Original Article

Pak J Med Res

Vol. 51, No. 3, 2012

Measles Antibodies in Children Aged 5-7 Years

in Karachi
Sultana Habibullah
PMRC Research Centre, Dow Medical College, Karachi.

Abstract
Objectives: To assess the presence of antibodies in children aged between 5-7 years and correlate it with the vaccination
and previous exposure to measles and also assess the need for a booster dose of vaccine.
Subjects and Methods: A serological cross-sectional survey was conducted in school children age 5-7 years, selected using
convenient sampling technique from Saddar town, Karachi. Variables included age, gender, immunization status, past
history of clinical measles and the age at time of disease. Measles specific IgG antibody titers were estimated by ELISA at
PMRC, Shaikh Zayed Hospital, Lahore. Consent was obtained from guardians of the children. Study was analyzed on
SPSS version 15.
Results: A total of 500 children were studied with 278(55%) aged between 6.1-7 years and equal male to female ratio. Of
the total, 415(83%) children had received measles vaccination in the past amongst whom 68(16%) had history of suffering
from measles in the past. IgG antibodies were found in 401(80%) with majority (58% n=231) aged between 6.1-7 years and
more females showed protection (M:F ratio 43:57). Despite receiving vaccination 42 children suffered from clinical
measles between 1-7 years of age while another 22 suffered from measles before their first birthday.
Conclusions: Protective antibodies were found in 80% school children while 20% were still un-protected with the current
regime of measles vaccination.
Policy statement: Vaccination strategy for measles needs to be reviewed for two dose vaccination schedule.
Key words: Measles vaccination, disease, seroprevalence.

Introduction
easles is a leading vaccine-preventable killer of
children worldwide and was estimated to cause
614,000 global deaths in 2002 with 50% occurring in
Sub-Sahara Africa. Its vaccination has been an extremely
successful public health intervention resulting in
elimination of measles in most areas of the globe while,
in some areas it still remains an important public health
1,2
problem . Successful measles immunization depends on
the absence of maternal antibodies at the time of
vaccination which are transferred via placenta during the
first trimester of pregnancy and gradually wane in the
first year of life3. The optimum age for measles
vaccination varies from country to country and there is no
standardized vaccination schedule. A study conducted in
Mozambique showed measles antibodies in children
between 6-9 months age4 . However, determining the
optimal age for measles vaccination program in
developing countries is crucial because the virus

transmission is very efficient and disease of measles at an

early age is so great that children must be vaccinated
soon after they lose maternal protection 5. Though WHO
recommends age of measles vaccination in developing
6
countries at nine months .
Despite universal use of measles vaccines in recent
decades, epidemics of the disease continued to occur.
Understanding the role of primary vaccine failure (failure to
sero-conversion after vaccination) and secondary vaccine
failure (waning immunity after sero-conversion) in measles
epidemic is important for the evaluation of measles control
7
programmes in developing countries .
In Pakistan measles vaccine is given free as a
single dose through EPI at 9 months, while many
affording parents take it through private pediatricians by
paying for vaccination. Considering these facts this study
was conducted to (i) determine the presence of antibodies
in children aged between 5-7 years and (ii) correlate it
with the vaccination and previous exposure to measles
and also assess the need for a booster dose of vaccine.

Corresponding Author:
Sultana Habibullah
PMRC Research Centre
Dow Medical College
Karachi.
Email: s.habib@duhs.edu.pk

Subjects and Methods

This is a secondary data analysis from a national
sampling for serological survey of measles antibodies in

Pakistan Journal of Medical Research, 2012 (July - September)

68

Sultana Habibullah

Table 1: Vaccination status, gender, age and disease status.

Variables
Gender
Male
Female
Age groups
Upto5 years
5.1-6 years
6.1-7 years
Disease status
Yes
No

p value

No

Total
n=500

95% C. I

Yes

Vaccination status

188(45%)
227(55%)/415

50(59%)
35(41%)/85

238
262/500

1.15-1.26
1.09-1.17

0.238

45(11%)
144(35%)
226(54%)/415

4(5%)
29(34%)
59(61%)/85

49
173
278/500

1.0-1.16
1.11-1.22
1.14-1.23

0.000

68(16%)
347(84%)/415

15(18%)
70(82%)/85

83
417/500

1.09-1.26
1.13-1.20

0.000

Table 2: Distribution of antibodies in relation to gender, age and disease status.

Variables
Gender
Male
Female
Age groups
Upto5 years
5.1-6 years
6.1-7 years
Disease status
Yes
No

p value

No

Total
n=500

95% C.I

Yes

Antibody status

187(47%)
214(53%)/401

51(51%)
48(49%)/99

238
262//500

1.16-1.26
1.13-1.23

0.238

36(9%)
134(33%)
231(58%)/401

13(13%)
39(39%)
47(47%)/99

49
173
278/500

1.13-1.39
1.16-1.28
1.12-1.21

0.000

79(20%)
322(80%)/401

4(4%)
96(95%)/99

83
417/500

1.00-1.09
1.18-1.26

0.000

school going children aged between 5-7 years8 . Total

sample size of the primary study was 2500 while the
present analysis is an in depth analysis of 500 children
from Karachi.
Variables of the study were age, gender,
immunization status, past history of suffering from clinical
measles, age at the onset of disease and the presence of
measles specific IgG antibodies.
Children suffering from any chronic illness and
recent history of acute illness like fever, skin rash, parotid
enlargement and joint pains were excluded from the study.
Proformas were filled by Co-investigator and one
data collector. Blood samples were collected by trained
phlebotomists. Sera were separated and frozen, which were
later transported in cold chain to Pakistan Medical
Research Council, National Health Research Complex
Shaikh Zayed Hospital, Lahore, where test for measles
(IgG) antibodies were done using commercially available
Enzyme-linked Immunosorbant Assay (ELISA) kits (IBL
International Germany). According to the manufacturers
guidelines when concentration of IgG antibody was < 200
m IU, it was considered negative (non-protective), levels
between 200-300 m IU were border line and > 300 m IU
were positive.
Permission was obtained from Federal Ministry
of Education, Executive District Officers (Education) and
principals of selected schools. Consent was taken from the
parents. The child was called on pre-fixed day for blood
sample collection.

