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

DR. HARIVANSH CHOPRA-(www.observerzparadise.com)
MEASLES Dr. Harivansh Chopra, DCH, MD Professor,Community Medicine, LLRM Medical College, Meerut. DR. HARIVANSH CHOPRA-(

Objectives To study the epidemiology of Measles. To study the differential diagnosis of Measles. How Measles can be prevented. DR. HARIVANSH CHOPRA-(

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

Papule - A circumscribed, elevated, solid lesion, less than 1 cm. DR. HARIVANSH CHOPRA-(

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

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. DR. HARIVANSH CHOPRA-(

Measles (Rubeola – Redspots) Acute febrile eruption. Communicable viral disease. Stages – Incubation stage. Prodromal stage. Final stage. DR. HARIVANSH CHOPRA-(

Problem Statement Affects childhood population. Causes malnutrition. Breaks immunological barrier. Flaring of existing T.B. Infection. DR. HARIVANSH CHOPRA-(

Problem Statement 5. Developing countries – times more mortality. 6. Major cause of morbidity & child hood mortality. 7. Good vaccine is available. Case fatality rate  1-3% DR. HARIVANSH CHOPRA-(

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 DR. HARIVANSH CHOPRA-(

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 population. DR. HARIVANSH CHOPRA-(

Measels in India During lakh cases were reported. After the implementation of UIP, the number of cases have decreased to with 44 deaths in the year 2009. ? DR. HARIVANSH CHOPRA-(

Agent Factors Agent  RNA paramyxovirus. Source of infection  Case. Infective material  Secretions of Nose, Throat & Respiratory tract of case. DR. HARIVANSH CHOPRA-(

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. DR. HARIVANSH CHOPRA-(

Host Factors Age  Developing countries – 6 mths to 3 yrs. Developed countries – over 5 years. 2. Sex  Equal incidence. DR. HARIVANSH CHOPRA-(

Host Factors 3. Immunity  One attack – Life long. Second attack – Rare. Infants – Transplacentally from mother (for 4-6 months). DR. HARIVANSH CHOPRA-(

Host Factors 4. Nutrition  400 times more mortality in malnourished children. Measles Healthy Child Severe Weight Loss Malnutrition DR. HARIVANSH CHOPRA-(

Environmental Factors
Any season. 2. More in winters  over crowding. 3. Population density & Movement. 4. Poorer the socio-economic condition  lower the age of attack. DR. HARIVANSH CHOPRA-(

Transmission  Person to Person by droplet infection & droplet nuclei. Incubation period  10 days from exposure to onset of fever. 14 days to appearance of rash. DR. HARIVANSH CHOPRA-(

Clinical Manifestations
Three stages in the natural history of measles are: (1) Prodormal or Pre-Eruptive stage. (2) Eruptive stage. (3) Post-measles stage. DR. HARIVANSH CHOPRA-(

Prodromal Stage 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. DR. HARIVANSH CHOPRA-(

Koplik’s Spots Occur opposite to lower molars, but may spread irregularly over rest of the buccal mucosa. Grayish white dots usually as small grains of sand. With slight reddish areola occasionally hemorrhagic. DR. HARIVANSH CHOPRA-(

Eruptive Stage Temperature rises abruptly; often reaches º C. Rash starts on upper lateral parts of neck behind the ears along hair line & posterior part of cheek. DR. HARIVANSH CHOPRA-(

Eruptive Stage 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. DR. HARIVANSH CHOPRA-(

Eruptive Stage 4.On 2-3rd day it finally reaches feet & begins to fade on face. DR. HARIVANSH CHOPRA-(

Eruptive Stage Measles rash as seen in a dark skinned child. 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. DR. HARIVANSH CHOPRA-(

Eruptive Stage 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. DR. HARIVANSH CHOPRA-(

Eruptive Stage Lymph nodes at the angle of jaws & in the posterior cervical region are usually enlarged & slight splenomegaly may be noted. DR. HARIVANSH CHOPRA-(

Eruptive Stage Mesentric Lymphadenopathy may be noted. Symptoms of Appendicitis appears when there is obliteration of lumen of appendix. DR. HARIVANSH CHOPRA-(

