RE: Measles girl Leigh loses her battle

October 1, 2004

If this girl was 17 years old, that means she as born in 1987. The MMR

vaccine was available in 1986 in the UK as far as I've heard and even

earlier than that in the US. But apart from that, monovalent measles vaccine

has been used on a mass basis since 1972. So what are the chances do you

think that this poor girl hadn't been vaccinated against measles? Slim to

nil, I would suspect. Not only that, but it's known and reported on in the

medical literature that the risk of SSPE increases if someone who has had

wild measles then receives the measles vaccines. So did this girl get SSPE

because she had gotten the wild illness (and would have had life-long

immunity as a result) and then got vaccinated anyway? So many questions and

so much tragedy.

Take care,

Meryl

Measles girl Leigh loses her battle

This is tragic, but SSPE can result from the vaccine...

Love, light and peace,

Sue

" Learn from the mistakes of others--you can never live long enough to make

them all yourself. " - Luther

-------------------------------------------

http://www.barnsleytoday.co.uk/ViewArticle2.aspx?SectionID=86 & ArticleID=8645

52

Measles girl Leigh loses her battle

---

Outgoing mail is certified Virus Free.

Checked by AVG anti-virus system (http://www.grisoft.com).

Version: 6.0.771 / Virus Database: 518 - Release Date: 28/09/2004

October 1, 2004

If the vaccine can cause this, that should have been mentioned in the

article as well, now, shouldn't it?

Measles girl Leigh loses her battle

> This is tragic, but SSPE can result from the vaccine...

>

> Love, light and peace,

>

> Sue

>

> " Learn from the mistakes of others--you can never live long enough to make

> them all yourself. " - Luther

>

> -------------------------------------------

>

http://www.barnsleytoday.co.uk/ViewArticle2.aspx?SectionID=86 & ArticleID=8645

> 52

>

> Measles girl Leigh loses her battle

>

> A WOMBWELL teenager who developed a fatal illness after catching measles

as

> a baby has died.

>

> Leigh Wraith, aged 17, died from the rare degenerative brain disorder

SSPE,

> which develops years after the original measles infection.

>

> Today, as her family struggled to come to terms with their loss, mum Mandy

> urged all parents of young children to ensure they are properly vaccinated

> against the childhood infection.

>

> " Leigh got measles when she was 18 months old, before the MMR vaccine was

> available. I don't want to preach to other parents, but if they had seen

> happen to their child what we watched with Leigh they would not hesitate,

> they would have their child vaccinated, " said Mandy, aged 38, of

> Road, Wombwell.

>

> " People worry about a possible link to autism. That link has not been

proven

> but the condition Leigh developed, even though it is one chance in a

> million, has been proved. We know our daughter has died because she caught

> measles. "

>

> Leigh, who was only diagnosed with the fatal condition three years ago,

knew

> it would kill her. It was something she had lived with since being told on

> her 16th birthday.

>

> She had even planned her own funeral, telling her parents Del and Mandy

> exactly what coffin, music and readings she wanted at the service.

>

> " Leigh dug her heels in, she wasn't going to sit in corner and wait to

die,

> she was determined to live every day, " said Mandy.

>

> " It had to be Leigh's way or no way. She sat her GCSEs last year. She knew

> she would never go to college or get a job, she knew she was not going to

> live that long, but she wanted to sit and pass them because that was the

way

> she was.

>

> " We were told when her condition, sub-acute sclerosing panencephalitis,

was

> diagnosed that she might have, at the most, two years. We had her for

> another 18 months and for that we are grateful.

>

> " But although her going is something we have been prepared for, something

we

> knew would one day happen, nothing can really prepare you for watching

your

> beautiful child die. "

>

> Leigh spent her last three weeks in the Royal Hallamshire Hospital,

> Sheffield.

>

> 01 October 2004

>

October 1, 2004

Maybe, we should all send these links!

http://users.adelphia.net/~cdc/VaccineInfo.htm#SSPE

> If the vaccine can cause this, that should have been mentioned in

the

> article as well, now, shouldn't it?

> Measles girl Leigh loses her battle

>

> > This is tragic, but SSPE can result from the vaccine...

> >

> > Love, light and peace,

> >

> > Sue

> >

> > " Learn from the mistakes of others--you can never live long

enough to make

> > them all yourself. " - Luther

> >

> > -------------------------------------------

> >

> http://www.barnsleytoday.co.uk/ViewArticle2.aspx?

SectionID=86 & ArticleID=8645

> > 52

> >

> > Measles girl Leigh loses her battle

> >

> > A WOMBWELL teenager who developed a fatal illness after catching

measles

> as

> > a baby has died.

> >

> > Leigh Wraith, aged 17, died from the rare degenerative brain

disorder

> SSPE,

> > which develops years after the original measles infection.

> >

> > Today, as her family struggled to come to terms with their loss,

mum Mandy

> > urged all parents of young children to ensure they are properly

vaccinated

> > against the childhood infection.

> >

> > " Leigh got measles when she was 18 months old, before the MMR

vaccine was

> > available. I don't want to preach to other parents, but if they

had seen

> > happen to their child what we watched with Leigh they would not

hesitate,

> > they would have their child vaccinated, " said Mandy, aged 38, of

> > Road, Wombwell.

> >

> > " People worry about a possible link to autism. That link has not

been

> proven

> > but the condition Leigh developed, even though it is one chance

in a

> > million, has been proved. We know our daughter has died because

she caught

> > measles. "

> >

> > Leigh, who was only diagnosed with the fatal condition three

years ago,

> knew

> > it would kill her. It was something she had lived with since

being told on

> > her 16th birthday.

> >

> > She had even planned her own funeral, telling her parents Del and

Mandy

> > exactly what coffin, music and readings she wanted at the service.

> >

> > " Leigh dug her heels in, she wasn't going to sit in corner and

wait to

> die,

> > she was determined to live every day, " said Mandy.

> >

> > " It had to be Leigh's way or no way. She sat her GCSEs last year.

She knew

> > she would never go to college or get a job, she knew she was not

going to

> > live that long, but she wanted to sit and pass them because that

was the

> way

> > she was.

> >

> > " We were told when her condition, sub-acute sclerosing

panencephalitis,

> was

> > diagnosed that she might have, at the most, two years. We had her

for

> > another 18 months and for that we are grateful.

> >

> > " But although her going is something we have been prepared for,

something

> we

> > knew would one day happen, nothing can really prepare you for

watching

> your

> > beautiful child die. "

> >

> > Leigh spent her last three weeks in the Royal Hallamshire

Hospital,

> > Sheffield.

> >

> > 01 October 2004

> >

October 1, 2004

Here is another. I tried to find the full study on that 3 year old

boy, but cannot find it. The way it reads it seems definite he had

the vaccine.

Here is another I just found. Of course it states because of the

vaccine the rates dropped. But here is an interesting paragraph.

http://pmj.bmjjournals.com/cgi/content/full/78/916/63

Widespread immunisation has produced greater than 90% reduction in

the incidence of SSPE in developed nations.17 When the disease occurs

in vaccinated children, it is thought to result from a subclinical

measles infection that occurred before the age of 1 year, when

immunisation is usually begun. There is no evidence to suggest that

attenuated vaccine virus is responsible for sporadic cases of SSPE.1

> > If the vaccine can cause this, that should have been mentioned in

> the

> > article as well, now, shouldn't it?

> > Measles girl Leigh loses her battle

> >

> > > This is tragic, but SSPE can result from the vaccine...

> > >

> > > Love, light and peace,

> > >

> > > Sue

> > >

> > > " Learn from the mistakes of others--you can never live long

> enough to make

> > > them all yourself. " - Luther

> > >

> > > -------------------------------------------

> > >

> > http://www.barnsleytoday.co.uk/ViewArticle2.aspx?

> SectionID=86 & ArticleID=8645

> > > 52

> > >

> > > Measles girl Leigh loses her battle

> > >

> > > A WOMBWELL teenager who developed a fatal illness after

catching

> measles

> > as

> > > a baby has died.

> > >

> > > Leigh Wraith, aged 17, died from the rare degenerative brain

> disorder

> > SSPE,

> > > which develops years after the original measles infection.

> > >

> > > Today, as her family struggled to come to terms with their

loss,

> mum Mandy

> > > urged all parents of young children to ensure they are properly

> vaccinated

> > > against the childhood infection.

> > >

> > > " Leigh got measles when she was 18 months old, before the MMR

> vaccine was

> > > available. I don't want to preach to other parents, but if they

> had seen

> > > happen to their child what we watched with Leigh they would not

> hesitate,

> > > they would have their child vaccinated, " said Mandy, aged 38,

of

>

> > > Road, Wombwell.

> > >

> > > " People worry about a possible link to autism. That link has

not

> been

> > proven

> > > but the condition Leigh developed, even though it is one chance

> in a

> > > million, has been proved. We know our daughter has died because

> she caught

> > > measles. "

> > >

> > > Leigh, who was only diagnosed with the fatal condition three

> years ago,

> > knew

> > > it would kill her. It was something she had lived with since

> being told on

> > > her 16th birthday.

> > >

> > > She had even planned her own funeral, telling her parents Del

and

> Mandy

> > > exactly what coffin, music and readings she wanted at the

service.

> > >

> > > " Leigh dug her heels in, she wasn't going to sit in corner and

> wait to

> > die,

> > > she was determined to live every day, " said Mandy.

> > >

> > > " It had to be Leigh's way or no way. She sat her GCSEs last

year.

> She knew

> > > she would never go to college or get a job, she knew she was

not

> going to

> > > live that long, but she wanted to sit and pass them because

that

> was the

> > way

> > > she was.

> > >

> > > " We were told when her condition, sub-acute sclerosing

> panencephalitis,

> > was

> > > diagnosed that she might have, at the most, two years. We had

her

> for

> > > another 18 months and for that we are grateful.

> > >

> > > " But although her going is something we have been prepared for,

> something

> > we

> > > knew would one day happen, nothing can really prepare you for

> watching

> > your

> > > beautiful child die. "

> > >

> > > Leigh spent her last three weeks in the Royal Hallamshire

> Hospital,

> > > Sheffield.

> > >

> > > 01 October 2004

> > >

October 1, 2004

Sorry for the horrible formating - copies from a pdf file. This claims to

show that it was other than a measles vaccine strain causing this higher

than normal rate of SSPE, but it remains that many more vaccinated than

unvaccinated children were getting SSPE.

******************************************************8

Journal of Medical Virology 68:105–112 (2002)

Molecular Analysis of Measles Virus Genome Derived

From SSPE and Acute Measles Patients in Papua,

New Guinea

Kenji Miki,1,2* Katsuhiro Komase,2 S. Mgone,3 Ryuta Kawanishi,1,2

Masumi Iijima,2

Joyce M. Mgone,4 G. Asuo,4 P. Alpers,3 Toshiaki Takasu,1,5 and

Tomohiko Mizutani1

1Department of Neurology, Nihon University School of Medicine, Tokyo, Japan

2Division of Research and Development, Research Center for Biologicals, The

Kitasato Institute, Tokyo, Japan

3Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea

4Goroka Base General Hospital, Papua New Guinea

5University Research Center, Nihon University, Tokyo, Japan

A very high annual incidence of 56 per million

population below the age of 20 years for subacute

sclerosing panencephalitis (SSPE) has been

reported from Papua New Guinea (PNG). In a

more recent study, we have confirmed this unusual

high incidence for Eastern Highlands

Province (EHP) of PNG. In the study, it was

observed that the vaccination rate among SSPE

patients registered at Goroka Base General

Hospital (GBGH) in EHP was higher than that of

other infants in the province in recent years. To

identify the measles virus (MV) responsible for

SSPE in EHP, sequence analysis of hypervariable

region of the N gene was performed from 13 MV

genomes: 2 amplified from clinical specimens of

SSPE patients and 11 from acute measles patients.

In2 cases amongthe 11withacutemeasles,

nucleotide sequence of the entire H gene derived

from isolated viruses was determined. Both

nucleotide sequence and phylogenetic tree

analyses showed that the amplified MV cDNAs

were closely related to one another and belonged

to the D3 genotype though they were different

from any previously reported MV sequences.

No genome sequences of vaccine strains were

detected. These findings suggest that the MV

strains prevailing in the highlands of PNG belong

to genotype D3 of the MV and this wildtype

MV rather than the vaccine strains was

likely to be responsible forSSPEin these patients.

J. Med. Virol. 68:105–112, 2002.

2002 Wiley-Liss, Inc.

KEY WORDS: RT-PCR; genomic variability;

phylogenetic tree analysis; nucleoprotein;

hemagglutinin

INTRODUCTION

Subacute sclerosing panencephalitis (SSPE) is a rare

late complication of measles virus (MV) infection.

Before the extensive use of measles vaccine in industrialized

nations, the annual incidence of SSPE was

reported to range from 0.24 to 1.00 cases per million

population [soffer et al., 1976; CDC, 1982; Dyken,

1985]. The prevalence of SSPE has been estimated as

2.4 to 12.5 per 100,000 cases of measles [Dyken, 1985;

Okuno et al., 1989], and the female to male ratio to vary

from1:1.8 to 1:2.3 [Dyken, 1985; Okuno et al., 1989].

SSPE usually occurs 6 to 7 years after MV infection,

and individuals who have measles before the age of

2 years are at a higher risk of developing SSPE

[Jabbour et al., 1972]. The majority of SSPE patients

manifest neurological symptoms before the age of

10 years with a typical clinical picture that consists of

four stages. The first stage presents with behavioral

changes and intellectual deterioration. This progresses

into the second stage, which is characterized by the appearance

of myoclonic jerks, pyramidal, extrapyramidal

Grant sponsor: Ministry of Education, Science and Culture of

Japan Grants for International Research Projects; Grant numbers:

08041183, 16044322, 11694333; Grant sponsor: Nihon

University Grants for International Scientific Research; Grant

numbers: DC 96004, DC 97002; Grant sponsor: The Ministry of

Health and Welfare of Japan Grants for Specified Disease

Investigation and Research Projects—Slow Virus Infection

Research for 1996–2001.

*Correspondence to: Dr. Kenji Miki, Department of Neurology,

Nihon University School of Medicine, 30-1 Oyaguchikami-machi,

Itabashi-ku, Tokyo 173-8610, Japan.

E-mail: hippocam@...

Accepted 5 February 2002

DOI 10.1002/jmv.10176

Published online in Wiley InterScience

(www.interscience.wiley.com)

2002 WILEY-LISS, INC.

and cerebellar signs, and cortical blindness. Dementia

develops in the third stage, which deteriorates into

the fourth stage in which patients develop decerebrate

rigidity, followed by death within 1 to 3 years after the

onset of SSPE [Jabbour et al., 1975].

A previous study in Papua New Guinea (PNG)

identified 87 SSPE cases at six hospitals (four in highlands

and two in coastal provinces) during the period

from September 1988 to April 1991 by demonstration of

high-titre measles antibody in their cerebrospinal

fluids (CSF). Forty-seven of them were diagnosed in

1990. The population below 20 years of age for the

provinces of origin of the SSPE cases in 1990 (50% of

the total population) was 841,326. In the report, the

annual incidence of SSPE in the study provinces was

estimated to be 56 per million population below the age

of 20 years in 1990 [Lucas et al., 1992]. More recently

basing on progressive neurological disorder with

positive measles antibody in cerebrospinal fluid and

the presence of myoclonic jerks, we have estimated a

higher annual incidence of SSPE in EHP between 1997

and 1998 [Takasu et al., manuscript submitted]. Among

the 34 children with SSPE in a provisional progress

note of the mentioned study 15 (44%) of them (including

10 with documentation) had a positive history of

measles vaccination in comparison with 35% immunization

rate for 9-month-old infants in EHP in recent

years [Takasu et al., 1999]. The measles immunization

rates for EHP were 16% in 1993, 7% in 1994, 37% in

1995, 71% in 1996, 29% in 1997, and 54% in 1998 [PNG

Department of Health Promotive and Preventive

Health Services, 1998]. Several factors have been

postulated as the cause of this high incidence of SSPE

in PNG, including genetic predisposition, environment

factors, and low measles vaccination coverage. Higher

vaccination coverage among SSPE patients than in

non-SSPE cases raises the possibility that the vaccines

in use are either ineffective in preventing SSPE or are

responsible for the condition. Total annual hospital

admissions for measles is the only reliable information

on measles morbidity that is available in PNG. Measles

hospital admissions have increased 12-fold between

1963 and 1981, resulting in the introduction of mass

immunization in 1982. Between 1981 and 1989 measles

admissions have fluctuated widely. After 1993, the

number of admission decreased steadily to the lowest

level in 1998 that was similar to that of 1963 [PNG

Department of Health, 1986, 1991; PNG Department of

Health Promotive and Preventive Health, 1998]. The

rate of total admission for measles per 100,000 population

between 1990 and 1994 was 59.6 in five highland

regions (Southern Highlands, Enga, Western Highlands,

and Simbu provinces and EHP) and 39.6 in the

entire country; the total population in 1990 being

300,648 in EHP and 3,607,954 in entire PNG [PNG

Department of Health, 1996]. GBGH experienced

measles epidemics in 1985, 1988, between 1992 and

1993, and between 1998 and 1999 [Coakley et al., 1991;

Mgone et al., 2000]. At GBGH measles illness among

children under the age of 1 year has been common

among hospital cases [Coakley et al., 1991; Mgone et al.,

2000] and was also common among the SSPE patients

in the current study (Mgone et al., manuscript in

preparation).

