MAJOR ARTICLE

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
Cesario Martins,1 May-Lill Garly,1 Carlitos Bale,1 Amabelia Rodrigues,1 Jainaba Njie-Jobe,3 Christine S. Benn,1,2
Hilton Whittle,3 and Peter Aaby1,2
1
Bandim Health Project, Indepth Network, Bissau, Guinea-Bissau; 2Research Center for Vitamins and Vaccines, Bandim Health Project, Statens Serum
Institut, Denmark; and 3MRC Laboratories, Fajara, Gambia

The World Health Organization recommends administration of measles vaccine (MV) at age 9 months in low-
income countries. We tested the measles virus antibody response at 4.5, 9, 18, and 24 months of age for children
randomly assigned to receive standard-titer Edmonston-Zagreb MV at 4.5 and 9 months, at 9 months, or at 9
and 18 months of age. At 4.5 months of age, 75% had nonprotective measles virus antibody levels. Following
receipt of MV at 4.5 months of age, 77% (316/408) had protective antibody levels at 9 months of age; after a
second dose at 9 months of age, 97% (326/337) had protective levels at 24 months of age. In addition, the re-
sponse at both 9 and 24 months of age was inversely correlated with the antibody level at receipt of the first dose
of MV, and the second dose of MV, received at 9 months of age, provided a significant boost in antibody level to
children who had low antibody levels. In the group of 318 children who received MV at 9 months of age, with or
without a second dose at 18 months of age, 99% (314) had protective levels at 24 months of age. The geometric
mean titer at 24 months of age was significantly lower in the group that received MV at 4.5 and 9 months of age
than in the group that received MV at 9 months of age (P = .0001). In conclusion, an early 2-dose MV schedule
was associated with protective measles virus antibody levels at 24 months of age in nearly all children.
Clinical Trials Registration. NCT00168558.
Keywords. antibody response; early measles vaccination; Edmonston-Zagreb measles vaccine; non-specific
effects of vaccines; two-dose measles vaccination.

Following withdrawal of the high-titer measles vaccine
(MV) [1], it was suggested to study early 2-dose sched-
ules to lower the age of MV [2, 3]. From 1995 to 2002,
we conducted an early 2-dose MV trial in Guinea-
Bissau [4, 5]; the children were randomly assigned to re-
ceive MV at 6 and 9 months of age or inactivated polio
vaccine (IPV) at 6 months of age and MV at 9 months
Received 2 April 2013; accepted 24 February 2014; electronically published 31
March 2014.
Correspondence: Cesario Martins, Bandim Health Project, Apartado 861, Bissau,
Guinea-Bissau (c.martins@bandim.org).
The Journal of Infectious Diseases 2014;210:693–700
© The Author 2014. Published by Oxford University Press on behalf of the Infectious
Diseases Society of America. All rights reserved. For Permissions, please e-mail:
journals.permissions@oup.com.
DOI: 10.1093/infdis/jiu117
of age. The early 2-dose schedule increased coverage
considerably and provided better protection against
measles virus infection [5]. Edmonston-Zagreb MV
(EZ) and Schwarz MV (SW) were used in 2 different pe-
riods, and EZ seemed to boost a secondary immune re-
sponse better than SW [5]. Previous trials have shown
that standard-titer EZ provided good seroconversion
at 4–6 months of age [6–8]. We therefore focused on
EZ for early measles vaccination.
Following elimination of measles from the Americas,
the age of vaccination was raised to 12 months because
the antibody response is better at 12 months [9, 10]. A
similar policy is recommended in other low-income
countries once measles is under control. To implement
that policy in Africa could potentially be disastrous.

