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BASIC CHARACTERISTICS: Highly infectious vaccine-preventable disease, one of the most important causes of childhood mortality worldwide, responsible for 454 000 deaths in the world in 2004 The word measles is derived from the German word for blister. Also called as RUBEOLA (red spots) Caused by a paramyxovirus : RNA, single stranded No carriers Seasonal Peaks in late winter or spring Tropical countries: dry, cool season Males and females affected equally

Epidemiology: : 

Epidemiology: 1995 : 44 million cases 1/3 of children born worldwide 1.1 million deaths for children <5 Currently: 1-2 million cases reported yearly Thought to be gross underestimation Most countries require reporting WHO focused on measles in 1990’s Current goal: decrease cases by 90% and mortality by 95%

Trends : : 

Trends : Pre-Vaccine Epidemics Every 1-3 years Age: 3-15 months More frequent epidemics = younger age = urban > rural Post-Vaccine Small epidemics Every 5-10 years Age of onset = older Adolescents Majority of cases may be in vaccinated patients Cause: accumulation of unvaccinated population

Geographic Distribution : : 

Geographic Distribution : In 2004, Measles killed over 454,000 worldwide. 182,000 in South East Asian region. Western Hemisphere and most of Europe Vaccine strategies (2 shots) have interrupted transmission Middle East, Arabian Peninsula Decreasing #’s with vaccination campaigns Africa Poor control; most of the deaths every year.

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Distribution / India: : 

Distribution / India: Seventh largest and the second most populated country in the world with a population of 1.02 billion (2001, census). In 2004, approximately 27.5 million live births with 25.6 million surviving infants. Each day, over 68,000 births; a baby is born in India every 1.3 seconds. Of the total population, 363 million persons (~35%) are < 15 years of age (2001 Census). 162,560 cases of measles in 1989 51,546 cases in 2004

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Reported/surveyed annual measles coverage and cases India, 1974-2004 :

Evaluated Measles vaccination coverage by State India, 2001-02 : : 

Evaluated Measles vaccination coverage by State India, 2001-02 :

Evaluated Measles vaccination coverage by Districts of India, 2001-02 : : 

Evaluated Measles vaccination coverage by Districts of India, 2001-02 :

Reported measles cases and deaths in A.P : : 

Reported measles cases and deaths in A.P :

Transmission: : 

Transmission: Person to person transmission Humans are only reservoir Droplet nuclei or aerosols Highly contagious 90% attack rate for close contacts In MD office – transmitted 2 hours later Patients are contagious for 7-10 days Begins with onset of symptoms Includes 2-4 day prodrome before the rash It replicates initially in the upper/lower respiratory tract. Followed by replication in lymphoid tissues leading to viremia and growth in a variety of epithelial sites.

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The disease develops 1 - 2 weeks after infection. Affects children mainly between 6 months – 3 years. Incubation period – 10 days from exposure to onset of fever 14 days from exposure to appearance of rash. Contd.

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Clinical features- exposure Post measles I.P Prodromal phase (2 – 4 days) Eruptive phase (5 – 6 days) 0 day 10th day 14th day Period of infectivity – 4 days before and after appearance of rash

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Classification of measles Epidemiological Clinical Suspect case Cofirmed case Probable case Indigenous case Imported case

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CASE DEFINATION – Generalized rash lasting >3 days, and Temperature 101°F (>38.3°C), and Cough or coryza or conjunctivitis Suspected Case - febrile illness accompanied by a generalized maculopapular rash. Probable Case – Case definition with no or noncontributory serologic or virologic testing and not epidemiologically linked to a confirmed case. Confirmed Case - case definition and is epidemiologically linked to another confirmed or probable case or is laboratory confirmed. A laboratory- confirmed case does not need to meet the clinical case definition.

Clinical Manifestations : : 

Clinical Manifestations : Prodromal stage – Begins 10 days after infection, lasts till day 14. Characterised by fever 38-40 °C: subsides after 1 week , coryza, redness of eyes, lacrimation, photophobia, Kopliks spots Part of prodrome: day 1-3 before rash Raised papules on buccal mucosa and conjunctiva Usually adjacent to molars Often bluish white on red base Disappear about time rash occurs

Contd: : 

Contd: Eruptive phase – Macular or maculo-papular rash, begins behind the ears Travels inferior over 2-3 days. Coalesces into macular “splotches” Often desquamates at end of illness In absence of complications, lesions and fever disappear in 3-4 days.

Contd: : 

Contd: Post measles stage – Weight loss, remains weak Growth retardation, diarrhoea, Susceptibility to other pyogenic and viral infections. Peak of Illness 2-4 days after onset of rash Resolution Rapid improvement at end of febrile period (1 week) Complete recovery in 10-14 days

A classic day-4 rash with measles. : 

A classic day-4 rash with measles. A 4 yr old boy with corneal ulceration & scar following measles

Complications : : 

Complications : Secondary bacterial infection – eg. diarrhoea(8%), otitis media(7%) and bronchitis . Measles Pneumonia (6%)– Mainly in immunocompromised patients. Severe infection with an often protracted and fatal course. Responsible for 60% deaths due to measles. Acute measles encephalitis – Frequency of around 1 in 1000-5000, 2-6 days after rash. The mortality rate is around 15%, 20-40% are left with residual neurological sequelae. Subacute measles encephalitis – Only occurs in immunosuppressed patients. The condition commences with focal convulsions, hemiplegia, coma. Death supervenes within weeks or a few months.

