1969;43;264PediatricsPhilip Fireman, Gilbert Friday and Jesus Kumate

EFFECT OF MEASLES VACCINE ON IMMUNOLOGIC RESPONSIVENESS

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1969;43;264PediatricsPhilip Fireman, Gilbert Friday and Jesus Kumate

EFFECT OF MEASLES VACCINE ON IMMUNOLOGIC RESPONSIVENESS

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Online ISSN: 1098-4275.Copyright 1969 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0031-4005. American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007.has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked by the PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it

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(Received June 3, 1968; revision accepted for publication August 20, 1968.)Supported by Grants HD-02662 and FR-05507 from the National Institutes of Health, U.S. Public

Health Service.P.F. is recipient of Research Career Development Award, HD-18,243, National Institutes of Health,

U.S. Public Health Service.ADDRESS: (P.F.) Childrens Hospital of Pittsburgh, Pittsburgh, Pennsylvania 15213.

PEDIATRICS, Vol. 43, No. 2, February 1969

264

EFFECT OF MEASLES VACCINE ONIMMUNOLOGIC RESPONSIVENESS

Philip Fireman, M.D., Gilbert Friday, M.D., and Jesus Kumate, M.D.Department of Pediatrics, University of Pittsburgh School of Medicine, Childrens Hospital

of Pittsburgh and Hospital Infantil de Mexico, Mexico City

ABSTRACT. Immunologic responses, both humoraland cellular, following vaccination with live atten-uated measles vaccine were studied in 11 childrenand compared to the immunologic responses ob-served following vaccination with killed attenuatedmeasles virus and placebo. The attenuated measlesvirus temporarily suppressed the cutaneous delayedhypersensitivity reaction to purified protein deriva-tive for 1 to 4 weeks; in addition, the delayedhypersensitivity reactions to candida, vaccinia,diphtheria toxoid, poison ivy, and 2,4-dinitro-chlorobenzene antigens were also temporarilysuppressed for 1 to 4 weeks. A modest de-pression of total leucocyte counts, includingsmall lymphocytes, was noted for 1 to 3 weeks; atthe same time, the capacity of lymphocytes frompatients who received live measles vaccine to re-spond in vitro to stimulation with purified proteinderivative, candida, and ragweed antigens was

suppressed without decrease in their in vitro re-sponse to phytohemagglutinin. Administration oflive measles vaccine did not decrease pre-existinghumoral antibody titers to diphtheria toxoid or po-liovirus, serum yG-, yA- and yM-globulin concen-trations or immediate wheal and flare hypersensitiv-ity skin reactions. The mechanism of the suppressionof delayed hypersensitivity by live measles vaccineappears dependent on a viable virus since killedmeasles vaccine had no demonstrable effect onpre-existing cutaneous delayed hypersensitivity oron the in vitro lymphocyte responses. This studydemonstrates that live attenuated measles virus in-terferes with the capacity of the recipient to ex-press cutaneous delayed hypersensitivity withoutsuppression of humoral antibody. Pediatrics,43:264, 1969, si.ss vccnir, rMMuNo-suP-PRESSION, HYPERSENSITIVITY-DELAYED vAccINA-

TION-MEASLES.

T HE temporary suppression of cutaneousdelayed hypersensitivity to tuberculin

in man by measles virus, both natural andattenuated, has been reported by several in-vestigators.T The mechanism of this ob-served decrease in skin reactivity to tuber-culin has not been elucidated. It is also notknown if the measles virus affects any otherparameters of the human hosts immunologicresponse. The use of measles vaccine in thegeneral pediatric population has providedan opportunity to study in detail both hu-moral and cellular immunologic responsive-ness of the human host during a syndromewhich resembles a mild case of naturallyacquired measles in which the date of in-fection is known and alterations of symp-toms, physical findings, and laboratory re-

suits can be accurately recorded. The re-suits of this study show that the administra-lion of live attenuated measles virus inter-fered with the capacity of the recipients toexpress cutaneous delayed hypersensitivitywithout suppression of humoral antibody.In addition, the capacity of peripheral lym-phocytes from patients who received livemeasles vaccine to respond to antigenicstimulation in vitro was suppressed.