MV is a negative-sense RNA virus that belongs to the

Morbillivirus genus in the Paramyxoviridae family.

MV spreads by budding and fusion and comprises six

structural proteins, namely, the nucleoprotein (N),

phosphoprotein (P), matrix protein (M), fusion protein

(F), hemagglutinin protein (H), and large protein (L).

SSPE is caused by MV, which has a gene mutation of

certain virion proteins such as M, H, and F. These

proteins are necessary both for alignment of the virus

along the host-cell plasma membrane and for subsequent

budding and release of the virus from the host

cell. Defects in these proteins of MV or some host

factors, or both may cause the prolonged persistence of

MV infection. The precise mechanism of SSPE pathogenesis

is not fully established, although accumulated

evidences suggest that infecting viruses are not eliminated

by the immune mechanism of the hosts and

persist in infected cells, spreading from cell to cell and

eventually leading to the development of SSPE [

and Bellini, 1996].

In the current study, we amplified part of the N gene

and the entire H gene of MV genomes from clinical

specimens of SSPE patients and acute measles patients

as well as from MVs isolated from acute measles patients

in PNG using reverse-transcriptase polymerase

chain reaction (RT-PCR) method, and compared the

nucleotide sequences with those of wild MV strains

circulating in other parts of world and vaccine strains.

In addition, phylogenetic tree analyses were performed

based on the sequences of both the N and H genes by

using the nomenclature recommended by the World

Health Organization (WHO) [2001]. This is the first

report on the characterization of MV from PNG.

MATERIALS AND METHODS

Specimens

Based on clinical features and positiveCSFand serum

MV antibodies, 25 children were diagnosed as having

SSPE between March 1997 and April 1998 at GBGH

[Takasu et al., 1998]. CSF and peripheral blood mononuclear

cells (PBMC) specimens were collected from 19

SSPE patients aged between 8 and 16 years. Between

June 1999 and October 1999, throat swabs (TS) were

collected from14patients with typical clinical features of

acute measles aged between 7 months and 6 years. The

TS specimens were collected within 2 days after onset of

measles rash. The PBMC were separated from 3 ml of

heparinized venous blood using ficoll-hypaque centrifugation

and washed at least five times in phosphatebuffered

saline (PBS).TheTSwassuspended in1mlPBS

and specimens frozen at 808C until used.

Virus Isolation

B95a cells were grown in RPMI 1640 medium supplemented

with 5% fetal calf serum (FCS) in 12-well

106 Miki et al.

plates; 100 ml of the TS or PBMC was inoculated in

confluent B95a cells and maintained in RPMI 1640

supplemented with 1% FCS in 5% CO2 incubator at

32.58C. Two to four days after inoculation, cultures

forming syncytia were centrifuged and cell pellets and

supernatants recovered and frozen at 808C until used.

RNA Extraction

Two hundred microliters each of CSF, TS, PBMC, or

supernatant of virus culture were used for total RNA

extraction using Trizol LS (Gibco BRL, Gaithersburg,

MD) according to the manufacturer’s recommended

protocol. The extracted RNA was dissolved in 20 ml of

diethylpyrocarbonate (DEPC)-treated water. RNA

solution was frozen at 808C until used.

RT-PCR for Hypervariable Region of N Gene

To amplify the hypervariable region of the N gene

(Nv region) of the MV genome from clinical specimens,

four PCR primers (PNG MF1160 50-GAAACTCCATGGGAGGTTTGAAC-

30, PNG MF1186; 50- GGCCGATCTTACTTTGATCCAGC-

30, PNG MR1692; 50- AGATGTTGTTCTGGTCCTCGGCCTC-

30, and PNG MR1705 and

50- GGGTAGGCGGATGTTGTTCT-30) were designed

based on the nucleotide sequence of the Edmonston

strain [ et al., 1991; WHO, 2001]. The cDNA

synthesis using ReverTra Ace reverse transcriptase

(TOYOBO, Tokyo, Japan) and first PCR using KOD

Dash DNA polymerase (TOYOBO, Tokyo, Japan) was

carried out with primers PNG MF1160 and PNG

MR1705 to produce a 546 base pair (bp) fragment.

Then nested PCR was performed with primers PNG

MF1186 and PNG MR1692 that yielded a 506 bp. The

first PCR was performed using 30 cycles of 10 sec at

988C, 5 sec at 558C, and 20 sec at 748C, whereas the

second PCR was performed with 30 cycles of 10 sec at

988C, 5 sec at 608C, and 20 sec at 748C. The PCR

products were electrophoresed through 1.5% agarose

gel and specific bands excised. The bands were then

purified and sequenced directly in both directions with

primers at 300–350 base intervals by using an automated

nucleotide analyzer (377 DNA sequencer)

(Applied Biosystems, City, CA).

RT-PCR for the Entire H Gene

Synthesis of the entire H gene cDNA from the

supernatants of isolated MV infected cells and ampli-

fication by PCR was performed with primers PNG

MF7207 (50-GCATCAAGCCCACCTGAAATTATCTCC-

30) and PNG MR9608 (50-GCCGTGAGTTAGTGTCCCTTAAGCATTG-

30) by using ReverTra Ace reverse

transcriptase and KOD Dash DNA polymerase. PCR

parameters used were 40 cycles of 10 sec at 988C, 5 sec

at 658C, and 1 min at 748C. Amplified 2,458 bp DNA

fragments that contained the entire H gene were cloned

into pUC18 plasmid. Nucleotide sequence was determined

in both directions with primers constructed at

300–400 intervals along the H gene sequence.

To minimize cross contamination, pasteurized filtered

tips and pipettes were used during all steps of RTPCRs.

Solutions and reagents such as enzyme, enzyme

buffers, dNTPs, and primers were subdivided into

small aliquots and discarded after single use. All manipulations

were done on a in clean bench and in every

PCR multiple negative controls were included.

Phylogenetic Analysis

Nucleotide alignment and phylogenetic distance

analyses were performed with a ClustalW [

et al., 1994] by the neighbor-joining algorithm as unrooted

trees tested with 10,000 bootstraps. All phylogenetic

trees were drawn using the TreeView software

1.5.2. Referred strains used for genetic analysis in this

study are shown in Table I. The sequences obtained in

this study were compared with those available from

GenBank and will appear in GenBank nucleotide sequence

databases with accession numbers AB075200 to

AB075214.

RESULTS

RT-PCR and Sequencing of SSPE Specimens

Among the CSF and PBMC specimens collected from

the 19 SSPE patients, it was possible to amplify the Nv

region of the MV genome from PBMC of two patients

who had been previously vaccinated. No MV genome

was detected from CSF specimens. The first among

these was a 4-year-old girl who came from Western

Highlands Province (WHP) who had been vaccinated

twice, first at the age of 4 and then at 13 months (22

September 1993 and 14 June 1994, respectively). She

had no history of measles infection. She was brought to

GBGH on 18 September 1997 for abnormal myoclonic

movement. She was continent and able to walk but

unsteadily and unable to speak. Measles antibodies

were positive in both serum and CSF. She was diagnosed

as having SSPE Jabbour stage II. The second

patient was a 4-year-old boy who came from Simbu

Province presenting with a history of being vaccinated

at the age of 6 and 9 months (27 May and 2 September

1993, respectively) and he had a documented history of

measles infection at 6 month (5 May 1993). He presented

at GBGH on 17 September 1997 with aggressive

behavior and falling attacks. He had abnormal myoclonic

movements and unsteady gait, but clear speech.

An electroencephalogram recorded characteristic periodic

synchronous discharges. Measles antibodies were

positive in both serum and CSF and he was diagnosed

as having SSPE Jabbour stage II.

cDNA nucleotide sequence analysis from both

patients revealed novel sequences that located near

genotype D3 of MV (Fig. 1). These sequences that were

closely related to each other though not identical were

named MVs/Goroka.PNG/38.97 SSPE (obtained from

the first patient) and MVs/Goroka.PNG/39.97 SSPE

from the second. Genome sequences of the Edmonston-

Zagreb and Schwarz strains, both located in genotype A

Measles Virus Genome in Papua New Guinea 107

known to have been used for immunization in PNG,

were not detected.

RT-PCR and N Gene Sequencing

of Acute Measles Specimens

It was possible to amplify the Nv sequences from 11

TS specimens of the 14 acute measles patients. Among

the 11 specimens, three sequences each (MVs/Goroka.

PNG/42.99/1, MVs/Goroka.PNG/43.99/3, and MVs/

Goroka.PNG/43.99/5, and MVs/Goroka.PNG/42.99/3,

MVs/Goroka.PNG/43.99/1, and MVs/Goroka.PNG/

43.99/4) and two (MVs/Goroka.PNG/42.99/2 and MVs/

Goroka.PNG/43.99/2) were identical to each other in

them, but the other three sequences (Mvi/Goroka.PNG/

26.97, Mvi/Goroka.PNG/42.99/4, and MVs/Goroka.

PNG/42.99/5) were not identical to each other nor

to any sequences other than their own, so the 11 were

classified into six groups. All 11 sequences resembled

each other and were positioned close to genotype D3

similar to the two MV genomes that were derived from

SSPE patients. However, they were not identical to

neither of the two (Fig. 1). Vaccine-strain sequences

were not detected.

Virus Isolation and H Gene Sequencing

Two MVs, named Mvi/Goroka.PNG/26.99 and MVi/

Goroka.PNG/42.99, were isolated from 14 TS using

B95a cells. The virus-infected cells were reacted with

anti-MV antibody. The entire H sequences were ampli-

fied from culture of the viruses infected cells. Sequence

analysis showed that these two H sequences were

similar to each other and also located in the neighborhood

of genotype D3 like the Nv region (Fig. 2).

Phylogenetic Analysis

The analysis and construction of the phylogenetic

tree of the two regions (Nv and H) were performed

based on the standard strains from WHO measles-

TABLE I. MV Strains of the Present Study and Sequence References*

Genotype Strain

Accession Number

Nv H Material

This study MVs/Goroka.PNG/38.97 SSPE AB075213 PBMC

This study MVs/Goroka.PNG/39.97 SSPE AB075214 PBMC

This study MVi/Goroka.PNG/26.99 AB075202 AB075200 TS

This study MVs/Goroka.PNG/42.99/1 AB075203 TS

This study MVs/Goroka.PNG/42.99/2 AB075204 TS

This study MVs/Goroka.PNG/42.99/3 AB075205 TS

This study MVi/Goroka.PNG/42.99/4 AB075206 AB075201 TS

This study MVs/Goroka.PNG/42.99/5 AB075207 TS

This study MVs/Goroka.PNG/43.99/1 AB075208 TS

This study MVs/Goroka.PNG/43.99/2 AB075209 TS

This study MVs/Goroka.PNG/43.99/3 AB075210 TS

This study MVs/Goroka.PNG/43.99/4 AB075211 TS

This study MVs/Goroka.PNG/43.99/5 AB075212 TS

A Edmonston-wt.USA/54a U01987 U03669

B1 Yaounde.CAE/12.83a U01998 AF079552

B2 Libreville.GAB/84a U01994 AF079551

B3 New York.USA/77a L46753 L46752

B3 Ibadan.Nie/97/1a AJ232203 AJ239133

C1 Tokyo.JPN/84/Ea AY043459 AY047365

C2 land.USA/77a M89921 M81898

C2 Erlangen.DEU/90a X84872 Z80808

D1 Bristol.UNK/74a D01005 Z80805

D2 Johannesburg.SOA/88/1a U64582 AF085198

D3 Illinois.USA/89/1a U01977 M81895

D4 Montreal.CAN/89a U01976 AF079554

D5 Palau.BLN/93a L46758 L46757

D5 Bangkok.THA/93/1a AF079555 AF009575

D6 New Jersey.USA/94/1a L46750 L46749

D7 .AUS/16.85a AF243450 AF247202

D7 Illinois.USA/50.99a AF037020 AY043461

D8 Mabchester.UNK.30.94a AF280803 U29285

E Goettingen.DEU/71a X84879 Z80797

F MVs/Madrid.SPA/94 SSPEa X84865 Z80830

G1 Berkeley.USA/83a U01974 AF079553

G2 Amsterdam.NET/49.97a AF171232 AF171231

G3 MVs/.AUS/24/99a AF353622 AF353621

H1 Hunan.CHN/93/7a AF045212 AF045201

H2 Beijing.CHN/94/1a AF045217 AF045203

*PBMC, peripheral blood mononuclear cells; TS, throat swab; MVs,measles

virus sequence; Mvi, measles

virus isolate.

aWHO, 2001.

108 Miki et al.

strain bank [WHO, 2001]. The phylogenetic tree both in

the Nv (Fig. 1) and the H regions (Fig. 2) showed that

sequences were located close to each other in nucleotide

divergence and nearby genotype D3. The maximum

nucleotide divergence between Mvi/Goroka.PNG/26.99

and Illinois.USA/89 sequences on the phylogenetic tree

of the Nv region was 2.74% (Fig. 1) and between MVi/

Goroka.PNG/42.99/4 and Illinois.USA/89 on the phylogenetic

tree of the H gene was 1.88% (Fig. 2). Recently,

WHO proposed the molecular biological criteria for

identification of a new genotype that requires minimum

nucleotide divergences of 2.5% for COOH-terminus of N

and 2.0% for full length H region from the next most

closely related strain. Therefore according to the

criteria recommended by WHO the MVs prevailing in

PNG belong to genotype D3 and not a new genotype.

DISCUSSION

The incidence of SSPE in PNG, especially in the

EHP, remains high. The cause of this high incidence is

unclear. Properties of the prevailing MV may have

relevance to such a high incidence. In addition, the

vaccination rate among SSPE patients at GBGH was

higher than the average rate of other infants in EHP in

recent years. This raised the question of whether the

vaccine used was ineffective or was responsible for the

SSPE. To clarify the cause of this high incidence of

SSPE in EHP, we have analyzed the nucleotide sequence

of the MV prevailing in the eastern highlands of

PNG and compared it with that of the MV vaccine

strains and that of wild MVs from other parts of the

world.

Fig. 1. Unrooted phylogenetic tree relationships based on the C terminal 456

nt of the N gene protein

cording region in MV. The tree was drawn by neighbor-joining algorithm using

the ClustalW and

TreeView 1.5.2. Representative sequences of 6 groups of 11 acutemeasles were

cited. Strain abbreviations

are described in Table I. The scale indicates 1% nucleotide divergence.

