Sero-epidemiology of measles antibodies in the Netherlands, a cross-sectional study in a national sample and in communities with low vaccine coverage
Introduction
Measles is a highly contagious, viral disease. In industrialised countries, the most common complications are otitis media (7–9%), pneumonia (1–6%) and encephalitis (0.05–0.1%) [1]. The risk of serious complications is highest in young children and adults [2].
To prevent these complications, measles vaccination was incorporated in the Dutch National Immunisation Programme (NIP) in 1976. Initially a plain live attenuated measles vaccine was offered to toddlers aged 14 months. Since 1987 a combined measles, mumps and rubella (MMR) vaccine has been given at the age of 14 months and 9 years. A catch-up campaign was carried out for 4-year-olds for 3 years. The second dose was introduced to provide a second chance of immunisation for persons in whom the first vaccination did not induce immunity and for persons who had not received the first dose [3].
Mass vaccination has led to a dramatic reduction in the number of measles cases reported in the Netherlands [4]. However, vaccination may have undesirable secondary effects. Several studies have shown that vaccine-induced antibody levels are lower than naturally acquired antibody levels [5], [6]. Women born in the vaccine era are approaching child-bearing age. Their infants will be protected by maternal antibodies for a shorter time due to lower titres [5], [7], [8]. Furthermore, with the decrease in virus circulation as a result of mass vaccination, both vaccine-induced and naturally acquired measles antibodies may wane in time since the immune system will receive no or less boosting [9], [10]. Most of the cases reported in the Netherlands are unvaccinated, usually for religious and other ideological reasons [4]. If the circulation of wild measles virus is limited, susceptible persons will accumulate in these unvaccinated groups and, as a consequence, outbreaks may occur. Another consequence of a decline in virus circulation is an increase in mean age of those infected by measles, when complications are more often seen [2]. However, despite the increasing age of measles cases in the Netherlands, no increase in the rate of complications has yet been observed [4].
To obtain insight into these possible undesirable effects of mass vaccination, antibodies against measles were measured in the Dutch general population and in municipalities where religious groups that refuse vaccination are clustered sociogeographically [11]. Results from this cross-sectional study might provide insight into the persistence of maternal antibodies and of measles antibodies induced by vaccination, into possible signs of circulation of the measles virus, and into clustering of susceptible people. The study results may also help to focus further surveillance activities in view of the World Health Organization (WHO) initiative to eliminate measles by the year 2007 [12].
Section snippets
Study population
A cross-sectional population-based serosurveillance study was carried out in the Netherlands in 1995/1996. The study design is described elsewhere in detail [13]. In short, a sample of eight municipalities was drawn proportional to their number of inhabitants out of each of five geographical regions of approximately equal population. Within each municipality an age-stratified sample (0, 1–4, 5–9, …, 75–79 years) of 380 persons was drawn. The first two age strata were oversampled because of an
Results
In the national sample, the overall prevalence of a measles antibody level of ≥0.2 IU/ml was 95.7% and the GMT was 1.59 IU/ml (Table 1). The GMT of the orthodox reformed people was statistically significantly higher than the GMT in the national sample (Table 1).
The seroprevalence and GMT of 0 to 24-year-olds were statistically significantly lower than of the 25 to 79-year-olds in the national sample and in the nonorthodox reformed people in the LVC municipalities. For the orthodox reformed
Immunity in the general Dutch population
Like others we showed that vaccine-induced measles antibody levels were lower than naturally acquired antibody levels [5], [6], [7].
Elimination of measles can only be reached if population susceptibility is below levels that can sustain transmission of measles. The WHO has set targets for the elimination of measles. For the age group 0 to 4-year-olds, the susceptibility target amounts to 15% or less; for 5 to 9-year-olds, to 10% or less; and for the older age groups, to 5% or less [12]. The WHO
Note added in proof
In June 1999 an outbreak of measles was reported in an orthodox reformed primary school with ±400 children, situated in a municipality enclosed in our low vaccine coverage sample. It was estimated that approximately 50% of the children fell ill. The diagnosis measles has been laboratory confirmed in some cases. The vaccination coverage for measles in the school as registered by the Provincial Vaccination Administrations was 7%. Most children fell ill in the lower grades, which is consistent
Acknowledgements
The authors thank all participating Public Health Services and municipalities, the Pienter Project team, and P. van der Kraak and A. Schakelaar for their useful contributions to the study realisation.
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