Correspondence
The Measles–Mumps–Rubella Vaccination Program in Finland
N Engl J Med 1995; 332:1102-1103April 20, 1995
- Article
To the Editor:
The comprehensive program in Finland described by Peltola et al. (Nov. 24 issue)1 shows what can be achieved when a two-dose strategy of immunization with measles–mumps–rubella (MMR) vaccine is fully implemented. As discussed in the report and the accompanying editorial,2 the challenges facing the United States differ from those encountered in Finland, because of both our larger population (50 times larger than that of Finland) and our greater diversity.
We have recently strengthened the U.S. immunization program and implemented a two-dose strategy for MMR vaccination. Between 1989 and 1991, there was a resurgence of measles in the United States3; 18,193 cases were reported in 1989 and 27,786 cases were reported in 1990, as compared with an average of 3700 cases per year between 1984 and 1988. Inadequate vaccination coverage, particularly in preschool-age children, was the principal cause. Before 1991, the highest level of vaccination with a measles-containing vaccine among preschool-age children (19 to 36 months old) was 67 percent, in 1982.4 In response to the epidemic, we intensified efforts to vaccinate preschool-age children with MMR vaccine, and the level of coverage rose to 83 percent by 1992.4 In addition, about half of all school-age children received a second dose of MMR vaccine between 1989 and 1993.
The results of these efforts were soon evident. During 1993 only 312 cases of measles were reported — the lowest incidence in history — and mumps (1692 cases) and rubella (192 cases) were also at or near record low levels.5 The incidence of measles in the United States during 1993 (312 cases in a population of 259 million, or 1.2 cases per million) was less than half that in Finland (13 cases in a population of 5 million, or 2.6 cases per million). In addition, the genotypes of measles strains isolated in 1993 and 1994 differed from those isolated from 1989 through 1991, suggesting an interruption in the transmission of the earlier strains.6 During 1994, 874 cases were reported in the United States — the second lowest number ever.
In 1993 the United States initiated the Childhood Immunization Initiative, a five-point program to reduce or eliminate diseases that can be prevented by vaccination.7 the five areas of emphasis are improvement in the quality and quantity of vaccination services, increased community participation, reduced cost for parents, improved surveillance for vaccination coverage and vaccine-preventable diseases, and improved vaccines.
In both Finland and the United States, maintaining these historically low levels of incidence will require continued vigilance until worldwide eradication is achieved.
7 ReferencesStephen C. Redd, M.D.
Melinda Wharton, M.D., M.P.H.
Stephen C. Hadler, M.D.
Walter A. Orenstein, M.D.
Centers for Disease Control and Prevention, Atlanta, GA 303331
Peltola H ,Heinonen OP ,Valle M , et al. The elimination of indigenous measles, mumps, and rubella from Finland by a 12-year, two-dose vaccination program. N Engl J Med 1994;331:1397-1402
Full Text | Web of Science | Medline2
Heisler MB ,Richmond JB . Lessons from Finland's successful immunization program. N Engl J Med 1994;331:1446-1447
Full Text | Web of Science | Medline3
Atkinson WL ,Orenstein WA ,Krugman S . The resurgence of measles in the United States, 1989-1990. Annu Rev Med 1992;43:451-463
CrossRef | Web of Science | Medline4
Vaccination coverage of 2-year-old children -- United States, 1991-1992
Medline5
Summary of notifiable diseases, United States 1993 6
Measles -- United States, first 26 weeks, 1994
Medline7
Reported vaccine-preventable diseases -- United States, 1993, and the Childhood Immunization initiative
Medline
To the Editor:
Peltola et al. note that in both their study of Finnish twins1 and our study of children in Omaha, Nebraska,2 few adverse reactions could be attributed to the MMR vaccine. In their presentation of the results of our study in Table 1, however, Peltola et al. failed to subtract the reaction rates among our placebo recipients from the reaction rates among our vaccine recipients. The rates should be as follows: temperature above 38.3°C but below 39.5°C, 1 percent instead of 25 percent; rash, 11 percent instead of 20 percent; cough or coryza, -2 percent instead of 72 percent; and erythema at the injection site, 1 percent instead of 8 percent. The authors did make the appropriate adjustment in the table for reaction rates among placebo recipients in their study of twins.
These corrections support the authors' contention that placebo-controlled studies show that MMR vaccine in widespread use around the world causes few side effects in children.
2 ReferencesStephen J. Lerman, M.D., M.P.H.
Harvard Community Health Plan, Boston, MA 02215-25231
Peltola H ,Heinonen OP . Frequency of true adverse reactions to measles-mumps-rubella vaccine: a double-blind placebo-controlled trial in twins. Lancet 1986;1:939-942
CrossRef | Web of Science | Medline2
Lerman SJ ,Bollinger M ,Brunken JM . Clinical and serologic evaluation of measles, mumps, and rubella (HPV-77:DE-5 and RA 27/3) virus vaccines, singly and in combination. Pediatrics 1981;68:18-22
Web of Science | Medline
Author/Editor Response
The authors reply:
To the Editor: We are delighted to learn from Redd et al. that MMR vaccination has been so successful in the United States, a country so much larger than Finland. We congratulate our colleagues on these results.
Dr. Lerman correctly points out that in the controlled study he and his colleagues performed, adverse reactions were practically as common in the placebo recipients as in the vaccine recipients. We realized and stated clearly, using respiratory symptoms as an example, that Dr. Lerman and his collaborators reported virtually identical incidence rates for their vaccinated and unvaccinated groups. However, we considered the difference between two rates, one in a very small placebo group (n = 42), somewhat unstable. We agree that the study by Dr. Lerman and his colleagues and our study show conclusively that the MMR vaccine causes adverse reactions very infrequently.
Heikki Peltola, M.D.
Olli P. Heinonen, M.D., D.Sc
Children's Hospital, SF-00290 Helsinki, Finland- Citing Articles (1)
Citing Articles
1
Pentti Ukkonen. (1996) Rubella Immunity and Morbidity: Impact of Different Vaccination Programs in Finland 1979–1992. Scandinavian Journal of Infectious Diseases 28:1, 31-35
CrossRef
