the risks of early vaccination. What are these risks, and how should we respond when parents ask about early vaccination?
The safety and efficacy of early vaccination are well documented. Early vaccination is a technique employed to curb outbreaks both in the United States and worldwide. Guidelines from the Centers for Disease Control and Prevention (CDC) recommend vaccinating infants at 6 months of age if they will be traveling,2 and the World Health Organization (WHO) recommends vaccinations during a measles outbreak as part of intensified service delivery or in settings, such as daycare facilities, in which there is an increased risk for disease exposure during an outbreak.3 Any dose given before 12 months is considered supplemental, and the child must still complete the regular 2-dose vaccine schedule. Studies on the adverse effect profiles of vaccines show that the younger the infant, the fewer adverse events occur—because adverse events reflect the increasingly robust immune response that comes with age.4
Many physicians are concerned about adequate immune response. In vaccine research, this is gauged by the proportion of patients with seroconversion after vaccination. This is also reflected in vaccine efficacy (VE), which gradually increases with age and maturity of the immune system. For example, measles VE is 60% to 70% in 6-to-8-month cohorts5 and 70% to 80% in 9-to-11-month cohorts.6 VE at 12 months is in the 90% range, and completion of the 2-dose series yields a VE of ≥ 95%.7 Thus, while the vaccine is more effective at later ages, it still provides protection to younger cohorts.
“Blunting” (ie, a reduced immune response to the second dose of vaccine3) is another concern with early measles vaccination, but a WHO meta-analysis proved this concern to be unfounded.1,3 Twelve papers examining seropositivity in children who received a second measles vaccine after early primary vaccination found a pooled proportion of seropositivity of 97%.1,8,9 Furthermore, evidence shows that children have sustained measles-specific T-cell responses after early primary measles immunization.10
Early vaccination has few risks and significant benefit. Therefore, in light of the recent measles outbreak, relaxing the lower boundary for the measles vaccine is appropriate. In addition to physically protecting the patient and general population, honoring parents’ requests for vaccination respects their autonomy and fosters trust. Synthesis of good science with a trusting doctor–patient relationship is key to ending the measles outbreak.
Rachel Roth, MD
Tel Aviv, Israel
1. Conclusions of the SAGE Working Group on Measles and Rubella. 21-22 June 2017. Geneva WHO Policy Recommendation on administration of MCV to infants. SAGE. https://www.who.int/immunization/sage/meetings/2017/october/2_measles_vaccination_before_6_months_for_yellow_book_FINAL.pdf. Accessed April 24, 2019.
2. Centers for Disease Control and Prevention. Measles (Rubeola). For healthcare professionals. https://www.cdc.gov/measles/hcp/index.html. Accessed April 24, 2019.
3. World Health Organization. Measles vaccines: WHO position paper, April 2017 - recommendations. Vaccine. 2017;92:205-227.
4. van der Maas NA, Woudenberg T, Hahné SJ, et al. Tolerability of early measles-mumps-rubella vaccination in infants aged 6-14 months during a measles outbreak in the Netherlands in 2013-2014. J Infect Dis. 2016;213:1466-1471.
5. Lochlainn LN, de Gier B, van der Maas NA, et al. Measles vaccination below 9 months of age: systematic literature review and meta-analyses of effects and safety. National Institute for Public Health and the Environment. https://www.who.int/immunization/sage/meetings/2015/october/2_MCV1_below_9_months_Effect_safety_28092015.pdf. Published September 28, 2015. Accessed April 24, 2019.
6. Uzicanin A, Zimmerman L. Field effectiveness of live attenuated measles-containing vaccines: a review of published literature. J Infect Dis. 2011;204(suppl 1):S133-S149.
7. Woudenberg T, van der Maas NA, Knol MJ, et al. Effectiveness of early measles, mumps, and rubella vaccination among 6-14-month-old infants during an epidemic in the Netherlands: an observational cohort study. J Infect Dis. 2017;215:1181-1187.
8. Martins C, Garly ML, Bale C, et al. Measles virus antibody responses in children randomly assigned to receive standard-titer edmonston-zagreb measles vaccine at 4.5 and 9 months of age, 9 months of age, or 9 and 18 months of age. J Infect Dis. 2014;210:693-700.
9. Njie-Jobe J, Nyamweya S, Miles DJ, et al. Immunological impact of an additional early measles vaccine in Gambian children: responses to a boost at 3 years. Vaccine. 2012;30:2543-2550.
10. Gans HA, Yasukawa LL, Sung P, et al. Measles humoral and cell-mediated immunity in children aged 5–10 years after primary measles immunization administered at 6 or 9 months of age. J Infect Dis. 2013;207:574-582.