Patients

MATERIALS AND METHODS

The children selected to receive live at-tenuated measles vaccine were followed inthe outpatient allergy clinics of ChildrensHospital of Pittsburgh. Their ages ranged

ARTICLES 265

from 5 to 16 years. Two of the patientswere receiving isoniazid therapy because ofrecent conversion from a negative tuberculinskin test to a positive tuberculin skin test.Three of the patients studied had a priorclinical history of measles, confirmed by se-rologic examination. As a comparisongroup, five other children received formalde-hyde inactivated measles virus, and five ad-ditional children were given as a placebo 0.5ml of the diluent used to reconstitute theattenuated live measles virus. The prevac-cine data were obtained at least 1 weekprior to administration of the measles vac-clues or placebo.

Measles VaccinesThe reconstituted lyophilized live vac-

cine was given subcutaneously in a vol-ume of 0.5 ml which contained at least 1,000TCID5O of attenuated measles virus pre-pared from the Edinonston strain. The forrnmaldehyde inactivated, alum precipitatedrubeola virus, which was also derived fromthe Edmonston strain, was administered in-tramuscularly in a volume of 0.5 ml. Nogamma-globulin was given with eitherthe live attenuated or inactivated measlesvaccines.

Bacill. Calmeff. GurIn (BCG)*Each recipient received 0.1 ml of viable

BCG intracutaneously in the deltoid region.

Skin TestsDelayed hypersensitivity skin tests were

read at 24 and 48 hours after challengewith appropriate antigen. Skin tests of lessthan 5 mm of erythema and induration wereinterpreted as negative. Immediate hyper-sensitivity skin tests were read at 15 and 20minutes after challenge with appropriateantigen. Skin tests which exhibited lessthan 5 mm of wheal and erythema wereinterpreted as negative. All skin tests weremeasured by two observers, one of whomwas not aware of the protocoL

. Kindly provided by the Allegheny CountyHealth Department, Pittsburgh, Pennsylvania.

Skin Test Antigens

Purified protein derivative (PPD),$ 0.1iLg, was administered intradermally in a vol-ume of 0.1 ml and, if no skin reactivity waselicited after 48 hours, then 5 tg was ad-ministered intradermally in a volume of 0.1ml. Candida antigen was given intrader-mally in a concentration of 1/1,000 and, ifno reactivity developed, then 1/100 dilutionin 0.1 ml was given intradermally. Vacciniavaccine was heated for 1 hour at 60#{176}Cpriorto use as an intradermal skin test antigen.Diphtheria toxoid diluted 1/10 was appliedintradermally in a volume of 0.1 ml and, ifno delayed hypersensitivity was elicited,then 0.1 ml of a 1/1 dilution was given in-tradermally A contact dermal sensitizer of2,4.dinitrochlorobenzene diluted 1/100 incorn oil was applied; 10 days later, thesensitized patients were challenged bypatch testing with 1/1,000 dilution of2,4-dinitrochlorobenzene. Poison ivy anti-gen was applied topically as a patch test.House dust, ragweed, and egg skin test an-tigens were applied intradermally in a volume of 0.02 ml and examined at 15 and 20minutes.

Leucocyte Cultures

Human peripheral leucocytes were iso-lated and cultured by a modification of themethod of Hirshhorn.8 A concentration of106 leucocytes per milliliter were cultured in5 ml of Eagles modified minimum essentialmedium, which contained 1% 200 mM1-glutamine and 20% fetal calf serum. Leu-cocyte cultures were incubated at 37#{176}Cfor3 days following the addition of 0.1 ml phy-tohemagglutinin and for 5 days followingthe addition of 0.05 mg of PPD, 10 proteinnitrogen units (PNU) of candida antigen,and 10 PNU of ragweed antigen. After anadditional incubation period, with 0.2 ml of0.01% colchicine at 37#{176}Cfor 2 hours, thecells were harvested by gentle centrifuga-tion at 1,000 rpm and washed twice with cul-

fKindly provided by Parke, Davis Co., Detroit,Michigan.

266 MEASLES VACCINE

Numbers in parentheses indicate number of patients studied.

ture media. The harvested cells were fixedin 75% alcohol and 25% glacial acetic acidand then stained with giemsa stain and with1% acetic orcein. The percentages of smalllymphoid cells, large lymphoid cells, andmitoses were determined by counting atleast 1,000 cells from randomly chosenfields. The sum of large lymphoid cells andmitoses was the total number of stimulatedcells. All cell counts were performed in du-plicate by two observers, one of whom wasnot aware of the protocol.