Contd - : 

Contd - Subacute sclerosing panencephalitis (SSPE) – (0.1%) 2-15 years after infection SSPE is a rare slowly progressing fatal degeneration of the brain. Starts with generalized intellectual deterioration or psychological disturbance. Other neurological signs eg. convulsions, aphasia, myoclonic jerks. Inevitably leads to death. Case fatality rate 15% Myocarditis – Thrombocytopenic purpura – This is a rare complication of measles Measles in pregnancy – Leads to a high rate of spontaneous abortion and premature delivery. Measles may be transmitted transplacentally.

Diagnosis : 

Diagnosis Clinical – - Clusters of children with fever, cough, conjunctivitis, coryza, morbilliform rash - Koplik’s spots can be classic, but easily missed Microscopy – - Multinucleate giant cells with inclusion bodies is pathognomonic. Immunofluorescence – - Direct and indirect immunofluorescence to demonstrate MV antigens. Virus isolation – - Isolated from throat or conjunctival washings, sputum, urinary sediment cells and lymphocytes. Expensive and at reference labs Serology – - If Antibody titres rise by 4 fold between the acute and the convalescent phase (Ig G) measles-specific IgM is found. - The methods that can be used include HAI, CF, neutralization and ELISA tests.

Prognosis- : 

Prognosis- Mortality varies by age / nutritional status Historically 1-5% Higher with close contact secondary cases from presumed high viral exposure Developed countries: mortality = 3/1000 Developing countries: 15 - 25% Death: pneumonia, encephalitis, malnutrition, diarrhea Risk factors Immune compromise, Vitamin A deficiency

Management - : 

Management - Measles is an acute self-limiting disease that will run its course without the need for specific treatment. Supportive Care Rest, hydration, nutrition, Rinse eyes daily (saline or sterile water) Look for and treat bacterial super-infections Vitamin A May decrease mortality by 40% Benefit may be independent of deficiency, prevents eye damage and blindness Two doses, 24 hours apart immediately after diagnosis 0 - 5 months – 50,000 IU / day for 2 days 6 – 11 months – 100,000 IU / day for 2 days > 12 months – 200,000 IU / day for 2 days Ribavirin Inhibits viral replication in cell culture Limited benefit in immune compromised patients High cost makes = impractical in developing world

Contd. : 

Contd. Alternatively, the exposed individual can simply be vaccinated within 72 hours of exposure. Pneumonia – Antibiotics may be indicated in cases of secondary bacterial pneumonia or otitis media. Encephalitis – Treatment of acute measles encephalitis is only symptomatic. A wide variety of treatment has been tried for SSPE but no convincing effects have been demonstrated.

Prevention - : 

Prevention - Vaccine Immunization Live attenuated vaccine Usually given at 9 months Efficacy (seroconversion) 10 years to lifelong immunity 9 months: 80-85% (used in developing countries) >12 months: 95% (used in developed world) Contraindications (live vaccine) Immune suppressed, leukemia, lymphoma, pregnancy, anaphylaxis to neomycin or gelatin Immunoglobulin should be given to those for whom the vaccine is contraindicated. HIV patients – vaccine can be given There are no ill effects from immunizing individuals who are already immune.

Prevention - : 

Prevention - Passive Immunization Gamma globulin (0.25mg/kg) For: high risk pts and exposure within 3 days Pregnant, immune suppressed, children too young for vaccine, active TB, leukemia, known HIV with severe immuno compromised status. Impractical for developing world Maternal antibodies Protect for 3-12 months; usually 6 months Presence of Ab’s makes vaccine less effective Vitamin A Recommended at regular intervals (3-6 months) in developing countries Targets children >= 6 months old Decrease mortality by improving nutrition Benefit likely involves many infections, but measles is at the top


MEASLES VACCINE : Live attenuated vaccine available in form of freeze dried product. Should be kept in freezer compartment. Reconstituted with distilled water, used within 1 hour. Administration- single subcutaneous dose of 0.5 ml Reactions – in 15-20% of vaccinees, develop fever and rash. Toxic shock syndrome – Occurs due to poor quality of immunisation services. Severe watery diarrhoea, vomitting, high fever within few hours of vaccination. Clustering of cases. Case fatality is very high. Combined vaccines- Can be combined with other live attenuated vaccines Eg- MMR, MMRV

Mission Impact - : 

Mission Impact - One of the first disease that can wreak havoc on displaced populations War torn areas Refugee camps Natural calamities Preventable Vitamin A can be given immediately One of first vaccinations to consider

WHO/UNICEF Comprehensive Strategy for Sustainable Measles Mortality Reduction: : 

WHO/UNICEF Comprehensive Strategy for Sustainable Measles Mortality Reduction: Strong routine immunization. At least 90% of children should be reached by routine immunization services every year, in every district. A 'second opportunity' for measles immunization is provided to all children. This assures measles immunity in children who failed to receive a previous dose of measles vaccine, as well as in those who were vaccinated but failed to develop immunity following vaccination. Surveillance. Standard measles surveillance guidelines. Prompt recognition and investigation of measles outbreaks. Clinical management of measles cases is improved. vitamin A supplementation and adequate treatment of complications, if needed, with antibiotics. Vitamin A supplementation -

Summary- : 

Summary- Distribution: worldwide; worst in Africa Clinical Disease Prodrome, Koplik’s spots, morbilliform rash Treatment: supportive and Vitamin A Diagnosis: clinical, IgM serum antibody Prevention: Vitamin A, Vaccine Mission Impact: Devastating disease of refugees Priority when giving aide to displaced people

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