Since the measles outbreak in the Pacific Northwest (where I did my training and remain in touch with colleagues and patients), parents with infants ages 6 to 11 months are requesting vaccinations before 12 months—the standard age to start immunizations.1 But physicians decline to provide inoculation, citing institutional policy on the risks of early vaccination. What are these risks, and how should we respond when parents ask about early vaccination?
The safety and efficacy of early vaccination are well documented. Early vaccination is a technique employed to curb outbreaks both in the United States and worldwide. Guidelines from the Centers for Disease Control and Prevention (CDC) recommend vaccinating infants at 6 months of age if they will be traveling,2 and the World Health Organization (WHO) recommends vaccinations during a measles outbreak as part of intensified service delivery or in settings, such as daycare facilities, in which there is an increased risk for disease exposure during an outbreak.3 Any dose given before 12 months is considered supplemental, and the child must still complete the regular 2-dose vaccine schedule. Studies on the adverse effect profiles of vaccines show that the younger the infant, the fewer adverse events occur—because adverse events reflect the increasingly robust immune response that comes with age.4
Many physicians are concerned about adequate immune response. In vaccine research, this is gauged by the proportion of patients with seroconversion after vaccination. This is also reflected in vaccine efficacy (VE), which gradually increases with age and maturity of the immune system. For example, measles VE is 60% to 70% in 6-to-8-month cohorts5 and 70% to 80% in 9-to-11-month cohorts.6 VE at 12 months is in the 90% range, and completion of the 2-dose series yields a VE of ≥ 95%.7 Thus, while the vaccine is more effective at later ages, it still provides protection to younger cohorts.
“Blunting” (ie, a reduced immune response to the second dose of vaccine3) is another concern with early measles vaccination, but a WHO meta-analysis proved this concern to be unfounded.1,3 Twelve papers examining seropositivity in children who received a second measles vaccine after early primary vaccination found a pooled proportion of seropositivity of 97%.1,8,9 Furthermore, evidence shows that children have sustained measles-specific T-cell responses after early primary measles immunization.10
Early vaccination has few risks and significant benefit. Therefore, in light of the recent measles outbreak, relaxing the lower boundary for the measles vaccine is appropriate. In addition to physically protecting the patient and general population, honoring parents’ requests for vaccination respects their autonomy and fosters trust. Synthesis of good science with a trusting doctor–patient relationship is key to ending the measles outbreak.
Rachel Roth, MD
Tel Aviv, Israel
Since the measles outbreak in the Pacific Northwest (where I did my training and remain in touch with colleagues and patients), parents with infants ages 6 to 11 months are requesting vaccinations before 12 months—the standard age to start immunizations.1 But physicians decline to provide inoculation, citing institutional policy on the risks of early vaccination. What are these risks, and how should we respond when parents ask about early vaccination?
The safety and efficacy of early vaccination are well documented. Early vaccination is a technique employed to curb outbreaks both in the United States and worldwide. Guidelines from the Centers for Disease Control and Prevention (CDC) recommend vaccinating infants at 6 months of age if they will be traveling,2 and the World Health Organization (WHO) recommends vaccinations during a measles outbreak as part of intensified service delivery or in settings, such as daycare facilities, in which there is an increased risk for disease exposure during an outbreak.3 Any dose given before 12 months is considered supplemental, and the child must still complete the regular 2-dose vaccine schedule. Studies on the adverse effect profiles of vaccines show that the younger the infant, the fewer adverse events occur—because adverse events reflect the increasingly robust immune response that comes with age.4
Many physicians are concerned about adequate immune response. In vaccine research, this is gauged by the proportion of patients with seroconversion after vaccination. This is also reflected in vaccine efficacy (VE), which gradually increases with age and maturity of the immune system. For example, measles VE is 60% to 70% in 6-to-8-month cohorts5 and 70% to 80% in 9-to-11-month cohorts.6 VE at 12 months is in the 90% range, and completion of the 2-dose series yields a VE of ≥ 95%.7 Thus, while the vaccine is more effective at later ages, it still provides protection to younger cohorts.
“Blunting” (ie, a reduced immune response to the second dose of vaccine3) is another concern with early measles vaccination, but a WHO meta-analysis proved this concern to be unfounded.1,3 Twelve papers examining seropositivity in children who received a second measles vaccine after early primary vaccination found a pooled proportion of seropositivity of 97%.1,8,9 Furthermore, evidence shows that children have sustained measles-specific T-cell responses after early primary measles immunization.10
Early vaccination has few risks and significant benefit. Therefore, in light of the recent measles outbreak, relaxing the lower boundary for the measles vaccine is appropriate. In addition to physically protecting the patient and general population, honoring parents’ requests for vaccination respects their autonomy and fosters trust. Synthesis of good science with a trusting doctor–patient relationship is key to ending the measles outbreak.