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 First, maternal antibody levels have declined following the in-
troduction of MV 25 years ago. Many children are now suscep-
tible already at 2–4 months of age; in a recent epidemic in an
urban area with high coverage, the incidence was 19% before
9 months of age in the cohort born just before the epidemic
[11]. Increasing the age to 12 months would leave more infants
exposed to measles virus infection in situations in which mea-
sles is not fully controlled. Second, later vaccination would re-
duce the period during which the children benefitted from the
nonspecific effects of MV [12–15]. During a war period with
high mortality, children randomly assigned to receive early
MV had significantly lower mortality [13]. Hence, it is justified
to examine earlier measles vaccination.
We have recently examined an early 2-dose strategy with
standard EZ at 4.5 and 9 months of age; it prevented measles
before 9 months and reduced all-cause mortality between 4.5
and 36 months of age [11, 15]. Control children randomly as-
signed to receive EZ or SW at 9 months of age had 99% protec-
tive antibody levels at 24 months of age [16]. In the present
article, we examine measles antibodies levels following standard
EZ at 4.5 and 9 months of age and compare them to those of
children who received 1 dose of EZ at 9 months of age or 2 doses
of EZ at 9 and 18 months of age.
METHODS
Subjects and Methods
The study was conducted in the Bandim Health Project (BHP)
study area with approximately 102 000 inhabitants. BHP has
implemented a routine data collection system; all residents
have an identification number, and information on socioeco-
nomic and demographic information is available. All houses
are visited every month to register new pregnancies and births.
Children are visited every 3 months until 3 years of age; at these
visits we collect information on breast-feeding, infections, hos-
pitalizations, vaccination status, and other factors associated
with child survival or mortality. There are 3 health centers in
the area. The people of Bissau travel frequently to visit relatives
living in other parts of the country.
Study Design
The present trial compared different MV strategies, using 2
strains of measles virus and different ages of vaccination. All
children were randomly assigned at 4.5 months of age to 1 of
3 groups: group I received EZ at 4.5 and 9 months of age,
group II received no vaccine at 4.5 months of age and SW at
9 months of age, and group III received no vaccine at 4.5
months of age and EZ at 9 months of age. At 18 months of
age, children in groups II and III were invited back to the health
center and after additional maternal consent randomized to a
second dose of MV or no booster dose (Figure 1). The primary
outcomes were survival at 3 years of age, measles virus antibody
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levels at 24 months of age, and clinical protection against mea-
sles. To detect a 25% difference in mortality between any of the
groups we needed to enroll 5755 children and follow them to 3
years of age [15]. The present study compares the antibody re-
sponse after early EZ at 4.5 and 9 months of age with the stan-
dard EZ at 9 months of age (ie, group I and group III; Figure 1).
Assuming 85% seroconversion we needed 400 children to detect
a 10% difference in the proportion of nonseroconverters in the
long-term follow-up at 24 months of age; because of expected
loss to follow-up, we recruited around 450 in each group.
On the basis of a community survey in the same community
[17], the expected human immunodeficiency virus type 1 (HIV-
1) prevalence among mothers was 4%–5%. Children in the trial
were not tested for HIV infection. Normally, all children are
breast-fed at 4 months of age in Guinea-Bissau, but during
the trial period the nongovernmental organization responsible
for prevention of maternal HIV transmission recommended
that HIV-infected mothers not breast-feed their children. At en-
rollment, 4% were not breast-fed [15].
Enrollment Procedures
Eligible Children
Newborn infants were identified in the BHP registration system.
To ensure that children had received 3 doses diphtheria-
tetanus-pertussis vaccine (DTP) 4 weeks before inclusion, we
contacted mothers of children aged 6, 10, and 14 weeks and re-
minded them to go to a health center to receive DTP and oral
poliovirus vaccine. Enrollment took place at 4.5 months of age.
During morning hours, a field-worker contacted mothers/
guardians of eligible children. The field-worker explained the
study, filled in a questionnaire on background factors, and
obtained verbal consent. The mother/guardian was asked to
bring the child to the health center in the afternoon.
Enrollment, Informed Consent, and Randomization
In the afternoon, the mothers/guardians received an oral and a
written explanation from a physician. The physician performed
a medical examination. The children received treatment accord-
ing to local standards. Children who were sick could only par-
ticipate when they had recovered. If mothers consented, they
selected an envelope, which specified the randomization
group. Clinical examination and treatment was independent
of randomization group. At 9 months of age, all children were
invited back to the health center; those in group I received a sec-
ond dose of EZ, and those in group III received standard EZ.
Measles Vaccine
Standard-titer EZ from the Serum Institute of India (Pune,
India) was used (batch 2360). According to the manufacturer,
the dose was at least 1000 median tissue-culture infective
doses, and, when assayed at the MRC Laboratories, batches
ranged between 3000 and 6000 plaque-forming units per dose.
 Figure 1. Trial profile for collection of blood samples and reasons for loss to follow-up. Abbreviation: MV, measles vaccine.