Measles Virus Genome in Papua New Guinea 109

In the current study, we established a highly sensitive

RT-PCR method that could amplify theMVgenome

cDNA directly from the clinical samples, especially of

SSPE patients. Since there have been only a very few

previous studies that report successful detection of the

MV genome from clinical samples such as PBMC or

CSF of SSPE patients [Nakayama et al., 1995; Vardas

et al., 1999], the present detection of the MV genome

from SSPE patients is significant. However, we have

been able to detect the MV genome only from PBMC

specimens and not from CSF. This may suggest that

concentration of SSPE virus in PBMC is higher than in

CSF as was suggested previously in one SSPE patient;

single RT-PCR could amplify genome in PBMC but not

in CSF, while nested RT-PCR could amplify genome in

CSF [Nakayama et al., 1995]. Otherwise quality of CSF

may be too low because of denaturation during preservation

or transportation of the samples to detect

small amount of MV genome. The nucleotide sequence

of the amplified genome cDNAs of Nv were determined

by direct sequencing, which has the advantage of

minimizing possible errors in RT-PCR [Rima et al.,

1997] and genome variations that may occur during

virus culture. In fact the 2 Nv sequences from the SSPE

patients were not identical to each other and neither of

them were identical to any of the six Nv sequences from

the acute measles patients (Fig. 1) nor to any that have

been reported before.

Although MV is a monotypic virus, sequence analysis

has shown that distinct lineages of wild-type viruses

exist and co-circulate. Most of the genotyping has

been carried out by sequencing the genes that code for

Fig. 2. Unrooted phylogenetic tree relationships based on the sequence of

the protein coding region of

the H gene (1,854 nt) in MV. The tree was drawn by neighbor-joining

algorithm using the ClustalW and

TreeView 1.5.2. Strain abbreviations are described in Table I. The scale

indicates 0.5% nucleotide

divergence.

110 Miki et al.

N and/or H proteins, which are the two most variable

genes of the MV. The genetic variability of MV has been

observed worldwide, and 21 genotypes grouped in eight

clades (A–H) are recognized as reference strains.

Although any of the different genotypes are not geographically

restricted, some appear to be predominant

in certain areas and are regarded as endemic in these

areas [Rima et al., 1995]. This distribution also varies

temporally [Nakayama et al., 1995; Yamaguchi, 1997].

We analyzed the 13 sequences of Nv region derived

from 11 acute measles patients in 1999 and 2 SSPE

patients. These sequences were very similar to each

other and all were genotype D3 (Fig. 1). The 11 sequences

derived from acute measles patients were

assorted into six sequences, which were very similar

but not identical to each other. Since the clinical

specimens were collected in the same hospital in EHP

in 1999 it is likely that both the SSPE and the acute

measles patients were infected through the same

transmission chain. On the other hand, the MVs/

Goroka.PNG/39.97 SSPE strain must have originated

from the stock of MV that prevailed in 1993. The SSPE

from whom this sequence was obtained had a positive

history of contracting measles virus at that time.

Sequence results mean that the causative virus strain

to the SSPE patient was similar to those that were

circulating in 1999 though therewas an interval of about

6 years. This implies that the MV strains in the highlands

of PNG may be fairly stable with low mutation

rates in comparison with those that have been described

from other areas [Nakayama et al., 1995; Jin et al., 1997;

Yamaguchi, 1997]. Alternatively, it is also possible that

the same stock that had prevailed about 6 years before

may have reemerged in 1999. As PNG is a relatively

isolated country, there is a little exchange with people

from overseas. Its high mountains segregate the highlands

from other areas of PNG. People living in PNG,

especially in the highlands, do not get around very

much because of poor infrastructure. Such an environment

may account for the stability of MV genome.

Ideally, molecular epidemiologic studies of MV

should include surveys of viral genetic groups from all

areas of the world and especially from developing

countries. However, developing countries are grossly

underrepresented in current studies concerning the

molecular epidemiology of MV, although these countries

account for the majority of measles patients and

chains of transmission. Molecular epidemiological

studies like ours will prove to be useful not only in

the surveillance of MV but also in the understanding of

SSPE.

Two MV genomes obtained from SSPE patients who

had histories of MV vaccination were similar to those of

the wild-type MV prevailing in 1999 and not to vaccine

strains. This result means that wild-type MV rather

than vaccine strains may be responsible for SSPE in

EHP. We noticed that many of the children who

developed SSPE had a history of immunization against

measles. It is likely that this may be due to the vaccine

used being ineffective because of loss of potency caused

by an inadequate cold-chain system. Such problems are

very common in poor-resource settings, especially with

inadequate infrastructure and personnel [bass, 1993].

It is also possible that the children were infected before

being vaccinated and that these infections were not

diagnosed or were misdiagnosed. At present, the risk

factors responsible for this high incidence of SSPE in

PNG are not well understood. Detailed virological,

immunological, and epidemiological studies will be

necessary. Such virological studies may include examination

of fresh brain tissues from autopsies.

ACKNOWLEDGMENTS

We thank all our patients and their parents as well as

the PNG Institute of Medical Research and GBGH staff

who were involved in this study.

REFERENCES

Bass AG. 1993. Vaccine in the national immunization programme.

PNG Med J 36:141–157.

CDC. 1982. Subacute sclerosing panencephalitis surveillance.MMWR

Weekly 31:585–588.

Coakley KJ, Coakley CA, Spooner V, TA, Javati A, Kajoi M.

1991. A review of measles admissions and deaths in the paediatric

ward of Goroka Base Hospital during 1989. PNG Med J 34:6–12.

Dyken PR. 1985. Subacute sclerosing panencephalitis. Current status.

Neurol Clin 3:179–196.

DE, BelliniWJ. 1996. Measles virus. In: Fields BN, Knipe DM,

Hensky PM, Chanock RM, Hirsch MS, Melnick JL, Monath TP,

Roizman B, editors. Fields Virology, 3rd edition. Philadelphia:

Lippincott-Raven. p 1267–1312.

Jabbour JT, Duenas DA, Sever JL, Krebs HM, Horta-Barbosa L. 1972.

Epidemiology of subacute sclerosing panencephalitis (SSPE): a

report of the SSPE registry. JAMA 220:959–962.

Jabbour JT, Duenas A, Modlin J. 1975. SSPE: clinical staging, course

and frequency, abstracted. Arch Neurol 32:493–494.

Jin L, Brown DW, Ramsay ME, Rota PA, Bellini WJ. 1997. The

diversity of measles virus in the United Kingdom, 1992–1995.

J Gen Virol 78:1287–1294.

Lucas KM, RC, Rongap A, Rongap T, Pinai S, Alpers MP.

1992. Subacute sclerosing panencephalitis (SSPE) in Papua New

Guinea: a high incidence in young children. Epidemiol Infect

108:547–553.

Mgone JM, Mgone CS, Duke T, D, Yeka W. 2000. Contral

measures and outcome of the measles epidemic of 1999 in Eastern

Highlands Province. PNG Med J 43:91–97.

Nakayama T, Mori T, Yamaguchi S, Sonoda S, Asamura S, Yamashita

R, Takeuchi Y, Urano T. 1995. Detection of measles virus genome

directly from clinical samples by reverse transcriptase-polymerase

chain reaction and genetic variability. Virus Res 35:1–16.

Okuno Y, Nakao T, Ishida N, Konno T, Mizutani H, Fukuyama Y,

Sato T, Isomura T, Ueda S, Kitamura I, Kaji M. 1989. Incidence of

subacute sclerosing panencephalitis following measles and

measles vaccination in Japan. Int J Epidemiol 18:684–689.

Papua New Guinea Department of Health. 1986. The National Health

Plan, 1986–1990. Port Moresby: Department of Health.

Papua New Guinea Department of Health. 1991. The National Health

Plan, 1991–1995. Port Moresby: Department of Health.

Papua New Guinea Department of Health. 1996. The National Health

Plan, 1996–2000. Port Moresby: Department of Health.

Papua New Guinea Department of Health Promotive and Preventive

Health Services. 1998. Routine immunization results for 1990–

1998. Port Moresby: Department of Health.

Rima BK, Earle JA, Yeo RP, Herlihy L, Baczko K, ter Meulen V,

Carabana J, Caballero M, Celma ML, Fernandez-Munoz R. 1995.

Temporal and geographical distribution of measles virus genotypes.

J Gen Virol 76:1173–1180.

Rima BK, Earle JA, Baczko K, ter Meulen V, Liebert UG, Carstens C,

Carabana J, Caballero M, Celma ML, Fernandez-Munoz R. 1997.

Sequence divergence of measles virus hemagglutinin during

Measles Virus Genome in Papua New Guinea 111

natural evolution and adaptation on cell culture. J Gen Virol

78:97–106.

Soffer D, Rannon L, Alter M, Kahana E, Feldman S. 1976. Subacute

sclerosing panencephalitis: an epidemiological study in Israel. Am

J Epidemiol 103:67–74.

Takasu T, Mgone JM, Mgone CS, Miki K, Komase K, Namae H,

Kokubun Y, Nishimura T, Marcus J, Asuo P, Alpers MP. 1998. A

continuing high incidence of sub-acute sclerosing panencephalitis

(SSPE) in the Eastern Highlands of Papua New Guinea. Abstracts

of the Medical Societyof Papua New Guinea. 34th Annual Medical

Symposium, 7–11 September. p 41–42 (Abstract).

Takasu T, Komase K, Miki K, Kawanishi R, Mgone CS, Alpers MP,

Mgone JM, Marcus J, Asuo GP. 1999. Subacute sclerosing

panencephalitis (SSPE) in Papua New Guinea (PNG): epidemiology

and virus analysis. Part 1 Characteristics of measles

immunization, age at measles, length of incubation period and

age at SSPE onset among SSPE patients and characteristics of

age at measles among measles patients, in Goroka area, Eastern

Highlands Province. Annual Report of the Slow Virus Infection

Research Committee, The Ministry of Health and Welfare of Japan

(Chairman: Kitamoto T.), p 38–43 (in Japanese with English

Abstract).

MJ, Godfrey E, Baczko K, ter Meulen V, Wild TF, Rima BK.

1991. Identification of several different lineages of measles virus.

J Gen Virol 72:83–88.

JD, Higgins DG, Gibson TJ. 1994. CLUSTAL W:

improving the sensitivity of progressive multiple sequence

alignment through sequence weighting, position-specific gap

penalties and weight matrix choice. Nucleic Acids Res 22:4673–

4680.

Vardas E, Leary PM, Yeats J, BadrodienW, Kreis S. 1999. Case report

and molecular analysis of subacute sclerosing panencephalitis in a

South African Child. J Clin Microbio 37:775–777.

World Health Organization. 2001. Standardization of nomenclature

for describing the genetic characteristics of the wild-type measles

viruses. Wkly Epidemiol Rec 76:242–247.

Yamaguchi S. 1997. Identification of three lineages of wild measles

virus by nucleotide sequence analysis of N, P, M, F, and L genes in

Japan. J Med Virol 52:113–120.

112 Miki et al.

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October 1, 2004

Subacute Sclerosing Panencephalitis in Perspective

CPSP resource article published September 2000

Principal investigator: W. Walop, PhD

Three different forms of infections in the central nervous system have been

associated with the measles virus: acute postinfectious encephalitis, acute

progressive infectious encephalitis (also known as measles inclusion body

encephalitis or MIBE) and subacute sclerosing panencephalitis (SSPE).1 The

postinfectious encephalitis is considered an autoimmune reaction, MIBE

appears as a direct attack by the virus on the brain cells, while SSPE is a

slow viral infection of the central nervous system, usually resulting in

death within months or years.2

Can measles vaccine cause MIBE?

From 1995 to 1998, no definite cases of SSPE were reported through the

Canadian Paediatric Surveillance Program (CPSP). In 1999, however, two

definite cases, as defined by very high serum and CSF IgG ratios in the

presence of typical clinical manifestations, were identified through the

CPSP.3

There also was a Canadian case report on MIBE caused by the vaccine strain

of the measles virus, published in 1999.4 An apparently healthy male infant

with no history of measles received measles-mumps-rubella vaccine at about

age one. Eight and a half months later he was diagnosed with MIBE and died

51 days after hospitalization. This disease is associated with

immunodeficiency and usually develops within one to seven months after

infection with the measles virus. On brain biopsy, measles antigens were

detected by immunohistochemical staining and confirmed by reverse

transcription polymerase chain reaction. They were identified as belonging

to the Moraten and Schwarz vaccine strains, and not to known genotype A

wild-type viruses. On further investigation it was found that the child had

an abnormality in the humoral arm of the immune system in the form of a

profound deficiency of CD8 cells as well as dysgammaglobulinemia.

The authors concluded that: " Most significant primary immunodeficiency

states in children will be detected before the age of MMR vaccination, and

for such children live virus vaccines should be avoided. Clearly, a serious

outcome such as occurred for this patient is an exceedingly rare event, and

this report should not lead to changes in current immunization practices. " 2

Is SSPE still current?

SSPE manifests itself as progressive mental deterioration, myoclonia, motor

disabilities, coma, and death.5 The average period between exposure and

onset of SSPE ranges from seven to twelve years, while the average age of

onset is nine years. Both laboratory findings and epidemiologic data have

linked SSPE with exposure to the measles virus. Before measles immunization,

SSPE was a rare complication of measles infection at 1 per 100,000 cases.5

Since the introduction of immunization programs, the incidence of SSPE

following measles infection has declined drastically to 0.06 per 1,000,000

in the U.S.2

A case-control study in Israel comparing Sephardic Jews and Arabs versus

Ashkenazic Jews identified the following risk factors for SSPE: early

measles infection, large family, overcrowding in the home, older age of the

mother, higher birth order, fewer years of schooling of the parents, fewer

cultural activities, and rural place of birth.6

Because SSPE is only one of a number of degenerative neurological diseases,

it requires a high level of diagnostic suspicion. It is very important that

all suspect cases be followed up with laboratory investigations to determine

a definite case of SSPE. Serum and CSF measles IgG antibody levels should be

determined. Actual titre values are preferred over more general terms such

as positive or negative. With the elimination of indigenous measles disease

in Canada, due to widespread measles immunization programs, it is essential

that brain tissue specimens be collected post-humously on all suspect cases

of SSPE for virus detection.

Brain biopsy material can be examined for measles virus RNA by reverse

transcription polymerase chain reaction. Subsequent DNA sequencing of the

viral nucleoprotein or hemagglutinin genes allows differentiation of vaccine

and wild-type measles strains.7 In Canada, the Viral Exanthemata Lab at the

Bureau of Microbiology performs vaccine versus wild-type strain

differentiation for measles, rubella and varicella-zoster viruses.

The following summary on SSPE was modified from the Pediatric Database

(PEDBASE) website,8 although for a definite IMPACT case of SSPE it is

essential to have detected measles virus antigen on a brain tissue biopsy.

What is needed to confirm a case of SSPE (PEDBASE)?

Pathogenesis:

Background

pathogenesis involves the accumulation of incomplete measles virus that

cannot be cleared by B or T cell mechanisms

measles genomes in SSPE are larger and contain multiple mutations

begins in cortical grey matter, progresses to subcortical grey and white

matter, then to lower structures

Pathology:

Intranuclear Inclusion Bodies

inflammation, necrosis, gliosis, and repair

panencephalitis involves cortical and subcortical grey and white matter and

blood vessels with an increasing number of glial cells

Clinical Features:

Clinical Course

First clinical stage – Behavioural change

insidious onset

subtle changes in behaviour and declining school work:

aggression

withdrawal

followed by overtly bizarre behaviour and dementia

occasional headache

Second clinical stage – Neurological change

seizures

myoclonic – symmetrical involving axial muscles

generalized tonic-clonic develop later

movement disorders

cerebellar ataxia, chorea, choreoathetosis, dystonia, progressive bulbar

palsy, spasticity

optic changes

chorioretinitis, macular pigmentation, optic atrophy, papilledema,

retinopathy

dementia progresses to stupor and coma in either flaccid or spastic

decorticate postures

Investigations:

Serology

IgG and IgM to measles virus

Cerebral Spinal Fluid

elevated IgG and IgM fractions to measles virus on oligoclonal

electrophoresis

normal cell count

normal or elevated total protein

Brain Biopsy

measles virus antigen

EEG

First Stage – moderate nonspecific slowing

Second Stage – episodes of " suppression-burst; " high amplitude slow and

sharp waves recur at intervals of 3-5 seconds on a slow background

Imaging Studies

CT/MRI

variable cortical atrophy and ventricular enlargement

normal study or single or multiple focal low-density lesions in the white

matter

Top of Page

Selected Literature Abstracts from Medline

TI: Adult-onset subacute sclerosing panencephalitis: case reports and

review of the literature

AU: Singer C; Lang AE; Suchowersky O

AD: Department of Neurology, University of Miami School of Medicine, FL

33136, USA.

