TOPICS:1. SMALL POX

2. CHICKEN POX3.RUBELLA

4. MEASLES

Caused by Variola virus

Double stranded DNA virus

Variola major or minor

Stable outside host(retains infectivity)

SMALLPOX (चेचक ,शीतला, बड़ी माता)

CLINICAL CASE DEFINITION An illness with acute onset of fever >101°F

(38.3°C) followed by a rash: firm, deep seated vesicles or pustules.

LABORATORY CRITERIA FOR CONFIRMATION

PCR identification of variola DNA in a clinical specimen, OR

Isolation of smallpox (variola) virus from a clinical specimen with variola PCR confirmation.

(WHO Smallpox Reference laboratory or laboratory with appropriate reference capabilities)

CASE DEFINITION

RESERVOIR Before global eradication, the only reservoir for variola

virus was humans. No natural reservoir for the virus currently exists. AGENT variola major or minor

EPIDEMIOLOGY

• Initially via aerosol• Then person-to-person• Hospital outbreaks from coughing

patients• Highly infectious

Airborne routeInfectious Materials:

SalivaVesicular fluid

ScabsUrine

Conjunctiva fluid

Possibly blood

Transmission

CLINICAL FORMS1. VARIOLA MAJOR severe and most common form of

smallpox, more extensive rash and higher

fever. 1. ordinary the most frequent type 90% or more of cases2. modified mild and occurring in previously

vaccinated persons);3. flat,4. hemorrhagic

both rare and very severe variola major has an overall

fatality rate of about 30%

flat and hemorrhagic smallpox usually are fatal.

2.VARIOLA MINOR less common presentation

much less severe disease, with death rates historically of 1% or less

Stages of Smallpox

Three stages of disease:• 1. Incubation

• Asymptomatic• 2. Prodromal

• Nonspecific febrile illness, flu-like• 3. Eruptive

• Characteristic rash

INCUBATION PERIOD Incubation Period 10-13 days ( 7 to 19 days)

Not contagious Initial Symptoms (Prodrome)

2 to 4 daysSometimes contagious

SYMPTOMS

The smallpox vaccine is the only known way to prevent smallpox in an exposed person.

The smallpox vaccine helps the body develop immunity to smallpox.

PREVENTION

Vaccine Administration

Jet gun• Rapid• High

maintenanceBifurcated needle • High efficacy,

sterilizable, rapid

• Uses less vaccine

• Mainstay for the WHO eradication campaign

COMPLICATIONS OF VACCINATION

Eczema vaccinatum Progressive vaccinia

Generalized vaccinia Post-vaccinial encephalitis

WHO Smallpox Eradication Campaign Begins

CAMPAIGN CONTINUES

Smallpox was officially declared eradicated in 1980

the first disease to have been fought on a global scale.

Last case in india- Saiban Bibi; Assam; 24 may 1977

The Smallpox Eradication Programme - SEP (1966-1980)

Oct 26, 1977, last case of smallpox. May 8, 1980, official declaration by WHO -

Smallpox Eradicated!

The End of Smallpox

Last case of Variola minor, Somalia 1977

Last case of Variola major, Bangladesh 1975

CHICKENPOX(छोटी माता)

Herpesvirus (DNA) Primary infection causes varicella (chickenpox) Reactivation of latent infection results in herpes zoster

(shingles) Short survival in environment

INTRODUCTION

CLINICAL DESCRIPTION An illness with acute onset of diffuse (generalized) maculo-

papulovesicular rash without other apparent cause.

LABORATORY CRITERIA FOR DIAGNOSIS Isolation of varicella virus from a clinical specimen,  OR Varicella antigen detected by direct fluorescent antibody test,  OR Varicella-specific nucleic acid detected by polymerase chain

reaction (PCR),  OR Significant rise in serum anti-varicella immunoglobulin G (IgG)

antibody level by any standard serologic assay.

CASE DEFINITION

RESERVOIR - human TRANSMISSION person to person respiratory tract secretions direct contact with lesions TEMPORAL PATTERN peak in winter and early spring (U.S.)

EPIDEMIOLOGY

14 to 16 days (range 10 to 21 days) Mild prodrome -for 1 to 2 days (adults) RASH generally appears first on head; most concentrated

on trunk Successive crops over several days with lesions present in

several stages of development

INCUBATION PERIOD

DAY 0-3 - INFECTION OF CONJUCTIVAE AND MUCOSA OF THE UPPER RESPIRATORY TRACT.

