Altered Reactivity to Measles Virus in Previously Vaccinated Children

In children vaccinated with killed measles vaccine, exposure to natural rubeola within two to four years can result in a clinical syndrome of altered measles reactivity.During a small epidemic of measles in Edmonton, Alberta, 51 children who had received their last killed measles vaccination 27 to 45 months before, were admitted to hospital with this syndrome.The syndrome consists of a prodromal cough and high fever followed by a maculopapular rash appearing on the extremities and progressing centrally. Pulmonary consolidations with or without pleural effusions were evident, but these cleared rapidly in four or five days. Initial WBC and ESR values suggested a bacterial etiology, but no pathogens could be isolated.Complement fixation titres for rubeola are present in acute and convalescent sera and indicate a definite measles infection.Previous killed measles vaccination excites a delayed hypersensitivity which is activated by the natural measles infection to account for this syndrome.It is recommended that killed measles vaccine be no longer used in routine vaccinations.     

Measles outbreak in 31 schools: risk factors for vaccine failure and evaluation of a selective revaccination strategy.

OBJECTIVE: To examine the risk factors for measles vaccine failure and to evaluate the effectiveness of a selective revaccination strategy during a measles outbreak. DESIGN: Matched case-control study. SETTING: Thirty-one schools in Mississauga, Ont. SUBJECTS: Eighty-seven previously vaccinated school-aged children with measles that met the Advisory Committee on Epidemiology''s clinical case definition for measles. Two previously vaccinated control subjects were randomly selected for each case subject from the same homeroom class. INTERVENTIONS: All susceptible contacts were vaccinated, and contacts who had been vaccinated before Jan. 1, 1980, were revaccinated. When two or more cases occurred in a school all children vaccinated before 1980 were revaccinated. MAIN OUTCOME MEASURES: Risk of measles associated with age at vaccination, time since vaccination, vaccination before 1980 and revaccination. RESULTS: Subjects vaccinated before 12 months of age were at greater risk of measles than those vaccinated later (adjusted odds ratio [OR] 7.7, 95% confidence interval [CI] 1.6 to 38.3; p = 0.01). Those vaccinated between 12 and 14 months of age were at no greater risk than those vaccinated at 15 months or over. Subjects vaccinated before 1980 were at greater risk than those vaccinated after 1980 (adjusted OR 14.5, 95% CI 1.5 to 135.6). Time since vaccination was not a risk factor. Revaccination was effective in reducing the risk of measles in both subjects vaccinated before 1980 and those vaccinated after 1980 (adjusted OR reduced to 0.6 [95% CI 0.1 to 5.3] and 0.3 [95% CI 0.13 to 2.6] respectively). However, only 18 cases were estimated to have been prevented by this strategy. CONCLUSIONS: Adherence to routine measles vaccination for all eligible children is important in ensuring appropriate coverage with a single dose. The selective revaccination strategy''s high labour intensiveness and low measles prevention rate during the outbreak bring into question the effectiveness of such a strategy.     

Analysis of a measles epidemic; possible role of vaccine failures.

A measles epidemic occurred in the Greensville (Ont.) Unit schools during January and February 1975. There were 47 cases of measles in 403 students: 26 (55%) of the children had a history of being vaccinated and 18 (38%) had not been vaccinated. Among children known to have been vaccinated at less than 1 year of age 7 of 13 contracted measles, while among the 48 children who had not been vaccinated 18 contracted measles. The attack rate among vaccinees increased with increasing time since vaccination. The observations of this study as well as those of similar studies suggest that vaccine failures contributed to the genesis of the epidemic. It is recommended that all children initially vaccinated at less than 1 year of age should be revaccinated with live attenuated measles virus vaccine.     