Statistical package for Social Sciences (SPSS)

version 15 was used for data analysis. Results were
expressed in percentages, where appropriate, chi-square at
0.05 alpha level was applied for test of significance.

Results
Secondary data analysis was done on 500
children from Karachi. Majority i.e. 278(55%) children
were between 6.1-7 years of age with a male to female
ratio of 48:52.
As per parents recall, 415(83%) children had
received one dose of measles vaccine. The male to female
ratio of vaccinated children was 45:55 and majority i.e.
226(54%) were 6.1-7 years old. Out of 500 children, 83
had history of suffering from measles in the past. When
vaccination status of these children was checked, it was
found that 68 were vaccinated while 15 were not
vaccinated Table-1.
Protective antibodies (> 300 m IU) were found in
401(80%) with no gender discrimination. Majority i.e.
231(58%) of children with protective antibodies were
between 6.1-7 years of age. Out of 401 children with
protective antibodies 79(20%) had history of suffering
from clinical measles in the past (Table-2).
Out of 79(20%) children who suffered from
clinical measles disease 64(16%) were vaccinated and
15(4%) were not vaccinated. Out of 64 children, 22

Pakistan Journal of Medical Research, 2012 (July - September)

69

Measles Antibodies in Children Aged 5-7 Years in Karachi

suffered before their first birthday while 42 suffered

between 1-7 years of age (Table-3).
Table 3: Distribution of antibody in relation to vaccination
and age at disease.
Age at clinical
measles disease
Year one
Year two
Year three
Year four
Year five
Year six
Year seven
Total

Presence of protective antibody

Vaccination status
Yes
No
22
11
12
7
7
4
1
64(16%)

3
2
2
3
3
1
1
15(4%)

Total

25
13
14
10
10
6
2
79(20%)

Out of 99 children who did not have protective

antibodies, 4 had a history of suffering from clinical
measles disease and vaccination in the past. Of these 2
developed disease before first birthday and one each at
the age of four and five years.

Discussion
The overall prevalence of protective antibody
against measles virus in primary school children in
Saddar town, Karachi was 80% while 16% (64 cases)
suffered from measles despite receiving vaccine with
maximum cases suffering before one year of age. The
presence of protective antibody indicates that an
individual would be protected from clinical disease if
exposed to wild virus9. Elimination of measles require
continued commitment to increase vaccination coverage
levels, the genetic analysis of circulating strains and serosurvey of vaccinated individuals to establish the
population at risk of contracting the infection 10,11. In the
present study 16% vaccinated children developed measles
disease but whether it was due to primary vaccine failure
or due to waning of specific antibody could not be
7
evaluated here though it was reported in other study . The
frequency of primary vaccine failure varies with the
immune function at the time of vaccination, number of
doses, immunogenicity of virus used to manufacture the
12
vaccine and the geographical region . However, it is
reported that in highly vaccinated population, measles
outbreak occurs due to secondary vaccine failure 13. The
test for the assessment of IgG antibody avidity is a
reliable tool for differentiating between the immune
response occurring in immunologically nave patient
(primary vaccine failure) and the immune response that
occur in patients with a pre-existing B cell memory
(secondary failure)14 . The test uses the fact that in
primary infection, the specific IgG antibody response
begins with IgG antibody that binds weakly with antigen
(low avidity), in the secondary infection the rapid

antibody response characterized the production of high

avidity antibody 15 . In the present study 16% children had
high titers of measles specific antibody (IgG >5000mIU).
The present study showed that antibody titer was more in
children aged between 6.1-7 years as compared to those
aged less than 6 years of age. Despite vaccination 6%
children suffered from measles before their first birthday
indicating that our children lose their maternal antibody
at an early age and therefore, are more vulnerable to
disease at an early age. Older children are more protected
as compared to younger children and same finding was
reported in other studies from Pakistan16,17.
To achieve high rates of sero-conversion,
vaccination programmes in developing countries are
designed by vaccinating at an age when maximum
number of children have neither maternal antibodies nor
antibodies acquired through natural infection the
window period 18. The window period can be overcome
by adopting a two-phase vaccination programme in
which vaccination is initially targeted at an early age 6-9
months and then at school going age i.e. 4-7 years when
the second dose will boost the immunity as well as
maintain it for a long time19,20.
The present study shows that 20% children are
unprotected with the current regime of measles
immunization and to give full protection they need a
second dose of vaccine later.

Acknowledgement
The study was funded by Pakistan Medical
Research Council vide grant No.4-5/08/RDC/Multicentre/NIH, Islamabad. We acknowledge Education
department, Principals of schools, parents and guardians
of children who gave their consent to include their
children in this study.

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