MEASLES

UPDATE

Dr.T.V.Rao MD

Early History of Measles

Reports of measles go back to at least 700 years, however, the first scientific description of the disease and its distinction from smallpox attributed to the Muslim physician Ibn Razi(Rhazes) 860-932 who published a book entitled "Smallpox and Measles" (in Arabic: Kitab fi aljadari wa-al-hasbah).
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Serious disease as Per WHO.

It remains a leading cause of death among young children globally, despite the availability of a safe and effective vaccine. An estimated 197 000 people died from measles in 2007, mostly children under the age of five.

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Measles - Parmyxoviridae
Measles is an infection of the respiratory system caused by a virus, specifically a Paramyxoviruses of the genus Morbillivirus Morbilliviruses, like other paramyxoviruses, are enveloped, singlestranded, negativesense RNA viruses.

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Measles Virus
The measles virus is a spherical, no segmented, singlestranded RNA virus in the Morbillivirus family, closely related to the rinderpest and canine distemper viruses. It contains six structural proteins, three that are complexed to the RNA and three that are associated with the viral membrane envelope.
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Fusion Protein
The F (fusion) protein is responsible for fusion of virus and host cell membranes, viral penetration and haemolysis. The H (hemagglutinin) protein is responsible for adsorption of the virus to cells.
There is only one serotype of Measles virus and no subtypes have yet been Dr.T.V.Rao MD recognized

Measles
More than 20 million people worldwide are affected by measles each year. Measles outbreaks are common in many areas, including Europe. For many U.S. travellers and expatriates, the risk for exposure to measles can be high, but the illness can be prevented by a measles-containing vaccine
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How the Measles is Spread

Measles is spread through respiration (contact with fluids from an infected person's nose and mouth, either directly or through aerosol transmission), and is highly. The infection has an average incubation period of 14 days (range 6-19 days) and infectivity lasts from 2-4 days prior to 2-5 days following the onset of the rash.
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Measles threat to Developing World

In developing countries, measles affects 30 million children a year and causes 1 million deaths. Measles causes 15,000-60,000 cases of blindness per year.

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Measles a Childhood Infection

Age-specific attack rates may be highest in susceptible infants younger than 12 months, school-aged children, or young adults, depending on local immunization practices and incidence of the disease.
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Patients on Physical examination

Patients tend to appear moderately ill and uncomfortable because of their viral prodromal symptoms. The Koplik spots are 1-2 mm, blue-gray macules on an erythematous base. The measles rash is a Maculopapular erythematous rash that involves the palms and soles. Lesion density is greatest above the shoulders, where macular lesions may coalesce

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A rash is leading manifestations

Typically begins at the hairline and spreads caudally over the next 3 days as the prodromal symptoms resolve.
The rash lasts 4-6 days and then fades from the head downward. Desquamation may be present but is generally not severe. Complete recovery from the illness generally occurs within 7-10 days from the onset of the rash
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Rash is a Prominent Feature

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Risk factors for infection

Children with immunodeficiency due to HIV or acquired immunodeficiency syndrome (AIDS), leukaemia, alkylating agents, or corticosteroid therapy, regardless of immunization status
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Spread of Virus
The highly contagious virus is spread by coughing and sneezing, close personal contact or direct contact with infected nasal or throat secretion
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Early Symptoms in Measles

The incubation period from exposure to onset of symptoms ranges from 812 days. The prodromal phase is marked by malaise, fever, anorexia, and conjunctivitis, cough, and coryza (the "3 Cs"). 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
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Beginning of Illness in Measles

Approximately 10 days after the initial exposure to the virus, the classic viral prodrome occurs. Fever Non-productive cough Coryza Conjunctivitis

Additional prodromal symptoms may include malaise, myalgias, photophobia, and periorbital oedema.
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Koplik Spots leading clue to Measles

With in 2-3 days, the pathognomonic Koplik spots typically arise on the buccal, gingival, and labial mucosa
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Risk factors for severe Measles

Malnutrition
Underlying immunodeficien cy

Pregnancy
Vitamin A deficiency
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Mortality Rate in Measles

The mortality rate associated with uncomplicated measles in immunocompetent, well nourished children is low but raises rapidly with malnourishment (marked in African children ), in immunocompromised, and to lesser extent with age.
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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.
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Atypical Measles
When they are exposed to the measles virus, a mild or non-existent prodrome of fever, headache, abdominal pain, and myalgia's precedes a rash that begins on the hands and feet and spreads centrally. The rash is most prominent in the body creases and may be macular, haemorrhagic vesicles, petechial, or urticarial.

Complications may include pneumonia, pleural effusion, hilar lymphadenopathy, Hepatosplenomegaly, hyperesthesia, or paraesthesia.

Atypical measles occurs in individuals who were previously immunized with the killed measles vaccine between 1963 and 1967 and who have incomplete immunity.

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Sub acute sclerosing pan encephalitis SSPE SSPE is a neurodegenerative disease caused by persistent infection of the brain by an altered form of the measles virus. Neither the biology underlying the viral persistence nor the triggering mechanism for viral reactivation is well understood. In most cases, infected children remain symptom-free for 6-15 years after acute measles infection[
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Sub acute sclerosing pan encephalitis

Sub acute sclerosing pan encephalitis (SSPE) is a rare chronic, progressive encephalitis that affects primarily children and young adults, caused by a persistent infection of immune resistant measles virus (which can be a result of a mutation of the virus itself). 1 in 100,000 people infected with measles develop SSPE. SSPE is 'incurable' but the condition can be managed by medication if treatment is started at an early stage.
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Clinical Presentation of SSPE

Characterized by a history of primary measles infection usually before the age of 2 years, followed by several asymptomatic years (615 on average), and then gradual, progressive psycho neurological deterioration, consisting of personality change, seizures, myoclonus, ataxia, photosensitivity, ocular abnormalities, spasticity, and coma.