Blood Sampling and Antibody Analysis
We collected blood samples to assess measles virus antibody
levels at 4.5, 9, and 24 months of age in group I and at 9, 18,
and 24 months of age in group III (Figure 1). The mothers
were sampled when their child was sampled the first time to en-
sure that samples were collected in the same season. The
samples at 4.5 months of age in group I and at 9 months of
age in group III were obtained before vaccination, to reflect ma-
ternal antibody levels. The samples obtained at 9 months of age,
in group I, and at 18 months, in group III, were collected before
a possible second dose of MV and were therefore used to assess
antibody levels after one dose of MV. The sample at 24 months

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 of age was used to assess long-term maintenance of antibody and 95% confidence intervals (CIs). The subjects reporting
levels and to examine the possible effect of a booster dose of measles virus infection before receipt of the first dose of MV
standard MV. The collection of the first samples was imple- were excluded from the analysis (Table 1). The GMT was com-
mented between March and December 2004. If consent was re- pared for different vaccination groups, using the nonparametric
ceived, we collected blood samples from all trial participants Kruskal–Wallis test. Additionally, comparisons were conducted
enrolled in this period. by Tobit regression, which is a censored normal regression
The samples were analyzed by the measles hemagglutination method [21]. Undetectable levels are not assigned a given
inhibition test (HAI) at MRC Laboratories in Gambia [18, 19]. value but are instead regarded as censored with the true level
The HAI test had a sensitivity of 15.6 mIU/mL, and, with a being below the detection limit. This did not change the results
starting dilution of 1:2, the minimum detectable titer was (data not shown).
31.2 mIU/mL. We have previously shown that the protective
level is 125 mIU/mL (ie, a positive reading in a 1:8 dilution)
RESULTS
[20]. Children with 31–63 mIU/mL of measles virus antibody
were considered to have low (but detectable), nonprotective The number of samples collected at different ages and reasons
levels. for loss to follow-up are indicated in Figure 1. Background var-
iables were compared between group I and group III for chil-
Statistical Analysis dren whose antibody samples were analyzed (Table 1); length
The statistical analysis was performed with Stata, version 10.0, and arm circumference were significantly shorter in group I;
statistical software. All antibody data were log-transformed. Un- otherwise, there were no differences between the 2 groups.
detectable antibody levels were counted as 0 on the log-scale.
Measles titers are presented as geometric mean titers (GMTs) Measles Virus Antibody Levels in Mothers and Maternal
Measles Antibody Levels in Children
Among mothers, 4% (33/846) had a nonprotective titer (<125
Table 1. Background Factors of Children With Early Receipt of
mIU/mL); the GMT was 1042 mIU/mL (95% CI, 946–1157).
Edmonston-Zagreb Measles Vaccine (EZ) and EZ Receipt at 9 Among the children tested at 4.5 months of age, 75% had
Months of Age nonprotective levels (72% of boys [165/228] and 78% of girls
[162/207]; risk ratio [RR; boys/girls], 0.92 [95% CI, 0.83–
EZ Receipt at 4.5 EZ Receipt at 9 1.03]; P = .155). The prevaccination GMT was 43 mIU/mL in
Factor Mo (Group I) Mo (Group III)
the early vaccination group; for 292 children aged 4 months,
Male sex 52 (228/435) 51 (211/415) the GMT was 45 mIU/mL; for 127 children aged 5 months,
Age at inclusion, d 151 ± 12 150 ± 12 the GMT was 41 mIU/mL; and for 16 children aged 6 months,
From Bandim District 40 (175/435) 42 (175/415)
the GMT was 23 mIU/mL. In a logistic regression analysis that
Risk factors at enrollment
at age 4.5 mo controlled for maternal antibody level, the antibody level de-
Not being breast-fed 3 (14/433) 3 (11/412) clined significantly with age in days [22]. Antibody levels
Pigs in household 15 (63/426) 15 (62/411) were significantly lower in the rainy season (GMT, 38 mIU/
Persons/bed, no.a 2.9 ± 0.7 3.0 ± 0.6 mL) than in the dry season (GMT, 49 mIU/mL; P = .024; data
Toilet inside 17 (72/435) 15 (63/414) not shown). The age at enrollment was the same in the dry and
Electricity 40 (174/433) 39 (160/413) the rainy seasons.
Functioning electricity 28 (110/390) 26 (103/391) At 9 months of age, 92% (382/415) of the unvaccinated chil-
Morbidity and dren in group III had nonprotective antibody levels. A similar
anthropometry
Hospitalization before 1.4 (6/434) 1.5 (6/411)
proportion was unprotected among boys (94% [198/211]) and
age 4.5 mo girls (90% [184/204]), with a RR (boys/girls) of 1.04 (95% CI,
Weight, kg 7.12 ± 0.95 7.24 ± 0.98b 0.98–1.10). The GMT before the vaccination was 23 mIU/mL.
Length, cm 63.6 ± 2.4 64.5 ± 2.8 The GMT did not differ by season (data not shown).
Arm circumference, mm 140 ± 10.8 142 ± 11.3
Maternal arm 273 ± 32.8 272 ± 31.8 Measles Virus Antibody Levels at 9 Months of Age After the First
circumference, mmc
Dose of EZ at 4.5 Months of Age Versus Prevaccination Levels at
BCG vaccine scar 81 (350/431) 80 (331/413)
9 Months of Age (Control Group)
Data are % (proportion) of children or mean ± SD, unless otherwise indicated, Of the 435 children in group I (Figure 1), 409 had follow-up
and they are limited to children with an analyzed blood sample (Figure 1).
a
Data are for 434 in group I and 414 in group III.
samples collected at 9 months of age; 1 sample had insufficient
b
Data are for 435 in group I and for 414 in group III. amount of blood for analysis (Figure 1). In group III, 415 sam-
c
Data are for 428 in group I and 401 in group III. ples were included in the analysis. In group I, 23% (92/408) had