An epidemiologic and immunologic study of measles under conditions of massive immunization against that infection]

Massive measles immunization in Riga led to a marked reduction of measles incidence and to a change of the principal regularities of the epidemic process in this infection. Among those who contracted the disease there was an increase in the percentage of schoolchildren; affection with measles of children attending creches and kindergartens and the intensity of the spread of the infection in them diminished. Selective examination of the immunological efficacy of the living measles vaccine prepared of the (see article) and applied in 1967--1972 demonstrated the presence of specific stimulation of the antibody formation in about 90% of the persons vaccinated. The intensity of humoral immunity in the persons vaccinated did not diminish with the advance of time after the vaccination, and 6--7 years after the vaccination over 90% of the vaccinated individuals were reliably protected from measles. The presence of numerous negative results in carrying out the vaccinations in individual institutions is apparently attributed chiefly to disturbances of the storage regimen of transportation and of the use of the vaccine.     

Revaccination of children during school-based measles outbreaks: potential impact of a new policy recommendation.

OBJECTIVE: To evaluate the potential impact of revaccination on measles outbreak control during school-based epidemics. DESIGN: Retrospective cohort study. SETTING: Thirty-two public elementary and high schools in 14 communities on the west island of Montreal. PARTICIPANTS: All 19,439 children attending these schools during the 1989 measles epidemic in Quebec. INTERVENTION: After notification of a case children with provider-verified records of vaccination on or after their first birthday were identified; the remaining children were vaccinated or excluded from school. OUTCOME MEASURE: Clinical or confirmed measles cases not prevented by this intervention that could have been prevented had revaccination been included during the outbreak. RESULTS: Of the 88 measles cases (74 confirmed) proof of one adequate vaccination was present in 48 (55%). Intervention generally occurred within 5 school days after case notification. The nonpreventable cases involved 75 children who had measles onset before the intervention and 11 (7 vaccinated) who had onset within 8 days after the intervention. The two remaining cases occurred 20 and 25 days after the intervention among nonvaccinated students who refused to be vaccinated. Except for these two cases measles was eliminated at every school. Application of the new Canadian guidelines for measles outbreak control would have required the administration of at least 10,000 additional doses during the outbreak to students vaccinated before 1980; implementation of the new US guidelines would have required the administration of 16,629 additional doses to children previously vaccinated only once. Well-enforced provincial regulations ensuring vaccination of every student upon school entry might have prevented 38 (43%) of the cases. The US recommendation of two routine doses of vaccine before school entry might have prevented 86 (98%) of the cases. However, revaccination during the outbreak would not have prevented a single additional case. CONCLUSION: Revaccination of previously vaccinated students during a measles outbreak would have been costly and of little benefit.     

Association between Birth Order and Emergency Room Visits and Acute Hospital Admissions following Pediatric Vaccination: A Self-Controlled Study

Objective

We investigated the association between a child''s birth order and emergency room (ER) visits and hospital admissions following 2-,4-,6- and 12-month pediatric vaccinations.

Methods

We included all children born in Ontario between April 1^st, 2006 and March 31^st, 2009 who received a qualifying vaccination. We identified vaccinations, ER visits and admissions using health administrative data housed at the Institute for Clinical Evaluative Sciences. We used the self-controlled case series design to compare the relative incidence (RI) of events among 1^st-born and later-born children using relative incidence ratios (RIR).

Results

For the 2-month vaccination, the RIR for 1^st-borns versus later-born children was 1.37 (95% CI: 1.19–1.57), which translates to 112 additional events/100,000 vaccinated. For the 4-month vaccination, the RIR for 1^st-borns vs. later-borns was 1.70 (95% CI: 1.45–1.99), representing 157 additional events/100,000 vaccinated. At 6 months, the RIR for 1^st vs. later-borns was 1.27 (95% CI: 1.09–1.48), or 77 excess events/100,000 vaccinated. At the 12-month vaccination, the RIR was 1.11 (95% CI: 1.02–1.21), or 249 excess events/100,000 vaccinated.

