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Measles, Mumps &Rubella(MMR)

Dr Rajkumar PatilProfessor,Community Medicine

MGMCRI

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Learning objectives

At the end of the class student should be able to:

• Describe the important agent, host and environmental factors of Measles, Mumps and Rubella

• Describe the preventive and control measures Measles ,Mumps and Rubella

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Measles (Rubeola)

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Measles-Introduction

• Acute highly infectious disease of childhood caused by a specific virus (RNA paramyxovirus).

• Characterized by fever and respiratory symptoms followed by typical rash.

• Associated with high morbidity and mortality in developing countries.

• 2% of under 5 mortality in India (WHO 2014)

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Problem statement

• In 2014, there were 114900 measles deaths globally – about 314 deaths every day or 13 deaths every hour.

• Measles vaccination resulted in a 79% drop in measles deaths between 2000 and 2014 worldwide.

• Measles is still common in many developing countries – particularly in parts of Africa and Asia.

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Agent factors

• Agent- RNA virus (Paramyxo virus family, genus Morbillivirus)

• Can’t survive outside the human body

• Source of infection: case of measles (no carriers).

• No animal reservoir

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Agent factors• Infective material- Secretions of nose, throat and respiratory tract

• Virus remains active and contagious in the air or on infected surfaces for up to 2 hours.

• Period of communicability: 4 days before to 4 days after the appearance of rash

• Highly infectious during prodromal period and at the time of eruption.

• Secondary Attack Rate(SAR): > 80%

Host factorsAge:• Commonly 6 months to 3 years in developing and

underdeveloped countries• More than 5 years in developed countriesSex: Incidence equal in both sexesImmunity:• No age is immune if there is no previous immunity• One attack-life long immunityNutrition: Malnourished children highly susceptible, mortality is more

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Environmental factors

• In tropical climate: Dry season

• In temperate climate: Winter season, over crowding

• In India: January to April

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Transmission:Droplet infection,droplet nucleiPortal of entry and exit: Respiratory tract, Minor- conjunctiva

Incubation period:10-14 days

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Clinical features

• Prodromal stage

• Eruptive stage

• Post-measles stage

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Prodromal stage

• From 10th day of infection to 14th day• 3 Cs (Cough, Coryza with sneezing and nasal

discharge & Conjunctivitis)• Lacrimation and photophobia• Fever for 4 days• May be- Vomiting or Diarrhoea • Koplik spots

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Koplik’s spots

• Pathognomic sign

• 1-2 days before appearance of rash

• Small, bluish-white spots over a red base

• On buccal mucosa opposite the first and second lower molars

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

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Eruptive stage

• Dusky red, generalized, maculopapular, erythematous rash.

• Begins behind the ear and rapidly spreads to face, neck and extends down the body within 2-3 days.

• In the absence of complications, rash and fever disappears in 3-4 days.

• Rash fades in the order of appearance.

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Courtesy : This media comes from the Centers for Disease Control and Prevention's Public Health Image Library (PHIL), with identification number #3168

19Courtesy : Adapted from Mims et al. Medical Microbiology, 1993, Mosby

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Post Measles Stage

Growth retardationSusceptibility to other infectionsComplications:• Pneumonia(20-80% in developing countries, less than 10% in developed)• Diarrhoea • Respiratory Infections• Otitis Media(5-15%)• Rarely Febrile convulsions, Encephalitis

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What is a probable case of Measles?

In the absence of a more likely diagnosis, an illness characterized by: Generalized rash lasting ≥3 days; andTemperature ≥101°F or 38.3°C; and

Cough, coryza, or conjunctivitis; and

No epidemiologic linkage to a confirmed case of measles; &Non-contributory or no serologic or virologic testing.

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What is a confirmed case of Measles?• Laboratory confirmation by any of the following:• Positive serologic test for measles IgM antibody;• Isolation of measles virus from a clinical specimen; or• Detection of measles-virus specific nucleic acid by polymerase chain

reaction (PCR)(Note: A lab-confirmed case does not have to have generalized rash lasting ≥3 days; temperature ≥101°F or 38.3°C; cough, coryza, or conjunctivitis. ) OR

An illness characterized by• Generalized rash lasting ≥3 days; and• Temperature ≥101°F or 38.3°C; and• Cough, coryza, or conjunctivitis; and• Epidemiologic linkage to a confirmed case of measles.

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Treatment of Measles

• Isolation for 7 days after the onset of rash

• No specific antiviral treatment.• Supportive care: good nutrition, adequate fluid intake and

treatment of dehydration.

