Tag: titer testing

How Could Seven of My Vaccinated Kids Have the Measles Right Now?

Seven vaccinated kids with measles?!?

But doesn’t the measles rash typically show up after three to five days of fever?

Wait, that couldn’t really happen, could it? Seven vaccinated kids with measles in one family?

How Could Seven of My Vaccinated Kids Have the Measles Right Now?

While anything is possible, this story is very improbable once you look at the details…

“When her 12-year-old son spiked a fever and started complaining of a sore throat right before Passover, Mrs. Pearl (not her real name) wasn’t worried. She confidently crossed off a host of possible infections that he was fully vaccinated for.

She thought he had strep throat, like two of his siblings.

They headed to urgent care for a rapid strep test, but the result was negative. Undeterred, she put her son on antibiotics at the nurse’s recommendation, and sent her son to bed.

He’d worsened by morning.

He woke feeling feverish and broken out in a rash.”

Jennifer Margulis

Could that be measles?

He ended up testing positive for measles, even though he was fully vaccinated. Only two days of fever before he developed his rash though, and no word that the fever continued, as you would expect with measles…

“Not long after, Mrs. Pearl’s 10-year-old broke out in a similar rash.

This child didn’t spike a fever but his breathing was labored and he complained that his eyes hurt.

He also tested positive for the measles.”

Jennifer Margulis

Although they all could have been exposed to someone else, it is important to note that the incubation period for measles is 7 to 14 days. The “not long after” scenario sounds like too short a time to get “measles” from his brother. Also, no fever, which would be very strange for measles…

But the other five kids had more classic symptoms of measles, right?

Nope.

“Of the seven other children that Mrs. Pearl had tested—all of whom had been fully vaccinated—five more showed no immunity to measles.”

Jennifer Margulis

What about the negative titer tests?

That’s actually not unusual after measles vaccination. It’s not proof or any kind of indication that the vaccine didn’t work. It has been long known that most vaccinated people who have negative measles titers will show an anamnestic immune response if they get another dose of MMR.

What does that mean? It means that they were likely immune, even with the negative titer.

“In the event that a HCP who has 2 documented doses of MMR vaccine is tested serologically and determined to have negative or equivocal measles titer results, it is not recommended that the person receive an additional dose of MMR vaccine. Such persons should be considered to have presumptive evidence of measles immunity. Documented age-appropriate vaccination supersedes the results of subsequent serologic testing.”

Immunization of Health-Care Personnel: Recommendations of the Advisory Committee on Immunization Practices

In fact, we don’t routinely check titers after MMR, at least not for measles.

And their symptoms?

“Two hours after getting the MMR booster, Mrs. Pearl’s 16-year-old spiked a 102-degree fever and broke out in a measles rash.

Four days later her three other children, all of whom had received the MMR booster, all had measles rashes, canker sores in their mouths, gastrointestinal problems, and lethargy.”

Jennifer Margulis

Canker sores with measles? Kids with measles get Koplik spots, but no one describes them as canker sores.

Fever and a rash developing at the same time?

Yeah, none of that sounds like measles. At all.

Remember, the classic symptoms of measles include 3 to 5 days of a high fever with cough, coryza, and conjunctivitis, followed by a rash, with continued fever.

“According to Mrs. Pearl, the health department official also told her that measles vaccine failure is common and that about half the people getting measles in the current measles clusters in Brooklyn are fully vaccinated.”

Jennifer Margulis

Actually, only 27 of the 566 people in Brooklyn with measles have been known to be fully vaccinated, with two doses of MMR. How much less than half is that? It is less than 5% of cases.

Measles vaccine failure is not common at all.

Why Did They Say That Seven of My Vaccinated Kids Have Measles?

So how do you explain what happened to this family?

Besides the likelihood that they had another, more common virus causing their symptoms? With mouth ulcers and diarrhea, like maybe Coxsackie virus?

Do you really need another explanation?

How do you explain the positive measles tests?

They were almost certainly a false positive.

“The test kits in use have been shown to have high sensitivity and specificity. However, cross-reactions with other viral diseases, e.g. rubella and Parvovirus, may occur.”

