Epidemiologic Notes and Reports Measles in HIV-Infected Children, United States

The Centers for Disease Control has received reports of six cases of measles that occurred among children infected with human immunodeficiency virus (HIV) in the United States during the period 1986-1987 (Table 1). Two of these children died from measles. Like many other infections, measles appears to be more severe in persons with HIV infection.

Patients 1-3 became ill during a nosocomial outbreak in a New York City hospital (1). These patients had acquired HIV infections perinatally. None had received measles vaccine nor were they receiving intravenous immune globulin (IGIV). All were assumed to have had a common source of exposure to measles in the hospital, but the source was never identified. A medical student, who probably acquired disease from the same source, developed a rash several days before the children did. The medical student, whose rash illness was initially thought to be varicella because she recently had been exposed to a patient with varicella, had contact with the HIV-infected patients. Consequently, Patient 2 received varicella- zoster immune globulin (VZIG), and Patient 1 received intramuscular immune globulin (IG). Both patients developed measles within several days of globulin administration and thus may have received globulins more than 6 days after exposure. Patient 1, a 7-month-old with HIV class P-0 infection (indeterminant), and Patient 3, a 4-year-old with HIV class P-2, subclass D-1 infection (cryptosporidiosis) (2), had typical measles illnesses with cough, coryza, conjunctivitis, Koplik spots, and rash. Patient 1 had a measles hemagglutination-inhibition (HI) antibody titer of 10 on the first day of rash (due either to residual, passively transferred maternal antibody or to passive immunization). Patient 2, a 2-year-old with HIV class P-2, subclass D-2 infection (recurrent bacterial infections), had only a transient rash and Koplik spots. Both Patients 2 and 3 developed severe pneumonia and were treated with aerosolized ribavirin (4). Patient 3 died, and autopsy showed diffuse giant-cell pneumonia typical of measles infection consisting of multinucleate giant cells with nuclear and cytoplasmic inclusions (5).

Patient 4, a 2-year-old with perinatally acquired HIV infection, had HIV class P2, subclass A infection (hepatosplenomegaly, generalized lymphadenopathy, and her- pes stomatitis) at the time of onset of measles. She acquired measles during hospitalization at a different hospital in New York City. The source of her infection was not determined. This patient had never been vaccinated against measles and was not receiving IGIV. She developed generalized rash, fever, coryza, conjunctivitis, Koplik spots, and otitis media but no other complications.

Patient 5, a 4-year-old child with perinatally acquired HIV class P-2, subclass C infection (lymphoid interstitial pneumonitis), was admitted with fever and pneumonia to a hospital in Miami, Florida. The patient had never been vaccinated against measles but was receiving IGIV (200 mg/kg) prophylactically every month. The last dose had been received 3 weeks before onset of illness. Her measles antibody titer at the time of onset of illness is not known. The patient developed respiratory failure and died 8 days after admission. There was no history of rash. The diagnosis of measles pneumonia was made on postmortem examination of lung tissue that showed multinucleate giant cells with nuclear and cytoplasmic inclusions. This patient was not isolated during her hospitalization, and nosocomial transmission of measles resulted: a pediatric nurse and a patient, neither of whom had been vaccinated, acquired measles from the child. One additional patient acquired infection from the nurse.

Patient 6, a 14-year-old with HIV Group IV infection (thrombocytopenia) (3), had acquired HIV as a result of a blood transfusion. He had been immunized with live, attenuated measles vaccine at 15 months and again at 9 years of age. The patient was admitted to a hospital with fever and later developed rash and pneumonia. Measles was serologically confirmed. The patient was treated with aerosolized ribavirin and recovered without sequelae. Reported by: K Krasinski, MD, W Borkowsky, MD, S Chandwani, MD, R Lawrence, MD, New York Univ Medical Center-Bellevue Hospital Center; S Friedman, MD, MPH, New York City Dept of Health; DL Morse, MD, MS, State Epidemiologist, New York State Dept of Health. C Mitchell, MD, G Scott, MD, K Roach, E Roldan, MD, M Saldana, MD, Jackson Memorial Hospital, Miami; MH Wilder, MD, State Epidemiologist, Florida Dept of Health and Rehabilitative Svcs. AIDS Program, Center for Infectious Diseases; Div of Immunization, Center for Prevention Svcs, CDC. Editorial Note: In addition to these six measles cases in children with HIV infection, CDC has received reports of two measles cases in HIV-infected adults. Both survived the acute measles infection, although one was hospitalized. The two measles deaths involving HIV-infected children in 1987 were the first deaths due to measles in the United States to be reported to CDC since 1985. While there may be underreporting of nonhospitalized or nonfatal measles cases in persons with HIV infection, the case-fatality rate for measles in HIV-infected children is clearly higher than the case-fatality rate for measles in recent years in the United States, 0.1% (6).