SO: Mov Disord 1997 May;12(3):342-53

AB: Subacute sclerosing panencephalitis (SSPE) is mainly thought of as a

disorder of childhood and adolescence and may not be readily recognized when

presenting later in life. Prior reports have suggested that adult-onset SSPE

may have atypical features. We have added two cases to the existing

literature on adult-onset SSPE, compared them with a more classic juvenile

presentation, and extensively reviewed those reports that were published

after the etiological link with the measles virus had been established.

Adult-onset SSPE patients present at a mean age of 25.4 years (range 20-35

years). They have a higher proportion of either negative history of measles

exposure or undocumented history by the reporting authors. Those with

available history of measles exposure tend to have it either earlier

(younger than 3 years old) or later (after 9 years) than the usual childhood

measles infection. Where the primary infection is known, unusually long

measles-to-SSPE intervals have been documented, ranging from 14 to 22 years.

None of the cases followed measles vaccination. Visual symptomatology was

very frequent, with 8 of the 13 cases reviewed having a purely

ophthalmological presentation; only 2 patients presented with behavioral

changes. Although the course of the disease was progressive and fatal in the

majority, there appeared to be a higher rate of spontaneous remission as

compared with childhood-onset SSPE. Myoclonus, spastic hemiparesis,

bradykinesia, and rigidity were the predominant motor manifestations.

Neuropathology revealed cortical and subcortical gray matter involvement

preferentially of the occipital lobes, thalamus, and putamen. The importance

of recognizing the spectrum of potential presentations of SSPE and providing

an early diagnosis will increase as more effective treatments become

available.

TI: Measles virus in the brain.

AU: Norrby E; sson K

AD: Microbiology and Tumorbiology Center, Karolinska Institute, Stockholm,

Sweden.

SO: Brain Res Bull 1997;44(3):213-20

AB: Measles virus can give three different forms of infections in the

central nervous system. These are acute postinfectious encephalitis, acute

progressive infectious encephalitis, and subacute sclerosing panencephalitis

(SSPE). The postinfectious acute disease is interpreted to reflect an

autoimmune reaction. The acute progressive form of brain disease, also

referred to as inclusion body encephalitis, reflects a direct attack by the

virus under conditions of yielding cellmediated immunity. The late

progressive form of encephalitis (SSPE) has been extensively analyzed.

Recent molecular genetic studies have unravelled a range of mechanisms by

which a defective expression of either the matrix, the fusion, or the

hemagglutinin proteins may lead to viral persistence in brain cells under

conditions not allowing identification by immune surveillance mechanisms.

Many aspects of virus-cell interactions have been examined by use of explant

cultures of neuronal cells of human and animal origin. Some of the findings

are reviewed. Experimental animals, in particular rodents, have been used to

establish systems in which phenomena, pivotal to the evolution of acute as

well as persistent measles virus infections in the brain, can be studied. A

wide range of potentially important mechanisms has been highlighted and is

discussed. More recently, mice with genetic defects in immune functions were

used to evaluate consequences as to initiation and dissemination of virus

infection in the brain.

TI: Fulminating subacute sclerosing panencephalitis: case report and

literature review.

AU: PeBenito R; Naqvi SH; Arca MM; Schubert R

AD: Department of Pediatrics, Brookdale University Hospital and Medical

Center, Brooklyn, NY 11212-3198, USA.

SO: Clin Pediatr Phila 1997 Mar;36(3):149-54

AB: We describe a young urban boy with atypically fulminant subacute

sclerosing panencephalitis (SSPE). He had measles at 3 years of age despite

receiving measles immunization in infancy. The literature describing acute

SSPE is reviewed and summarized. This report reiterates the need to include

SSPE as a diagnostic possibility in acute encephalopathic processes. The

dismal prognosis of SSPE furtheremphasizes the need for measles vaccination

and revaccination of all children who are initially immunized at an age of

less than 15 months.

TI: Subacute sclerosing panencephalitis.

AU: Gascon GG

AD: Department of Neurology, Brown University, Rhode Island Hospital,

Providence, USA.

SO: Semin Pediatr Neurol 1996 Dec;3(4):260-9

AB: Subacute sclerosing panencephalitis (SSPE), a neurodegenerative disease

caused by a persistent " slow virus infection " with a mutated measles virus,

is endemic in much of the developing world. Its incidence will increase in

the USA, not only in immigrants, but also because of the 1988-1990 measles

epidemic. This report reviews the pathogenesis, clinical and laboratory

diagnosis, and future perspectives in treatment and prevention.

References

Norrby E, sson K. Measles virus in the brain. Brain Res Bull

1997;44:213-20.

Subacute Sclerosing Panencephalitis Surveillance – United States. MMWR

Weekly 1982;31(43):585-8.

Canadian Paediatric Surveillance Program. 1999 Results 1999:26-8.

Bitnun A, P, Durward A, et al. Measles inclusion-body encephalitis

caused by the vaccine strain of measles virus. Clin Infect Dis

1999;29:855-61

Redd SC, Markowitz LE, Katz SL. Measles vaccine. In: Plotkin SA, Orenstein

WA.(eds). Vaccines 3rd ed. Toronto: W.B. Saunders Company, 1999:222-66.

Zilber N, Kahana E. Environmental risk factors for subacute sclerosing

panencephalitis (SSPE). Acta Neurol Scand 1998;98:49-54

WHO. Standardization of the nomenclature for describing the genetic

characteristics of wild-type measles viruses. Weekly Epidemiological Record

1998;73:265-72

http://www.icondata.com/health/pedbase/files/SUBACUTE.HTM

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Be aware that SSPE is also linked with oral polio vaccine.

************************************************************

NEUROPROGRESSIVE DISEASE OF POSTINFECTIOUS

ORIGIN: A REVIEW OF A

RESURGING SUBACUTE SCLEROSING

PANENCEPHALITIS (SSPE)

Dyken*

The USA/International SSPE Registry, The Institute of Research in Childhood

Neurodegenerative Diseases, Mobile, Alabama

Subacute sclerosing panencephalitis (SSPE) is a progressive, essentially

untreatable, disease of the nervous system. When first described in the

20th Century, it was characterized more for its neuropathological features

than for its pathophysiology or cause. It was not until the 1960s that a

clear

relationship to the measles virus was established. It is now thought that

this

uncommon infectious encephalopathy is caused by a “slow,” altered or

persistent form of the wild measles virus which has harbored in the nervous

system for years. Then a “breakout” occurs and the more lytic and virulent

organisms produce the progressive and spreading inflammatory and destructive

lesions which are confined to the nervous system. Epidemiological

study of the disease confirms its relationship to measles. In the years

since

the development of national measles immunization programs, there has

been a dramatic decline in the incidence of measles exanthem and until

recently a corresponding decline in the incidence of SSPE. In recent years

there has been a mild to moderate increase in cases of SSPE as reported to

the USA/International SSPE Registry. As yet, there has not been a totally

effective treatment. The purpose of this paper is to give an overall review

on

SSPE and its relationship to measles. This review will include a prospectus

of

its history, considerations as to its etiology, correlation of

clinicopathological

features, and thoughts on the past and present epidemiology and treatment.

MRDD Research Reviews 2001;7:217–225.

Key Words: measles; subacute sclerosing panencephalitis; SSPE; slow

measles encephalopathy; subacute sclerosing leukoencephalitis; SSLE;

rubeolla

Subacute sclerosing panencephalitis (SSPE) is a progressive

disease of the nervous system. It is caused by a slow or

persistent measles virus. Once acquired, the virus harbors

in the nervous system for years and then breaks out to attack

neurons, glia, axons, myelin sheaths, and supporting elements.

The first clinicopathological effects are related to inflammation

of the neurons and glia of the cerebral cortex, producing mental

and behavioral symptomatology and, occasionally, epileptic seizures.

Irritative lesions are followed by destructive lesions and

dementia ensues. Pathoanatomical spread to the subcortical

white matter, basal ganglion and brain stem occur in a caudally

directed order. When the process reaches the subcortical white

matter, signs reflecting an inflammatory demyelination occur.

When the process reaches the basal ganglion, a characteristic

myoclonia, unique to this disease, develops. This is due to

irritation of this primitive motor system. Myoclonia lasts from a

few days to several months. It is progressive in repetitiveness,

frequency, and severity. With conversion of the irritative lesion

to a destructive one, the myoclonus then disappears only to be

replaced by more pronounced signs of motor loss, such as

rigidity and immobility. Further spread of the virus to the brain

stem is associated with loss of vegetative functions. Ultimately

death ensues, usually within 4 years after onset. This devastating

neuropathological disease is easily contrasted to the usual childhood

exanthem which has been called by the colloquial names

“red” and “seven day” measles and by the more scientific one,

rubeolla. This disorder has been known since antiquity and is

characterized by such a characteristic clinical presentation manifest

by fever and rash and mucus membrane and other systemic

as well as neurological manifestations that it needs little further

discussion here. Yet both diseases, in spite of the obvious contrasts,

are due to the same virus, although each is of a different

form.

In the 1960s, several important events highlighted the

relationship of SSPE and measles. In the late 1950s and 1960s

great advancements in our knowledge of measles occurred,

particularly in regards to understanding the basic structure and

function of the wild virion and in the correlation of this to a

better understanding of the clinical dynamics of measles exanthem.

A national immunization program against measles was

begun in the USA in 1963. At this time, great advancements

were being made in our knowledge about a whole new class of

diseases which were identified as slow or persistent viral infections.

In 1969, the measles or rubeolla virus was isolated, after

co-culture, from the brains of several patients with SSPE. At this

time in the US, a national disease registry for SSPE was also

founded. In the US, measles immunization has reached over

95% of the susceptible population and is judged to be over 95%

effective [Redd et al., 1999]. Consequently, measles exanthem

in this country has reached near elimination levels. Additionally,

SSPE has also declined in numbers. In the 1970s, the heyday of

SSPE in the United States, 40 to 50 cases of SSPE were reported

*Correspondence to: Dyken, The USA/International SSPE Registry,

c/o The Institute of Research in Childhood Neurodegenerative Diseases

(IRCND),

P.O. Box 70191, Mobile, AL 36670-0191. E-mail: pdyken@...

MENTAL RETARDATION AND DEVELOPMENTAL DISABILITIES

RESEARCH REVIEWS 7: 217–225 (2001)

to the USA SSPE Registry per year,

whereas in the late 1980s, an average of

only 1 to 2 cases was reported. This decline

in SSPE seemed directly related to

the corresponding decline in natural

measles. However, in the last few years,

an average of over 4 cases of SSPE has

been reported per year. Furthermore, in

the year 2000 alone, 24 cases of SSPE

were reported to the agency, with 13 of

them from the US. Such numbers represent

the highest number of cases reported

since 1976—the heyday of SSPE in this

country [Dyken and Papania, 2000]. The

resurgence of SSPE, in this country particularly,

indicates that this disease is not

a thing of the past, either in the US or the

world. Moreover, it justifies a fresh review

since certainly much more needs to

be learned about the disorder (Fig. 1).

HISTORICAL DEVELOPMENT

Zeman, in a classical presentation,

reflected on the etiology and pathogenesis

of the disorder which only then was

beginning to be called “subacute sclerosing

panencephalitis” [Zeman and Kolar,

1968]. Van Bogaert had previously used

the English terms “subacute sclerosing

leukoencephalitis” (la sclerose inflammatoire

de la substance blanche des hemispheres)

for this disease because of the

extensive demyelination that he observed

in his first published report in 1939 [Van

Bogaert and De Busscher, 1939]. In the

same year as van Bogaert’s first case, Pette

and Doring saw a similar pathology but

emphasized the involvement of the entire

brain and first suggested the term “panencephalomyelitis”

as more acceptable

[see Zeman and Kolar, 1968]. An American

general pathologist from Tennessee

had described the disease five years before

[Dawson, 1934]. Dawson published

an unusual finding of cellular inclusions

in several patients who were considered

to have an epidemic form of encephalitis

but were later considered to be examples

of SSPE. Dawson pointed out that the

pathology was quite unique and was very

suggestive of the findings usually associated

with herpes simplex. Yet he was

unable to culture any virus from the

specimens or to pass what he considered

to be infective material on to lower animals.

The reports by Dawson, van Bogaert

[van Bogaert et al., 1961] and Pette

and Doring were of key importance in

characterizing SSPE as a separate disease

in the then quagmire of childhood neurodegenerative

diseases. Yet, as Zeman

commented upon, neither of the above

scientists really first described the disease

we now call SSPE. It is very likely (I am

told the evidence of support was based

upon Zeman’s personal examination of

the post mortem material still found in the

Institute of Neuropathology in Vienna)

that SSPE was really first described by the

great Austrian, Schilder. In one of

Schilder’s classic descriptions of the now

“dead” disease which he called “encephalitis

periaxialis diffusa” [schilder, 1912]

and what American physicians simply

called “Schilder’s disease,” there was

strong evidence to support a “proper”

diagnosis of SSPE. At any rate, it is now

fairly obvious that what was considered

to be “Schilder’s disease” most likely represents

all of the following disorders: adrenoleukodystrophy,

metachromatic leukodystrophy,

and, as Zeman maintains,

subacute sclerosing panencephalitis.

In the period between 1934 and

the early 1960s many studies were undertaken

to attempt to find the cause of

SSPE, but all were unsuccessful. Yet it

was the strong opinion of most investigators

that the cause was infectious and of

viral etiology. Viral research in these days

was rather naive compared to our present

more sophisticated methods. As an example,

it was not until 1954 that Enders

and Peebles first successfully isolated the

wild measles virus in human and monkey

tissue cultures. This isolation set the stage

to develop an antigen and, in turn, an

effective vaccine. The strain of rubeolla

virus was called the Edmondson strain,

subcultures of which are still used. The

licensure for the vaccine was given in

1963. Connolly et al. [1967] demonstrated

an elevated measles antibody in a

patient with SSPE which suggested but

did not prove that the measles antigen

was responsible for the disease. It was not

until 1969 that Chen et al. and others

[Horta-Barbbosa et al., 1969; Payne et

al., 1969] co-cultured the measles virus

from the brains of patients with SSPE.

Curiously, one of the patients described

by Chen et al. was named Mantooth.

The Mantooth strain of measles

virus survived for many years at NIH and

was the basis of many basic investigations

[Zhdanov, 1980]. was clinically

managed from diagnosis to death by

Dyken, a young pediatric neurologist

who was then an Assistant Professor of

Pediatric Neurology at Indiana University

School of Medicine. This clinical

scientist was the first to make the clinical

diagnosis.

In 1969, a pediatric neurologist

from Memphis, Tennessee, J.T. Jabbour,

established the first disease registry on

SSPE in the world. This data bank would

also become one of the largest collections

of epidemiological material on a rare disease

in the world. Jabbour did much to

solidify the clinical knowledge and multidisciplinary

aspects of this disease Jabbour

et al. [1969], as well as the epide-

Fig. 1. Bar graph of cases reported to the USA and USA/International SSPE

Registry from the

origin of the Registry in 1969 by J.T. Jabbour (arrow), to the transfer of

the Registry to P.R. Dyken

in 1980 (arrow), and to the time when cases from foreign countries were

first accepted in 1989

(arrow, designated as stippled on the graph). After 1989, US cases began to

be differentiated into

so-called imported cases born outside the US but reported here (crossed bar

designation on the

graph), and the naturally born US cases (blackened). It is probable many of

the cross bar designated

patients were previously reported as black bars. The vast majority of

“foreign” cases of SSPE are

reported to the Registry as a “block” (such as the 118 cases reported by

Anlar et al. from Turkey).

The foreign cases here only represent individually reported cases directly

to the Registry.

218 MRDD RESEARCH REVIEWS c SSPE AND MEASLES c DYKEN

miology [Modlin et al., 1977; 1979;

Halsey et al., 1978; 1980]. In 1980, however,

Jabbour transferred the files and an

already extensive data base of about 600

patients to Dyken, then located in

Augusta, Georgia. A wealth of investigations

in other parts of the world was also

being carried out, particularly in the

work of F.S. Haddad, a neurosurgeon

from Lebanon, who contributed much

about the disease in the Middle East

[Haddad et al., 1977; Risk et al., 1978;

Risk and Haddad, 1979]. In 1984, the

USA SSPE Registry was transferred to

Mobile, Alabama, still under Dyken’s

directorship.