VIRAL REPLICATION IN REGIONAL LYMPH NODES

DAY 4-6 - PRIMARY VIREMIA,VIRAL INFECTION IN LIVER,SPLEEN AND OTHER ORGANS

DAY 10-12 - SECONDARY VIREMIA DAY 14 - INFECTIN OF SKIN AND APPERANCE OF

VESICULAR RASH

EXCORIATION

CONGENTIAL VARICELLA SYNDROME SEVERE VARICELLA SYNDROME RISK OF NEONATAL DEATH

CHICKENPOX DURING PREGNENCY MAY RESULT IN:

DRUGS USED IN THE TREATMENT OF CHICKENPOX : ANTIVIRALDRUGS ,ANTIHISTAMINES & ANTIPYRETICS. COMMOLNLY USED DRUGS: ACYCLOVIR FAMICLOVIR

ANTIVIRAL MEDICINES CAN BE TAKEN ORALLY INTRAVENOUSLY OR APPLIED ON THE SKIN.

THESE ARE PRESCRIBED TO PEOPLE WITH LONG TERM ILLNESS.

IMPAIRED IMMUNE SYSTEM & PREGNANT WOMEN. ALSO OTHER DRUGS ARE GIVEN TO REDUCE FEVER, COLD,

ITCHING, IRRITATIONOF THE RASH , SORE THROAT etc.

TREATMENT

CHICKEN POX OR VARICELLA VACCINE PROTECT 70% TO 90% OF THOSE PEOPLE WHO ARE VACCINATED.

VARICEELA VACCINE CONTAINS LIVE VIRUS AND SO IS NOT RECOMMENDED TO CHILDREN HAVING COMPROMISED IMMUNE SYSTEM OR SEVRE ILLNESS.

THIS VACCINE IS GIVEN TO ADULTS WHICH ALSO PREVENTS SHINGLES.

SIDE EFECT OF VACCINE IS REDNESS OR SORENESS AT THE SITE OF INJECTION.

PREVENTION

TREATING CHICKEN POX WITH FOLK MEDICINE

garlic lemonvalerian

aloe vera

St. John’s Wortcalendula

echinaceaginger

RUBELLA

•From Latin meaning “little red”•GERMAN MEASLES•Discovered in 18th century•thought to be variant Of measles•Togavirus •RNA virus

Clinical confirmation: Rubella cannot be confirmed clinically: laboratory confirmation is required

Laboratory-confirmed rubella case: Because of the difficulty of clinical diagnosis of rubella, laboratory confirmation is required.

A laboratory-confirmed case is a suspected case with a positive blood test for rubella-specific IgM.

The blood specimen should be obtained within 28 days after the onset of rash

Suspected rubella case: Any patient of any age in whom a health worker suspects rubella. A health worker should suspect rubella when a patient presents with: fever, maculopapular rash; and cervical, suboccipital or postauricular adenopathy or arthralgia/arthritis

CASE DEFINITIONS

Reservoir -human Transmission -respiratory agents Temporal pattern - peak in late winter and

spring

Communicability

Infants with CRS may shed virus for up to a 7 days before 5 to 7 days after rash onset ●

EPIDEMIOLOGY

Following respiratory transmission of rubella virus,replication of the virus is thought to occur in the nasopharynx and regional lymph nodes.

A viremia occurs 5 to 7 days after exposure with spread of the virus throughout the body. Transplacental infection of the fetus occurs during viremia.

Fetal damage occurs through destruction of cells aswell as mitotic arrest.

PATHOGENESIS

CLINICAL FEATURES Incubation period 14 days (range 12 to 23 days) Prodrome is rare in children Prodrome of low-grade fever in adults Maculopapular rash 14 to 17 days after exposure Lymphadenopathy occurs before rash and lasts for several weeks

COMPLICATIONS Arthralgia or arthritis (adult female) – up to 70% Arthralgia or arthritis (children) – rare Encephalitis - 1/6000 cases Hemorraghic manifestations (e.g. thrombocytopenic purpura) 1/3000 Orchitis, neuritis, progressive panencephalitis – rare

EPIDEMIC RUBELLA – UNITED STATES, 1964-1965 12.5 million rubella cases 20,000 CRS cases Estimated cost more than $840 million

Infection may affect all organs

May lead to fetal death or premature delivery

Severity of damage to fetus depends on gestational age

Up to 85% of infants affected if infected during first trimester

CONGENITAL RUBELLA SYNDROME

RUBELLA VACCINE Composition -live virus (RA 27/3 strain) Efficacy -95% or more Duration of Immunity -lifelong Schedule -at least 1 dose Should be administered with

measles and mumps as MMR or with measles, mumps and varicella as MMRV

CONTROL AND PREVENTION

morbilli, rubeola or red measles Paramyxovirus (RNA) Rapidly inactivated by - heat, sunlight, acidic

pH, ether and trypsin Highly contagious viral illness First described in 7th century Near universal infection of childhood in

prevaccination era Common and often fatal in developing countries

MEASLES (खसरा)

Clinical Definition An illness with acute onset of diffuse (generalized) maculo-

papulovesicular rash without other apparent cause. In vaccinated persons who develop varicella more than 42

days after vaccination (breakthrough disease), the disease is usually mild with fewer than 50 skin lesions and shorter duration of illness.

