dr. harivansh chopra- () measles dr. harivansh chopra, dch, md professor,community medicine, llrm...

DR. HARIVANSH CHOPRA-(www.observerzparadise.com)

MEASLES

Dr. Harivansh Chopra, DCH, MD

Professor,Community Medicine,LLRM Medical College, Meerut. [email protected]


Objectives

1. To study the epidemiology of Measles.

2. To study the differential diagnosis of Measles.

3. How Measles can be prevented.


Macule - A circumscribed flat area less than 1 cm of discoloration without elevation or depression of surface relative to surrounding skin.


Papule - A circumscribed, elevated, solid lesion, less than 1 cm.


Vesicle - A small, superficial, circumscribed elevation of the skin, less than 0.5 cm, that contains serous fluid.


Pustule - A small (< 1 cm in diameter), circumscribed superficial elevation of the skin that is filled with purulent material. Can also be described as a vesicle filled with pus.


1. Acute febrile eruption.2. Communicable viral disease.3. Stages –

i. Incubation stage.ii. Prodromal stage.iii. Final stage.

Measles (Rubeola – Redspots)


1. Affects childhood population.2. Causes malnutrition.3. Breaks immunological barrier.4. Flaring of existing T.B. Infection.

Problem Statement


5. Developing countries – 100-400 times more mortality.6. Major cause of morbidity & child hood mortality.7. Good vaccine is available.

Case fatality rate 1-3%

Problem Statement


Problem staement

1.Measles occurs in endemic as well

as in epidemic forms.

2.Epidemic occurs after every three

to four years

3. Cyclic trend is present

WHO definition of elimination of Measels

• Absence of endemic measels for a period of ≥12 months in the presence of adequate surveillence.

• One indicator is : a sustained measels incidence of less than 1 per 1000000 population.


Measels in India

• During 1987 2.47 lakh cases were reported.

• After the implementation of UIP, the number of cases have decreased to 40840 with 44 deaths in the year 2009.

• ?



1. Agent RNA paramyxovirus.

2. Source of infection Case.

3. Infective material Secretions of Nose, Throat & Respiratory tract of case.

Agent Factors


4. Communicability Prodromal period &

at time of eruption.5. Period of infectivity 4 days before + 5 days after appearance of rash.6. Secondary attack rate Over 80% in susceptible contact.

Agent Factors


1. Age Developing countries – 6 mths to 3

yrs. Developed countries – over 5 years.

2. Sex Equal incidence.

Host Factors


3. Immunity One attack – Life long.Second attack – Rare.Infants – Transplacentally from mother

(for 4-6 months).

Host Factors


4. Nutrition 400 times more mortality in malnourished children.

Healthy Child

Severe Weight Loss

Malnutrition

Measles

Host Factors


1. Any season.2. More in winters over crowding.3. Population density & Movement. 4. Poorer the socio-economic condition lower the age of attack.

Environmental Factors


Transmission Person to Person by droplet infection & droplet nuclei.

Incubation period 1.10 days from exposure to onset of

fever.2. 14 days to appearance of rash.


Three stages in the natural history of measles are:

(1) Prodormal or Pre-Eruptive stage.(2) Eruptive stage.(3) Post-measles stage.

Clinical Manifestations


It begins 10 days after infection & last until day 14.

Characterised by (1) Low grade to moderate fever.(2) A hacking dry cough.(3) Coryza.(4) Conjunctivitis.

A day or two before the appearance of rash; Koplik’s spots appear.

Prodromal Stage


1.Occur opposite to lower molars, but may spread irregularly over rest of the buccal mucosa.

2.Grayish white dots usually as small grains of sand.

3.With slight reddish areola occasionally hemorrhagic.

Koplik’s Spots


1.Temperature rises abruptly; often reaches 40-40.5º C.2.Rash starts on upper lateral parts of neck behind the ears along hair line

& posterior part of cheek.

Eruptive Stage


3.Individual lesions become increasingly maculopapulous as rash spreads rapidly – 1st 24 hrs. : Entire face neck upper arm

upper part of chest.Next 24 hrs. : Back abdomen entire

arms thighs.

Eruptive Stage


4.On 2-3rd day it finally reaches feet & begins to fade on face.

Eruptive Stage


In severe cases, with confluent rash Petechiae may be present in large numbers. There may be extensive Ecchymoses.