Immunoglobulins

#{149}G-,iA-, and tM-globulins were quanti-tated by a modification of the radial geldiffusion technique as described by Man-cmi, et #{224}l. .Transfer Factor

The transfer factor was prepared fromthe leucocytes of a donor who was exqui-sitely hypersensitive to PPD by the methodpreviously described.b0

Serum Antibody

Serum antibody concentrations todiphtheria toxoid were determined by he-

magglutination technique,h1 and serum anti-body levels to poliovirus were assayed byneutralization method.12

RESULTS

The patients with no prior history ofclinical measles had fever, exanthem, or co-ryza 7 to 10 days following administration ofattenuated measles virus; the patients witha prior history of measles had no symp-toms after receiving the measles vaccine.The patients receiving killed measles vac-cine had minimal local erythema and swell-ing with no fever or generalized rash. Asshown in Table I, 1 week after receipt ofthe live measles vaccine, the patients dem-onstrated a decrease in total leucocytecounts along with a concomitant decreasein peripheral lymphocytes and peripheraln#{233}utrophiles. Interestingly, eosinophilecounts decreased from 360/mm3 to only 9/mm3, and in three patients there were noperipheral eosinophiledetectable 1 weekafter receiving the Iive attenuated measlesvaccine. The total peripheral leucocyte,lymphocyte, neutrophile, and eosinophilecoUnts gradually returned to their prevac-cine levels at 3 to 4 weeks postvaccine. The

TABLE I

Emcr OF LIVE AND KILLED MEASLES VACCINES AND PLACEBO ON PERIPHERAL LEUCOCYTE COUNTS

Vaccine Leucocytes

Cell X 1O/mrn (average standard deviation)

Posivaccine (ti*)Prevaccine

1 2 3 8

Live(10)

TotalLymphocytesNeutrophilesEosinophiles

9.91.43.7.7

5.9.8.3608

6.91.12.4.5

4.4.4.0903

7.21.2c2.7.3

4.4.6.1405

8.91.5.8.7

5.9.7.4.05

10.71.63.3.S

7.01.0.3007

10.11.54.0.9

5.71.04.1

Killed(5)

TotalLymphocytesNeutrophilesEosinophiles

8.51.23.9.84.2.8

. 41 .09

9.31.54.1.64.8.9. 36 .06

9.11.04.0.54.7.6

. 39 . 05

8.91.23.8.64.7.7

. 42 .04

9.31.03.7.85.21.1. 37 .07

R.71.l3.6.74.74)9

. 39 .08

Placebo(5)

TotalLymphocytesNeutrophilesEosinophiles

9.11.04.l.74.6.9.39 .08

9.01.3.954.71.0.36 .09

9.41.04.0.65.0.7.39 .06

8.91.53.9.54.6.8.43 os

9.01.13.7.64.81.0.45 .08

8.91.03.9.74.607.40 .1

TABLE II

ErrEcr OF Livn MEASLES VACCINE ON Curuer.ousDELAYED HYPERSENSITIVITY

Delayed (48 hr)Hyperseneilivity(mm induration)

_4nligen Patient

J.B.*PPD P.!).

C.c.j.r.AS.

Postvaccine (wk)

* No prior history of measles.

ARTICLES 267

comparison groups of patients that receivedkilled measles vaccine or diluent demon-strated little change in leucocyte counts.

The ability of measles vaccine to reducethe cutaneous delayed hypersensitivityreaction to PPD was confirmed as shown inTable II. In none of these patients was thedelayed hypersensitivity reaction abolished.Prior history of measles infection did notalter the suppressive effect of the measlesvaccine on the delayed hypersensitivityreaction. The suppression of delayed hyper-sensitivity was most marked 1 to 2 weekspostvaccine, and by 4 to 8 weeks the pa-tients delayed hypersensitivity to PPD hadreturned to the prevaccine values. A simi-tar suppressive effect of measles vaccine oncutaneous delayed hypersensitivity reactions to candida antigen, diphtheria anti-gen, and vaccinia antigen was noted (TableII). Measles vaccine also suppressed but didnot abolish the contact dermatitis-type de-layed hypersensitivity reaction to poisonivy in two patients and to 2,4-dinitrochloro-benzene in two patients. There was no sup-pression of cutaneous delayed hypersensi-tivity reactions to PPD or candida after ad-ministration of killed measles vaccine or thediluent placebo.

