Although the measles vaccine has been part of routine national childhood vaccination programs throughout Europe, measles remains a public health concern. High numbers of cases and outbreaks have occurred throughout the European continent since 2011, and an increasing number of cases have been reported in Turkey since 2012. During a recent measles outbreak in Turkey, 2 pregnant women contracted measles prior to delivering preterm infants at Hacettepe University Hospital. Measles virus genomic RNA and IgM antibodies against measles were detected in the cord blood of infants and mothers in both cases. The infants were treated with intravenous immunoglobulin (IVIG) and vitamin A. Transient thrombocytopenia was present in 1 infant and treated with an additional dose of IVIG and vitamin A. The infants were discharged, without complications, within 10 days of birth. The successful treatment of these cases suggests that infants who have been exposed to, or infected with, measles may benefit from cotreatment of vitamin A and IVIG.
Prior to the introduction of measles vaccination programs, a majority of individuals contracted the measles virus early in childhood and developed lifelong immunity; thus, measles infection during pregnancy was an unusual event. The distribution of infected individuals has shifted to older age groups in the vaccine era, with proportionately more adolescent and young adults affected owing to a lack of complete vaccination coverage as well as primary and secondary vaccine failure. The potential risk for measles infection in women of childbearing age has therefore increased [
At the end of 2011, measles resurged throughout Turkey and further increased during 2012 through May 2013. At the time of this publication, 4,172 cases have been reported, constituting an epidemic. In this case report, we describe 2 preterm infants who contracted measles during this epidemic and their successful treatment with combined IVIG and vitamin A.
Two mothers who had contracted measles during an outbreak gave birth to preterm infants at Hacettepe University Hospital in Ankara, Turkey, in February 2013. We describe both cases and their course of treatment below and in Figure
Clinical follow-up of infants and mothers described in Case 1 (a) and Case 2 (b).
A preterm female infant (weight 2780 g) was delivered by caesarean section at 341/7 weeks, because of fetal distress, from a 38-year-old mother with measles pneumonitis. She was born on the sixth day after her mother’s exanthema necessitated noninvasive ventilation because of severe pneumonia (Figure
Posteroanterior lung radiograph of the mother described in Case 1 on the day of delivery (a) and computed tomography of the thorax on the day after delivery (b).
Cord blood and serum samples were collected from the infant and mother soon after delivery. An enzyme-linked immunosorbent assay (ELISA) indicated the presence of measles-specific IgM and IgG antibodies in the mother. The infant’s serum was positive by ELISA for the presence of measles specific IgM but negative for the presence of IgG antibodies. However, RNA extracted from cord blood mononuclear cells for use in a measles virus-specific reverse transcriptase-PCR assay indicated the presence of measles virus (Table
Laboratory findings of mothers and neonates.
Case | Age | Sample taken (after date of birth) | Platelet count (/ |
ELISA | Cord blood PCR | |
---|---|---|---|---|---|---|
IgG | IgM | |||||
1 | Newborn (preterm, 2780 g, C/S |
Day 1 | 228.000 | (−) | (+) | (+) |
Day 4 | 44.000 | |||||
Day 7 | 273.000 | |||||
|
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1 | Mother 38 years | Day 1 | 305.000 | (+) | (+) | |
|
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2 | Newborn (preterm, 2630 g, VB |
Day 1 | 217.000 | (+) | (+) | (+) |
Day 7 | 295.000 | |||||
|
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2 | Mother 27 years | Day 1 | 208.000 | (+) | (+) |
A preterm female infant (weight 2630 g) was delivered by vaginal route from a 27-year-old mother with measles pneumonitis at 36 weeks, on the fourth day after her mother’s exanthema had disappeared. The mother’s medical history indicated that she had received only 1 dose of the measles vaccine, and the serum obtained 1 month previously was negative by ELISA for antimeasles IgG and IgM. The infant showed no clinical signs of the disease at birth.
Cord blood and serum samples were collected from the infant and mother soon after the delivery and serum specimens were tested for the presence of measles-specific IgM, IgG, and RNA as described above. The infant’s serum was positive by ELISA for both measles-specific IgM and IgG antibodies. Measles-virus-specific RNA extracted from cord blood mononuclear cells was positive as well (Figure
The widespread availability of the 2 dose measles vaccine program has led to a marked decrease in the incidence of measles and resulted in less natural boosting of antibody levels. However, depending on the schedule of immunization, immunity declines in late childhood and adolescence leading to gaps in the immunity of adults. Further, measles outbreaks may occur in susceptible individuals despite widespread childhood vaccination [
Primary protection against infectious diseases at birth is provided mainly by maternal antibodies and several factors determine the amount of maternal antibodies in young infants. The coverage of universal immunization programs influences the amount of maternal antibodies and a higher level of coverage reduces the probability of natural antibody boosting. Infants of vaccinated women were born with significantly fewer antibodies compared to infants of naturally immune women. Because increased childbearing age is directly related to the prolongation of the time between childhood vaccination and childbirth, maternal antibodies are prone to be low. The rate of decay of maternal antibodies after birth determines the duration of protection in infants [
The effect of measles during pregnancy on the fetus has been the focus of several studies. Limited data is available regarding the spectrum of neonatal illness, but it can range from mild to rapidly fatal forms. Early studies have documented adverse fetal outcomes including increased mortality during the first two years of life, and it appears that the mortality rate of congenital measles is higher in preterm than in full-term infants [
The low morbidity of recent cases of congenital measles may reflect the effects of prophylactic immunoglobulin [
In conclusion, the two cases of congenital measles reported here highlight the need to improve immunization strategies for adolescents and young adults, which could decrease the incidence of maternal measles. Additionally, the survival of these preterm infants suggests that cotreatment with vitamin A and IVIG is a successful strategy for vulnerable individuals who have low levels of protective measles antibodies.
The authors declare that there is no conflict of interests regarding the publication of this paper.