By the early 1980s, much knowledge

was acquired about the wild measles

virus and the form which was believed

causative of SSPE. Differences were then

delineated between the wild or lytic and

the altered or persistent measles virus

[Hall et al., 1976; Choppin, 1981;Wechsler

et al., 1982]. These differences suggested

an explanation for the loss of virulence

of the wild virus when it was

converted to the persistent form.

Meanwhile much epidemiological

material concerning SSPE was being accumulated

in the US. Reports in 1985

and 1989 not only showed that SSPE was

decreasing in frequency in the USA, but

also that there was a changing clinical

expression of the disease. In this era,

there were many more slowly progressive

and milder forms being recognized as

examples of SSPE [Dyken, 1985; Dyken

et al., 1989]. These studies profiled the

clinical expression of SSPE and also developed

a method of measuring the response

these patients may have had to

various treatments. This measure was the

SSPE neurological disability index

(NDI), which is described in more detail

elsewhere [Dyken et al., 1982; 1986].

Several investigators [Huttenlocher and

Mattson, 1979; Dyken et al., 1982;

et al., 1982] showed both mortality and

morbidity improved in some SSPE patients

after using the immunomodulator,

inosiplex. These studies did not give consistent

results in all patients. Gascon et al.

[1991] treated several patients from Saudi

Arabia with alpha interferon and reported

beneficial results. Yalaz et al.

[1992] also reported on benefits to SSPE

patients from oral inosiplex and intraventricularly

administered alpha interferon.

Yet because of the uncertainties in patient

response, Gascon et al. [1995] organized

a consortium of investigators of

SSPE in San Francisco. At this meeting a

world organization of those interested in

SSPE was formed. At the first such offi-

cial meeting held in Ankara, Turkey later

in the year, two objectives were suggested:

1) an internationally planned research

protocol to study the treatment

with inosiplex and alpha interferon

would be developed, headed by Generoso

Gascon, stationed then and now in

Rhode Island; and 2) a world registry of

patients with SSPE would be formed,

directed by Dyken and added to the

responsibilities of the already existing

USA Registry.

ETIOLOGICAL

CONSIDERATIONS

The wild measles virus is an RNA

type virus belonging to the genus Morbillivirus

and the family Paramyxoviridae

[Redd et al., 1999]. The complete wild

virus is composed of six structural proteins.

Three of these are complexed with

RNA and form the nucleocapsid (phosphoprotein

or P-protein, large protein or

L-protein, and nucleoprotein or N-protein).

Three of these structural proteins

are complexed with the surrounding viral

envelope and are called the matrix protein

or M-protein, the hemagglutinin or

H-protein, and the fusion protein or Fprotein.

Regarding the known envelope

proteins, M-protein is different than the

other envelope proteins in that it is the

most internally located (that is, closest to

the core nucleocapsid) and is not glycosylated

as the other two. The nucleocapsid

proteins have the following functions:

L-protein 5 transcription, P-protein 5

neutralization and N-protein 5 formation,

whereas the envelope proteins’

functions are: F-protein 5 fusion,

H-protein 5 absorption and M-protein

5 assembly, orientation, and alignment

as a precursor for budding. The

M-protein is the innermost protein of the

envelope. It is not glycosylated. Thus,

M-protein has functions similar to those

of the nucleocapsid proteins. It directs

intracysoplasmic assembly after the uncoating

and synthesis phases have been

accomplished. M-protein has another

function which relates somewhat to the

outer-located envelope proteins and that

is to orientate or align the virion, now

fairly mature, to the inner cytoplasmic

membrane. The process of budding takes

place there; additionally, the envelope

proteins can cause dissolution of the

host’s cytoplasmic membrane (by fusion

and other means), escape from the cell,

and trophism and infection of other hosts

in many more numbers than had occurred

on the first passage. Budding, absorption,

dissolution of membranes, and

fusion are all very important functions

carried out by the envelope proteins in

order to produce virulent organisms, but

budding at least is not vital. Although the

wild measles virus has all six proteins, a

great deal of variability exists between

different strains. This variability probably

accounts for different levels of lytic activity

exhibited by different strains of measles

virus, with the most lytic virus being

the most virulent. Yet it is true that all

living measles viruses, whether lytic or

nonlytic, have all of the nucleocapsid

structural proteins listed above and probably

the H-protein and F-protein as well.

Alterations in their structure allow for

alteration in their function. Assembly is

required for full maturation. Yet immature

or persistent viruses can live for very

long periods and it is not necessary in

certain circumstances for them to bud to

carry on their progeny. Without budding,

the replicating intracellular virus

may go into a dormant phase, or “slow

down,” so to speak; it is undirected and

presumably wanders aimlessly within the

host. Without the M-protein the immature

virus is disoriented and lives the life

of a random intracellular wanderer. Fig. 2

offers a graphic representation of the proposed

structures and functions of viruses.

Although the wild measles virus,

with all of the proteins listed above, is

usually a virulent, wild sort of thing, at

the same time it is very susceptible to an

effective immune antibody response. In

an effective response, antibodies have

been formed against all of the proteins

and in most situations the free-floating

extracellular virus is eliminated by a hypersensitivity

reaction. If the immune response

is ineffective, however, the wild

virus escapes and continues to do damage.

If, on the other hand, only some of

the viral proteins are eliminated, not the

proteins which are vital for survival, altered,

persistent, slow viruses are formed.

If F-protein is lost, fusion is also lost and

the organism could still replicate but

never be able to escape from the host. In

SSPE, it is speculated that there is usually

no defect in the host’s immune system

but that the system is in most instances

immature. In many “normal” infants,

their immune system has simply not developed

the sophistication to develop

enough antibodies, or effective antibodies,

to totally destroy the rather complicated

six-proteined rubeolla wild virus.

In most of the persons who suffer from

SSPE there is a history (about 75% of the

time) of an early contact with measles

and often a history of having measles

exanthem at a very early age.

Natural measles is a very serious

disease in infancy opposed to what one

might believe it to be later in life (it is in

the 5 to 10 year range where the proto-

219 MRDD RESEARCH REVIEWS c SSPE AND MEASLES c DYKEN

typical fever, Koplick spots, and rash occur).

Yet the immune system in many

“normal” children is not always sufficient

in producing antibodies against all the

wild measles’s protein antigens. If they

have no effective response the virus wins

and even death occurs in association with

the many complications of measles in the

young child. If an effective response occurs

the child wins and is immune for

life. If, however, the response is only

partial, then both possibilities are possible.

On one hand if the nucleocapsid

proteins are damaged or destroyed, the

organism cannot replicate and therefore

dies and the child wins. If the envelope

proteins are damaged or destroyed in toto

the organism might survive, but it is so

hampered that it cannot survive the long

haul, dies, and the child wins again. If

however, the M-protein alone is damaged

or destroyed completely, a draw in

the combat is most likely, at least for a

while, for neither child nor virus wins,

and the virus stays dormant for years.

Thereafter, however, this dormancy

stops and the virus regains virulence, protected

by the nervous system which it

ultimately destroys—thus, the virus wins.

This is the story of the dynamics of SSPE.

Many of the cells in which the virus

harbors are the large neurons of the cerebral

cortex. These cells live a lifetime

under ordinary circumstances. In these

cells there is plenty of room in their

cytoplasm for small, unabrusive, altered

viruses such as our M-minus wanderer. It

is sure that they could live for many years

quiescently. It is possible in this quiescent

state the virus shuts down many of its

previously more active metabolic functions

to live in a symbiotic relationship

with this new host. It is probable that the

virus cannot live or, at least cannot live

and propagate, outside the nervous system.

Once it gets outside the cells within

the CNS—as long as it is not in physical

contact with an effective immune system

by way of a large extracellular space—it

can live in happiness, passing from one

susceptible cell to another, clinically dormant,

until that fateful time, 7 to 10 years

later, when it and its siblings “breakout”

and begin producing the neurological

symptoms and signs of SSPE through in-

flammation, irritation, and destruction.

At this time the shiftless, aimlessly wandering

culprit becomes a lytic, purposefully

directed murderer of cells with

whom they once lived in peace.

CLINICAL AND

PATHOLOGICAL

MANIFESTATIONS

Since it is assumed that in all instances

of SSPE there is an infantile or

early childhood contact with the wild

measles, the symptoms of SSPE probably

should be considered to begin at this time

rather than when the neurological symptoms

develop. When measles begins in

infancy, it is well known that it is a more

serious illness than when it appears in

later life. The usual age of onset of measles

exanthem in the US during the preimmunization

period was usually between

5 and 10 years of life [Redd et al.,

1998]. In later childhood the wild measles

infection takes the form of a fever, a

typical rash, and Koplick spots. All symptoms

usually last for about 7 days. As

mentioned before, the syndrome is due

to an antibody-antigen hypersensitivity

reaction. Yet, often in infancy, one observes

what is considered to be complications

of ordinary “red” or “seven day”

measles. The syndrome then takes the

Fig. 2. Graphic representation of life cycle of viruses in general and the

dynamics of the persistent

slow virus disease, SSPE. A large neuron is represented with a clear

cytoplasm and multiple

dendritic process. The axon is darkened. Mature viruses (illustrated by

circles representing the

nucleocapsid of the virus, surrounded by a flowery petal-like envelope), if

attracted to a host cell by

their own trophism, begin the stages of the next life cycle. Stage II & III

represent absorption and

penetration through the host membrane. Stage IV & V, uncoating of the mature

virus and synthesis

with host of new virions. Stage VI represents assembly of the new immature

virions into a more

mature package and Stage VII the orientation of these packages to the inner

cytoplasmic wall of

the host. Once at the membrane, Stage VIII & IX occur which dissolve the

host membrane and allow

escape of the mature virus into the extracellular space in greater numbers

than when it entered.

Mature viruses can then infect other host cells when repetition of the life

cycle continues. In the

nervous system there is scant extracellular space; and although the “normal”

passage of the virus

as pictured here can occur, it is a much less efficient way for the virus to

infect other systemic cells

with a large extracellular space, perhaps a reason why the CNS has been

thought to be somewhat

immunologically privileged. In SSPE, there has been a disturbance in

assembly and orientation as

pictured in this graphic as a large (assembly) and a smaller (orientation)

arrow. The altered measles

virus, therefore, can not escape as a mature form but rather exists as an

intracellular “wanderer.”

This process could go on for a long time but eventually, perhaps speeded up

by other processes, or

if nothing else, by axonal flow, the “wanderer” attaches on to the inner

wall of the host cell and

Stage VII & IX are carried out. Without budding (jutting out into the

extracellular space) fusion

depends upon having closely adjoined membranes to pass and the immature

virus goes not into

the space but directly into a neighboring cell. Only the nervous system (and

the eye) have “tight”

extracellular cells and closely adjoined fleshy cells to be able to sustain

this form of propagation of

virus. If the virus does find the extracellular space, and the immune system

is aware of it, viral

destruction ensues due to the antigen-antibody response of years ago. In

time, the harbored mass

of slowly accumulating organisms “break out” and produces the neurological

symptoms so

characteristic of SSPE.

220 MRDD RESEARCH REVIEWS c SSPE AND MEASLES c DYKEN

form of a severe pneumonia or severe

cardiac disturbance (myocarditis, pericarditis),

severe gastrointestinal disturbance

(hepatitis, appendicitis, ileocolitis), glomerulonephritis,

post-infectious encephalitis,

thrombocytopenia, or the -

syndrome. These complications

occur both with and without the other

more classically presenting symptoms of

measles exanthem. It has been estimated

that as high as 15% of all patients who

have had measles suffer from a subclinical

form of the disease. There is no reason to

assume that infants or young children do

not have equal numbers of subclinical

measles as well. Thus, by totaling all the

serious diseases in infancy regardless of

whether it was thought to be measles or

not (all instances of what was actually

considered to be measles and the 15%

who were considered to be subclinical

forms of measles), it is believed that almost

all of the patients reported to the

Registry would have been determined to

have had contact with the wild measles

virus at an early age, rather than the 75%

which has been reported in recent reports.

The first neurological symptoms of

SSPE usually occur in the period of life

between ages 5 and 15. In the most recent

report of the USA/World SSPE

Registry [Dyken and Papania, 2001] the

age range of neurological onset varied

between 3 and 24 years of age with the

average age of onset in 106 patients about

10 years. The average age of first measles

contact was between one and two years

of age. It is invariably true, regardless of

the type of SSPE patient (male or female,

racial distribution, US or foreign, syndrome

type) that the earliest symptoms

relate to inflammatory/irritative lesions

in the cerebral cortex. The symptoms

involved are usually subtle, and are then

often not believed to be related to neurological

dysfunction. Affected children

show irritability, mild distractibility,

shortened attention, brief temper outbursts,

transient forgetfulness, and other

such symptoms. School failure usually

follows and this is followed by even

harsher evidence to support a beginning

dementia, such as abnormal psychological

tests [swift et al., 1984] and so forth.

Occasionally, however, a single epileptic

seizure is the first documentation of the

disorder. These signs and symptoms,

which have been referred to as the typical

symptoms of the early stages of SSPE,

have been called Stage I [Jabbour et al.,

1969]. Typically this stage lasts from 3 to

6 months. In the chronic progressive

form (CPF) of SSPE, however, the signs

and symptoms of Stage I may last for

years and degeneration be so slow that

the disease may not be recognized as

even a neurodegenerative process for

many years [Dyken, 1985]. In the classical

subacute progressive form (SPF) of

the disease, however, the speed of unrelenting

progression is more rapid. In the

acute progressive form (APF), Stage I

symptomatology may only last days or

weeks. In this situation, the characteristic

staging may not aid in the diagnosis. The

pathological reactions which account for

the signs and symptoms of Stage I are due

to inflammation and then irritation of the

cells of the cerebral cortex. Secondarily,

there is destruction of these cells producing,

rather than a facilitory or stimulative

type of neurological lesion, a loss type

lesion of the cerebral cortex (i.e., polioencephalopathic).

The altered virus

has not yet involved deeper neuroanatomical

areas. Thus neuroimaging testing

at this stage of the disease process may be,

and often is, normal. Electroencephalography

(EEG) now shows only nonspecific

abnormalities or even normal patterns.

The neurological disability of SSPE

in Stage I varies between 1 and 33%

[Dyken, 1985]. The percent diasability is

calculated by use of a specially constructed

index of disability called the

NDI (Neurological Disability Index)

[Dyken et al., 1982; 1986].

The most characteristic signs and

symptoms of SSPE stem from the spread

of the viral induced lesions to deeper

neuroanatomical structures, as well as to

the continuing process of irritation and

destruction which continues in the cerebral

cortex. Deeper distributed lesions

manifest in one of the classical signs

known in the history of medicine and

herald the core feature of what has been

called Stage II. This hallmark sign of

SSPE is called massive myoclonus and is

due to irritation producing a transient

electrical discharge simultaneously in

large groups of neurons within the basal

ganglia. Whereas such discharge could be

found when the disease was limited to

the cerebral cortex in the form of single

epileptic seizure in Stage II, another form

of involuntary movement now begins to

occur. In this instance a similar type of

inflammatory/irritative lesion now involves

the more primitive motor systems

of the basal ganglia. Electrical discharge

in this instance first shows itself in the

form of an infrequent, quick movement

of a single muscle group without alteration

in the state of consciousness (i.e.,

myoclonus). Later this involuntary motor

activity becomes both more frequent and

more severe. It becomes more generally

distributed so that at any one time both

appendicular and axial muscle groups are

regularly involved together. Repetition

increases to rates of eight spasms or jerks

per minute or even more. Even at this

stage consciousness is not disturbed,

however, and that is why the massive

myoclonus of SSPE is considered to be

more a nonepileptic form of involuntary

movement rather than a form of epilepsy.