The effect of measles vaccine on pre-ex-isting serum antibody concentrations anddelayed hypersensitivity reactions todiphtheria toxoid is shown in Table III.There was a moderate depression of cuta-neous delayed hypersensitivity without re-duction of serum hemagglutination anti-body titer. In fact, there was a rise in serumantibody titer which probably reflected thehosts response to the weekly skin test withdiphtheria toxoid.

The effect of measles vaccine on the cu-taneous immediate hypersensitivity reactionto ragweed, house dust, and egg allergenswas studied in three patients. Following ad-ministration of measles vaccine, there wasno decrease in the size of the immediatewheat and flare skin reactions to these threeantigens in the three patients studied. Inthe 15 patients studied, there was nomarked change in the concentration of -1G-,-A-, or iM-globulins following receipt of

Pre-vaccine J# 8

16 9 6 6 1 15

15 10 4 7 14

10 9 3 4 6 916 14 4 6 14 171 10 5 8 10

13 8 5 6 1 110 9 8 8 10 1

.

Candela

s.P.*

C.D.*J.B.*R.J.B:J.P.D.C.C.J.T.

110

8

810

8

109

788

466

84

454

42

44

83478447

10689

10879

18

10101

91110

VacciniaC.D.*J.B.*P.D.

91012

48

48

14

8115

live or killed measles vaccine. In addition,there was no decrease in pre-existingdiphtheria or poliovirus antibody titers infour patients after receiving live measlesvaccine and in two patients after receivingkilled measles vaccine.

The in vitro responses of peripheral leu-cocytes from patients who had receivedmeasles vaccine were examined. As can beseen from Table IV, leucocytes were cul-tured immediately prior to administrationof measles vaccine and then periodicallyfollowing administration of live attenuatedmeasles virus. When phytohemagglutininwas added to the leucocyte cultures as thegrowth stimulant, there was only a slightreduction in the average percent stimulatedlymphoid cells; when this data was sub-jected to statistical analysis, the decreasenoted was not statistically significant(P> 0.01 ) . In the seven patients who had

268 MEASLES VACCINE

Numher in pnrentheses indicate number of patients studied.

TABLE III

EFFEC-F OF MEASLES VACCiNE ON IMMUN0LOOIC

RESPONSE TO DIPHTHERIA ANTIGEN

Patient

Delayed (8 hr) Hypersensitivity

Pre-vaccine

Postvaccsne (wk)

3 J 8

S.P.PD.S.G.

810

9

3

86

65

465

788

108

10

Serum Antibody(1/hemagglutination titer)

S.P. 3 SP.D. 18 l8S.G. 18 56

641856

645651

645651

18565i

delayed cutaneous hypersensitivity to PPDand had an average 14.2% 2.5 stimulatedcells when PPD was added to the leucocytecultures prior to administration of measlesvaccine, a decrease to an average 6.7% 1.5stimulated cells in response to PPD wasnoted 2 weeks after receiving measles vac-

cine. By 4 to 8 weeks, the percentage ofstimulated cells were similar to the percent-age of stimulated cells detected before re-ceiving the measles vaccine. A similarsuppression of the in vitro response of leu-cocytes in tissue culture to candida antigenwas also recognized in eight patients whohad cutaneous delayed hypersensitivity tocandida antigen. In vitro response of leuco-cytes to ragweed antigen was studied be-fore and after measles vaccination in fourpatients who had immediate 20-minutewheat and flare reactions on direct skintesting to ragweed antigen but no 48-hourcutaneous delayed hypersensitivity toragweed antigen. As can be noted in TableIV, there was considerable reduction in thepercentage of cells stimulated by ragweedantigen for 1 to 3 weeks after live measlesvaccination, even though these patients hadno cutaneous delayed hypersensitivity toragweed. The administration of killed mea-sles vaccine or placebo did not suppress thein vitro responses of peripheral leucocytesto phytohemagglutinin, PPD, or candida.