Dietz et al on The laboratory confirmation of suspected measles cases in settings of low measles transmission: conclusions from the experience in the Americas.

They didn’t state which test was done, but it is important to note that several are available. This includes an immunoglobulin test, PCR from a throat swab, and PCR from a urine specimen. The most accurate testing is done by the CDC.

“Detection of specific IgM antibodies in a serum sample collected within the first few days of rash onset can provide presumptive evidence of a current or recent measles virus infection. However, because no assay is 100% specific, serologic testing of non-measles cases using any assay will occasionally produce false positive IgM results.”

Serologic Testing for Measles in Low Prevalence Setting

Did they have confirmatory tests, after their initial positive test? Were they done at a state lab? Did all of her other kids test positive for measles?

“She’s angry at the measles vaccine failure and worried about her family members, especially her pregnant daughter.”

Jennifer Margulis

She should be angry at folks pushing misininformation in her community.

“I used to think people who don’t vaccinate were crazy,” Mrs. Pearl says. “Now I’m not so sure. Maybe they’re right. Maybe my body doesn’t want to take garbage. Something is a red flag. After my story, I’m not so sure where the measles started. I’m legit. I did vaccinate. All my kids are up to date. Children ages 22 to 7 all getting the measles?”

Jennifer Margulis

Something is indeed a red flag. To get to the bottom of it, Mrs. Pearl should revisit the idea that her kids really had measles.

More on Vaccinated Kids with Measles

Do You Need Another Dose of the MMR Vaccine?

The measles outbreaks have a lot of people concerned about measles.

And that means measles and vaccines are getting a lot of extra attention.

Unfortunately, getting extra attention doesn’t always translate into getting great advice, especially when it is leading a lot of folks into thinking they need to rush out and get another dose of MMR or to check their titers to make sure they are protected.

Do You Need Another Dose of the MMR Vaccine?

So are you protected against measles?

Have you had two doses of MMR? (Remember, kids typically get their first dose at age 12-15 months and a second dose when they are 4-6 years old, with early doses in high-risk situations.)

If you have documentation of two doses of MMR (or a measles containing vaccine), then you can confidently say that you are protected. No, it’s not 100% protection, but it’s close.

“Documented age-appropriate vaccination supersedes the results of subsequent serologic testing. If a person who has 2 documented doses of measles- or mumps-containing vaccines is tested serologically and is determined to have negative or equivocal measles or mumps titer results, it is not recommended that the person receive an additional dose of MMR vaccine. Such persons should be considered to have presumptive evidence of immunity.”

Prevention of Measles, Rubella, Congenital Rubella Syndrome, and Mumps, 2013: Summary Recommendations of the Advisory Committee on Immunization Practices (ACIP)

If you haven’t had two doses of MMR, then know that two doses are your best protection against measles.

Have you heard that people born before 1989 may need another dose?

What is the significance of the year 1989?

The recommendation to give a routine second dose of MMR started in 1990, so folks born much before then likely only had one dose, unless they were considered high risk and had the second dose before traveling out of the country, starting a healthcare job, or going to college, etc.

Instead of 1989, the typical cutoff year for protection is around 1986, since those kids would have been turning four years old in 1990, so would have gotten their second dose of MMR on schedule. If you were born before 1986, you would have started kindergarten before the recommendation to get a second dose.

The other years that are important are 1963 to 1967, as that’s when the very first measles vaccine was used, a vaccine that was later found to not be very effective. If that is the only time you were vaccinated, then you should be vaccinated again.

What about 1957?

In general, if you were born before 1957, we assume that you had measles because most people had measles back then. Maybe you didn’t though, so in a high-risk situation, like traveling out of the country or in the middle of an outbreak, this could be a good situation to check your measles titer to confirm that you are immune. If you aren’t, then get two doses of MMR.

How many doses of MMR have you had?
How many doses of MMR have you had?