Massive myoclonus occurs invariably in

all patients with SSPE who have reached

the level of Stage II whether they have

co-existing epilepsy or not. The almost

stereotypical massive myoclonus is characteristic

of no other disease and many

clinicians have considered the clinical

presentation to be not only pathognomonic

but essential to the diagnosis of

this disease. In fact, the characteristic

EEG pattern, which has been described

itself as diagnostic of SSPE [Pampiglione

and Harden, 1985], is only absolutely

characteristic and diagnostic when observed

in Stage II. In other Stages, the

EEG pattern is frequently abnormal but

not diagnostic. Although massive myoclonus

and the irritative involvement of

the basal ganglia is a characteristic feature

of Stage II, it is certainly not the only

pathoanatomical feature. By this time in

the neuroprogression, there has been a

continued destruction of the cells of the

cerebral cortex and an advancing level of

frank dementia is observed. Additionally,

because of death of motor neurons and

by an expanding direct effect on the oligodendrocytes

of the subcortical white

matter (demyelination is a pathological

hallmark of the disease at this stage),

motor phenomena (such as paresis, paralysis,

hyperreflexia, hypertonus, spasticity,

pathological reflexes) begin. All of these

abnormalities contribute to the increasing

neurological disability which varies in

this stage (Stage II) between 33% and

55% [Dyken, 1985; Dyken et al., 1986].

Towards the termination of Stage II, the

regular, frequent, and severe massive myoclonus

begins to disappear directly proportional

to the failure of motor systems.

Yet, it is not until Stage III, when

destruction of elements of the more

primitive motor systems residing in the

basal ganglia occurs, that the involuntary

movements of diagnostic nature totally

disappear. At this stage, with disability

varying between 55% and 80% [Dyken et

al., 1986], extrapyramidal symptoms of

another nature develop. These include

choreoathetosis, lead-pipe rigidity, immobility,

masked facies, rarely ballismus,

dystonia, even pill-rolling rest tremor,

intention tremor, torticollis, dromedary

pelvic posture, and other clinical signs

which suggest destructive lesions in the

221 MRDD RESEARCH REVIEWS c SSPE AND MEASLES c DYKEN

basal ganglia. Irritative lesions of the

more caudal motor systems of the brain

stem have also begun. By this stage moderately

severe dementia has developed

[swift et al., 1984].

Stage IV heralds the beginning loss

of the so-called vegetative body functions.

This is explained by the continued

pathoanatomical progression of the destructive

disease process to lower neuroanatomical

centers. At this stage there is

between 80% and 99% neurological disability.

Death occurs at 100%. After dividing

the types of neurological involvement

into those related to mental

disturbance (also called Part I of the

NDI), myoclonia/immobility (called Part

II of the NDI), motor/sensory loss (Part

III), and vegetative loss (Part IV), Dyken

et al. [1986] determined that the mental

disturbance level was 95%, the motor and

sensory loss level was 95%, and the vegetative

loss level was 90% among eight

living Stage IV patients (out of 50 SSPE

patients who were reviewed in depth).

At this level of disability, myoclonia was

replaced by immobility and Part II of the

NDI was scored at 95% disability, even

though there was never massive myoclonus

in these patients at Stage IV level of

disability. The level of total disability in

the eight patients averaged 91%. They

were obviously at low levels of neurological

functioning.

In regards to the other patients in

this study [Dyken et al., 1986] who were

evaluated in either Stage I, Stage II, or

Stage III, there was a corresponding average

total neurological disability, representing

23%, 48%, and 78%, respectively.

Stage I patients had an average mental

disability judged at a 50% level of severity

whereas myoclonia/immobility, motor/

sensory, and vegetative parts of the NDI

were negligible. Stage II patients had an

average mental disability level of 55%, a

myoclonia/immobility level of 45%, a

motor/sensory level of 55%, and a vegetative

level of 35%. Stage III patients had

mental disability levels of 90%, myoclonia/

immobility levels of 70%, motor/

sensory levels of 95%, and vegetative levels

of 65%. The NDI proved to be a very

effective measure of any SSPE patient’s

level of disability (Fig. 3). Dyken [1985]

was to differentiate five different syndromes

of SSPE. These were the subacute

progressive form (SPF), the acute

progressive form (APF), the chronic progressive

form (CPF), the subacute remitting

form (SRF), and the chronic stuttering

or remitting form (CRF). In earlier

reports from the USA SSPE Registry

[Jabbour et al., 1969; 1972] the vast

majority of SSPE patients had only the

characteristic “classical” pattern represented

by the SPF and APF syndromes.

In 1978, in the Middle East, Risk et al.

described the first remitting forms of

SSPE, designated as the SRF and the

CRF syndromes by Dyken. These remitting

forms represented about 9% of

the 118 patients that Risk and Haddad

[1979] reported.

For a time it was considered that

these were variant forms only known to

this area of the world. In 1985, however,

Dyken found about 9% of 100 US patients

to have either the SRF (7%) or the

CRF (2%) type of disease. Yet even then

a review of a population of SSPE patients

from the pre-immunization period in the

US revealed no such high numbers of

remitting forms. Then Dyken was also

able to differentiate yet another form of

the disease which varied from the syndromes

described before. This was a

milder and more slowly developing form

of SSPE (CPF). This atypical syndrome

of SSPE represented 24% of the patients

that Dyken reviewed and were particularly

important to him, because in some

of these patients the clinical presentation

was often without Stage II symptomatology

at the time of diagnosis, or regular

massive myoclonus was often severely attenuated.

Because they often had no clinically

diagnostic signs, there was a concern

that these patients might not have

been recognized before they were placed

on treatments, or if they were and were

then placed in an experimental treatment

protocol, they may have a false beneficial

response to whatever treatment was being

given. Dyken was worried because

this could have happened in some of his

own studies [Dyken et al., 1982; Durant

et al., 1982; Durant and Dyken, 1983]. In

1985, Dyken defined the CPF syndrome

as follows: “ . . . the chronic form does not

show a typical staging and does not develop

neurological disability as great as 66 per cent

until after nine months from the first symptoms.

In the chronic form, myoclonia or Stage

II symptoms may be greatly delayed. Stabilization

may occur in the relentless downhill

course . . . ” (Figs. 3 and 4).

The five syndromes that Dyken

differentiated can perhaps be broken

down into only two. The classical syndromes

are the SPF and the APF, both of

which were described in depth as variations

of SSPE as early as 1969. The more

recently described forms of SSPE are the

two remitting forms first described by

Risk and Haddad [1979] and by Dyken

[1985] as the CRF and the SRF syndromes

and the CPF which in 1985 represented

24% of the entire population of

patients who were reviewed from the

US. These forms are perhaps best considered

to be atypical since at this time

both in America and the Middle East

they together represent only around 10%

of the SSPE population [Dyken and Papania,

2000]. None of the 106 patients

reported by the USA/World SSPE Registry

in 2000 and none from the known

published reports from elsewhere in the

world [Nunes et al., 1999 for Brazil; Rebiere

and Goulet, 1992 for France; and

Anlar et al., 1999 for Turkey] reported

spontaneous remissions as first emphasized

by Risk and Haddad.

Fig. 3. Clinical representation of the three progressive forms of SSPE

related to both duration and

severity of the disease process.

222 MRDD RESEARCH REVIEWS c SSPE AND MEASLES c DYKEN

INTERNATIONAL

DISTRIBUTION AND

EPIDEMIOLOGY

SSPE is a worldwide disease. The

first description of the disease was probably

from Austria although this was not

really recognized as such until many years

afterwards and after the first accredited

descriptions by Dawson from Tennessee

in 1934. In its early days, however, most

of the best of the pathological work came

from Europe with the contributions of

Van Bogaert and Pette and Doring. It

was the contributions from the United

States in the 1960s, however, that really

put SSPE on the map. Not only was the

SSPE virus discovered in the US, but

much if not all of the work on the characteristics

of measles and the measles virus

has been conducted in the US. It is this

author’s impression that the greatest contributions

to the epidemiological nature

of SSPE came through the work originating

from the US and now the USA/

International SSPE Registry. Nevertheless,

worldwide distribution is universal,

although in some under-developed nations

it is possible that SSPE, or even

measles, is not yet recognized as a significant

health problem.

Communication between many

countries of the world is not ideal in this

time and age. The International Registry

regrets that little communication has

been developed between such potential

“hot spots” for SSPE as Indonesia, Iraq,

Iran, the distant Middle East, and

Polynesia. The Registry has had little

communication concerning SSPE with

three of the largest countries in the

world: Russia, China, and Japan. Low

numbers of reports from these countries

is a defect of this Registry rather than due

to low numbers of SSPE in these countries,

as published reports from these

countries seem to indicate. Of all of these

countries, it would seem that the largest

reporter of SSPE cases for all time is still

the United States. A profiling of the temporal

sequences of these reports tell us

much about the character and epidemiology

of SSPE (Fig. 1). This profiling,

until recently, has been directly related to

the experience we have gained about

measles exanthem, the measles virus,

measles vaccination, and the coordination

of information received from the

Registry [Dyken and Papania, 2001].

A curious demographic feature of

SSPE which has always been mentioned

but never explained is the striking male

predominance from all sources, regardless

of location. In the most recent report

about the experience in native born US

patients it was found that the male to

female ratio of affected patients was almost

4 to 1. In the past, ratios varying

from 1.4 to 1 and 2.2 to 1 were usual.

Although the phenomenon of male predominance

has never been explained in

SSPE there is no doubt that it is consistent

and suggests in some fashion a hormonal

influence. No such predominance

has been shown to be present in measles

exanthem or in the administration of

measles vaccine. This fact is unexplained.

It has been recently shown that

there is a unique racial distribution in the

cases reported to the US component of

the USA/International SSPE Registry.

Cases of Hispanic origin are far more

frequent in the United States, a melting

pot of races, than any other so-called

racial minority. In the recent survey of

106 reports, from within and outside the

US, there were no African-Americans

reported [Dyken and Papania, 2001].

Curiously no SSPE patients were reported

from Central Africa. Are these

differences in racial distribution then due

to genetic factors or do they simply relate

to a defective reporting process? This,

too, is unexplained.

There have been many reports of

large numbers of patients with SSPE

from many countries throughout the

world. In fact, at one time it was suggested

that this disease represented the

most commonly seen specific childhood

neuroprogressive disease in the world (or

at least the most commonly diagnosed).

The number of actual SSPE cases far exceeded

the estimates because of the following:

the aminoacid inborn errors of

metabolism, any specific basal ganglion

degeneration, any one of the leukodystrophies

(including the perioxisomal disorders),

any of the so-called neural lipid

storage diseases and, perhaps, all of the

popular mitochondrial encephalopathies.

In more recent times with the development

of national immunization programs

against measles and with the steady decline

in the incidence of naturally occurring

measles exanthem, there has been an

expected decline in the numbers of SSPE

patients as well, even in the so-called

developing nations. This trend towards

declining numbers of SSPE in the world

may need to be revamped in light of an

increasing incidence of SSPE on the

North American continent and the US in

the last 3 years as reported to the USA/

World SSPE Registry (Fig. 1).

CURATIVE THERAPIES

As might be expected, the response

to both curative and palliative treatments

is variable and dependent on the stage of

the disease at the commencement of

therapy. As a general principle, one

might hope to resolve much of the nonpermanent

inflammatory reaction and all

the destructive symptomatology and to

stop further progression. Even a remarkable

curative therapy might at one stage

be very successful and at another fail miserably.

Once permanent damage to the

nervous system has occurred there is little

hope of resolving the issue. Experimental

treatment protocols should keep these issues

in mind. In experimental treatment

plans, care must be given to measure the

neurological disability and to continue

long-term follow-up of these parameters

on a clinical basis. A patient’s changes for

better or worse is as important a measure

of the patient’s response to medication as

is a changing level of IgG synthesis.

At this time, SSPE remains an unsatisfactorily

treated disease. There are no

consistently successful curative treatments.

In this regard, success is measured

by the consistent resolution of the terrible

neurological disabilities which result

from the disease. In reality, several therapies

in the past have improved morbid-

Fig. 4. Graphic showing the three different progressive clinical syndromes

of SSPE. Stage of

disease, disability of the disease, and duration of the disease are all

shown and compared.

223 MRDD RESEARCH REVIEWS c SSPE AND MEASLES c DYKEN

ity and quality of life and increased survival

time. Yet one should never lose

sight of the fact that the best therapy for

SSPE has been and will always be prevention.

Amantadine has shown some improvements

in regards to the natural

course of the disease after long-term follow-

up [on et al., 1980]. These

improvements were in terms of long survival

in patients who when evaluated

soon after they first took the drug did not

seem to show a benefit (discussed in

Dyken’s article of 1985).

Al Rajeh from Saudi Arabia [1996]

reported one SSPE patient with acute

lymphoblastic leukemia (ALL) who was

treated with triple antileukemic agents.

This patient had a remarkable remission

in both SSPE and ALL. Gascon has also

examined this patient and it is said that

the response was spectacular with complete

resolution of the previous devastated

neurological status. It was suggested

by Gascon [personal communication]

that, although it was unclear which of the

triple therapy drugs was responsible for

the remission, the most effective agent

was probably L-asparaginase. There has

been no other attempts at treating SSPE

with cytotoxic agents to this author’s

knowledge. Yet for reasons which will be

commented upon further in this section

the area is an important one to reconsider

in large groups of patients.

It should be mentioned that carbamazepine

has been very useful not only

in controlling epileptic seizures in patients

with SSPE but also in helping the

violent massive myoclonus which is not

as easily resolved with other antiepileptic

agents. These are inconsistent improvements

and are possibly considerably biased

by the natural history of the progression,

i.e., “out of myoclonus” and “into

immobility” which is not recognized by

the reporter who wishes to find some sort

of help for this tragic condition. It is

certainly true that there have been no

so-called phase-reversals after the use of

carbamazepine and it can not be considered

a curative type of therapy.

Two treatments for SSPE exist

which have improved, although argumentatively,

both morbidity and mortality.

These are oral inosiplex and intrathecal

or intraventricular alpha interferon.

The beneficial responses to oral inosiplex

have been documented in small numbers

of patients since the Huttenlocher and

Mattson study [1979] and the Dyken et

al. study [1982]. et al. [1982]

pooled these patients and added others to

report a large series of patients with long

term survival after treatment with inosiplex

alone. Durant and Dyken [1983] in

their personally managed patients related

these improvements especially to the

CPF type of SSPE. In 1991, Gascon et al.

treated several affected Saudi Arabians

with intrathecal alpha interferon and

found improvements in mortality and

morbidity. Some of these patients were

also on inosiplex. From Turkey, Yalaz et

al. [1992] reported on 22 patients who

were treated with both intraventricular

alpha interferon and oral inosiplex. Interestingly

they found that five patients “stabilized,”

whereas before they had a progressively

downhill course. This might

have been what was expected in any

group of SSPE patients. Long stabilizations

at high levels of disability have been

a feature of SSPE since the days of improvements

in the long term care of disabled

patients, due in large to the use of

better antibiotics and better custodial

care. Three of the 22 treated patients had

remissions. This 14% of the study population

is not far removed from the 9%

spontaneous remission rate reported by

Risk and Haddad from the Middle East

in 1979. It should be pointed out at this

point, however, that in a larger series of

Turkish SSPE patients there were no

spontaneous remissions in 118 patients

[Anlar, 1999]. Anlar’s report covered the

year of onset of the disease from 1992 to

1999. Mysteries still existed, therefore,

whether either inosiplex or interferon

was really useful in the disorder. To develop

a better understanding, an International

Consortium was formed to organize

a treatment protocol on large

numbers of patients which would correct

some of the past encounters [Gascon et

al., 1995]. This study which has taken

about three years is not in its final stages.

Inosiplex and alpha interferon in various

combinations were given to over 120

patients. It is this author’s impression that

most of the patients were selected from

Turkey, the Philippines, and Pakistan/

India. Each had been carefully evaluated

and none were beyond Stage II at the

initiation of their treatment. It is hoped

that good news will be received concerning

this investigation. The principle investigator

and coordinator of the study is

Dr. Generoso Gascon in the Department

of Neurology at Brown University

School of Medicine in Providence,

Rhode Island.

SPECULATIONS ABOUT

THERAPIES

In general, the principles of treatment

that have been used so far might be

somewhat faulty. We, as therapists, have

focused upon the immunological aspects

of SSPE, perhaps with the somewhat false

idea that a usual antibody-antigen response

will overcome the devastations of

this avirulent, but now virulent, wanderer

and murderer of the nervous system.