The effect of measles vaccine on the pas-sive transfer of delayed hypersensitivity to

TABLE IV

IN VITRo RESPONSES OF LBucocrrus FROM PATIENTS AFFR Livi ANDKIuuD Mu.si.us VACCINES AND PLACEBO

Vaccine CultureStzrnulan1

% Stimulated Cells (averag. .tandard deviation)

Prevaccine

Postvoccine (wk)

1 3 4 8

.

Live

Phyto (10)PPD (7)Candida (8)Ragweed (4)

79.8.O14..513.1.11.5.7

78.57.69.5.09.91.9

I0.4.I

76.38.56.71.55.81.87.9.1

74.76.98.8.07.1.99.4.1

77.87.81.9.810.3.01.03.0

78.9 8.415.03.013.0.414.1.6

Killed

Phyto (5)PPD ()Candida (5)

75.16.810.811.6.8

77.57.10.511..0

78.97.611.411.0.5

7S.8.011.8

14.03.5

71.57.810.8

1L6.4

77.67.911.0

1.0.0

Placebo

Phyto (5) 71.7.0PPD () 1.4

Candida (5) 1.81.9

78.7.514.6I.2.6

76.08.011.81S.42.

70.6.81.811.91.8

75.47.18.81.7.6

76.87.813.01.0.1

ARTICLES 269PPD with intact leucocytes and transferfactor was also studied. The simultaneousadministration of measles vaccine and ei-ther intact leucocytes or transfer factorfrom a known PPD-positive donor to a pre-vious PPD-negative recipient did not pre-vent the passive transfer of delayed hyper-sensitivity to PPD as elicited 2 days later.Nevertheless, a transient suppression of cu-taneous delayed hypersensitivity to PPDwas noted for 1 to 2 weeks after measlesvaccination. In a further attempt to delin-eate the mechanism of the suppression ofdelayed hypersensitivity by measles vac-cine, BCG vaccine and measles vaccinewere administered simultaneously to twoPPD-negative recipients. There was no ap-parent interference in the development ofdelayed cutaneous hypersensitivity reac-tions which were elicited with PPD 6 weeksafter vaccination with both measles andBCG.

DISCUSSION

The data obtained in this study demon-strate that administration of live attenuatedmeasles virus to children interferes with thecapacity of the recipient to express pre-ex-isting cutaneous delayed hypersensitivitywithout suppression of pre-existing huinoralantibody. Besides confirming the previousreports of Meliman and Wetton,5 Starrand Berkovicho and Brody and McAlister7that measles vaccine suppresses cutaneousdelayed hypersensitivity to PPD, measlesvaccine was shown to be capable of sup-pressing cutaneous delayed hypersensitivityto candida, diphtheria, and vaccinia anti-gens and of suppressing the delayed hyper-sensitivity contact dermatitis response topoison ivy and 2,4-dinitrochlorobenzene an-tigens. The maximum suppression of de-layed hypersensitivity was noted 1 to 2weeks postvaccine and, as previously re-ported, the suppression of cutaneous de-layed hypersensitivity was temporary. Allthe recipients recovered their prevaccinedegree of delayed hypersensitivity between4 to 8 weeks postvaccine. Pre-existing hu-

moral antibody titers to diphtheria and po-liovirus and serum concentrations of G-,

TA-, and iM-globulins were not markedlychanged following administration of mea-sles vaccine. In addition, there was nosuppression of the immediate 20-minutewheal and flare cutaneous hypersensitivityresponse to several allergens (includingragweed, house dust, and egg) followinglive measles vaccination in the several pa-tients studied.