Conclusions

Birth order is associated with increased incidence of ER visits and hospitalizations following vaccination in infancy. 1^st-born children had significantly higher relative incidence of events compared to later-born children.     

Immunization with Live Measles Virus Vaccine

One hundred and fifty children who had no measurable serum measles antibody were vaccinated with live measles virus. All showed post-vaccinal serum antibody levels generally considered sufficient to prevent measles.One hundred and thirty-nine (93%) of the infants and children demonstrated one or more symptoms following vaccination. In view of their generally mild and limited nature, and of the protection subsequently afforded, this procedure would seem to be a real advance in preventive medicine.     

Swedish experience of two dose vaccination programme aiming at eliminating measles,mumps, and rubella.

In 1982 a two dose regimen was introduced in Sweden for the combined vaccination against measles, mumps, and rubella of children aged 18 months and 12 years. Since 1977 about half of the preschool children were vaccinated against measles annually, and since 1974 about 80% of 12 year old girls were vaccinated against rubella. During the period 1982 to 1985 90-93% of the eligible age cohorts of 18 month old children and 88-91% of the 12 year old children were immunised with the new combined vaccine. A study in 1982 of about 140 18 month old children who were nearly all seronegative before vaccination showed that 96%, 92%, and 99% seroconverted against measles, mumps, and rubella, respectively. A second study was carried out in 1983 of 247 12 year old children, of whom 11% lacked antibodies to measles, 27% to mumps, and 45% to rubella. This showed seroconversion in 82% and 80% against measles and mumps, respectively, and all children seroconverted against rubella. In the latest study in 1985 of 496 12 year olds 9% and 13% were seronegative against measles and mumps before vaccination, and 41% against rubella. Of these, 88% seroconverted to measles and 80% to mumps, and all converted to rubella when sera were tested by the haemolysis in gel method. After a neutralisation test against measles as well all children showed immunity to the disease. A low incidence of measles and declining figures for mumps and rubella were reported in 1984 to 1986. An outbreak of rubella during 1985 affected mainly boys in age cohorts in which only the girls had been vaccinated during the 1970s.     

Association between type 1 diabetes and Haemophilus influenzae type b vaccination: birth cohort study

ObjectivesTo determine the effect of Haemophilus influenzae type b vaccination and its timing on the risk of type 1 diabetes in Finnish children.DesignCumulative incidence and relative risk of type 1 diabetes was compared among three birth cohorts of Finnish children: those born during the 24 months before the H influenzae type b vaccination trial, those in the trial cohort who were vaccinated at 3 months of age and later with a booster vaccine, and those in the trial cohort who were vaccinated at 24 months of age only. The probability of type 1 diabetes was estimated using regression analysis assuming that there were no losses to 10 year follow up and no competing risks.SettingFinland (total population 5 million and annual birth rate 1.3%).Subjects128 936 children born from 1 October 1983 to 1 September 1985, and 116 352 children born from 1 October 1985 to 31 August 1987.ResultsNo statistically significant difference was found at any time during the 10 year follow up in the risk of type 1 diabetes between the children born before the vaccination period and those vaccinated at the age of 24 months only (relative risk 1.01). The difference in the risk between the cohort vaccinated first at the age of 3 months and the cohort vaccinated at the age of 24 months only was not statistically significant either (1.06).ConclusionIt is unlikely that H influenzae type b vaccination or its timing cause type 1 diabetes in children.

Key messages

• The gradual increase in vaccination programmes does not permit any particular one to be pinpointed as being responsible for the increase in type 1 diabetes in Finland
• There is no difference in the risk of type 1 diabetes between children not vaccinated against H influenzae type b and those vaccinated at the age of 24 months only
• The difference in risk between children vaccinated against H influenzae type b at the age of 3 months and those vaccinated at the age of 24 months was not statistically significant
• It is very unlikely that H influenzae type b vaccination or its timing causes type 1 diabetes in Finnish children

     

Evaluation of the eight-year period of compulsory measles vaccination in the Czech Socialist Republic (CSR)