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 Table 2. Proportion of Children With Nonprotective Antibody (Ab) Levels and Geometric Mean Titers (GMTs), by Age at Receipt of
Edmonston-Zagreb Measles Vaccine and Number of Doses

Vaccination at 4.5 and 9 Mo (Group I) Vaccination at 9 Mo or at 9 and 18 Mo (Group III)

Nonprotective Ab Level, Nonprotective Ab Level,

% (Proportion) [No. GMT, mIU/mL % (Proportion) GMT, mIU/mL
Age at Sampling Nondetectable] (95% CI) [No. Nondetectable] (95% CI)
4.5 mo 75.2 (327/435) [199] 42 (38–48) NA NA
9 mo 22.6 (92/408) [35] 215 (188–243) 92.1 (382/415) [360] 23 (20–2479)
18 mo NA NA 0.9 (3/344) [1] 948 (927–977)
24 mo 3.3 (11/337) [2] 657 (581–744) 9 and 18 mo: 1.8 (3/167) [0]; 9 and 18 mo: 1246 (1058–1467);
only 9 mo: 0.7 (1/151) [0] only 9 mo: 1287 (1067–1553)

Group I had significantly higher antibody levels at 9 months of age than group III (P < .0001). At 24 months of age, the GMT of group III was significantly higher than
that for group I (P < .0001).
Abbreviations: CI, confidence interval; NA, not applicable.

nonprotective levels after receipt of the first EZ dose, in contrast
to 92% (382/415) in group III (Table 2), with a RR (group I/
group III) of 0.24 (95% CI, 0.20–0.29).
Antibody Levels at 24 Months of Age After 2 Doses of EZ at 4.5
and 9 Months of Age (Group I)
In group I, 337 samples were analyzed at age 24 months (Fig-
ure 1). Only 3% (11/337) had nonprotective measles virus anti-
body levels (Table 3). Nine had low but detectable levels; of the
2 children who had an undetectable antibody level at 24
months, one had had a protective level and one had a low de-
tectable level at 9 months after the first dose of EZ. Since no
children would have maternal antibodies at 24 months of age,
all children with the possible exception of 1 had seroconverted
to having specific measles virus antibodies following early MV
receipt. The GMT was 657 mIU/mL (Table 3). We did not find
any significant difference in nonprotective level between boys
and girls, and the GMT did not differ by season of the first
MV dose (data not shown).
The titer at 24 months depended on the antibody level at re-
ceipt of the first MV dose, with the highest levels for those with
no detectable antibody at 4.5 months of age (P = .001; Table 3).
Most children with nonprotective levels at 24 months had had
protective levels at the initial vaccination, probably because of
maternal antibodies. The antibody titer at 24 months depended
also on the antibody level at 9 months of age, before the booster
dose was administered (Table 4); however, those who had the
highest titers at 9 months continued to have the highest titers
at 24 months of age (P < .0001). Of those who had undetectable
or low detectable levels at 9 months of age, 89% (63/71) had ac-
quired protective levels by 24 months of age. We also tested how
many children had a 4-fold increase in antibody titer between 9
and 24 months of age (Table 4). The majority of children who
had had nonprotective level at 9 months of age (60/71) or me-
dium protective levels (105/210) had a significant boost, where-
as only 18% (19/56) of those with a high level had a further
boost (P < .0001).
Measles Virus Antibody Levels at 18 Months of Age After 1 Dose
of EZ at 9 Months of Age (Group III)
In group III, 344 children had a sample at 18 months of age
(Figure 1). Only 1% (3/344) had nonprotective measles virus