• Antibiotics: to treat eye and ear infections, and pneumonia.

• All children diagnosed with measles should receive two doses of vitamin A supplements, given 24 hours apart.

Vitamin A can help prevent eye damage and blindness. (Vitamin A supplements reduces the deaths from measles by 50%)

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Prevention of MeaslesImmunization:• Eradication can be achieved by immunization rate of

atleast 96% under one year of age • Ongoing immunization against measles • Measles vaccination: live attenuated, subcutaneous,0.5

ml, at 9-12 months, life long immunity in 90-99%; Reactions: Mild fever

• MMR vaccine • Immunoglobulin(human):with in 3-4 days of exposure

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Measles outbreak control

• Isolation for 7 days after the onset of rash

• Active Immunization of contacts within 2 days of exposure (or passive immunization within 3-4 days)

• Prompt immunization at the beginning of outbreak

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Enhanced measles eradication strategy-WHO 1) Catch up: First, a one-time-only "catch-up" measles

vaccination campaign is conducted among children aged 9 months to 14 years.

2) Keep up: Efforts are then made to vaccinate through routine health services ("keep-up") at least 95% of each

newborn cohort at 12 months of age.

3) Follow up: Finally, to assure high population immunity among preschool-aged children, indiscriminate "follow-up" measles vaccination campaigns are conducted approximately every 4 years.

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Challenges for Measles elimination

• Weak immunization systems• High infectious nature of measles• Inaccessible population in certain areas• Refusal to immunization by some people • Changing epidemiology(adolescents and adults)• Catch up immunization to more than 130 million

children in India• Lack of human and financial resources

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Mumps

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Mumps-Introduction

• "to mump" (british word): grimace or grin (as a result of parotid gland swelling)

• Acute infectious disease due to “myxovirus parotiditis” ; RNA paramyxovirus (Genus Rubulavirus) affecting mainly glands and nervous system

• Mortality is negligible

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Source: Centers for Disease Control and Prevention's Public Health Image Library (PHIL), with identification number #130 Content Providers: CDC/NIP/Barbara Rice

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Agent factors

• Myxovirus parotidis –RNA virus

• Source of infection: Clinical and subclinical cases; mainly saliva; others:blood,urine,human milk,CSF

• Period of communicability: 4-6 days of onset of symptoms to 7 days after

(Maximum just before and at the onset of parotid swelling)• Secondary attack rate: 86%

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Host factors• Age: mostly 5-9 yrs, but can be seen in any age • Sex: females • Immunity: less than 6 months of age infants are immune,

life long immunity after one infection

Environmental factor • Any time but peak in winter and spring season • Overcrowding

Mode of transmission: droplet infection and direct contact with the infection personI.P.: 2-4 weeks

Clinical features• One third cases: asymptomatic• Initial symptoms: ear ache on affected side, pain and

stiffness on opening the mouth

• Pain and swelling due to involvement of parotid, sublingual and submandibular glands,

• Swelling subsides in 1-2 weeks

• Can affect testes,pancreas,ovaries,prostate,CNS• Severe cases: Fever 3-5 days

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Source : Adapted from Mims et al. Medical Microbiology, 1993, Mosby

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Complications of MumpsFrequent but not serious:• Orchitis (25-40%): 7-10 days after parotitis,with high fever (Unilateral in 75% orchitis cases, Most common extra-salivary gland manifestation in adults)• Epididymitis• Pancreatitis(4%)• Mild form of meningitis• Thyroiditis, Neuritis, Hepatitis,Ovaritis,• Oophoritis (5% adult women)• Spontaneous abortion(25% in pregnancy)Rare:Hearing loss, Polyarthritis, Encephalitis, Cerebellar ataxia

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Management of Mumps

• Supportive

• Case should be isolated till symptoms subside

• Contacts should be kept under surveillance

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Prevention of Mumps

Immunization• Mumps vaccine: Live attenuated,0.5 ml, IM• MMR vaccine

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Rubella

(German measles)

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Introduction-Rubella

• Rubella (Latin term) means "little red."

• It is a generally mild disease caused by the rubella virus.

• Rubella is also known as German Measles or 3-day Measles.

• Typical course of rubella exanthema starts initially on the face and neck and spreads centrifugally to the trunk and extremities within 24 hours, It then begins to fade on the face on the second day and disappears throughout the body by the end of the third day.

