MEASLESDr. Muhammad

Sajjad Sabir DCH , MCPS, FCPS

Assist Prof of Paediatrics

DEFINITION Measles is an acute highly contagious viral disease

caused by measles virus characterized by Fever Cough , coryza ,conjunctivitis Koplik spots Maculopapular rash

ETIOLOGY Measles Virus RNA virus ( Paramyxo virus family) One antigenic type

Rapidly inactivated by heat and light

Source of infection Patients of measles, No carriers No animal reservoir

Routes of transmission air-borne / droplet

immunity permanent acquire after disease Incidence equal in both sexes Epidemic features season: winter and spring age: 6 months to 5 years old

EPIDEMIOLOGY

Measles is one of the most highly infectious

diseases known Highly infectious during prodromal period and at

the time of eruption

90% of people without immunity sharing a house with an infected person will catch it.

Communicability

Spread of Virus-droplet infection

The highly contagious virus is spread by coughing and sneezing, close personal contact or direct contact with infected nasal or throat secretion-

INFECTIVITY It lasts from 4 days

before to 5 days after the onset of the rash

INCUBATION PERIOD

The infection has n average incubation period of 10 days (range 6-19 days)

Measles Pathogenesis● Respiratory transmission of virus ● Replication in nasopharynx and regional

lymph nodes ● Primary viremia 2-3 days after exposure ● Secondary viremia 5-7 days after exposure

with spread to tissues

Incubation period (from exposure to onset of symptoms)

Approximately 10 days( 6~18days) after the initial exposure to the virus, the classic viral prodrome occurs

Beginning of Illness in Measles

The prodromal phase is marked by malaise, fever, anorexia, and  conjunctivitis, cough, and coryza (the "3 Cs")

Koplik’s spotsAdditional prodromal symptoms may include

malaise, myalgias, photophobia, and periorbital oedema

Beginning of Illness in MeaslesProdromal phase 3~4 days

Koplik Spots leading clue to Measles With in 2-3 days,

the pathognomonic Koplik spots typically arise on the buccal, gingival, and labial mucosa

KOPLIK SPOTSource: http://phil.cdc.gov/PHIL_Images/20040908/4f54ee8f0e5f49f58aaa30c1bc6413ba/6111_lores.jpg

Time: the3~5 days after fever ; but the 4th day is most common

Shape: maculopapular Sequence: face → trunk→ limbs The temperature rise continuously and

accompanied with toxic symptoms Persists 5-6 days Fades in order of appearance

Measles Eruption stage

Rash is a Prominent Feature

Sequence: behind the ear → along the hairline →face → neck → chest → back→ abdomen → limbs→ hand and feet

Convalescent stage

brown staining fine branny desquamation course:10-14 days complete healing

Atypical measles

1 . mild measles; 2 . severe measles (toxic and shock type

measles); 3. hemorrhagic measles; 4 . variant measles.

Duration of Symptoms in Measles

The entire course of uncomplicated measles, from late prodrome to resolution of fever and rash, is 7-10 days.

Cough may be the final symptom to appear

Risk factors for severe measles

Malnutrition Immunodeficiency Pregnancy Vitamin A deficiency

Mortality Rate in Measles Low mortality rate associated with

uncomplicated measles in immunocompetent, well nourished children

The mortality rate high with malnourishment immunocompromised, and to lesser extent with age

Modified Measles Modified measles occurs in children who have

received serum immunoglobulin after their exposure to measles

The measles symptom complex may still occur, but the incubation period is as long as 21 days, with the same symptoms as measles but milder

Atypical Measles When they are exposed to the measles virus, a mild or

nonexistent prodrome of fever, headache, abdominal pain, and myalgias precedes rash

Rash begins on the hands and feet and spreads

centrally.

The rash is most prominent in the body creases and may be macular

Atypical measles occurs in individuals who were previously immunized with incomplete immunity

BronchopneumoniaMyocarditisLaryngitisDiarrheaOtitis mediaEncephalitis

COMPLICATIONSSSPEHaemorrhagic

MeaslesMalnutrition Death

Haemorrhagic Measles Sever form of measles Rash is confluent rash is hemorrhagic or

petechial Bleeding from

mouth,nose or bowel Death may occur before

rash

Subacute Sclerosing Panencephalitis (SSPE)

a history of primary measles infection

usually before the age of 2 years followed by several asymptomatic years (6–15 on average) and then gradual, progressive psycho neurological

deterioration, consisting of personality change, seizures, myoclonus, ataxia, photosensitivity, ocular abnormalities, spasticity, and coma

Diagnosis of Measles

Most cases of Measles are diagnosed clinically

Direct Virological confirmation is difficult in most of the Developing countries

Laboratory confirmation Multinucleated giant cells are detected

in nasopharynx mucosa secretions

Measles virus can be isolated in tissues culture

Antibody titer--measles-specific IgM (ELISA tests)

CBC--- WBC is relative low

DIFFERENTIAL DIAGNOSIS Rubella (German measles) Roseola infantum (exanthem subitum) Meningococcemia Scarlet fever Erythema infectiosum/ slapped cheek

(parvovirus B-19) Other viral exanthems Drug rashes

Management General therapy:

rest Good nursing diet

Symptomatic therapy: fever and cough Support therapy Vitamin A treatment of complications

Treatment options in Developing Countreis

All children in developing countries diagnosed with measles should receive two doses of vitamin A supplements, given 24 hours apart 6mo-12mo 1,00,000 U Blue Cap Above 1 yr 2,00,000 U Red Cap

This can help prevent eye damage and blindness

Vitamin A supplements have been shown to reduce the number of deaths from measles by 50%

PREVENTION

Control source of infection

Interruption of transmissions

Protection of the susceptible person

Measles VaccineActive immunization Lived attenuated measles vaccine at 9 months ( can be after 6mo) post exposure : with in 2 days Passive immunization Immunoglobulin <5 days prevent onset >5 days relieve symptoms

VACCINATION

The Vaccines are Live attenuated seroconversion rate of 90%

The immunity produce may be life long

Two doses of Measles Vaccine

All children receive two doses of measles vaccine

First dose at 9 months

Second dose at 15 months The measles vaccine (in use for 40

years) is safe, effective and relatively inexpensive

Measles vaccine as MMR Vaccine

The measles vaccine is often incorporated with rubella and mumps vaccines in countries where these illnesses are problems

The combination proved to be equally effective and safe

Measles vaccine is given as MMR Vaccine

Doses of MMR vaccine

First dose at 12-15 months

Second dose after 6 months

Third dose between 4-6 yrs age

Vaccination for Measles continues to be a Top Priority

QUIZ

Measles Clinical Case Definition

Cough, coryza, or conjunctivitis

Temperature >38.3 C (101 F)

Generalized rash lasting >3 days

3 Cs of Measles

Clinical features 3 Cs (Cough, Coryza & Conjunctivitis) Koplik spots Four days fever (400c) Generalized, maculopapular,erythematous  rash.

Coryza catarrhal inflammation of the mucous

membrane in the nose with discharge of mucus

Measles Clinical Features● Incubation period 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, 14 days after exposure ■ persists 5-6 days ■ begins on face and upper neck ■ maculopapular, becomes confluent ■ fades in order of appearance

Measly Look

Measly Look Red eyes Puffy eyelids Swollen bridge of nose Copious nasal discharge Toxic look Maculopapular , erythematous  rash.

Post Exposure Immunization Active immunization with Lived attenuated measles vaccine

should be done with in 2 days post exposure

WHY?