Complications Diarrhea is the most common complication of Measles in India. DR. HARIVANSH CHOPRA-(

Complications 2. Otitis media 3. Pneumonia 4. Encephalitis DR. HARIVANSH CHOPRA-(

Pneumonia Pneumonia may be caused by the measles virus itself. Bronchopneumonia is most common complication in India. It is due to secondary invading bacteria particularly Pneumococcus, Streptococcus, & Haemophilus influenzae. DR. HARIVANSH CHOPRA-(

Encephalitis Encephalitis may present in the incubation period, or may be post measles Incidence is 1 in 1000 cases of measles. DR. HARIVANSH CHOPRA-(

Sub-acute Sclerosing Pan-Encephalitis
SSPE – Sub-acute Sclerosing Pan-Encephalitis Rare complication. Develops many years after the initial measles infection. Incidence 7 cases for each million cases of natural measles. DR. HARIVANSH CHOPRA-(

Other Complications Exacerbation of an existing tubercular process is one of potential danger of measles. Myocarditis is an infrequent complication. DR. HARIVANSH CHOPRA-(

DIFFERENTIAL DIAGNOSIS
Viral Others German Measles. Meningococcemia. Roseola Infantum. Typhoid fever. Erythema Infectiosum. Scarlet fever. Infectious Mononucleosis. Live viral vaccine. Drug eruption. DR. HARIVANSH CHOPRA-(

TYPICAL RASH OF MEASLES
Maculopapulous rash of Measles is often slightly hemorrhagic. May have Petechiae, and Ecchymoses. DR. HARIVANSH CHOPRA-(

RUBELLA / GERMAN MEASLES
Tender lymph node  post-cervical, post-occipital, post-auricular region, post-occipital & post-auricular never enlarged in measles. Evolution of rash is very rapid. No rise in temperature. Occurs mainly in teenagers & young adults. DR. HARIVANSH CHOPRA-(

RASH OF RUBELLA Evolution of rash in Rubella is very rapid and not associated with fever. DR. HARIVANSH CHOPRA-(

ROSEOLA INFANTUM High fever ( OF); no accompanying signs. No photophobia or conjunctivitis & little cough may be present. After 3-5 days Maculopapular rash starting on trunk  arm & neck & slightly involves face & leg. DR. HARIVANSH CHOPRA-(

ROSEOLA INFANTUM As soon as rash appears fever disappears. Duration of rash is hardly 24 hrs. Caused by Human Herpes Virus 6 (HHV-6). DR. HARIVANSH CHOPRA-(

RASH OF ROSEOLA INFANTUM
Fever disappears as soon as maculopapular rash of Roseola Infantum appears. DR. HARIVANSH CHOPRA-(

ERYTHEMA INFECTIOSUM (Fifth Disease)
Usually in school going age group. No prodromal symptoms; Fever absent or low grade. Slapped face appearance. DR. HARIVANSH CHOPRA-(

ERYTHEMA INFECTIOSUM (Fifth Disease)
A day or later Maculopapular rash on arms, legs & trunk but rarely on palms & soles. Duration of rash quite long (2-6 wks); with waxing & waning Rash is highly pruritic in nature – caused by Parvo-virus B19. DR. HARIVANSH CHOPRA-(

RASH OF ERYTHEMA INFECTIOSUM
Maculopapular lesions of Erythema Infectiosum give Slapped Face appearance. The rashes remain for longer time. DR. HARIVANSH CHOPRA-(

INFECTIOUS MONONUCLEOSIS
Moderate fever (102OF). Pharyngitis, Lymphadenopathy & Splenomegaly. DR. HARIVANSH CHOPRA-(

INFECTIOUS MONONUCLEOSIS
Lymphocytosis & presence of atypical lymphocytes. Caused by Ebstein Barr Virus. DR. HARIVANSH CHOPRA-(

RASH OF INFECTIOUS MONONUCLEOSIS
Enanthema at junction of hard & soft palate. Maculopapular rash in Infectious Mononucleosus appears on treatment with Ampicillin. DR. HARIVANSH CHOPRA-(

