1. MEASLES Katie Townes, MD UMass Medical School and HEARTT Emmanuel Okoh, MD Acting Director of Pediatrics, JFKMC and HEARTT Adapted from a lecture by Rick Moriarty, MD, UMass Medical School (also a HEARTT doctor)

2. 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

4. 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

8. Measles: Differential Diagnosis Scarlet fever Staphylococcal toxin diseases Rubella Drug rash – SJS Infectious mononucleosis Dengue

9. 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.

10. 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)

11. 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

12. 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

13. 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.

15. 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

17. 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 1 st shot (85% success), so having 2 nd shot should catch more children

18. 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)

19. From 2000-2008, measles deaths dropped by 78% because of vaccination. Measles Vaccine Coverage

20. Measles at JFK From the Pedi Wards*: January: 0 cases February: 1 male 5 females March: 1 male 1 female April: 1 male 9 females May: 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.

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

22. 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.

23. Thank you!