The object of the study is the evaluation of a more than 8-year period of compulsory vaccination against measles in the CSR. So far, a total of 1,850,000 children have been vaccinated. A pronounced decrease has been achieved in morbidity while mortality and lethality reached zero values as early as in 1973. Changes occur in the epidemiological characteristic of measles manifested primarily by the shift of the age distribution of notified cases into older age groups, by continuous prolongation of interepidemic intervals and by gradual disappearances of typical seasonal incidence. Regular immunological surveys have become the most efficient tools in epidemiological surveillance of this infection and in monitoring the vaccination programme. The results of immunological surveys indeed led to the introduction in 1975 of so-called second vaccination compulsory for children starting the first year of school attendance. Up to the present, a total of 24,000 cases of measles have been recorded in children vaccinated earlier, i.e., 1.5% of the total of vaccinated children. It can be expected that measles as a mass disease will be eliminated from the territory of the CSR in the next few years.     

Epidemic of mumps in a partially immune population.

The incidence of mumps in vaccinated and nonvaccinated schoolchildren was studied after a recent epidemic. Information was collected by telephone interviews with the parents and a review of the physicians'' records. The vaccine appeared to be effective, for the incidence of mumps in the 145 vaccinated children--5.5%, or 8 cases--was significantly less (P less than 0.001) than the incidence in the 350 children considered susceptible to infection--21.7%, or 76 cases. The percentage of children who had been immunized decreased with increasing age, and acquisition of immunity through natural infection had the reverse trend; thus, the proportions of children susceptible to infection in each age group were about the same, and the age-specific attack rates were similar. Although the mothers were accurate in indicating absence of vaccination, they incorrectly indicated vaccination of their children 43.0% of the time; this error in reporting could influence vaccine administration in older children. Our findings suggest that mumps vaccination may substitute for natural illness in immunizing populations, and that more extensive use of the vaccine over a broader age range is required to prevent similar epidemics in the future.     

Transitions from injection-drug-use-concentrated to self-sustaining heterosexual HIV epidemics: patterns in the international data

Background

Injecting drug use continues to be a primary driver of HIV epidemics in many parts of the world. Many people who inject drugs (PWID) are sexually active, so it is possible that high-seroprevalence HIV epidemics among PWID may initiate self-sustaining heterosexual transmission epidemics.

Methods

Fourteen countries that had experienced high seroprevalence (<20%) HIV epidemics among PWID and had reliable data for injection drug use (IDU) and heterosexual cases of HIV or AIDS were identified. Graphs of newly reported HIV or AIDS cases among PWID and heterosexuals were constructed to identify temporal relationships between the two types of epidemics. The year in which newly reported cases among heterosexuals surpassed newly reported cases among PWID, aspects of the epidemic curves, and epidemic case histories were analyzed to assess whether it was “plausible” or “highly unlikely” that the HIV epidemic among PWID might have initiated the heterosexual epidemic in each country.

Results

Transitions have occurred in 11 of the 14 countries. Two types of temporal relationships between IDU and heterosexual HIV epidemics were identified, rapid high incidence transitions vs. delayed, low incidence transitions. In six countries it appears “plausible” that the IDU epidemic initiated a heterosexual epidemic, and in five countries it appears “highly unlikely” that the IDU epidemic initiated a heterosexual epidemic. A rapid decline in incidence among PWID after the peak year of new cases and national income were the best predictors of the “highly unlikely” initiation of a heterosexual epidemic.

Discussion

Transitions from IDU concentrated epidemics to heterosexual epidemics are common in countries with high seroprevalence among PWID though there are distinct types of transitions. Interventions to immediately reduce HIV incidence among PWID may reduce the likelihood that an IDU epidemic may initiate a heterosexual epidemic.     