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The Progress of SSPE

The initial symptoms of SSPE usually involve regressive changes in intellect and personality. Within several months, the psychological symptoms are compounded by neurological ones, most often consisting of myoclonic jerks. A relentless mental and motor deterioration then ensues, culminating in extreme neurologic dysfunction and death within several years of the onset of symptoms. Our patient's clinical course reflected this typical natural history.
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Diagnosis of Measles
Most cases of Measles are diagnosed clinically, usually in patients home or in General practice
Direct Virological confirmation is difficult in most of the Developing countries
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Diagnosis by Microscopy
Production of multinucleate giant cells with inclusion bodies is path gnomonic for measles. During the prodromal phase, such cells are detectable in the NPS (nasopharyngeal secretions). This is more rapid and practical than virus isolation
Doctortvraos e learning series

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Diagnosis with Immunofluorescence

Direct and indirect immunofluorescence have been used extensively to demonstrate MV antigens in cells from NPS specimens. This technique can also be applied to the urine as such cells may be present in the urine 2 to 5 days after the appearance of the rash

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Diagnosis by Viral Isolation

Measles virus can be isolated form a variety of sources, e.g. throat or Conjunctival washings, sputum, urinary sediment cells and lymphocytes. Primary human kidney (HEK) cells are the best, although primary monkey kidney can be used as well. Continuous cell lines such as Vero cells can also be used
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Diagnosis by Serology
Diagnosis of measles infection can be made if the antibody titres rise by 4 fold between the acute and the convalescent phase or if measlesspecific IgM is found. The methods that can be used include HAI, CF, neutralization and ELISA tests.

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Diagnosis of SSPE
The presence of measles specific antibodies in the CSF is the most reliable means of laboratory diagnosis of SSPE. Demonstration of MV-specific antibodies in the CSF may be sufficient with, if necessary, demonstration of MVspecific restricted heterogeneity by isoelectric focusing
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Treatment
Severe complications from measles can be avoided though supportive care that ensures good nutrition, adequate fluid intake and treatment of dehydration with WHO-recommended oral rehydration solution (to replace fluids and other essential elements lost from diarrhoea or vomiting). Antibiotics should be prescribed to treat eye and ear infections, and pneumonia.

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Treatment options in Developing Countries

All children in developing countries diagnosed with measles should receive two doses of vitamin A supplements, given 24 hours apart. This can help prevent eye damage and blindness. Vitamin A supplements have been shown to reduce the number of deaths from measles by

50%.
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VACCINATION
The Vaccines are Live attenuated containing Edmonston B or Schwartz strains which will give seroconversion rate of 90%. The immunity produce may be life long.
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Measles vaccine is given as MMR Vaccine

The measles vaccine is often incorporated with rubella and/or mumps vaccines in countries where these illnesses are problems. It is equally effective in the single or combined form
The combination proved to be effective and safe
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Measles Vaccine is cheap and Effective

The measles vaccine (in use for 40 years) is safe, effective and inexpensive. It costs less than one US dollar to immunize a child against measles.
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Epidemiological Trends
Measles epidemics occur every 2 year in developed countries in the absence of widespread use of vaccine Poverty and overcrowding increases epidemics
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Two doses of Measles Vaccine

Continued progress depends on ensuring that all children receive two doses of measles vaccine including one dose by their first birthday, strengthening disease surveillance systems, and providing effective treatment for measles.
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Changing trends for a Booster Dose

About 15% of vaccinated children fail to develop immunity from the first dose.)
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Autism and Vaccination

In UK vaccine uptake has fallen recently due to fear over its safety, particularly as cause of Autism.
These fears have now been confirmed as Unsubstantiated.

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CDC disproves Autism Theory

The official perspective of the CDC is that there is no proven connection between live-virus vaccines and autism.
Neither the CDC nor proponents of the vaccine theories think that parents should avoid vaccines. Clearly, vaccines have saved untold lives, and will continue to do so.
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WHO and UNICEF are

collaborating
Strong routine immunization: for children by their first birthday.
A 'second opportunity' for measles immunization through mass vaccination campaigns, to ensure that all children receive at least one dose. Effective surveillance in all countries to quickly recognize and respond to measles outbreaks. Better treatment of measles cases, to include vitamin A supplements, antibiotics if needed, and supportive care that prevents complications.
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Global Initiatives
The Measles Initiative - a collaborative effort of WHO, UNICEF, the American Red Cross, the United States Centres for Disease Control and Prevention, and the United Nations Foundation and other public and private partners play key roles in advancing the global measles strategy
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Global Epidemiology
Approximately 30 million measles cases are reported annually. Most reported cases are from Africa. In 1998, the cases of measles per 100,000 total population reported to the World Health Organization
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Tropics and Measles

In tropical areas particular in Africa children under 1 year of age suffer more attacks, and mortality rate increases
Malnutrition is a major contributing factor.
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Vaccination for Measles Continues to be a Top Priority

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Programme Created by Dr.T.V.Rao MD for Medical and Paramedical Students in Developing World
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