Table 3. Measles Virus Antibody (Ab) Level at 9 Months and 24 Months of Age, by Prevaccination Ab Level at 4.5 Months Age (Group I)

Ab Response at 9 Mo Ab Response at 24 Mo

Nonprotective Antibody Level, % GMT, mIU/mL Nonprotective Antibody Level, % GMT, mIU/mL
Ab Level at 4.5 Mo (Proportion) [No. Nondetectable] (95% CI) (Proportion) [No. Nondetectable] (95% CI)
0 mIU/mL (undetectable 12.8 (24/188) [7] 330 (280–390) 1.3 (2/151) [0] 817 (693–964)
level)
31.25–62.5 mIU/mL (low 19.9 (23/122) [6] 195 (160–237) 1.9 (2/104) [0] 666 (543–816)
detectable level)
≥125 mIU/mL (protective 45.9 (45/98) [22] 104 (76–141) 8.5 (7/82) [2] 433 (323–580)
level)
Total 22.6 (92/408) [35] 214 (188–244) 3.3 (11/337) [2] 657 (581–744)

Children with a protective level of maternal Ab at 4.5 months of age had a significantly lower Ab level at 9 months of age after 1 dose of EZ (P < .0001) but also at
24 months of age after 2 doses of EZ (P = .001).

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 Table 4. Geometric Mean Titer (GMT) of Measles Virus Antibody (Ab) at 24 Months of Age After 2 Doses of Edmonston-Zagreb Measles
Vaccine (EZ), by Ab Level Before Booster Vaccination at 9 Months of Age (Group I)

Ab Response at 24 Mo

Nonprotective Level, % GMT, mIU/mL ≥4-fold Increase From Level at

Ab Level at Age 9 Mo (Proportion) [No. Nondetectable] (95% CI) 9 Mo, % (Proportion)
0 mIU/mL (undetectable level) 11.5 (3/26) [0] 293 (201–429) 96.2 (25/26)
31.25–62.5 mIU/mL (low detectable level) 11.1 (5/45) [1] 287 (197–419) 77.8 (35/45)
125–500 mIU/mL (protective level) 1.4 (3/210) [1] 707 (617–810) 50.0 (105/210)
≥1000 mIU/mL (higher level) 0 (0/56) [0] 1414 (1094–1828) 17.9 (10/56)
Total 3.3 (11/337) [2] 657 (581–744) 51.9 (175/337)
Children who had a high level of antibody at 9 months of age after 1 dose of EZ at 4.5 months of age continued to have significantly higher antibody level at 24 months
of age after 2 doses of EZ (P < .0001).