Cyclical Patterns of Hand,Foot and Mouth Disease Caused by Enterovirus A71 in Malaysia

Enterovirus A71 (EV-A71) is an important emerging pathogen causing large epidemics of hand, foot and mouth disease (HFMD) in children. In Malaysia, since the first EV-A71 epidemic in 1997, recurrent cyclical epidemics have occurred every 2–3 years for reasons that remain unclear. We hypothesize that this cyclical pattern is due to changes in population immunity in children (measured as seroprevalence). Neutralizing antibody titers against EV-A71 were measured in 2,141 residual serum samples collected from children ≤12 years old between 1995 and 2012 to determine the seroprevalence of EV-A71. Reported national HFMD incidence was highest in children <2 years, and decreased with age; in support of this, EV-A71 seroprevalence was significantly associated with age, indicating greater susceptibility in younger children. EV-A71 epidemics are also characterized by peaks of increased genetic diversity, often with genotype changes. Cross-sectional time series analysis was used to model the association between EV-A71 epidemic periods and EV-A71 seroprevalence adjusting for age and climatic variables (temperature, rainfall, rain days and ultraviolet radiance). A 10% increase in absolute monthly EV-A71 seroprevalence was associated with a 45% higher odds of an epidemic (adjusted odds ratio, aOR1.45; 95% CI 1.24–1.69; P<0.001). Every 10% decrease in seroprevalence between preceding and current months was associated with a 16% higher odds of an epidemic (aOR = 1.16; CI 1.01–1.34 P<0.034). In summary, the 2–3 year cyclical pattern of EV-A71 epidemics in Malaysia is mainly due to the fall of population immunity accompanying the accumulation of susceptible children between epidemics. This study will impact the future planning, timing and target populations for vaccine programs.     

Seroprevalence of measles-, mumps- and rubella-specific IgG antibodies in german children and adolescents and predictors for seronegativity

We have undertaken a seroprevalence study with more than 13,000 children, who had been included in the German KIGGS survey, a representative sample of children and adolescents 0-17 years of age. The IgG titres against measles, mumps and rubella were determined in 1 to 17 year olds While 88.8% of the children were MMR-vaccinated at least once, 76.8% of children aged 1 to 17 years showed prevalence of antibodies to MMR. The highest seronegativity was seen with respect to mumps. Gender differences were most pronounced with regard to rubella IgG titres: girls aged 14 to 17 years were best protected, although seronegativity in 6.8% of this vulnerable group still shows the need of improvement. Search for predictors of missing seroprevalence identified young age to be the most important predictor. Children living in the former West and children born outside of Germany had a higher risk of lacking protection against measles and rubella, while children with a migration background but born in Germany were less often seronegative to measles antibodies than their German contemporaries. An association of seronegativity and early vaccination was seen for measles but not for mumps and rubella. A high maternal educational level was associated with seronegativity to measles and rubella. In vaccinated children, seronegativity was highest for mumps and lowest for rubella. For mumps, high differences were observed for seronegativity after one-dose and two-dose vaccination, respectively. Seronegativity increases as time since last vaccination passes thus indicating significant waning effects for all three components of MMR.     

Epidemiology of the Hong Kong/68 Variant of Influenza A2 in Britain

Two influenza epidemics in Britain in 1968-9 and 1969-70, were due to the Hong Kong/68 variant of influenza A2 virus. The first epidemic was prolonged with low morbidity and mortality rates; the second was sharp with high rates. The difference between total morbidity and mortality in the two epidemics, however, was less than it appeared to be—the estimated excess morbidity and mortality due to all causes in 1969-70 was only about 50% greater than in 1968-9.Antibody studies showed that about one-quarter of two groups of adults investigated were infected in the first epidemic and about one-third in the second. After the two epidemics about one-third still had no antibody to the A2/Hong Kong/68 virus.     

