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Measles on call
Suzanne Meredith Specialty Registrar in Public Health
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Measles on call
•Clinical Features
•Epidemiology
•Prevention and Control
•Diagnosis
•Example of On call case / action
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Measles
Measles is one of the most highly infectious diseases known. Agent: Systemic viral infection caused by a paramyxovirusReservoir: HumansTransmission: spread person to person by direct contact with nose and throat secretions or respiratory droplets, Incubation period: 7-18 days, av 10 daysInfectious period: 4 days before – 4 days after rash.Laboratory confirmation: PCR testing of oral fluid , urine, CSF or tissue or serology (single raised IgM or rise in IgG).
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Clinical Features• Prodromal illness – high fever, coryzal respiratory infection
• Cough, Conjunctivitis, runny nose
• Koplik’s spots – early part of illness, look like grains of salt on a red inflamed background in the mouth
• Rash starts day 3 or 4, red, blotchy, maculopapular, not itchy, begins on face and behind ears, then generalised
• Complications: debilitation, pneumonitis, acute otitis media, pneumonia, encephalitis.
• Measles can be particularly severe in susceptible infants, pregnant women, and immunocompromised individuals.
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Surveillance
Suspected
Suspected by clinician or person with fever and maculopapular rash and one of: cough, coryza or conjunctivitis
Confirmed
Measles IgM positive in blood or oral fluid
Epidemiologically linked
Person with signs and symptoms of measles in contact with a lab confirmed case 7-18 days before onset of symptoms
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Confirmed Measles Cases 2007-2012
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Confirmed measles cases in travellers, 2012 (n=210)
Level 3 outbreak declared week 29
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Region Confirmed (by Colindale)
Not confirmed
Not yet tested
Grand total
EM East Midlands North 8 (8) 1 3 12EM East Midlands South 9 (9) 3 8 20
EoEBedfordshire and
Hertfordshire 4 (4) 0 0 4London South West London 0 0 2 2
NE North East 4 (4) 0 11 15NW Cumbria and Lancashire 30 (29) 2 13 45NW Cheshire and Merseyside 13 (13) 1 6 20NW Greater Manchester 9 (9) 0 3 12SE Sussex and Surrey 4 (4) 1 3 8SE Thames Valley 2 (4) 0 3 5SW South West (North) 1 (1) 0 1 2WM West Midlands East 15 (15) 0 7 22WM West Midlands North 6 (6) 0 8 14WM West Midlands West 10 (10) 0 5 15Y&H South Yorkshire 2 (1) 0 2 4
Y&HNorth Yorkshire and
Humber 10 (10) 1 7 18Y&H West Yorkshire 1 (1) 0 0 1
Grand Total 128 (126) 9 82 219
Measles cases in travellers reported in HPZone 2012 (up to Sep 2012)
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Prevention and Control
• Measles Vaccination introduced in 1968
• MMR 1988
• 2 doses required
• Late 1990s- early 2000s controversy links with autism and Crohns disease
• WHO target 95%
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%England 91.2
East Midlands 92.9Bassetlaw PCT 90.1Derby City PCT 93.4Derbyshire County PCT 94.5Leicester City PCT 93.0Leicestershire County & Rutland PCT 94.6Lincolnshire Teaching PCT 91.8Northamptonshire Teaching PCT 93.9Nottingham City PCT 88.8Nottinghamshire County Teaching PCT 92.0
MMR Percentage of children immunised by their 2nd birthday, 2011-12 by PCT
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On call 28th – 29th September 2012
23:52 28th September (Friday night)
Paediatric Registrar notification of suspected measles in a traveller 15 year old girl.
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On Call action
Obtain history of immunisation
Contact with suspected or confirmed cases and travel
Is diagnosis likely?