The administration of live measles vac-cine to patients also interfered with the ca-pacity of peripheral lymphocytes fromthese patients to respond in vitro. Whereasthere was little suppression of the in vitrolymphocyte response to phytohemag-glutinin following live measles vaccine,there was a considerable reduction in thenumber of lymphoid cells stimulated in tis-sue culture by PPD or candida antigens.The suppression of the in vitro responses toPPD and candida antigens was maximum 1to 2 weeks postvaccine, was temporary and,in general, coincided with the suppressionof the cutaneous delayed hypersensitivityreaction to these same antigens. In a pre-liminary communication, Smithwick13 alsoreported the diminution of both the de-layed hypersensitivity skin reactions to PPDand the in vitro lymphocyte stimulation toPPD in two children during natural measlesinfection. Whether the in vitro lymphocytestimulation studies represent an in vitrocorrelate of cutaneous delayed hypersensi-tivity cannot be stated with certainty. Pa-tients with Hodgkins disease, chronic lym-phatic leukemia, sarcoidosis, and ataxia tel-angiectasia-diseases which demonstrateimpaired cutaneous delayed hypersensi-tivity reactions-also show a depressed invitro lymphocyte stimulation.17 Studies inguinea pigs by Millsls and Oppenheim, etal.10 have suggested a direct relationshipbetween the cutaneous delayed hypersensi-tivity reaction and the in vitro lymphocytestimulation. Yet, studies in animals by Dut-ton and Eady2#{176}and Vischer and Stastny21suggest a relationship between in vitro lym-

270 MEASLES VACCINE

phocyte stimulation and humoral antibodyformation. The fact that leucocytes fromthree patients with immediate hypersensi-tivity to ragweed were stimulated in vitrowith ragweed antigen in spite of a lack ofcutaneous delayed hypersensitivity toragweed antigen suggests the possibilitythat either the in vitro lymphocyte stimula-tion studies reflect parameters of cellular orhumoral immunity in addition to cutaneousdelayed hypersensitivity or that the in vitrolymphocyte stimulation is a more sensitiveindex of cellular immunity than delayed hy-persensitivity skin test. The in vitro respon-siveness of lymphocytes from patients with

immediate hypersensitivity and humoral an-tibody to several allergens in the absence ofdelayed hypersensitivity to these allergenshas been reported previously by several in-vestigators.22.23 Interestingly, the in vitrolymphocyte response to ragweed antigenwas suppressed following administration ofmeasles vaccine. This suppression was tem-porary and the data resembled that seen inthe postmeasles vaccine lymphocyte cul-tures which were stimulated with PPD orcandida antigens. There was no changepostmeasles vaccine in these patients ca-pacity to express immediate hypersensitiv-ity to ragweed as demonstrated by direct20-minute wheal and flare skin tests. Eventhough measles vaccine suppressed pre-ex-isting cutaneous delayed hypersensitivity,measles vaccine did not abolish the devel-opment of delayed hypersensitivity to PPDfollowing active immunization with BCG orfollowing passive immunization with leuco-cytes or transfer factor.

The mechanism of the suppression of de-layed hypersensitivity by live measles vac-cine appears dependent on a viable virussince the inactivated alum precipitatedmeasles vaccine had no demonstrable effecton pre-existing cutaneous delayed hyper-sensitivity or on the in vitro lymphocyte re-sponses. Even though the precise mecha-nism of the suppression of delayed hyper-sensitivity by live measles vaccine is notclear, the possibility that the live measlesvirus directly affects the lymphocytes must

be considered. Smithwick and Berkovich24have reported that the addition of live mea-sles virus directly to human peripheral lym-phocyte tissue cultures obtained from pa-tients with delayed hypersensitivity to PPDsuppressed the in vitro reactivity of theselymphocytes to PPD that was added to thelymphocyte cultures. Besides coincidingwith a diminished in vitro lymphocyte re-sponse, the suppression of cutaneous de-layed hypersensitivity after measles vaccinealso coincided in part with decreased num-bers of circulating peripheral leucocytes,neutrophiles, eosinophiles, and lympho-cytes. However, the decreased responsive-ness of the lymphocytes in vitro was not areflection of fewer cells added to the cul-ture, since the numbers of cells added toeach culture were always the same. It maybe that the mechanisms responsible for thedecrease in circulating peripheral lympho-cytes were also operative in the diminishedresponsiveness of the lymphocyte in vitro.Black and Sheridan2 have reported similarchanges in peripheral leucocyte countsafter measles vaccine, as have Benjaminand Ward2#{176}after natural measles infection.The possibility that the decrease in cuta-neous delayed hypersensitivity and de-creased in vitro lymphocyte responsivenessmay be due to increased endogenous corti-costeroid production must also be consid-ered, since corticoid therapy can suppresscutaneous delayed hypersensitivity. Yet,Aceto, et al.2 have reported normal cortico-steroid synthesis in children during measles.

