Rare measles case warrants caution

To vaccinate immunosuppressed not prudent

Reporting the unusual death of a severely immunocompromised HIV patient due to administration of the measles-mumps-rubella (MMR) vaccine, the Centers for Disease Control and Prevention in Atlanta, is advising caution in administering the vaccine in such situations.1 The CDC Advisory Committee on Immunization Practices (ACIP) continues to recommend that MMR be considered for all asymptomatic HIV-infected persons who would otherwise be eligible for measles vaccine, however, because measles virus infection can cause severe illness and death in such people.

Severely immunocompromised HIV-infected patients who are exposed to measles should receive immune globulin (IG), regardless of prior vaccination status. Because of the case and other evidence indicating a diminished antibody response to measles vaccination among severely immunocompromised persons, ACIP is re-evaluating recommendations for vaccination of severely immunocompromised persons with HIV infection. In the interim, it may be prudent to withhold MMR or other measles-containing vaccines from HIV-infected persons with evidence of severe immunosuppression.

In addition, health care providers should weigh the risks and benefits of measles vaccination or IG prophylaxis for severely immunocompromised HIV-infected patients who are at risk for measles exposure because of outbreaks or international travel. Because the immunologic response to both live and killed antigen vaccines may decrease as HIV disease progresses, vaccination early in the course of HIV infection may be more likely to induce an immune response. Therefore, HIV-infected infants without severe immunosuppression should routinely receive MMR as soon as possible after their first birthday. Evaluation and testing of asymptomatic persons to identify HIV infection are not necessary before deciding to administer MMR or other measles-containing vaccine.

The CDC reported a fatal case of progressive vaccine-associated measles pneumonitis in a 20-year-old, HIV-infected man who received MMR to fulfill a college vaccination requirement. His CD4+ T-lymphocyte count was reported as "too few to enumerate," but at the time of vaccination, he did not have HIV-related symptoms and was not taking antiretroviral therapy or prophylactic treatment for Pneumocystis carinii pneumonia (PCP). The patient had continuing complications over the next year and eventually died. The measles virus was identified from tissue-culture cells inoculated with the lung biopsy tissue, and a match was eventually made with the vaccine virus.

"This report is the first known case of a serious adverse event following the documented administration of a measles-containing vaccine to a severely immunocompromised person with HIV infection," the CDC noted. "The case described in this report also is unusual because the patient did not have clinical onset of measles pneumonitis until almost one year after vaccination -- a finding also not previously reported."

Reference

1. Centers for Disease Control and Prevention. Measles pneumonitis following measles-mumps-rubella vaccination of a patent with HIV infection, 1993. MMWR 1996; 45:603-606. *