antibody levels after 1 dose of EZ, at 9 months of age. As de-
scribed elsewhere, the GMT was 807 mIU/mL [16]. The anti-
body titer was analyzed in relation to the prevaccination
antibody level. Children who had undetectable or low detectable
levels at 9 months of age essentially had the same GMT at 18
months (780 and 757 mIU/mL, respectively). The children
who had protective levels at 9 months of age continued to
have a high antibody level (GMT, 1219 mIU/mL), possibly re-
flecting that a protective level at 9 months of age represented
subclinical measles virus infection, rather than maternal anti-
body (Table 5) [16].
Comparison of Early and Later Measles Vaccination at 24
Months of Age (Groups I and III)
In group I, 3% (11/337) had nonprotective antibody levels after
they had received 2 doses of MV, in contrast to 1% (4/318) in
group III, a difference that was not statistically significant. In
group III, the antibody level and proportion with nonprotective
antibody levels was similar for children who had received 1 dose
at 9 months of age or 2 doses at 9 and 18 months of age
(Table 2). The antibody level at 24 months in group III depend-
ed on the season of the first MV; children vaccinated in the
rainy season had a significantly higher titer (GMT, 1376 mIU/
mL) than children vaccinated in the dry season (GMT, 1008
mIU/mL; P = .013). The difference by season of vaccination per-
sisted when we controlled for the antibody level at 9 months of
age in a Tobit analysis (data not shown).
The GMT was lower in group I than group III (P = .0001;
Table 2). The 4 children in group III who had a nonprotective
level at 24 months all had protective levels at 18 months, sug-
gesting that essentially 100% of the children who received EZ at
9 months of age had been protected against measles. In group I,
3 of the 11 children having a nonprotective level at 24 months of
age had had protective levels at 9 months, and 7 had detectable
measles virus antibody levels, indicating that they probably had
some protection against measles.

Table 5. Geometric Mean Titers (GMTs) at 18 Months and 24 Months of Age After 1 Dose of Edmonston-Zagreb Measles Vaccine (EV) at 9
Months of Age or 2 Doses at 9 and 18 Months of Age, by Prevaccination Antibody (Ab) Level at 9 Months of Age (Group III)

Ab Level at 18 Mo Ab Level at 24 Mo

Nonprotective Level, % Nonprotective Level, % ≥4-fold Increase From

(Proportion) [No. GMT, mIU/mL (Proportion) [No. GMT, mIU/mL Level at 18 Mo, %
Ab Level at 9 Mo Nondetectable] (95% CI) Nondetectable] (95% CI) (Proportion)
0 mIU/mL 1.0 (3/301) [1] 780 (694–876) 1.4 (4/277) [0] 1224 (1074–1396) 27.1 (75/277)
(undetectable
level)
31.25–62.5 mIU/mL 0 (0/15) [0] 757 (440–1305) 0 (0/14) [0] 1160 (839–1604) 21.4 (3/14)
(low detectable
level)
≥125 mIU/mL 0 (0/28) [0] 1219 (717–2075) 0 (0/27) [0] 1852 (1175–2918) 29.6 (8/27)
(protective level)
Total 0.9 (3/344) [1] 808 (722–904) 1.3 (4/318) [0] 1266 (1120–1430) 27.0 (86/318)

The group with protective levels at 9 months of age tended to have higher antibody levels than the other 2 groups at both 18 months of age (P = .108) and 24 months
of age (P = .110).
Abbreviation: CI, confidence interval.

