John J. Witte

Prophylaxis of varicella in high-risk children: Dose-response effect of zoster immune globulin

Immunodeficient patients who were presumed to be susceptible received zoster immune globulin prophylaxis after exposure to varicella. The highest clinical attack rate (35.9%) was seen in household contacts; the lowest attack rate (0%) was observed in children exposed at school. Among household contacts, 48 of 100 patients who received high titer ZIG (reciprocal complement fixation titer greater than or equal to 2,560) developed fourfold rises in serum CF antibody between pre- and 48-hour post-treatment specimens, compared to only one of 34 patients treated with lower titer ZIG lots (P less than 0.001). Patients who developed fourfold antibody rises were significantly less likely to contract clinical varicella (P less than 0.01). Patients who received high titer ZIG also had significantly lower risks of death (P = 0.025) and complications (P = 0.006). Among ZIG-treated patients who contracted clinical varicella, 80% developed mild disease (less than 100 pox), and the median incubation period was prolonged. Immunodeficient children exposed to varicella benefit from ZIG prophylaxis and higher titer ZIG is of greatest benefit.

Benefits due to immunization against measles.

IN THE PAST, measles has been an almost universal childhood disease. Although many consider it to be rather benign, it sometimes has serious complications, such as encephalitis, otitis, and pneumonia. Before vaccines were widely used, this disease represented a major public health problem in the United States; an estimated 4 million cases of measles, 4,000 cases of measles encephalitis, and 400 deaths occurred each year. The isolation of measles virus in 1954 (1) led to the development of effective vaccines. With the licensure of the live virus vaccine in 1963, a means of protecting susceptible persons in the population through vaccination became available. When in 1966 iit became apparent that measles could be eradicated in the United States, private medicine and Federal, Statei, and local governments collaborated on a major program to eliminate the disease (2, 3). This nationwide effort has had an unmisitakable effect on the incidence of measles. In 1968 the estimated number of measles cases was 250,000 or about 6 percent of the estimated mean for the 10yea,r period (1953 through 1962) prec,eding immunization. Our objective is to quantify the national impact of immunization against mea,sles. The benefits derived from immunization can be translated into savings in school days, hospital days, dollars, morbidity, and mortality. This kind of information is pa,rticularly relevant today, when decision ma,kers in the

Further attenuated live measles vaccines: the need for revised recommendations.

50-billion health services indus,try-now one of the largest and most sensitive segments of the national economy-are all too often forced to base decisions on seriously inadequa,te data.

Impotency of live-virus vaccines as a result of improper handling in clinical practice

R E C E N T L Y M O D I F I E D R E C O M M E N D A T I O N S 1 ~ f o r the use of live attenuated measles vaccines call for routine immunization of children at 15 months of age or older. During epidemics, infants may be immunized at 6 months of age or older, but must be reimmunized at 15 months. A change in the age recommended for administration, from 12 to 15 months was originally suggested by the retrospective observations of Yeager and associates. 3 This report presents the results of two studies designed to study prospectively the relationship between age at immunization and response to measles vaccine. The first study, done during 1974 and 1975, measured seroconversion rates in 6to 12-month-old children. The second study measured seroconversion following measles vaccine given as measles-mumps-rubella vaccine at 12 months of age simultaneously with trivalent oral polio vaccine.

Surveillance of mumps in the United States as background for use of vaccine.

IN 197 1, AN ISOLATED EPIDEMIC of measles was att r ibu ted to the use o f meas les vacc ine 1 which had become ineffective as the result of improper storage. The vaccine, stored in the door of a refrigerator, was apparen t ly inac t iva ted by f luc tua t ion in t e m p e r a t u r e caused by frequent opening and closing of the refrigerator door. The present report summarizes a study carried out in 1972 to determine the relevance of improper handling of four live-virus vaccine preparations: measles, rubel la , c o m b i n e d m e a s l e s r u b e l l a , and TOPV. Evidence for mishandling was obtained in two ways: (1) from historical information provided by the user and (2) by comparison of infectivity titrations of samples returned from the field with specimens from the same lots stored under ideal r ecommended conditions at BoB. Vaccine samples were obtained within the officially prescribed one-year period of mainta ined potency from public health clinics, private offices, and health depart-

Current status of vaccine-preventable diseases.

MUMPS is a common infectious disease, particularly among children. Although the illness is not usually severe, considerable morbidity and loss of time from school occur because of the large numbers affected. In addition, a number of complications may ensue. Meningeal involvement is the most common complication, but central nervous system disease with residua is rare. However, orchitis, which occurs in approximately 20 percent of postpubertal males with clinical mumps, is a significant complication. The symptomatic ininvolvement of other organs occurs less frequently. The loss of productive time because of uncomplicated mumps as well as the morbidity associated with meningitis and orchitis are reasonable justification for mumps prevention. In the past, the use of hyperimmune globulin and inactivated vaccines has proved to be less than optimal in both effectiveness and duration of protection. A live attenuated mumps virus vaccine, developed recently, appears to be both safe and effective (1-3). No adverse reactions, including fever, have been observed among the more than 6,000 susceptible persons who have received this mumps vaccine. Although antibodies have developed in more than 95 percent of the vaccinees, knowledge regarding the duration of immunity is not yet available. Currently, studies of natural challenge and antibody levels indicate a durable immunity beyond 1 year. The availability of the live attenuated mumps virus vaccine demands a rationale for its use. Since recommendations for the use of a vaccine must relate to the epidemiologic characteristics of the disease, this paper presents a review of the available surveillance data for mumps in the United States.

Epidemiologic Studies of Measles, Measles Vaccine, and Subacute Sclerosing Panencephalitis

Wide use of effective vaccines has substantially reduced the morbidity and mortality from vaccine-preventable diseases. The record is not good enough, however, as indicated by 25 to 30 deaths per year from measles and almost 2,000 cases per year of pertussis. Immunization activities must be given a higher priority.