MENINGOCOCCEMIA Rash similar to measles, but cough & conjunctivitis are usually absent. In acute meningococcemia rash is characteristic – Petechial Purpuric. DR. HARIVANSH CHOPRA-(

RASH OF MENINGOCOCCEMIA
The rash in acute meningococcemia is petechial purpuric. It is due to presence of organisms and rupture of small vessels in subcutaneous tissue. DR. HARIVANSH CHOPRA-(

RASH OF TYPHOID Macular rose spots involving primarily the anterior trunk are seen in typhoid. DR. HARIVANSH CHOPRA-(

SCARLET FEVER Caused by Streptococci elaborating one of three pyrogenic toxins. Incubation Period  1-7 days. Onset  Acute. DR. HARIVANSH CHOPRA-(

SCARLET FEVER Characterized by  Fever, Vomiting, Headache. Toxicity, Pharyngitis, Chills. White strawberry tongue; followed by Red Strawberry Tongue. DR. HARIVANSH CHOPRA-(

SCARLET FEVER Characterized by  Exanthem is red, punctate & finally papular. May be palpated more readily than seen (Goose Flesh Texture or Coarse Sand paper). Rash initially in Axilla. Involves groin and neck within 24hrs. DR. HARIVANSH CHOPRA-(

SCARLET FEVER There is circumoral pallor In severe disease  small vesicular lesions (Miliary syndrome) – may appear over abdomen; hands & feet DR. HARIVANSH CHOPRA-(

SCARLET FEVER 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 Desquamation is directly proportional to intensity of rash & it may continue for as long as 6 wks. DR. HARIVANSH CHOPRA-(

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. DR. HARIVANSH CHOPRA-(

RASH OF DRUG ERUPTION Patient receiving Penicillins, Sulphonamides, Captopril, Phenytoin or Gold may develop maculopapular rash. DR. HARIVANSH CHOPRA-(

PREVENTION OF MEASLES In May 1974, W.H.O. officially launched a programme to protect all children of world against 6 vaccine preventable diseases. Measles vaccination was introduced through U.I.P. (Universal immunization programme) in 1985. DR. HARIVANSH CHOPRA-(

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. DR. HARIVANSH CHOPRA-(

MEASLES VACCINE Freezed dried vaccine contains live attenuated virus 1000 T.C.I.D.50; Stored at 2-8oC. Dose  0.5 ml; Route  Subcutaneous. DR. HARIVANSH CHOPRA-(

MEASLES VACCINE 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% Duration of immunity– Lifelong. DR. HARIVANSH CHOPRA-(

Measles vaccine 6.It is freezed dried vaccine 7.Has to be reconstituted with distilled water 8.Reconstituted vaccine must be used as early as possible DR. HARIVANSH CHOPRA-(

Measles vaccine 9.It has shell life for 2 years 10.Must be stored between 2-8 degree centirgade DR. HARIVANSH CHOPRA-(

MEASLES VACCINE 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. DR. HARIVANSH CHOPRA-(

Complications of vaccine
Fever Rash Rarely S.S.P.E T.S.S DR. HARIVANSH CHOPRA-(

CONTRAINDICATIONS TO MEASLES VACCINE
Impaired cell-mediated immunity. Convulsions. Patient on steroids. Pregnancy. DR. HARIVANSH CHOPRA-(

CONTRAINDICATIONS TO MEASLES VACCINE
Active T.B. Acute infectious disease. Generalized allergy. DR. HARIVANSH CHOPRA-(

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. DR. HARIVANSH CHOPRA-(

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

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 DR. HARIVANSH CHOPRA-(

TREATMENT OF MEASLES Ribavirin (10mg/kg/day) X 5 days. PCM (10mg/kg/dose) 4 – 6 hourly. Codeine (1 mg/ kg/ day). DR. HARIVANSH CHOPRA-(

TREATMENT OF MEASLES Humidification of room for laryngitis & irritating cough. Protect from exposure to light. Extra nutrition to child. DR. HARIVANSH CHOPRA-(