The rash may also be atypical in appearance (maculopapular with few or no vesicles).

Laboratory Criteria for Diagnosis Isolation of varicella-zoster virus (VZV) from a clinical specimen Detection of VZV DNA by direct fluorescent antibody (DFA) or by

polymerase chain reaction (PCR) tests from a clinical specimen, ideally scabs, vesicular fluid, or cells from the base of a lesion

CASE DEFINITION

Reservoir -human

Transmission - respiratory Airborne

Temporal pattern -peak in late winter–spring

Communicability -4 days before to 4 days after rash onset

EPIDEMIOLOGY

10-12 days Prodrome 2-4 days stepwise increase in fever to 103°F–105°F cough, coryza, conjunctivitis Koplik spots (rash on mucous membranes)

Rash: 2-4 days after prodrome, persists 5-6 days begins on face and upper neck maculopapular, becomes confluent fades in order of appearance

INCUBATION PERIOD

Diarrhea 8% Otitis media 7% Pneumonia 6% Encephalitis 0.1% Seizures 0.6-0.7% Death 0.2% (Based on 1985-1992 surveillance data)

COMPLICATIONS

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In the USA 1963 – killed and live attenuated

(Edmonston B strain) vaccine licensed

1965 – live attenuated (Schwarz strain)

1967 – killed vaccine withdrawn 1968 – live attenuated s

(Edmonston-Enders strain) 1971 – combined MMR vaccine

licensed 2005 – combined MMRV vaccine

licensed

VACCINE

MMR Vaccine First dose of MMR at 12-15 months 12 months is the minimum age MMR given before 12 months should not be counted as a valid dose Revaccinate at 12 months of age or older

Second Dose of Measles Vaccine Second dose of MMR at 4-6 years Second dose may be given any time at least 4 weeks after the first dose Intended to produce measles immunity in persons who failed to respond to the first

dose (primary vaccine failure) May boost antibody titers in some persons

MMR and MMRV Vaccine For the first dose of measles, mumps, rubella, and varicella vaccines either MMR and

varicella vaccines or MMRV vaccine can be used Providers should discuss the benefits and risks of both vaccination options with the

parents or caregivers Unless the parent or caregiver expresses preference for MMRV, CDC recommends

using MMR and varicella vaccines for the first dose Providers who face barriers to clearly communicating benefits and risks for any reason,

such as language barriers, should administer MMR and varicella vaccines separately For the second dose at any age, use of MMRV vaccine generally is preferred over

separate injections of MMR and varicella vaccines

VACCINATION SCHEDULE

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MEASLES CONTROL IN INDIA

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The South-East Asia Region (SEAR) has a goal of 90% reduction in measles mortality by 2010 in comparison to 2000 estimates

Achieved by all countries in the region except India by 2008

Including India, overall mortality reduction only reached 46%, with routine coverage up to 75% (2008) from 61% (2000)

CONTROL ACHIEVED BY SEAR

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Coverage With 1 Dose Of Measles-containing Vaccine Among Children Aged 12–23 Months, By District — India, 2007–2008*

• DLHS 3 reports a coverage of 69.6% for MCV1

• CES 2009 reported a coverage of 74.1% for MCV1

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Decision to introduce 2nd dose measles vaccination -the draft comprehensive Multi Year Strategic Immunization Plan of the Government of India (cMYP 2010-2017)

May 2010 -GOI announced its decision to implement NTAGI recommendation to introduce MCV2

* Measles Catch Up Immunization Campaign- Guidelines for Planning and Implementation. June 2010 Ministry of Health and Family Welfare, Government of India.

#Minutes and Recommendations of National Technical Advisory Group on Immunization (NTAGI), 16th June 2008, Ministry of Health and Family Welfare, Government of India.

INTRODUCTION OF MCV2

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90% of confirmed measles outbreak occur in states with low MCV1 coverage (<80%) are among children less than 10 years of age

Hence, measles catch-up campaigns target children 9 months to 10 years of age in the 14 states

*Measles Catch Up Immunization Campaign- Guidelines for Planning and Implementation. June 2010 Ministry of Health and Family Welfare, Government of India.

AGE FOR SECOND DOSE

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