Drought and child vaccination coverage in 22 countries in sub-Saharan Africa: A retrospective analysis of national survey data from 2011 to 2019

BackgroundExtreme weather events, including droughts, are expected to increase in parts of sub-Saharan Africa and are associated with a number of poor health outcomes; however, to the best of our knowledge, the link between drought and childhood vaccination remains unknown. The objective of this study was to evaluate the relationship between drought and vaccination coverage.Methods and findingsWe investigated the association between drought and vaccination coverage using a retrospective analysis of Demographic and Health Surveys data in 22 sub-Saharan African countries among 137,379 children (50.4% male) born from 2011 to 2019. Drought was defined as an established binary variable of annual rainfall less than or equal to the 15th percentile relative to the 29 previous years, using data from Climate Hazards Group InfraRed Precipitation with Station (CHIRPS) data. We evaluated the association between drought at the date of birth and receipt of bacillus Calmette–Guérin (BCG), diphtheria–pertussis–tetanus (DPT), and polio vaccinations, and the association between drought at 12 months of age and receipt of measles vaccination. We specified logistic regression models with survey fixed effects and standard errors clustered at the enumeration area level, adjusting for child-, mother-, and household-level covariates and estimated marginal risk differences (RDs). The prevalence of drought at date of birth in the sample was 11.8%. Vaccination rates for each vaccination ranged from 70.6% (for 3 doses of the polio vaccine) to 86.0% (for BCG vaccination); however, only 57.6% of children 12 months and older received all recommended doses of BCG, DPT, polio, and measles vaccinations. In adjusted models, drought at date of birth was negatively associated with BCG vaccination (marginal RD = −1.5; 95% CI −2.2, −0.9), DPT vaccination (marginal RD = −1.4; 95% CI −2.2, −0.5), and polio vaccination (marginal RD = −1.3; 95% CI −2.3, −0.3). Drought at 12 months was negatively associated with measles vaccination (marginal RD = −1.9; 95% CI −2.8, −0.9). We found a dose–response relationship between drought and DPT and polio vaccinations, with the strongest associations closest to the timing of drought. Limitations include some heterogeneity in findings across countries.ConclusionsIn this study, we observed that drought was associated with lower odds of completion of childhood BCG, DPT, and polio vaccinations. These findings indicate that drought may hinder vaccination coverage, one of the most important interventions to prevent infections among children. This work adds to a growing body of literature suggesting that health programs should consider impacts of severe weather in their programming.

Jason M. Nagata and colleagues investigate the association between drought and child vaccination coverage in 22 countries in sub-Saharan Africa, using Demographic and Health Survey data from 2011 to 2019.     

Implementation of a National Measles Elimination Program in Iran: Phylogenetic Analysis of Measles Virus Strains Isolated during 2010–2012 Outbreaks

Measles virus (MV) causes small and large outbreaks in Iran. Molecular assays allow identifying and the sources of measles imported from neighboring countries. We carried out a phylogenetic analysis of measles virus circulating in Iran over the period 2010–2012. Specimens from suspected cases of measles were collected from different regions of Iran. Virus isolation was performed on urine and throat swabs. Partial nucleoprotein gene segments of MV were amplified by RT-PCR. PCR products of 173 samples were sequenced and analyzed. The median age of confirmed cases was 2 years. Among all confirmed cases, 32% had unknown vaccination status, 20% had been vaccinated, and 48% had not been vaccinated. Genotypes B3 and D8 (for the first time), H1 and D4 were detected mainly in unvaccinated toddlers and young children. Genotype B3 became predominant in 2012 and was closely related to African strains. H1 strains were also found in small and large outbreaks during 2012 but were not identical to Iranian H1-2009 strains. A majority of the Iranian D4 strains during 2010–2012 outbreaks were linked to the D4 strain identified in the Pakistan in 2007. We identified a single case in 2010 belonging to D8 genotype with 99.7% identity to Indian isolates. Although the vaccination program is currently good enough to prevent nationwide epidemics and successfully decreased measles incidence in Iran, the fraction of protected individuals in the population was not high enough to prevent continuous introduction of cases from abroad. Due to increasing number of susceptible individuals in some areas, sustained transmission of the newly introduced viral genotype remains possible.     