Identify vulnerable contacts and assess susceptibility
(Hawker and Begg)
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Clinical History
6 day history of headache, sore throat, sore eyes, cough, runny nose
Seen by GP previous day ?viral tonsillitis Had 1 day of antibiotics
Today onset of maculopapular rash- started on face, behind ears, spread to include chest and back
1 white spot in mouth - ?Koplik Spot
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Information from Registrar obtained from mother
Not had MMR
Lives on a traveller site
No known cases on site but attends a church where measles has been reported
Lives in a caravan with mother, father and brother, aged 4
A number of other children on the site are unvaccinated
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Diagnosis
The positive predictive value of a clinical diagnosis of measles is generally poor when cases are sporadic and outside of an outbreak situation but in recent months HPU reported more ad-hoc cases.
In the absence of laboratory results, the diagnosis of measles will depend upon a combination of epidemiological and clinical factors
Management will normally have to precede the results of laboratory testing (even where requested urgently)
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Is measles likely/unlikely?
• Assessment by experienced member of HPU
• Source?
Contact with another case?
Traveller community?
Recent travel to endemic country?
• Vaccination status?
• Clinical History
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Assessment of Contacts 1.Immunocompromised2.Pregnant women, infants3.Health Care Workers4.Healthy contacts
Has there been a significant exposure?• 4 days before – 4 days after rash appears• Less than 15 minutes exposure to a case can lead to disease in a susceptible person.
Is the exposed individual likely to be susceptible?•Infants, pregnant women and immunosuppressed individuals should be assessed for susceptibility according to the HPA Post Exposure Prophylaxis for Measles guidelines.
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Contact information given by Paediatric Registrar 00:34 on Saturday morning
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Contact information given by Mother 9am on Saturday morning
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Actions:• Pregnant lady asked to go to QMC for IGG test
• Phoned QMC to arrange
• 2 other babies to attend local hospitals for HNIG
• Details obtained and provided to 2nd on call to arrange with Birmingham
• HPA advised unless confirmed epi link to a confirmed case not to issue HNIG until case tested IgM +ve.
• New swab and blood test taken and sent for urgent testing
• Grandmother – not immunocompromised- no further action
• MMR for other children – now dispersed- advised to attend GP on Monday
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Post on-call outcome•2nd on call spoke again to 2 mothers re HNIG for babies and risks
Monday:
•PCT’s alerted to probable measles case
•01/10/12 Measles confirmed +ve IgM PCR nasal swab and blood
•Practice Nurse contacted to arrange MMRs @ caravan site – majority from site attended the practice for MMR
•HNIG organised for babies – 1 had it, 1 refused
•The mother who refused HNIG for baby attended practice to get 2nd child MMR
•Staff reiterated the importance of HNIG and the risks of measles
•Pregnant woman tested IgG +ve – no HNIG required
•Visit to site by HPA – only 2 caravans left – most moved away- revisited again to take swabs 4 days later
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Secondary cases
MMR
MMR HNIG HNIG
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Key points:
• Communication issues – no phones/ did not answer
• Moved away – difficult to contact / spread of infection to other sites
• Lots of young children – all with no MMR
• Large amounts of communication and work between HPA/ GP and PCT re immunisation
• Several secondary cases
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References:
1- Hawker & Begg, Communicable Disease Control and Health Protection Handbook, Wiley-Blackwell, 3rd Edition, 2012.
2. Health Protection Agency National Measles Guidelines http://www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1274088429847
3. Health Protection Agency Measles Surveillance Information http://www.hpa.org.uk/web/HPAweb&HPAwebStandard/HPAweb_C/1223019390211?printable=true
4. Department of Health, The Green Book https://www.wp.dh.gov.uk/immunisation/files/2012/07/Chap-21-dh_122643.pdf
5. Health Protection Agency. Post Exposure Prophylaxis for Measles guidelines. http://www.hpa.org.uk/web/HPAwebFile/HPAweb_C/1238565307587
6. The NHS Information Centre , NHS Immunisation Statistics, England 2011-12 https://catalogue.ic.nhs.uk/publications/public-health/immunisation/nhs-immu-stat-eng-2011-2012/nhs-immu-stat-eng-2011-12-rep.pdf
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Acknowledgements
Jane Freeman, East Midlands HPU (North)
Vanessa Macgregor, East Midlands HPU (North)