P A Sutcliffe, E Rea

To examine the factors associated with measles vaccine effectiveness and the effect of two doses of vaccine on measles susceptibility during an outbreak. Retrospective cohort study. A secondary school in the City of Toronto. The entire school population (1135 students 14 to 21 years of age). Risk of measles during an outbreak associated with age at first measles vaccination, length of time since vaccination, vaccination before 1980 and whether date of vaccination was estimated; vaccine efficacy of one dose versus two doses. Eighty-seven laboratory-confirmed or clinically confirmed cases of measles were identified (for an attack rate of 7.7%). The measles vaccination rate was 94.2%, and 10% of the students had received two doses of measles vaccine before the outbreak. Among those who had received only one dose of vaccine, vaccination at less than 15 months of age was associated with vaccine failure (relative risk 3.62, 95% confidence interval 2.32 to 5.66). There was no increased risk of vaccine failure associated with length of time since vaccination once the relative risk was adjusted for age at vaccination in a stratified analysis. Vaccination before 1980 and an estimated date of vaccination were not associated with increased risk of vaccine failure. Administration of a second dose of vaccine during the outbreak was not protective. Two doses of vaccine given before the outbreak conferred significant protection, and the relative risk of failure after one dose versus two doses was 5.0 (95% confidence interval 1.25 to 20.15). Of the 87 cases, 76 (87%) could have been prevented had all the students received two doses of measles vaccine before the outbreak, with the first at 12 months of age or later. Delayed primary measles vaccination (at 15 months of age or later) significantly reduced measles risk at later ages. However, revising the timing of the current 12-month dose would leave children vulnerable during a period in which there is increased risk of complications. The findings support a population-based two-dose measles vaccination strategy for optimal measles control and eventual disease elimination.