If the supposition is correct that

SSPE, in the quiescent dormant period

and in the early stages of development,

represents a disease not of the extracellular

space, which is the primary site of the

immune reaction, but of the intracellular

space where the virus resides, then we

need to address our therapies to intracellular

sites and not extracellular ones. In

spite of the fact that the few intracellularly

acting agents that are known to us

are also, in large part, cytotoxic to the

host cell and, therefore, very dangerous,

we must pay more attention to these

intracellular and cytotoxic agents in the

treatment of SSPE. In one noteworthy

case, cytotoxic agents were used on an

unfortunate patient who had both SSPE

and ALL and not only the symptoms of

leukemia disappeared, but also the symptoms

of SSPE [Al Rajeh et al., 1996]. A

single case report can not appropriately

be used as a recommended treatment for

an “untreatable” disease. Yet such a remarkable

story should instigate for further

activity in similar realms of possible

“antiviral” agents.

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225 MRDD RESEARCH REVIEWS c SSPE AND MEASLES c DYKEN

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October 2, 2004

I clipped this from the article below-

The first stage presents with behavioral

changes and intellectual deterioration. This progresses

into the second stage, which is characterized by the appearance

of myoclonic jerks, pyramidal, extrapyramidal

And this happens years after measles infection. hmmmmm. Yet parents are

reporting regressive and behavioral symptoms within weeks or a few months

after the MMR. Any thoughts on this?

RE: Re: Measles girl Leigh loses her battle

Sorry for the horrible formating - copies from a pdf file. This claims to

show that it was other than a measles vaccine strain causing this higher

than normal rate of SSPE, but it remains that many more vaccinated than

unvaccinated children were getting SSPE.

******************************************************8

Journal of Medical Virology 68:105–112 (2002)

Molecular Analysis of Measles Virus Genome Derived

From SSPE and Acute Measles Patients in Papua,

New Guinea

Kenji Miki,1,2* Katsuhiro Komase,2 S. Mgone,3 Ryuta Kawanishi,1,2

Masumi Iijima,2

Joyce M. Mgone,4 G. Asuo,4 P. Alpers,3 Toshiaki Takasu,1,5 and

Tomohiko Mizutani1

1Department of Neurology, Nihon University School of Medicine, Tokyo, Japan

2Division of Research and Development, Research Center for Biologicals, The

Kitasato Institute, Tokyo, Japan

3Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea

4Goroka Base General Hospital, Papua New Guinea

5University Research Center, Nihon University, Tokyo, Japan

A very high annual incidence of 56 per million

population below the age of 20 years for subacute

sclerosing panencephalitis (SSPE) has been

reported from Papua New Guinea (PNG). In a

more recent study, we have confirmed this unusual

high incidence for Eastern Highlands

Province (EHP) of PNG. In the study, it was

observed that the vaccination rate among SSPE

patients registered at Goroka Base General

Hospital (GBGH) in EHP was higher than that of

other infants in the province in recent years. To

identify the measles virus (MV) responsible for

SSPE in EHP, sequence analysis of hypervariable

region of the N gene was performed from 13 MV

genomes: 2 amplified from clinical specimens of

SSPE patients and 11 from acute measles patients.

In2 cases amongthe 11withacutemeasles,

nucleotide sequence of the entire H gene derived

from isolated viruses was determined. Both

nucleotide sequence and phylogenetic tree

analyses showed that the amplified MV cDNAs

were closely related to one another and belonged

to the D3 genotype though they were different

from any previously reported MV sequences.

No genome sequences of vaccine strains were

detected. These findings suggest that the MV

strains prevailing in the highlands of PNG belong

to genotype D3 of the MV and this wildtype

MV rather than the vaccine strains was

likely to be responsible forSSPEin these patients.

J. Med. Virol. 68:105–112, 2002.

2002 Wiley-Liss, Inc.

KEY WORDS: RT-PCR; genomic variability;

phylogenetic tree analysis; nucleoprotein;

hemagglutinin

INTRODUCTION

Subacute sclerosing panencephalitis (SSPE) is a rare

late complication of measles virus (MV) infection.

Before the extensive use of measles vaccine in industrialized

nations, the annual incidence of SSPE was

reported to range from 0.24 to 1.00 cases per million

population [soffer et al., 1976; CDC, 1982; Dyken,

1985]. The prevalence of SSPE has been estimated as

2.4 to 12.5 per 100,000 cases of measles [Dyken, 1985;

Okuno et al., 1989], and the female to male ratio to vary

from1:1.8 to 1:2.3 [Dyken, 1985; Okuno et al., 1989].

SSPE usually occurs 6 to 7 years after MV infection,

and individuals who have measles before the age of

2 years are at a higher risk of developing SSPE

[Jabbour et al., 1972]. The majority of SSPE patients

manifest neurological symptoms before the age of

10 years with a typical clinical picture that consists of

four stages. The first stage presents with behavioral

changes and intellectual deterioration. This progresses

into the second stage, which is characterized by the appearance

of myoclonic jerks, pyramidal, extrapyramidal

Grant sponsor: Ministry of Education, Science and Culture of

Japan Grants for International Research Projects; Grant numbers:

08041183, 16044322, 11694333; Grant sponsor: Nihon

University Grants for International Scientific Research; Grant

numbers: DC 96004, DC 97002; Grant sponsor: The Ministry of

Health and Welfare of Japan Grants for Specified Disease

Investigation and Research Projects—Slow Virus Infection

Research for 1996–2001.

*Correspondence to: Dr. Kenji Miki, Department of Neurology,

Nihon University School of Medicine, 30-1 Oyaguchikami-machi,

Itabashi-ku, Tokyo 173-8610, Japan.

E-mail: hippocam@...

Accepted 5 February 2002

DOI 10.1002/jmv.10176

Published online in Wiley InterScience

(www.interscience.wiley.com)

2002 WILEY-LISS, INC.

and cerebellar signs, and cortical blindness. Dementia

develops in the third stage, which deteriorates into

the fourth stage in which patients develop decerebrate

rigidity, followed by death within 1 to 3 years after the

onset of SSPE [Jabbour et al., 1975].

A previous study in Papua New Guinea (PNG)

identified 87 SSPE cases at six hospitals (four in highlands

and two in coastal provinces) during the period

from September 1988 to April 1991 by demonstration of

high-titre measles antibody in their cerebrospinal

fluids (CSF). Forty-seven of them were diagnosed in

1990. The population below 20 years of age for the

provinces of origin of the SSPE cases in 1990 (50% of

the total population) was 841,326. In the report, the

annual incidence of SSPE in the study provinces was

estimated to be 56 per million population below the age

of 20 years in 1990 [Lucas et al., 1992]. More recently

basing on progressive neurological disorder with

positive measles antibody in cerebrospinal fluid and

the presence of myoclonic jerks, we have estimated a

higher annual incidence of SSPE in EHP between 1997

and 1998 [Takasu et al., manuscript submitted]. Among

the 34 children with SSPE in a provisional progress

note of the mentioned study 15 (44%) of them (including

10 with documentation) had a positive history of

measles vaccination in comparison with 35% immunization

rate for 9-month-old infants in EHP in recent

years [Takasu et al., 1999]. The measles immunization

rates for EHP were 16% in 1993, 7% in 1994, 37% in

1995, 71% in 1996, 29% in 1997, and 54% in 1998 [PNG

Department of Health Promotive and Preventive

Health Services, 1998]. Several factors have been

postulated as the cause of this high incidence of SSPE

in PNG, including genetic predisposition, environment

factors, and low measles vaccination coverage. Higher

vaccination coverage among SSPE patients than in

non-SSPE cases raises the possibility that the vaccines

in use are either ineffective in preventing SSPE or are

responsible for the condition. Total annual hospital

admissions for measles is the only reliable information

on measles morbidity that is available in PNG. Measles

hospital admissions have increased 12-fold between

1963 and 1981, resulting in the introduction of mass

immunization in 1982. Between 1981 and 1989 measles

admissions have fluctuated widely. After 1993, the

number of admission decreased steadily to the lowest

level in 1998 that was similar to that of 1963 [PNG

Department of Health, 1986, 1991; PNG Department of

Health Promotive and Preventive Health, 1998]. The

rate of total admission for measles per 100,000 population

between 1990 and 1994 was 59.6 in five highland

regions (Southern Highlands, Enga, Western Highlands,

and Simbu provinces and EHP) and 39.6 in the

entire country; the total population in 1990 being

300,648 in EHP and 3,607,954 in entire PNG [PNG

Department of Health, 1996]. GBGH experienced

measles epidemics in 1985, 1988, between 1992 and

1993, and between 1998 and 1999 [Coakley et al., 1991;

Mgone et al., 2000]. At GBGH measles illness among

children under the age of 1 year has been common

among hospital cases [Coakley et al., 1991; Mgone et al.,

2000] and was also common among the SSPE patients

in the current study (Mgone et al., manuscript in

preparation).

MV is a negative-sense RNA virus that belongs to the

Morbillivirus genus in the Paramyxoviridae family.

MV spreads by budding and fusion and comprises six

structural proteins, namely, the nucleoprotein (N),

phosphoprotein (P), matrix protein (M), fusion protein

(F), hemagglutinin protein (H), and large protein (L).

SSPE is caused by MV, which has a gene mutation of

certain virion proteins such as M, H, and F. These

proteins are necessary both for alignment of the virus

along the host-cell plasma membrane and for subsequent

budding and release of the virus from the host

cell. Defects in these proteins of MV or some host

factors, or both may cause the prolonged persistence of

MV infection. The precise mechanism of SSPE pathogenesis

is not fully established, although accumulated

evidences suggest that infecting viruses are not eliminated

by the immune mechanism of the hosts and

persist in infected cells, spreading from cell to cell and

eventually leading to the development of SSPE [

and Bellini, 1996].

In the current study, we amplified part of the N gene

and the entire H gene of MV genomes from clinical

specimens of SSPE patients and acute measles patients

as well as from MVs isolated from acute measles patients

in PNG using reverse-transcriptase polymerase

chain reaction (RT-PCR) method, and compared the

nucleotide sequences with those of wild MV strains

circulating in other parts of world and vaccine strains.

In addition, phylogenetic tree analyses were performed

based on the sequences of both the N and H genes by

using the nomenclature recommended by the World

Health Organization (WHO) [2001]. This is the first

report on the characterization of MV from PNG.

MATERIALS AND METHODS

Specimens

Based on clinical features and positiveCSFand serum

MV antibodies, 25 children were diagnosed as having

SSPE between March 1997 and April 1998 at GBGH

[Takasu et al., 1998]. CSF and peripheral blood mononuclear

cells (PBMC) specimens were collected from 19

SSPE patients aged between 8 and 16 years. Between

June 1999 and October 1999, throat swabs (TS) were

collected from14patients with typical clinical features of

acute measles aged between 7 months and 6 years. The

TS specimens were collected within 2 days after onset of

measles rash. The PBMC were separated from 3 ml of

heparinized venous blood using ficoll-hypaque centrifugation

and washed at least five times in phosphatebuffered

saline (PBS).TheTSwassuspended in1mlPBS

and specimens frozen at 808C until used.

Virus Isolation

B95a cells were grown in RPMI 1640 medium supplemented

with 5% fetal calf serum (FCS) in 12-well

106 Miki et al.

plates; 100 ml of the TS or PBMC was inoculated in

confluent B95a cells and maintained in RPMI 1640

supplemented with 1% FCS in 5% CO2 incubator at

32.58C. Two to four days after inoculation, cultures

forming syncytia were centrifuged and cell pellets and

supernatants recovered and frozen at 808C until used.

RNA Extraction

Two hundred microliters each of CSF, TS, PBMC, or

supernatant of virus culture were used for total RNA

extraction using Trizol LS (Gibco BRL, Gaithersburg,

MD) according to the manufacturer’s recommended

protocol. The extracted RNA was dissolved in 20 ml of

diethylpyrocarbonate (DEPC)-treated water. RNA

solution was frozen at 808C until used.

RT-PCR for Hypervariable Region of N Gene

To amplify the hypervariable region of the N gene

(Nv region) of the MV genome from clinical specimens,

four PCR primers (PNG MF1160 50-GAAACTCCATGGGAGGTTTGAAC-

30, PNG MF1186; 50- GGCCGATCTTACTTTGATCCAGC-

30, PNG MR1692; 50- AGATGTTGTTCTGGTCCTCGGCCTC-

30, and PNG MR1705 and

50- GGGTAGGCGGATGTTGTTCT-30) were designed

based on the nucleotide sequence of the Edmonston

strain [ et al., 1991; WHO, 2001]. The cDNA

synthesis using ReverTra Ace reverse transcriptase

(TOYOBO, Tokyo, Japan) and first PCR using KOD

Dash DNA polymerase (TOYOBO, Tokyo, Japan) was

carried out with primers PNG MF1160 and PNG

MR1705 to produce a 546 base pair (bp) fragment.

Then nested PCR was performed with primers PNG

MF1186 and PNG MR1692 that yielded a 506 bp. The

first PCR was performed using 30 cycles of 10 sec at

988C, 5 sec at 558C, and 20 sec at 748C, whereas the

second PCR was performed with 30 cycles of 10 sec at

988C, 5 sec at 608C, and 20 sec at 748C. The PCR

products were electrophoresed through 1.5% agarose

gel and specific bands excised. The bands were then

purified and sequenced directly in both directions with

primers at 300–350 base intervals by using an automated

nucleotide analyzer (377 DNA sequencer)

(Applied Biosystems, City, CA).

RT-PCR for the Entire H Gene

Synthesis of the entire H gene cDNA from the

supernatants of isolated MV infected cells and ampli-

fication by PCR was performed with primers PNG

MF7207 (50-GCATCAAGCCCACCTGAAATTATCTCC-

30) and PNG MR9608 (50-GCCGTGAGTTAGTGTCCCTTAAGCATTG-

30) by using ReverTra Ace reverse

transcriptase and KOD Dash DNA polymerase. PCR

parameters used were 40 cycles of 10 sec at 988C, 5 sec

at 658C, and 1 min at 748C. Amplified 2,458 bp DNA

fragments that contained the entire H gene were cloned

into pUC18 plasmid. Nucleotide sequence was determined

in both directions with primers constructed at

300–400 intervals along the H gene sequence.

To minimize cross contamination, pasteurized filtered

tips and pipettes were used during all steps of RTPCRs.

Solutions and reagents such as enzyme, enzyme

buffers, dNTPs, and primers were subdivided into

small aliquots and discarded after single use. All manipulations

were done on a in clean bench and in every

PCR multiple negative controls were included.

Phylogenetic Analysis

Nucleotide alignment and phylogenetic distance

analyses were performed with a ClustalW [

et al., 1994] by the neighbor-joining algorithm as unrooted

trees tested with 10,000 bootstraps. All phylogenetic

trees were drawn using the TreeView software

1.5.2. Referred strains used for genetic analysis in this

study are shown in Table I. The sequences obtained in

this study were compared with those available from

GenBank and will appear in GenBank nucleotide sequence

databases with accession numbers AB075200 to

AB075214.

RESULTS

RT-PCR and Sequencing of SSPE Specimens

Among the CSF and PBMC specimens collected from

the 19 SSPE patients, it was possible to amplify the Nv

region of the MV genome from PBMC of two patients

who had been previously vaccinated. No MV genome

was detected from CSF specimens. The first among

these was a 4-year-old girl who came from Western

Highlands Province (WHP) who had been vaccinated

twice, first at the age of 4 and then at 13 months (22

September 1993 and 14 June 1994, respectively). She

had no history of measles infection. She was brought to

GBGH on 18 September 1997 for abnormal myoclonic

movement. She was continent and able to walk but

unsteadily and unable to speak. Measles antibodies

were positive in both serum and CSF. She was diagnosed

as having SSPE Jabbour stage II. The second

patient was a 4-year-old boy who came from Simbu

Province presenting with a history of being vaccinated

at the age of 6 and 9 months (27 May and 2 September

1993, respectively) and he had a documented history of

measles infection at 6 month (5 May 1993). He presented

at GBGH on 17 September 1997 with aggressive

behavior and falling attacks. He had abnormal myoclonic

movements and unsteady gait, but clear speech.