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Agent factors

• Agent: RNA virus (Togo virus family) • Source of infection: majority subclinical cases, minor-

clinical cases • Infective material: Respiratory secretions, blood, CSF,

urine• Period of communicablity: A week before symptoms to a

week after the rash

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Host factors-Age: 3-10 yrs(developing countries) 15 years developed countriesImmunity: Life long after first attack, maternal immunity upto 6 months of age

Environmental factors- winter and spring season, with epidemics every 4-9 years

Transmission- droplet inf, droplet nuclei, vertical transmission, portal of entry: respiratoryIncubation period- 2 to 3 weeks (average 18 days)

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Clinical features

• 50-60% asymptomatic

• Symptoms: Prodromal phase(mild): coryza,sore thorat, low grade fever Lymphadenopathy: post auricular and posterior

cervical lymph nodes enlargement

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Rash:• Minute,discrete,pinkish,macular • Starts on face within 24 hours of the onset of the

prodromal symptoms,spreads to trunk and extremities, clears more rapidly,disappears in 3 days

• Rash absent (25% cases) in subclinical cases

Conjunctivitis may occur.

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Image in a 4-year-old girl with a 4-day history of low-grade fever, symptoms of an upper respiratory tract infection, and rash. Courtesy of Pamela L. Dyne, MD.

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Complications of Rubella

Rare:ArthralgiaThrombocytopenic purpura

Very rare:Encepahlaitis

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Diagnosis

• Virus isolation by throat swab culture

• ELISA for IgM antibody

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Congenital Rubella Syndrome(CRS)

• Due to Rubella infection in pregnancy

• It is a chronic infection of foetus

• First trimester infection- severe

• Foetal death and spontaneous abortion

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Clinical features of CRS

• Congenital malformations(Triad of Deafness,Cradiac malformations,cataract)

• Other defects: Glaucoma,retinopathy,microcephalus,cerebral palsy,IUGR,LBW,Heapto-splenomegaly,mental and motor retardation

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Photo source: U.S. Centers for Disease Control and Prevention

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Salt and pepper retinopathy

Content Providers(s): CDC Creation Date: 1976

Courtesy http://phil.cdc.gov/phil_images/20030724/28/PHIL_4284_lores.jpg

http://www.kellogg.umich.edu/theeyeshaveit/congenital/retinopathy.html

Courtesy: Jonathan Trobe, M.D. - University of Michigan Kellogg Eye Center

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Prevention of Rubella

Immunization• Rubella vaccine: RA 27/3 strain,0.5 ml, SC,Life

long immunity in 95% • C/I for immunization: Pregnancy• Recipients of vaccine should be advised not to

become pregnant in 3 months after getting vaccine

• MMR vaccine

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Vaccination strategy for Rubella

• First protect women in 15-39 yr age• Second interrupt transmission by vaccinating

children aged 1-14 years• Third,all children at age 1

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MMR Vaccine

Live attenuated strains of:• Edmonston-Zagreb Measles virus• L-Zagreb Mumps virus • Wistar RA 27/3 Rubella virus

• The reconstituted vaccine contains, in single dose of 0.5 ml. not less than 1000 CCID50 of Measles virus 5000 CCID50 of Mumps virus 1000 CCID50 of Rubella virus.

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MMR vaccine contd…

• Diluent: Sterile water for injection. • MMR vaccine may be given after 12 months of age.

• After reconstitution the vaccine should be used immediately.

• Dose: 0.5 ml, deep SC in the upper arm. • If the vaccine is not used immediately then it should be

stored in the dark at 2°- 8°C for no longer than 8 hours.

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Global Measles and Rubella Strategic Plan 2012-2020In 2012, the M&R Initiative launched a new Global Measles and Rubella Strategic Plan which covers the period 2012-2020.

By the end of 2015 the plan aims:to reduce global measles deaths by at least 95% compared with 2000 levels;to achieve regional measles and rubella/congenital rubella syndrome (CRS) elimination goals.

By the end of 2020 the plan aims:to achieve measles and rubella elimination in at least 5 WHO regions.

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The strategy focuses on the implementation of 5 core components:

• achieve and maintain high vaccination coverage with 2 doses of measles- and rubella-containing vaccines;

• monitor the disease using effective surveillance, and evaluate programmatic efforts to ensure progress and the positive impact of vaccination activities;

• develop and maintain outbreak preparedness, rapid response to outbreaks and the effective treatment of cases;

• communicate and engage to build public confidence and demand for immunization; and

• perform the research and development needed to support cost-effective action and improve vaccination and diagnostic tools.

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Thank you