Fading of the rash proceeds down wards in the same sequence in which it appears.

Eruptive StageMeasles rash as seen in a dark skinned child.


Complete absence of rash is rare except in patients 1) Those who have received human antibodies during incubation period.2) Some patients with AIDS.3) In infants less than 8 months of age.

Eruptive Stage


Lymph nodes at the angle of jaws & in the posterior cervical region are usually enlarged & slight splenomegaly may be noted.

Eruptive Stage


Mesentric Lymphadenopathy may be noted. Symptoms of Appendicitis appears when there is obliteration of lumen of appendix.

Eruptive Stage


Complications

1. Diarrhea is the most common complication of Measles in India.


2. Otitis media

3. Pneumonia

4. Encephalitis

Complications


1.Pneumonia may be caused by the measles virus itself.

2.Bronchopneumonia is most common complication in India.

3. It is due to secondary invading bacteria particularly Pneumococcus, Streptococcus, & Haemophilus influenzae.

Pneumonia


Encephalitis may present in the incubation period, or may be post measles. Incidence is 1 in 1000 cases of measles.

Encephalitis


Rare complication.Develops many years after the

initial measles infection.Incidence 7 cases for each

1 million cases of natural measles.

SSPE – Sub-acute Sclerosing Pan-Encephalitis


Other Complications

1. Exacerbation of an existing tubercular process is one of potential danger of measles.

2. Myocarditis is an infrequent complication.


Viral Others

German Measles. Meningococcemia.

Roseola Infantum. Typhoid fever.

Erythema Infectiosum. Scarlet fever.

Infectious Mononucleosis.

Live viral vaccine.

Drug eruption.

DIFFERENTIAL DIAGNOSIS


TYPICAL RASH OF MEASLES

• Maculopapulous rash of Measles is often slightly hemorrhagic. May have Petechiae, and Ecchymoses.


1.Tender lymph node post-cervical, post-occipital, post-auricular region, post-occipital & post-auricular never enlarged in measles.

2. Evolution of rash is very rapid.3. No rise in temperature.4. Occurs mainly in teenagers & young adults.

RUBELLA / GERMAN MEASLES


RASH OF RUBELLA

• Evolution of rash in Rubella is very rapid and not associated with fever.


ROSEOLA INFANTUM

1)High fever (104-105OF); no accompanying signs.

2)No photophobia or conjunctivitis & little cough may be present.

3)After 3-5 days Maculopapular rash starting on trunk arm & neck & slightly involves face & leg.


ROSEOLA INFANTUM

4)As soon as rash appears fever disappears.5) Duration of rash is hardly 24 hrs.6) Caused by Human Herpes Virus 6 (HHV-6).


RASH OF ROSEOLA INFANTUM

• Fever disappears as soon as maculopapular rash of Roseola Infantum appears.


ERYTHEMA INFECTIOSUM(Fifth Disease)

1)Usually in school going age group.

2)No prodromal symptoms; Fever absent or low grade.

3)Slapped face appearance.


ERYTHEMA INFECTIOSUM(Fifth Disease)

4)A day or later Maculopapular rash on arms, legs & trunk but rarely on palms & soles.

5)Duration of rash quite long (2-6 wks); with waxing & waning

6)Rash is highly pruritic in nature – caused by Parvo-virus B19.


RASH OF ERYTHEMA INFECTIOSUM

• Maculopapular lesions of Erythema Infectiosum give Slapped Face appearance. The rashes remain for longer time.


INFECTIOUS MONONUCLEOSIS

1)Moderate fever (102OF).2)Pharyngitis, Lymphadenopathy &

Splenomegaly.


INFECTIOUS MONONUCLEOSIS

3)Lymphocytosis & presence of atypical lymphocytes.

4)Caused by Ebstein Barr Virus.


RASH OF INFECTIOUS MONONUCLEOSIS

5) Enanthema at junction of hard & soft palate.

6) Maculopapular rash in Infectious Mononucleosus appears on treatment with Ampicillin.


MENINGOCOCCEMIA

1.Rash similar to measles, but cough & conjunctivitis are usually absent.

2.In acute meningococcemia rash is characteristic – Petechial Purpuric.


RASH OF MENINGOCOCCEMIA

3. The rash in acute meningococcemia is petechial purpuric. It is due to presence of organisms and rupture of small vessels in subcutaneous tissue.