So here are your scenarios:

  • Were you born before 1957? Then you probably had measles, but can check your titers to make sure you are immune, especially if you will be in a high-risk situation, like near an outbreak or traveling.
  • Did you get a dose of measles vaccine between 1963 and 1967? If this was your only dose, then you should get a dose of MMR now.
  • Did you get a measles vaccine between 1968 and 1971, before the MMR became available? That counts as a dose of measles containing vaccine. If that is your only dose, then you might get another dose of MMR, if you will be in a high-risk situation, like near an outbreak or traveling.
  • Have you only had only one dose of MMR or other measles containing vaccine, which is more likely if you were born well before 1990? Then get another dose of MMR if you will be in a high-risk situation, like near an outbreak or traveling.
  • Have you had two doses of MMR vaccine or or other measles containing vaccine (and have your immunization records to prove it)? Then you should be protected. You don’t need to check your titers and you don’t need a third dose of MMR.

What if you aren’t sure? Then get at least one more dose of MMR.

If you don’t think that you were ever vaccinated against measles, then you might get two doses of MMR.

If you aren’t sure, but think that you already were vaccinated, then this would be a good situation to check your titer. Be prepared to get your MMR vaccines again if you are negative though.

Do all adults need two doses of MMR?

Surprisingly no, although that is considered the best protection against measles, there was never a general catch up program for older folks with the recommendation to get a second dose in 1990. So if you have had one dose of MMR and aren’t at any extra risk to get measles – no travel, no nearby outbreaks, and not a health professional, etc., then one dose might be enough… for now.

More on MMR Vaccines

What’s the Evidence for Measles Parties?

We know that folks are still having chicken pox parties.

How do we know.

Are they using MeetUp to have chicken pox parties?
Are they using MeetUp to have chicken pox parties?

For one thing, the Governor of Kentucky recently came out as having said he took his kids to one…

What’s the Evidence for Measles Parties?

But measles parties?

That can’t still be a thing, can it?

Until recently, I would have said, “no way!”

I mean, realistically, in most years, there were so few cases that it would have made it hard to find someone to intentionally expose your kid to.

That’s changed recently though.

“In Facebook group discussions, local activists have asked about holding “measles parties” to expose unvaccinated children to others infected with the virus so they can contract the disease and acquire immunity.”

Despite measles outbreak, anti-vaccine activists in Minnesota refuse to back down

As outbreaks get bigger, especially since they are typically concentrated among clusters of unvaccinated children and adults in small communities, the possibility of measles parties become more possible.

They might even be likely when you have anti-vaccine folks encouraging folks to have them!

A case of measles was reported in Indianapolis on March 27…

What about evidence of measles parties in Brooklyn?

Hopefully the The Chanukah Measles Song is someone’s idea of a really sick joke…

The health department, in their press conference, does mention reports of measles parties. And that they think some people may be using the exposures so that their intentionally sick kids will later test positive when titer tests are done.

I hope they aren’t, but who knows…

Literally hoping for a life-threatening disease for your kids? Really?

Unfortunately, there are plenty of people claiming that they would like to intentionally expose their kids to measles. Hopefully they are just folks trying to get attention and wouldn’t really do that to their kids.

Vaccines are safe, with few risks, and necessary. There is no good reason to intentionally expose your kids to a potentially life-threatening disease.

More on Measles Parties

Titers for Vaccine vs Natural Immunity

It probably seems like a silly question, but can titers help you tell the difference between vaccine induced vs natural immunity?

After all, you should know if you had the disease naturally or if you had a vaccine, right?

Titers for Vaccine vs Natural Immunity

Still, there might be situations in which you need to know if someone has immunity and you want to know if it was vaccine induced or if they earned their immunity naturally.

Unfortunately, you typically can’t, especially as most vaccines mimic having a natural infection.

In a few situations, if a vaccine targets a very specific part of a virus or bacteria, it may be able possible to tell the difference between vaccine-induced and natural immunity though.

anti-HBs is positive with natural infections and vaccination, but only anti-HBc is positive after a natural infection.

The hepatitis B vaccine, for example, is derived from HBsAg particles, so won’t induce antibodies against hepatitis B core antigen or other hepatitis B proteins.

Most other vaccines, like MMR and Varicella, aren’t so specific. Titers might just show that you are immune, although titer tests aren’t always sensitive enough to pick up vaccine-induced immunity. That’s why, expect for a few high risk situations, titer testing isn’t usually recommended.

More on Titers for Vaccine vs Natural Immunity