The possibility also exists that the ob-served alteration in the capacity of the re-cipients of measles vaccine to express de-layed hypersensitivity may be the result ofa substance in the measles vaccine otherthan the virus. This seems rather unlikelybecause of the similarity in the suppressionof delayed hypersensitivity shown duringinfection with natural measles virus andthat observed following vaccination withlive attenuated measles virus. Yet, one isfaced with the interpretation of the obser-vation that the prior history of measles orexistence of humoral antibody to measles

ARTICLES 271

virus does not interfere with the suppres-sive effect of the measles virus on delayedhypersensitivity.

SPECULATIONS

A positive relationship between the de-gree of delayed hypersensitivity to tubercu-lin and protective immunity in patientswith tuberculosis has never been es-tablished. Nevertheless, it has been stressedthat natural measles and live measles vac-cine may be harmful in patients with activetuberculosis because of the reduction in cu-taneous delayed hypersensitivity to tuber-culin.5 Besides its potential deleterious ef-fect, the possibility exists that live measlesvaccine, because of its capacity to suppressdelayed hypersensitivity, may be clinicallyefficacious. A marked improvement in symp-toms of many patients with atopic dermati-tis and asthma during natural measles is afrequent observation. It has been reportedthat at the height of the measles exanthem,usually 7 to 14 days after acquiring the in-fection, the symptoms related to the hyper-sensitivity syndrome demonstrate theirmaximum temporary improvement.28 In apreliminary report,29 a temporary clinicalimprovement in patients asthmatic andatopic dermatitis symptoms was noted afterreceipt of measles vaccine. This clinical im-provement was coincident with a decreasein cutaneous delayed hypersensitivity.Whether the observed improvement in theclinical hypersensitivity syndrome was a re-sult of a decrease in patients capacity toexpress delayed hypersensitivity remains tobe proven.

SUMMARY

Live attenuated measles virus was shownto temporarily suppress for 1 to 4 weeks therecipients cutaneous expression of delayedhypersensitivity to several antigens, includ-ing tuberculin, candida, vaccinia, diphthe-na, poison ivy, and 2,4-dinitrochloroben-zene. During the interval of suppression ofcutaneous delayed hypersensitivity, the invitro responsiveness of peripheral lympho-cytes from the patients who received mea-

sles vaccine to stimulation with tuberculin,candida, and ragweed antigens were alsosuppressed. There was no apparent de-crease in immediate hypersensitivity skinreactions, pre-existing humoral antibodytiters to diphtheria toxoid or poliovirus, orserum yG-, 1A-, and iM-globulin concen-tration after receipt of measles vaccine. Thesuppression of delayed hypersensitivity ofmeasles vaccine appears dependent on aviable virus since killed measles vaccine hadno demonstrable effect on the delayed hy-persensitivity skin reactions or the in vitrolymphocyte responses.

REFERENCES

1 . Von Pirquet, C. E. : Das Verhalten der KutaninTuberkulinreaktion w#{228}hrend der Maseru.Deutsch. Med. Wschr., 34: 1297, 1908.

2. Mitchell, A., Nelson, W., and Le Blanc, T.:Studies in immunity. V. Effect of acute dis-ease on the reaction of the skin to tubercu-lin. Amer. J. Dis. Child., 49:695, 1935.

3. Mascia, A., Chick, F., and Levy, W. : Effect ofrubeola on tuberculosis. J. Pediat., 43:294,1953.

4. Helms, S., and Helms, P. : Tuberculin sensitiv-ity during measles. Acta Tuberc. Scand.,35:166, 1956.

5. Meilman, W. J., and Wetton, R. : Depressionof tuberculin reaction by attenuated measlesvirus vaccine. J. Lab. Clin. Med., 61:453,1963.

6. Starr, S., and Berkovich, S. : Effects of measles,gamma-globulin modified measles and vac-cine measles on the tuberculin test. NewEng. J. Med., 270:387, 1964.

7. Brody, J. A., and McAlister, R.: Depression oftuberculin sensitivity following measles vac-cination. Amer. Rev. Resp. Dis., 90607,1964.

8. Hirshhorn, K.: Histocompatibility Testing.Washington, D.C.: National Academy ofSciences, National Research Council, p. 177,1965.