Acute Measles Encephalitis in Partially Vaccinated Adults

Background

The pathogenesis of acute measles encephalitis (AME) is poorly understood. Treatment with immune-modulators is based on theories that post-infectious autoimmune responses cause demyelination. The clinical course and immunological parameters of AME were examined during an outbreak in Vietnam.

Methods and Findings

Fifteen measles IgM-positive patients with confusion or Glasgow Coma Scale (GCS) score below 13, and thirteen with uncomplicated measles were enrolled from 2008–2010. Standardized clinical exams were performed and blood collected for lymphocyte and measles- and auto-antibody analysis. The median age of AME patients was 21 years, similar to controls. Eleven reported receiving measles vaccination when aged one year. Confusion developed a median of 4 days after rash. Six patients had GCS <8 and four required mechanical ventilation. CSF showed pleocytosis (64%) and proteinorrhachia (71%) but measles virus RNA was not detected. MRI revealed bilateral lesions in the cerebellum and brain stem in some patients. Most received dexamethasone +/− IVIG within 4 days of admission but symptoms persisted for ≥3 weeks in five. The concentration of voltage gated calcium channel-complex-reactive antibodies was 900 pM in one patient, and declined to 609 pM ∼ 3 months later. Measles-reactive IgG antibody avidity was high in AME patients born after vaccine coverage exceeded 50% (∼ 25 years earlier). AME patients had low CD4 (218/µl, p = 0.029) and CD8 (200/µl, p = 0.012) T-cell counts compared to controls.

Conclusion

Young adults presenting with AME in Vietnam reported a history of one prior measles immunization, and those aged <25 years had high measles-reactive IgG avidity indicative of prior vaccination. This suggests that one-dose measles immunization is not sufficient to prevent AME in young adults and reinforces the importance of maintaining high coverage with a two-dose measles immunization schedule. Treatment with corticosteroids and IVIG is common practice, and should be assessed in randomized clinical trials.     

Vaccination coverage in hard to reach Roma children in Slovenia

The results of the retrospective analysis of data on vaccination coverage in the preschool-aged and school-aged Roma children (436 preschool and 551 schoolchildren) in three geographical regions of Slovenia were analyzed to establish the differences concerning coverage for specific vaccinations: poliomyelitis, diphtheria, tetanus, pertussis, measles, mumps and rubella between the two generation. The data were obtained from health records, immunization records (Vaccination booklet) and National Computerized Immunization System (CEPI 2000). Vaccination coverage was calculated by comparing the number of children eligible for immunization with the number of vaccinated children. This article performs the log-rank statistical test, also known as the Mantel-Haenszel test. Log rang test is comparing survival curves for two generations. Preschool-aged Roma children showed higher vaccination coverage than the school-aged Roma generation. There was no significance difference in the generations of preschool aged and school aged Roma children fully vaccinated against poliomyelitis, diphtheria, tetanus and pertussis. Rubella vaccination was significantly lower in the school aged Roma generation. Only 33% of school aged Roma population received two doses of measles, mumps and rubella vaccine. Vaccination coverage of preschool Roma children in Slovenia against poliomyelitis, diphtheria, tetanus, pertussis and MMR (measles, mumps, rubella) were significantly lower then the national vaccination coverage for preschool aged Slovenia children. Many joint efforts will have to be made to improve the vaccination coverage in Roma communities.     

Measles: who pays the cost?

An epidemic of measles resulting in 164 cases in a Leicester group practice was analysed by means of a case-control study and a questionnaire. Estimates were made of the physical, social, and financial costs to children, parents, and family doctors. On average each child was ill for 10.8 days and the illness cost his parents pounds 11.06. His family doctor spent 26 minutes providing care. These results provide an additional stimulus to the primary care team to promote the uptake of measles vaccination.