Severe measles infections have been reported in other immunocompromised patients. Measles infection without rash has also been described (7). Physicians caring for patients with HIV infection should be aware that measles can be severe and may occur without the typical rash. This may preclude diagnosis and, thus, delay or prevent initiation of treatment, outbreak control measures, or appropriate hospital isolation. The fact that an unimmunized medical worker acquired measles from one of these cases and was involved in transmission to a hospitalized patient is note- worthy. In addition, five of the six measles cases in HIV-infected children were acquired in medical settings. Since hospital workers may acquire and/or transmit measles, hospitals should ensure that employees who may have occupational exposure to measles have proof of measles immunity (8).

During 1986 and 1987, large measles outbreaks occurred in urban areas of the United States among preschool-age children with low immunization levels (9). These areas (New York City, Jersey City, and Miami) also have high incidence rates of pediatric acquired immunodeficiency syndrome. Since HIV-infected children may live in areas where measles virus circulates because of low preschool measles immunization levels, they may be at higher risk of exposure to measles than other children in the United States.

As a result of these recent reports of measles in HIV-infected children, the Immunization Practices Advisory Committee (ACIP) now recommends that measles vaccine be considered for symptomatic as well as asymptomatic children with HIV infection (10). This approach to protect the HIV-infected child is consistent with the World Health Organization's recommendation to provide measles vaccination for all children in developing countries regardless of HIV and symptom status because of the high risk of measles and the severity of measles infection in general (11). References

1. Krasinski K, Holzman RS, Lacouture R, et al. Nosocomial measles: are current vaccination guidelines for staff adequate? (Abstract). In: Program and abstracts of the 27th Interscience Conference on Antimicrobial Agents and Chemotherapy, New York, October 4-7, 1987.

2. Centers for Disease Control. Classification system for human immunodeficiency virus (HIV) infection in children under 13 years of age. MMWR 1987:36:225-30,235-6.

3. Centers for Disease Control. Classification system for human T-lymphotropic virus type III/lymphadenopathy-associated virus infections. MMWR 1986;35:334-9.

4. Banks G, Fernandez H. Clinical use of ribavirin in measles: a summarized review. In: Smith RA, Knight V, Smith JAD, eds. Clinical applications of ribavirin. New York: Academic Press, 1980:203-9.

5. Chandra RS. Giant cell pneumonia. Pediatr Pathol 1984;2:226-9.

6. Centers for Disease Control. Measles surveillance report no. 11, 1977-1981. Atlanta: US Department of Health and Human Services, Public Health Service, 1982.

7. Enders JF, McCarthy K, Mitus A, Cheatham WJ. Isolation of measles virus at autopsy in cases of giant-cell pneumonia without rash. N Engl J Med 1959;261:875-81.

8. Immunization Practices Advisory Committee. Measles prevention. MMWR 1987, 36:409-418, 423-25.

9. Markowitz LE, Adams N, Rovira E, et al. Measles outbreaks, United States 1986 (Abstract). In: Program and abstracts of the 27th Interscience Conference on Antimicrobial Agents and Chemotherapy, New York, October 4-7, 1987.

10. Immunization Practices Advisory Committee. Immunization of children infected with human immunodeficiency virus--supplementary ACIP statement. MMWR 1988;37:181-3.

11. Global Advisory Group, World Health Organization. Expanded programme on immunization. Wkly Epidem Rec 1987;62:5-9.

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