9. Mancini, C., Carbonara, A. 0., and Heremans,J. E. : Imrnunochemical quantitation of anti-gens by single radial immunodiffusion. mt.J. Immunochem., 2:235, 1965.

10. Fireman, P., Boesman, M., Haddad, Z., andGitlin, D. : Passive transfer of tuberculinreactivity in vitro. Science, 155:337, 1967.

11. Stavitsky, A. B. : Micromethods for the studyof proteins and antibodies. J. Immunol.,72:360, 1954.

12. Michaels, R. : Studies of antiviral factors in

272 MEASLES VACCINE

human milk and serum. J. Immunol. 94:262,1964.

13. Smithwick, E. M.: Lymphocyte studies in chil-dren with tuberculosis. (Abst. ) Atlantic City,New Jersey: Society for Pediatric Research,p. 152, May, 1966.

14. Hersh, E. M., and Oppenheim, J. J. : Impairedin vitro lymphocyte transformation in Hodg-kins Disease. New Eng. J. Med., 273:1006,1965.

15. Hirshhorn, K., Schreibman, R. R., Bach, F. H.,and Sitzbach, L. E:. In vitro studies of lym-phocytes from patients with sarcoidosis andlymphoproliferative diseases. Lancet, 2:842,1964.

16. Oppenheim, J. J., Whang, J., and Frei, E. : Im-munologic and cytogenetic studies ofchronic lymphocytic leukemia. Arch. Path.,83:58, 1967.

17. Leiken, S. L., Bozelon, M., and Park, K. H.: Invitro lymphocyte transformation in ataxia tel-angiectasis. J. Pediat., 68:477, 1966.

18. Mills, J. A.: Immunologic significance of anti-gen induced lymphocyte transfonnation invitro. J. Immunol., 97:239, 1966.

19. Oppenheim, J. J., Wolstencroft, R. A., andCell, P. C. H. : Delayed hypersensitivitly inthe guinea pig to a protein-hapten conjugateand its relationship to in vitro transforma-tion of lymph node, spleen, thymus and pe-ripheral blood lymphocytes. Immunology,12:89, 1967.

20. Dutton, R. W., and Eady, J. D. : An in vitrosystem for the study of the mechanism ofantigenic stimulation in the secondary re-sponse. Immunology, 7:40, 1964.

21. Vischer, T. L., and Stastny, P. : Time of ap-pearance and distribution of cells capable ofsecondary immune response following pri-

mary immunization. Immunology, 12:675,1967.

22. Zeitz, J. S., Van Arsdel, P. P., and McClure,D. K. : Specific response of lymphocytes topollen antigen in tisssue culture. J. Allerg.38:321, 1966.

23. Girard, J. P., Rose, N. R., Kunz, M. L., Koby-a.ski, S., and Arbesman, C.: In vitro lympho-cyte transformation in atopic patients: In-duced by antigen. J. Allerg. 39:65, 1967.

24. Smithwick, E. M., and Berkovich, S. : In vitrosuppression of the lymphocyte response totuberculin by live measles vaccine. Proc.Soc. Exp. Biol. Med., 123:276, 1966.

25. Black, F. L., and Sheridan, S. R. : Blood leuco-cyte response to live measles vaccine. Amer.J. Dis. Child., 113:301, 1967.

26. Benjamin, B., and Ward, S. M.: Leucocyte re-spouse to measles. Amer. J. Dis. Child.,44:921, 1932.

27. Aceto, T., Mattimore, J. M., and Beckhom,G. D. : Cortisol metabolites in children withvaricella or rubeola. (Abst. ) Philadelphia:Society for Pediatric Research, May 1965.

28. Feingold, B. : The influence of acute infectionupon the course of allergy in children : Someclinical observations. J. Pediat., 34:545,1949.

29. Friday, G. A., Kumate, J., and Fireman, P.:Suppression of delayed hypersensitivity andatopic manifestation by measles vaccine.(Abst.) J. Allerg., 41:111, 1968.

Acknowledgment

The authors wish to acknowledge the manyhelpful suggestions of Dr. David Citlin and the as-sistance of the personnel of the Allergy Clinic ofChildrens Hospital of Pittsburgh