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 We have previously reported that neonatal vitamin A supple-
mentation (NVAS) had a major impact on child survival in
group I [15]. However, receipt of NVAS was not linked to mea-
sles virus antibody levels at 24 months of age in either group I or
group III (data not shown).
DISCUSSION
Four percent of mothers had nonprotective measles virus anti-
body levels. Previous studies in Bissau found a higher GMT
among mothers than we did in the present study [5]; there
are presumably fewer mothers who have had natural measles
virus infection [16]. Hence, children become susceptible to
measles virus infection earlier [11, 16, 23]; 75% had nonprotec-
tive levels before vaccination at 4.5 months of age, and this pro-
portion increased to 92% at 9 months of age. Many children
with protective levels at 9 months of age had probably had sub-
clinical infection [16].
Our study had several important findings. First, EZ receipt at
4.5 and 9 months of age provided protective levels for 97% at 24
months of age, and all children, except possibly 1 child, had re-
sponded with measles virus antibody. Second, the antibody re-
sponse at both 9 and 24 months of age depended on the level
of maternal antibodies at the time of the initial measles vaccina-
tion. Third, 89% of children who had not obtained a protective
antibody level after 1 dose did so after the second dose of EZ.
Fourth, children who had received EZ at 4.5 and 9 months of
age had lower antibody levels than children who received EZ at
9 months of age or 9 and 18 months of age, there was no signifi-
cant difference in the proportion with nonprotective levels. Fifth,
an additional dose of EZ, at 18 months of age, after receipt of the
initial MV dose at 9 months of age, did not booster the antibody
response, compared with having received just 1 dose at 9 months
of age; a similar observation has been made for SW [16].
A strength of this study is that the cohort experienced a mea-
sles epidemic just before blood samples were collected [11]. This
provided an opportunity for testing the efficacy of EZ against
clinical measles, and the vaccine performed very well [11]. On
the other hand, it meant that some samples had to be excluded
from the analysis because the children from whom they were
obtained already had had clinical measles virus infection. Still,
results were clear, so it is unlikely that this had any impact on
the overall result, apart from modifying the 95% CIs.
The loss to follow-up was 20%–25% between 4 and 24
months of age (Figure 1). In this community with high mortal-
ity, people move to find cheaper accommodations, urban fam-
ilies often go to rural areas to maintain contact with family, and
many women are away for several months for the annual har-
vest of cashew nuts and fruits in the late dry season. Loss to fol-
low-up was similar in group I and group III, and there is little
reason to think that this loss should have biased the comparison
between groups.
Ab Response to Early Measles Vaccine
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This study has several implications. Nearly all children re-
ceiving EZ at 4.5 and 9 months of age had acquired measles
virus–specific antibodies by 24 months of age. Since there had
been no measles epidemic after the provision of vaccine at 9
months of age, this effect is essentially due to the vaccine. A
nonprotective level at 24 months of age occurred mainly
among children who had high protective antibody levels at
4.5 months of age; since nearly all had specific measles virus an-
tibodies, they presumably had a modified immune response
with a strong cellular response [23] preventing a high antibody
response to the booster dose of EZ at 9 months of age. It is not
known whether such children are susceptible to measles virus
infection.
Achievement of protective antibody levels at 2 years of age
among 97% of vaccine recipients should make a 2-dose sched-
ule with standard EZ an attractive strategy in areas with low ma-
ternal antibody levels. Although the group that received EZ at 9
months of age had somewhat higher antibody levels, this does
not necessarily mean that the early 2-dose cohort is more sus-
ceptible to measles over the long term. We have previously
shown 94% protection against clinical measles and 100% pro-
tection against measles hospitalization or measles death before
9 months of age [11], even though only 77% had protective an-
tibody levels after receipt of 1 dose of EZ at 4.5 months of age.
Administering MV early may also increase the period with ben-
eficial nonspecific effects of MV [12–15]. We will continue to
follow the children to see whether there is any differential de-
cline in antibody levels between children receiving the first
dose of EZ at 4.5 or 9 months of age.
We have previously conducted studies of early 2-dose MV
strategies with either EZ or SW administered at 6 and 9 months
of age [4, 5, 14]. The level obtained with EZ at 4.5 and 9 months
of age was nearly as good as we experienced 10 years ago with
EZ at 6 and 9 months of age, presumably reflecting that mater-
nal antibody levels have continued to decline. In the previous
study, 1.3% (3/240) had nonprotective levels at 18 months of
age after 2 doses [5]. Our result in the present study with EZ
was distinctly better than the effect of SW at 6 months of age
in the previous study [5].
We only included children who had received DTP before en-
rollment [11]. If many children receive DTP simultaneously
with or after MV, results could be different. We have found
that receiving DTP with MV or after MV is associated with in-
creased mortality, compared with having MV as the most recent
vaccination [14, 24–29]. However, the impact of such changes
for the immune response to MV has not been studied.
In conclusion, EZ receipt at 4.5 and 9 months of age provided
protective antibody levels to 97% of recipients, and nearly all
had specific measles virus antibodies after vaccination. Since
we have previously shown that this strategy is protective against
clinical measles virus infection before 9 months of age [11] and
reduces all-cause mortality between 4.5 and 36 months of age
• JID 2014:210 (1 September) • 699
 [15], this should be a feasible measles control strategy in areas
with low maternal measles virus antibody levels.
Notes
Financial support. This work was supported by the Danish Council for
Development Research, Ministry of Foreign Affairs, Denmark (grant 104.
Dan.8.f.); the European Union FP7 Programme (OPTIMUNIZE; grant
261375 to C. M.); an ERC Starting Grant (ERC-2009-StG-243149 to
C. S. B.); the Novo Nordisk Foundation ( professorship grant to P. A.);
and the Danish National Research Foundation (to the Research Center for
Vitamins and Vaccines).
Potential conflicts of interest. All authors: No reported conflicts.
All authors have submitted the ICMJE Form for Disclosure of Potential
Conflicts of Interest. Conflicts that the editors consider relevant to the con-
tent of the manuscript have been disclosed.
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