RASH OF TYPHOID

• Macular rose spots involving primarily the anterior trunk are seen in typhoid.


SCARLET FEVER

1.Caused by Streptococci elaborating one of three pyrogenic toxins.

2.Incubation Period 1-7 days.3.Onset Acute.


SCARLET FEVER

Characterized by 1.Fever, Vomiting, Headache. 2.Toxicity, Pharyngitis, Chills.3.White strawberry tongue; followed

by Red Strawberry Tongue.


SCARLET FEVER

Characterized by 4.Exanthem is red, punctate & finally

papular.5.May be palpated more readily than seen

(Goose Flesh Texture or Coarse Sand paper).

6. Rash initially in Axilla. Involves groin and neck within 24hrs.


SCARLET FEVER

7.There is circumoral pallor 8.In severe disease small vesicular

lesions (Miliary syndrome) – may appear over abdomen; hands & feet


SCARLET FEVER

9.Disappearance of the rash is followed by desquamation of skin – which begin by the end of first week & starts on face & proceed to trunk & finally to hands & feet

10.Desquamation is directly proportional to intensity of rash & it may continue for as long as 6 wks.


RASH OF SCARLET FEVER

• Exanthem is red, punctate & finally papular (goose flesh texture or coarse sand paper). Red

Strawberry tongue is a typical feature of this disease.


RASH OF DRUG ERUPTION

Patient receiving Penicillins, Sulphonamides, Captopril, Phenytoin or Gold may develop maculopapular rash.


PREVENTION OF MEASLES

1. In May 1974, W.H.O. officially launched a programme to protect all children of world against 6 vaccine preventable diseases.

2. Measles vaccination was introduced through U.I.P. (Universal immunization programme) in 1985.


PREVENTION OF MEASLES

Prevention of measles is of two types:

1) Active prevention:

(a) Measles vaccine.

(b) M.M.R. Vaccine.

2) Passive prevention: by Gamma globulin.


1)Freezed dried vaccine contains live attenuated virus 1000 T.C.I.D.50; Stored at 2-8

oC.

2)Dose 0.5 ml; Route Subcutaneous.

MEASLES VACCINE


3.Time of administration 9 months in India. According to W.H.O if child is malnourished, 1st dose is b/w 6-8 months; 2nd dose after 1 year.4.Efficacy of Vaccine – 95%5.Duration of immunity– Lifelong.

MEASLES VACCINE


Measles vaccine

6.It is freezed dried vaccine

7.Has to be reconstituted with

distilled water8.Reconstituted

vaccine must be used as early as

possible


Measles vaccine

9.It has shell life for 2 years

10.Must be stored between

2-8 degree centirgade


Recent W.H.O. recommendation –

1st dose of measles 9 months.

2nd dose of M.M.R. – 15 months.

This vaccine may also be given to contacting person.

MEASLES VACCINE


Complications of vaccine

1. Fever

2. Rash

3. Rarely S.S.P.E

4. T.S.S


1.Impaired cell-mediated immunity.2.Convulsions.3.Patient on steroids.4.Pregnancy.

CONTRAINDICATIONSTO MEASLES VACCINE


5.Active T.B.6.Acute infectious disease.7.Generalized allergy.

CONTRAINDICATIONSTO MEASLES VACCINE

Vaccination strategy• catch-up, keep-up and follow-up, two

of which are supplementary vaccinations.

• Catch -up is defined as a one-time, nation wide vaccination campaign targeting usually all children aged 9 months to 14 years regardless of history of measles disease or vaccination status.



Keep-up is defined as routine service aimed at vaccinating more than 95 per cent of each successive-birth cohort.


Follow up is defined as subsequent nation wide vaccination campaign conducted every 2 -4 years targeting usually all children born after the catch-up campaign


TREATMENT OF MEASLES

1.Ribavirin (10mg/kg/day) X 5 days.2.PCM (10mg/kg/dose) 4 – 6 hourly.3.Codeine (1 mg/ kg/ day).


TREATMENT OF MEASLES

4.Humidification of room for laryngitis & irritating cough.

5.Protect from exposure to light.6.Extra nutrition to child.


VITAMIN A

The recommended regimen is a single dose of 100,000 IU orally for children 6 mo to 1 yr, and 200,000 IU for children 1 yr of age or older.


