MEASLESKatie Townes, MD

UMass Medical School and HEARTT

Emmanuel Okoh, MDActing Director of Pediatrics, JFKMC and HEARTT

Adapted from a lecture by Rick Moriarty, MD, UMass Medical School (also a HEARTT doctor)

Measles

• Cause: RNA paramyxovirus• Host: humans only• Spread: respiratory droplets• Incubation: 1-2 weeks• Attack rate: >90%• Attack leads to lifelong immunity• 30-40 million cases annually• 164,000 deaths in 2008

Measles Symptoms

• Incubation: 14 days• Fever• Cough• Coryza• Conjunctivitis• Malaise – “miserable”• Koplik spots• Rash: cephalo-caudad spread• Contagious: 1 day prior to sx- 5 days

after rash starts

Measles: Differential Diagnosis

• Scarlet fever

• Staphylococcal toxin diseases

• Rubella

• Drug rash – SJS

• Infectious mononucleosis

• Dengue

Diagnosis of Measles

• Clinical: History and Physical

-Koplik spots are pathognomonic

• Nasopharyngeal swab for viral culture*

• Serology: IgM positive* from 4 days-60 days of illness, IgG positive* after that.

*Not available in our current setting.

Measles Mortality

• West Africa – 12%• Displaced populations – up to 30%• Up to 20% mortality in infants• Developed countries – 0.02%• More mortality in children <5 years old• Leading cause of vaccine-preventable death

globally (40% of all vaccine-preventable deaths are due to measles)

Measles Complications

• Overcrowding promotes spread

• Poor nutrition or immunocompromise increase complication risk

• Measles often followed by other diseases (superinfection)

• Vitamin A deficiency increases risk of blindness

Measles Complications

• Bacterial superinfection (Staph aureus, pneumococcus, Ecoli, Pseudomonas)

• Respiratory: pneumonia (viral, secondary bacterial, or giant cell), croup, bronchiolitis. Activation of latent Tb.

• GI tract: diarrhea, malnutrition• Skin: desquamation• Ears: Acute otitis media

Measles Complications

• Eyes: conjunctivitis, corneal ulcer, blindness

• Mouth: buccal ulceration, cancrum oris• Hemorrhage• Acute encephalitis 1:1000. Often fatal. • Subacute sclerosing pan-encephalitis

(1:100,000) occurs years after acute illness. Demyelinating process.

Measles Treatment• Isolation

• Supportive care

• Fever therapy

• Hydration

• Consider antibiotics for superinfection

• Vitamin A– 200,000 IU once > age 1 year– 100,000 IU once if age 6-12 months– If eye complications 200,000 IU daily X 2 D,

then repeat in 4 weeks

Measles Vaccine• One serotype

• Live Attenuated Vaccine

• Usually given at 9, 12 or 15 mos after maternally acquired IgG has fallen

• Ideally children would get “second chance” for measles vaccine (2 shots) per WHO recommendations

-Not all children develop antibodies after 1st shot (85% success), so having 2nd shot should catch more children

Measles Vaccine• During outbreak, can vaccinate as early

as 6 months, but still need 9 month shot

• Contraindicated in pregnancy, malignancy. NOT in fever

• Side effects: fever and rash 5-10%

• Having a well-vaccinated population reduces the risk of babies <6 months getting measles (herd immunity)

From 2000-2008, measles deaths dropped by 78% because of vaccination .

Measles Vaccine Coverage

Measles at JFK

From the Pedi Wards*:

January: 0 casesFebruary: 1 male 5 femalesMarch: 1 male 1 femaleApril: 1 male 9 femalesMay: 6 males 2 females

*This does not include the large number of patients presenting to the OPD with simple measles, or the children admitted and discharged from the ER without admission to the wards.

Liberia immunization schedule

http://www.who.int/vaccines/globalsummary/immunization/ScheduleSelect.cfm

What next?• Vaccinate, vaccinate, vaccinate!

• Every health care provider should encourage all kids to get vaccines, and all parents to vaccinate their children.

• Don’t turn children away if they have fever (they may not come back!)

• Remember measles and its severe complications (which can occur years later) are completely preventable with a single shot.

Thank you!