An electroencephalogram recorded characteristic periodic

synchronous discharges. Measles antibodies were

positive in both serum and CSF and he was diagnosed

as having SSPE Jabbour stage II.

cDNA nucleotide sequence analysis from both

patients revealed novel sequences that located near

genotype D3 of MV (Fig. 1). These sequences that were

closely related to each other though not identical were

named MVs/Goroka.PNG/38.97 SSPE (obtained from

the first patient) and MVs/Goroka.PNG/39.97 SSPE

from the second. Genome sequences of the Edmonston-

Zagreb and Schwarz strains, both located in genotype A

Measles Virus Genome in Papua New Guinea 107

known to have been used for immunization in PNG,

were not detected.

RT-PCR and N Gene Sequencing

of Acute Measles Specimens

It was possible to amplify the Nv sequences from 11

TS specimens of the 14 acute measles patients. Among

the 11 specimens, three sequences each (MVs/Goroka.

PNG/42.99/1, MVs/Goroka.PNG/43.99/3, and MVs/

Goroka.PNG/43.99/5, and MVs/Goroka.PNG/42.99/3,

MVs/Goroka.PNG/43.99/1, and MVs/Goroka.PNG/

43.99/4) and two (MVs/Goroka.PNG/42.99/2 and MVs/

Goroka.PNG/43.99/2) were identical to each other in

them, but the other three sequences (Mvi/Goroka.PNG/

26.97, Mvi/Goroka.PNG/42.99/4, and MVs/Goroka.

PNG/42.99/5) were not identical to each other nor

to any sequences other than their own, so the 11 were

classified into six groups. All 11 sequences resembled

each other and were positioned close to genotype D3

similar to the two MV genomes that were derived from

SSPE patients. However, they were not identical to

neither of the two (Fig. 1). Vaccine-strain sequences

were not detected.

Virus Isolation and H Gene Sequencing

Two MVs, named Mvi/Goroka.PNG/26.99 and MVi/

Goroka.PNG/42.99, were isolated from 14 TS using

B95a cells. The virus-infected cells were reacted with

anti-MV antibody. The entire H sequences were ampli-

fied from culture of the viruses infected cells. Sequence

analysis showed that these two H sequences were

similar to each other and also located in the neighborhood

of genotype D3 like the Nv region (Fig. 2).

Phylogenetic Analysis

The analysis and construction of the phylogenetic

tree of the two regions (Nv and H) were performed

based on the standard strains from WHO measles-

TABLE I. MV Strains of the Present Study and Sequence References*

Genotype Strain

Accession Number

Nv H Material

This study MVs/Goroka.PNG/38.97 SSPE AB075213 PBMC

This study MVs/Goroka.PNG/39.97 SSPE AB075214 PBMC

This study MVi/Goroka.PNG/26.99 AB075202 AB075200 TS

This study MVs/Goroka.PNG/42.99/1 AB075203 TS

This study MVs/Goroka.PNG/42.99/2 AB075204 TS

This study MVs/Goroka.PNG/42.99/3 AB075205 TS

This study MVi/Goroka.PNG/42.99/4 AB075206 AB075201 TS

This study MVs/Goroka.PNG/42.99/5 AB075207 TS

This study MVs/Goroka.PNG/43.99/1 AB075208 TS

This study MVs/Goroka.PNG/43.99/2 AB075209 TS

This study MVs/Goroka.PNG/43.99/3 AB075210 TS

This study MVs/Goroka.PNG/43.99/4 AB075211 TS

This study MVs/Goroka.PNG/43.99/5 AB075212 TS

A Edmonston-wt.USA/54a U01987 U03669

B1 Yaounde.CAE/12.83a U01998 AF079552

B2 Libreville.GAB/84a U01994 AF079551

B3 New York.USA/77a L46753 L46752

B3 Ibadan.Nie/97/1a AJ232203 AJ239133

C1 Tokyo.JPN/84/Ea AY043459 AY047365

C2 land.USA/77a M89921 M81898

C2 Erlangen.DEU/90a X84872 Z80808

D1 Bristol.UNK/74a D01005 Z80805

D2 Johannesburg.SOA/88/1a U64582 AF085198

D3 Illinois.USA/89/1a U01977 M81895

D4 Montreal.CAN/89a U01976 AF079554

D5 Palau.BLN/93a L46758 L46757

D5 Bangkok.THA/93/1a AF079555 AF009575

D6 New Jersey.USA/94/1a L46750 L46749

D7 .AUS/16.85a AF243450 AF247202

D7 Illinois.USA/50.99a AF037020 AY043461

D8 Mabchester.UNK.30.94a AF280803 U29285

E Goettingen.DEU/71a X84879 Z80797

F MVs/Madrid.SPA/94 SSPEa X84865 Z80830

G1 Berkeley.USA/83a U01974 AF079553

G2 Amsterdam.NET/49.97a AF171232 AF171231

G3 MVs/.AUS/24/99a AF353622 AF353621

H1 Hunan.CHN/93/7a AF045212 AF045201

H2 Beijing.CHN/94/1a AF045217 AF045203

*PBMC, peripheral blood mononuclear cells; TS, throat swab; MVs,measles

virus sequence; Mvi, measles

virus isolate.

aWHO, 2001.

108 Miki et al.

strain bank [WHO, 2001]. The phylogenetic tree both in

the Nv (Fig. 1) and the H regions (Fig. 2) showed that

sequences were located close to each other in nucleotide

divergence and nearby genotype D3. The maximum

nucleotide divergence between Mvi/Goroka.PNG/26.99

and Illinois.USA/89 sequences on the phylogenetic tree

of the Nv region was 2.74% (Fig. 1) and between MVi/

Goroka.PNG/42.99/4 and Illinois.USA/89 on the phylogenetic

tree of the H gene was 1.88% (Fig. 2). Recently,

WHO proposed the molecular biological criteria for

identification of a new genotype that requires minimum

nucleotide divergences of 2.5% for COOH-terminus of N

and 2.0% for full length H region from the next most

closely related strain. Therefore according to the

criteria recommended by WHO the MVs prevailing in

PNG belong to genotype D3 and not a new genotype.

DISCUSSION

The incidence of SSPE in PNG, especially in the

EHP, remains high. The cause of this high incidence is

unclear. Properties of the prevailing MV may have

relevance to such a high incidence. In addition, the

vaccination rate among SSPE patients at GBGH was

higher than the average rate of other infants in EHP in

recent years. This raised the question of whether the

vaccine used was ineffective or was responsible for the

SSPE. To clarify the cause of this high incidence of

SSPE in EHP, we have analyzed the nucleotide sequence

of the MV prevailing in the eastern highlands of

PNG and compared it with that of the MV vaccine

strains and that of wild MVs from other parts of the

world.

Fig. 1. Unrooted phylogenetic tree relationships based on the C terminal 456

nt of the N gene protein

cording region in MV. The tree was drawn by neighbor-joining algorithm using

the ClustalW and

TreeView 1.5.2. Representative sequences of 6 groups of 11 acutemeasles were

cited. Strain abbreviations

are described in Table I. The scale indicates 1% nucleotide divergence.

Measles Virus Genome in Papua New Guinea 109

In the current study, we established a highly sensitive

RT-PCR method that could amplify theMVgenome

cDNA directly from the clinical samples, especially of

SSPE patients. Since there have been only a very few

previous studies that report successful detection of the

MV genome from clinical samples such as PBMC or

CSF of SSPE patients [Nakayama et al., 1995; Vardas

et al., 1999], the present detection of the MV genome

from SSPE patients is significant. However, we have

been able to detect the MV genome only from PBMC

specimens and not from CSF. This may suggest that

concentration of SSPE virus in PBMC is higher than in

CSF as was suggested previously in one SSPE patient;

single RT-PCR could amplify genome in PBMC but not

in CSF, while nested RT-PCR could amplify genome in

CSF [Nakayama et al., 1995]. Otherwise quality of CSF

may be too low because of denaturation during preservation

or transportation of the samples to detect

small amount of MV genome. The nucleotide sequence

of the amplified genome cDNAs of Nv were determined

by direct sequencing, which has the advantage of

minimizing possible errors in RT-PCR [Rima et al.,

1997] and genome variations that may occur during

virus culture. In fact the 2 Nv sequences from the SSPE

patients were not identical to each other and neither of

them were identical to any of the six Nv sequences from

the acute measles patients (Fig. 1) nor to any that have

been reported before.

Although MV is a monotypic virus, sequence analysis

has shown that distinct lineages of wild-type viruses

exist and co-circulate. Most of the genotyping has

been carried out by sequencing the genes that code for

Fig. 2. Unrooted phylogenetic tree relationships based on the sequence of

the protein coding region of

the H gene (1,854 nt) in MV. The tree was drawn by neighbor-joining

algorithm using the ClustalW and

TreeView 1.5.2. Strain abbreviations are described in Table I. The scale

indicates 0.5% nucleotide

divergence.

110 Miki et al.

N and/or H proteins, which are the two most variable

genes of the MV. The genetic variability of MV has been

observed worldwide, and 21 genotypes grouped in eight

clades (A–H) are recognized as reference strains.

Although any of the different genotypes are not geographically

restricted, some appear to be predominant

in certain areas and are regarded as endemic in these

areas [Rima et al., 1995]. This distribution also varies

temporally [Nakayama et al., 1995; Yamaguchi, 1997].

We analyzed the 13 sequences of Nv region derived

from 11 acute measles patients in 1999 and 2 SSPE

patients. These sequences were very similar to each

other and all were genotype D3 (Fig. 1). The 11 sequences

derived from acute measles patients were

assorted into six sequences, which were very similar

but not identical to each other. Since the clinical

specimens were collected in the same hospital in EHP

in 1999 it is likely that both the SSPE and the acute

measles patients were infected through the same

transmission chain. On the other hand, the MVs/

Goroka.PNG/39.97 SSPE strain must have originated

from the stock of MV that prevailed in 1993. The SSPE

from whom this sequence was obtained had a positive

history of contracting measles virus at that time.

Sequence results mean that the causative virus strain

to the SSPE patient was similar to those that were

circulating in 1999 though therewas an interval of about

6 years. This implies that the MV strains in the highlands

of PNG may be fairly stable with low mutation

rates in comparison with those that have been described

from other areas [Nakayama et al., 1995; Jin et al., 1997;

Yamaguchi, 1997]. Alternatively, it is also possible that

the same stock that had prevailed about 6 years before

may have reemerged in 1999. As PNG is a relatively

isolated country, there is a little exchange with people

from overseas. Its high mountains segregate the highlands

from other areas of PNG. People living in PNG,

especially in the highlands, do not get around very

much because of poor infrastructure. Such an environment

may account for the stability of MV genome.

Ideally, molecular epidemiologic studies of MV

should include surveys of viral genetic groups from all

areas of the world and especially from developing

countries. However, developing countries are grossly

underrepresented in current studies concerning the

molecular epidemiology of MV, although these countries

account for the majority of measles patients and

chains of transmission. Molecular epidemiological

studies like ours will prove to be useful not only in

the surveillance of MV but also in the understanding of

SSPE.

Two MV genomes obtained from SSPE patients who

had histories of MV vaccination were similar to those of

the wild-type MV prevailing in 1999 and not to vaccine

strains. This result means that wild-type MV rather

than vaccine strains may be responsible for SSPE in

EHP. We noticed that many of the children who

developed SSPE had a history of immunization against

measles. It is likely that this may be due to the vaccine

used being ineffective because of loss of potency caused

by an inadequate cold-chain system. Such problems are

very common in poor-resource settings, especially with

inadequate infrastructure and personnel [bass, 1993].

It is also possible that the children were infected before

being vaccinated and that these infections were not

diagnosed or were misdiagnosed. At present, the risk

factors responsible for this high incidence of SSPE in

PNG are not well understood. Detailed virological,

immunological, and epidemiological studies will be

necessary. Such virological studies may include examination

of fresh brain tissues from autopsies.

ACKNOWLEDGMENTS

We thank all our patients and their parents as well as

the PNG Institute of Medical Research and GBGH staff

who were involved in this study.

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Mgone JM, Marcus J, Asuo GP. 1999. Subacute sclerosing

panencephalitis (SSPE) in Papua New Guinea (PNG): epidemiology

and virus analysis. Part 1 Characteristics of measles

immunization, age at measles, length of incubation period and

age at SSPE onset among SSPE patients and characteristics of

age at measles among measles patients, in Goroka area, Eastern

Highlands Province. Annual Report of the Slow Virus Infection

Research Committee, The Ministry of Health and Welfare of Japan

(Chairman: Kitamoto T.), p 38–43 (in Japanese with English

Abstract).

MJ, Godfrey E, Baczko K, ter Meulen V, Wild TF, Rima BK.

1991. Identification of several different lineages of measles virus.

J Gen Virol 72:83–88.

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and molecular analysis of subacute sclerosing panencephalitis in a

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for describing the genetic characteristics of the wild-type measles

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112 Miki et al.

---

Outgoing mail is certified Virus Free.

Checked by AVG anti-virus system (http://www.grisoft.com).

Version: 6.0.771 / Virus Database: 518 - Release Date: 28/09/2004

October 2, 2004

They're hardly going to admit that, are they? Wellcome, one of the three

original manufacturers of the MMR vaccine in Britain, reported in the Data

Sheet Compendium that the MMR vax can " cause fever, rash, orchitis, nerve

deafness, febrile convulsions, encephalitis, GBS, **SSPE** and measles which

doesn't follow the usual symptoms. " (Vaccination Bible, McTaggart, pp69-70)

One study of SSPE victims showed that almost one third had received the

measles vaccine prior to the onset of their illness.

Sue

> Re: Measles girl Leigh loses her battle

>

> If the vaccine can cause this, that should have been mentioned in the

> article as well, now, shouldn't it?

> Measles girl Leigh loses her battle

>

> > This is tragic, but SSPE can result from the vaccine...

> >

> > Love, light and peace,

> >

> > Sue

> >

> > " Learn from the mistakes of others--you can never live long

> enough to make

> > them all yourself. " - Luther

> >

> > -------------------------------------------

> >

> http://www.barnsleytoday.co.uk/ViewArticle2.aspx?SectionID=86 & Arti

> cleID=8645

> > 52

> >

> > Measles girl Leigh loses her battle

> >

> > A WOMBWELL teenager who developed a fatal illness after catching measles

> as

> > a baby has died.

> >

> > Leigh Wraith, aged 17, died from the rare degenerative brain disorder

> SSPE,

> > which develops years after the original measles infection.

> >

> > Today, as her family struggled to come to terms with their

> loss, mum Mandy

> > urged all parents of young children to ensure they are properly

> vaccinated

> > against the childhood infection.

> >

> > " Leigh got measles when she was 18 months old, before the MMR

> vaccine was

> > available. I don't want to preach to other parents, but if they had seen

> > happen to their child what we watched with Leigh they would not

> hesitate,

> > they would have their child vaccinated, " said Mandy, aged 38,

> of

> > Road, Wombwell.

> >

> > " People worry about a possible link to autism. That link has not been

> proven

> > but the condition Leigh developed, even though it is one chance in a

> > million, has been proved. We know our daughter has died because

> she caught

> > measles. "

> >

> > Leigh, who was only diagnosed with the fatal condition three years ago,

> knew

> > it would kill her. It was something she had lived with since

> being told on

> > her 16th birthday.

> >

> > She had even planned her own funeral, telling her parents Del and Mandy

> > exactly what coffin, music and readings she wanted at the service.

> >

> > " Leigh dug her heels in, she wasn't going to sit in corner and wait to

> die,

> > she was determined to live every day, " said Mandy.

> >

> > " It had to be Leigh's way or no way. She sat her GCSEs last

> year. She knew

> > she would never go to college or get a job, she knew she was

> not going to

> > live that long, but she wanted to sit and pass them because that was the

> way

> > she was.

> >

> > " We were told when her condition, sub-acute sclerosing panencephalitis,

> was

> > diagnosed that she might have, at the most, two years. We had her for

> > another 18 months and for that we are grateful.

> >

> > " But although her going is something we have been prepared for,

> something

> we

> > knew would one day happen, nothing can really prepare you for watching

> your

> > beautiful child die. "

> >

> > Leigh spent her last three weeks in the Royal Hallamshire Hospital,

> > Sheffield.

> >

> > 01 October 2004

> >

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