Children with ophthalmologic evidence of vitamin A deficiency should be given additional doses the next day and 4 wk later.As per BSPM 2ND DOSE I MONTH LATER.


Conclusion 1. Important Vaccine preventable

disease.2. Number of illnesses resemble

measles.3. High suspicion index is required to

make a diagnosis.4. Making a right diagnosis will remove

the myths related to non-acceptance of measles vaccine.


MCQs

Q-1 Mortality in Measles is increased in malnourished children upto

1. 100 times

2. 200 times

3. 300 times

4. 400 times

Answer – 4.


• Q-2 Secondary attack rate is• 1 Occurrence of second attack of a

disease• 2 Percentage of contacts developing

the disease • 3 Percentage of susceptible contacts

developing the disease in one incubation period

• 4 All of the above

ANS 3


Q-3 Which of the following diseases have got a cyclic trend

1. Chicken pox 2. Measles3. Poliomyelitis4. Hepatitis B

ANS 2


Q-4 The incubation period of Measles is1. 10 days2. 5 days3. 15 days4. 20 days

ANS 1


Q-5 Secondary attack rate in Measles is

1 >50%2 >60%3 >70 %4 >80%

ANS 4


Q-6 The period of communicability in Measles is1. One week before & one week after the rash has appeared2. 4 days before & 5 days after the rash has appeared3. 5 days before & 4 days after the rash has appeared4. 5 days before & 5 days after the rash has appeared

ANS 2


Q-7 The rash in Measles is

1 Macculo-papular

2 Exanthems

3 Enanthems

4 All of the above ANS 4


Q-8 The rash in Measles first of all appears on

1. Trunk2. Palm & Sole3. Face4. Behind the ears

ANS 4


Q-9 The most common complication of measles in India is

1. Diarrhoea 2. Pneumonia3. Encephalitis4. S.S.P.E.

ANS 1


Q-10 Measles can occur below the age of 6 months only if1. Mother has not been immunized2. Mother did not have measles in childhood3. Mother is HIV positive4. All of the above

ANS 4


Q-11 Hemorrhagic Measles is1. When rash is hemorrhagic2. Synonym with Black Measles3. When there is bleeding from mouth, nose,

or bowel4. All of the above5. 2 &3 are correct6. 1 &3 are correct

ANS 5


Q-12 Which of the following diseases can exacerbate existing tuberculous process

1. Measles 2. Pertusis3. HIV4. All of the above

ANS 4


Q-13 Encephalitis due to Measles can occur in 1. Pre-eruptive stage2. Eruptive stage3. Post-eruptive stage4. All of the above.

ANS 4


Q-14 The efficiency of Measles vaccine is

1 >80%2 < 80%3 95%4 100%

ANS 3


Q-15 Which of the following condition is not a contraindication for the use of Measles vaccine

1. Pregnancy2. Child with untreated

tuberculosis3. Child with Leukaemia4. Child with H.I.V. infection

ANS 4


MCQs

Q-16 The rash in Measles first of all appears on

1. Trunk

2. Palm & Sole

3. Face

4. Behind the ears

Answer – 4.


Q-17 The risk of S.S.P.E. after natural infection of Measles is

1. One in one million

2. Seven in one million

3. One in seven million

4. Seven in seven million

MCQs

Answer – 2.


Q-18 Black Measles is

1. When measles is occurring in Blacks

2. When the colour of rash is black

3. When measles is occurring in Whites & color of rash is black

4. None of the above

MCQs

Answer – 4.


(0.25 ML/KG; MAXIMUM: 15 ML) INTRAMUSCULARLY AS SOON AS POSSIBLE AFTER EXPOSURE, BUT WITHIN 5 DAYS. IMMUNOCOMPROMISED PERSONS SHOULD RECEIVE IMMUNE GLOBULIN (0.5 ML/KG; MAXIMUM: 15 ML) I


Droplet nuclei" are a type of particles implicated in the spread of airborne infection. They are tiny particles (1-10 microns range) that represent the dried residue of droplets


THE PRECEDING FOUR EXANTHEMS WERE MEASLES, SCARLET FEVER, RUBELLA AND FILATOV-DUKES DISEASE (AN ATYPICAL SCARLET FEVER), WITH ROSEOLA INFANTUM AS THE "SIXTH DISEASE.

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