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. DR. HARIVANSH CHOPRA-(

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. DR. HARIVANSH CHOPRA-(

Conclusion Important Vaccine preventable disease. Number of illnesses resemble measles. High suspicion index is required to make a diagnosis. Making a right diagnosis will remove the myths related to non-acceptance of measles vaccine. DR. HARIVANSH CHOPRA-(

Thank You DR. HARIVANSH CHOPRA-(

MCQs Q-1 Mortality in Measles is increased in malnourished children upto 100 times 200 times 300 times 400 times Answer – 4. DR. HARIVANSH CHOPRA-(

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 DR. HARIVANSH CHOPRA-(

Q-3 Which of the following diseases have got a cyclic trend Chicken pox Measles Poliomyelitis Hepatitis B ANS 2 DR. HARIVANSH CHOPRA-(

Q-4 The incubation period of Measles is 10 days 5 days 15 days 20 days ANS 1 DR. HARIVANSH CHOPRA-(

Q-5 Secondary attack rate in Measles is 1 >50% 2 >60% 3 >70 % 4 >80% ANS 4 DR. HARIVANSH CHOPRA-(

Q-6 The period of communicability in Measles is One week before & one week after the rash has appeared 4 days before & 5 days after the rash has appeared 5 days before & 4 days after the rash has appeared 5 days before & 5 days after the rash has appeared ANS 2 DR. HARIVANSH CHOPRA-(

Q-7 The rash in Measles is 1 Macculo-papular 2 Exanthems 3 Enanthems 4 All of the above ANS 4 DR. HARIVANSH CHOPRA-(

Q-8 The rash in Measles first of all appears on Trunk Palm & Sole Face Behind the ears ANS 4 DR. HARIVANSH CHOPRA-(

Q-9 The most common complication of measles in India is Diarrhoea Pneumonia Encephalitis S.S.P.E. ANS 1 DR. HARIVANSH CHOPRA-(

Q-10 Measles can occur below the age of 6 months only if Mother has not been immunized Mother did not have measles in childhood Mother is HIV positive All of the above ANS 4 DR. HARIVANSH CHOPRA-(

Q-11 Hemorrhagic Measles is When rash is hemorrhagic Synonym with Black Measles When there is bleeding from mouth, nose, or bowel All of the above 2 &3 are correct 1 &3 are correct ANS 5 DR. HARIVANSH CHOPRA-(

Q-12 Which of the following diseases can exacerbate existing tuberculous process Measles Pertusis HIV All of the above ANS 4 DR. HARIVANSH CHOPRA-(

Q-13 Encephalitis due to Measles can occur in Pre-eruptive stage Eruptive stage Post-eruptive stage All of the above . ANS 4 DR. HARIVANSH CHOPRA-(

Q-14 The efficiency of Measles vaccine is 1 >80% 2 < 80% 3 95% 4 100% ANS 3 DR. HARIVANSH CHOPRA-(

Q-15 Which of the following condition is not a contraindication for the use of Measles vaccine Pregnancy Child with untreated tuberculosis Child with Leukaemia Child with H.I.V. infection ANS 4 DR. HARIVANSH CHOPRA-(

MCQs Q-16 The rash in Measles first of all appears on Trunk Palm & Sole Face Behind the ears Answer – 4. DR. HARIVANSH CHOPRA-(

MCQs Q-17 The risk of S.S.P.E. after natural infection of Measles is One in one million Seven in one million One in seven million Seven in seven million Answer – 2. DR. HARIVANSH CHOPRA-(

MCQs Q-18 Black Measles is When measles is occurring in Blacks When the colour of rash is black When measles is occurring in Whites & color of rash is black None of the above Answer – 4. DR. HARIVANSH CHOPRA-(

(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 DR. HARIVANSH CHOPRA-(

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 DR. HARIVANSH CHOPRA-(

The preceding four exanthems were measles, scarlet fever, rubella and Filatov-Dukes disease (an atypical scarlet fever), with roseola infantum as the "sixth disease. DR. HARIVANSH CHOPRA-(

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