Rachel Roth, MD
Tel Aviv, Israel
1. Conclusions of the SAGE Working Group on Measles and Rubella. 21-22 June 2017. Geneva WHO Policy Recommendation on administration of MCV to infants. SAGE. https://www.who.int/immunization/sage/meetings/2017/october/2_measles_vaccination_before_6_months_for_yellow_book_FINAL.pdf. Accessed April 24, 2019.
2. Centers for Disease Control and Prevention. Measles (Rubeola). For healthcare professionals. https://www.cdc.gov/measles/hcp/index.html. Accessed April 24, 2019.
3. World Health Organization. Measles vaccines: WHO position paper, April 2017 - recommendations. Vaccine. 2017;92:205-227.
4. van der Maas NA, Woudenberg T, Hahné SJ, et al. Tolerability of early measles-mumps-rubella vaccination in infants aged 6-14 months during a measles outbreak in the Netherlands in 2013-2014. J Infect Dis. 2016;213:1466-1471.
5. Lochlainn LN, de Gier B, van der Maas NA, et al. Measles vaccination below 9 months of age: systematic literature review and meta-analyses of effects and safety. National Institute for Public Health and the Environment. https://www.who.int/immunization/sage/meetings/2015/october/2_MCV1_below_9_months_Effect_safety_28092015.pdf. Published September 28, 2015. Accessed April 24, 2019.
6. Uzicanin A, Zimmerman L. Field effectiveness of live attenuated measles-containing vaccines: a review of published literature. J Infect Dis. 2011;204(suppl 1):S133-S149.
7. Woudenberg T, van der Maas NA, Knol MJ, et al. Effectiveness of early measles, mumps, and rubella vaccination among 6-14-month-old infants during an epidemic in the Netherlands: an observational cohort study. J Infect Dis. 2017;215:1181-1187.
8. Martins C, Garly ML, Bale C, et al. Measles virus antibody responses in children randomly assigned to receive standard-titer edmonston-zagreb measles vaccine at 4.5 and 9 months of age, 9 months of age, or 9 and 18 months of age. J Infect Dis. 2014;210:693-700.
9. Njie-Jobe J, Nyamweya S, Miles DJ, et al. Immunological impact of an additional early measles vaccine in Gambian children: responses to a boost at 3 years. Vaccine. 2012;30:2543-2550.
10. Gans HA, Yasukawa LL, Sung P, et al. Measles humoral and cell-mediated immunity in children aged 5–10 years after primary measles immunization administered at 6 or 9 months of age. J Infect Dis. 2013;207:574-582.
1. Conclusions of the SAGE Working Group on Measles and Rubella. 21-22 June 2017. Geneva WHO Policy Recommendation on administration of MCV to infants. SAGE. https://www.who.int/immunization/sage/meetings/2017/october/2_measles_vaccination_before_6_months_for_yellow_book_FINAL.pdf. Accessed April 24, 2019.
2. Centers for Disease Control and Prevention. Measles (Rubeola). For healthcare professionals. https://www.cdc.gov/measles/hcp/index.html. Accessed April 24, 2019.
3. World Health Organization. Measles vaccines: WHO position paper, April 2017 - recommendations. Vaccine. 2017;92:205-227.
4. van der Maas NA, Woudenberg T, Hahné SJ, et al. Tolerability of early measles-mumps-rubella vaccination in infants aged 6-14 months during a measles outbreak in the Netherlands in 2013-2014. J Infect Dis. 2016;213:1466-1471.
5. Lochlainn LN, de Gier B, van der Maas NA, et al. Measles vaccination below 9 months of age: systematic literature review and meta-analyses of effects and safety. National Institute for Public Health and the Environment. https://www.who.int/immunization/sage/meetings/2015/october/2_MCV1_below_9_months_Effect_safety_28092015.pdf. Published September 28, 2015. Accessed April 24, 2019.
6. Uzicanin A, Zimmerman L. Field effectiveness of live attenuated measles-containing vaccines: a review of published literature. J Infect Dis. 2011;204(suppl 1):S133-S149.
7. Woudenberg T, van der Maas NA, Knol MJ, et al. Effectiveness of early measles, mumps, and rubella vaccination among 6-14-month-old infants during an epidemic in the Netherlands: an observational cohort study. J Infect Dis. 2017;215:1181-1187.
8. Martins C, Garly ML, Bale C, et al. Measles virus antibody responses in children randomly assigned to receive standard-titer edmonston-zagreb measles vaccine at 4.5 and 9 months of age, 9 months of age, or 9 and 18 months of age. J Infect Dis. 2014;210:693-700.
9. Njie-Jobe J, Nyamweya S, Miles DJ, et al. Immunological impact of an additional early measles vaccine in Gambian children: responses to a boost at 3 years. Vaccine. 2012;30:2543-2550.
10. Gans HA, Yasukawa LL, Sung P, et al. Measles humoral and cell-mediated immunity in children aged 5–10 years after primary measles immunization administered at 6 or 9 months of age. J Infect Dis. 2013;207:574-582.