Case • A 12 months old child was brought to

RHTC, Rithora with c/oFever x 6 daysRunning nose x 6 daysAppearance of rash on face x

2days

• On examinationMalnourish childEye - Bitot spot bilateral

MEASLES(Rubeola–Redspots)

Dr Deepak UpadhyayDept. of Community Medicine

Rohilkhand Medical College & Hospital

History• References to measles – as early as 7th

century• Described by the Persian physician Rhazes

in the 10th century as “more dreaded than smallpox.”

• 1846 - Peter Panum described incubation period of measles and lifelong immunity after recovery

• 1954 - Enders and Peebles isolated the virus in human and monkey kidney tissue culture

Agent RNA paramyxovirus.Source of infection Case.Infective material Secretions of Nose, Throat & Respiratory tract.Mode of transmission – Air borne transmissionPeriod of infectivity 4 days before + 5 days after appearance of rash.Secondary attack rate Over 80% in susceptible contact.

Agent Factors

Age • Developing countries – 6 mths to 3 yrs. • Developed countries – over 5 years.

Male = Female. Immunity

• One attack – Life long.• Infants – Transplacentally from mother

(for 4-6 months)• Nutrition 400 times more mortality in

malnourished children

Host Factors

More in winters

High Population density & Movement.

Poorer the socio-economic condition lower the age of attack.

Transmission Person to Person by droplet infection & droplet nuclei.

Environmental Factors

Incubation period 10 days from exposure to onset of

fever. 14 days to appearance of rash.

Three stages in the natural history of measles are:

Prodormal or Pre-Eruptive stage. Eruptive stage. Post-measles stage.

Clinical Manifestations

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

Characterized by • Low grade to moderate fever.• A hacking dry cough.• Coryza.• Conjunctivitis.

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

Prodromal Stage

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.

Koplik’s Spots

Temperature rises abruptly (app.40 -40.5ºC).

Rash starts on upper lateral parts of neck behind the ears along hair line & posterior part of cheek.

Rash spreads rapidly – • 1st 24 hrs. : Entire face

neck upper arm upper part of chest.

• Next 24 hrs. : Back abdomen entire arms thighs.

Itching is generally slight

Eruptive Stage

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

As the rash fades, branny desquamation and brownish discoloration occur and then disappear within 7-10 days.

Lymph nodes at the angle of jaws & in the posterior cervical region are usually enlarged

Slight splenomegaly may be noted

ComplicationsDiarrhea is the most

common complication of Measles in India.

Otitis media

Pneumonia

Encephalitis

Other Complication

• SSPE (Sub-acute Sclerosing Pan-Encephalitis)

• Myocarditis• Exacerbation of an existing tubercular

process• Vitamin A Deficiency

Viral OthersGerman 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.

RUBELLA / GERMAN MEASLES1.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

ROSEOLA INFANTUM• High fever (104-105OF);

no accompanying signs

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

• As soon as rash appears fever disappears.

• Duration of rash is hardly 24 hrs.

• Caused by Human Herpes Virus 6 (HHV-6)

ERYTHEMA INFECTIOSUM(Fifth Disease)

1)Usually in school going age group.2)No prodromal symptoms; Fever absent or

low grade.3)Slapped face appearance.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

INFECTIOUS MONONUCLEOSIS

• Caused by Ebstein Barr Virus.

• Moderate fever (102OF).• Pharyngitis,

Lymphadenopathy & Splenomegaly.

• Enanthema at junction of hard & soft palate.

• Maculopapular rash in Infectious Mononucleosus appears on treatment with Ampicillin.

MENINGOCOCCEMIA

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

TYPHOID

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

• Associated with prolong fever

SCARLET FEVER• Caused by Streptococci• Exanthem is red, punctate &

finally papular (goose flesh texture or coarse sand paper).

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

• Red Strawberry tongue• Disappearance of the rash is

followed by desquamation of skin –begin by the end of first week & starts on face

Diagnosis • The diagnosis is usually Clinical• Leucopenia with relative lymphocytosis• Measles IgM antibodies – ELISA / HI• IgG antibodies > 4 times• Isolation of measles virus – by tissue

culture to identifying the genotype• All suspected measles cases should be

reported immediately

TreatmentThere is no specific antiviral therapy; Treatment is entirely supportive.

• Antipyretics (acetaminophen or ibuprofen) for fever

• Bed rest• Maintenance of an adequate fluid intake are

indicated. In immunocompromised/patient with

complication - Ribavirin (10mg/kg/day) X 5 days

Vitamin A Doses• All the cases of measles should be given

Vitamin A megadose

Age Immediately Next Day

< 6 month 50,000 IU 50,000 IU6 month – 12 month 1,00,000 IU 1,00,000 IU1 year – 5 year 2,00,000 IU 2,00,000 IU

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 MEASLESPrevention of measles is

of two types: 1) Active prevention:

(a) Measles vaccine.(b) M.M.R. Vaccine.

2) Passive prevention: by Gamma globulin.

Measles Vaccine• Type – live attenuated freeze dried vaccine• Composition – 5000 TCID-50 of Edmonsten

Zagreb Stain• Diluent – Distilled water• Dose – 0.5 ml• Route – Subcutaneous• Site – Right Upper arm (deltoid region)• Time for use – reconstituted vaccine should

be used with in 3-4 hr

Schedule of Measles • According to NIS

• 1st dose – 9 months• 2nd dose – 18 months

• Changes in schedule• During epidemic – 6-9 months• Revaccinate at 9 month & 18 month• Recently All doses of measles should be

replaced with MMR vaccine

• Side effect • Fever and rash• SSPE• Toxic Shock Syndrome

• Efficacy • After 1st dose – 85%• After 2nd dose – 95%

Vaccination strategy• In states with routine immunization

coverage≥80% • Introduction of 2nd Measles vaccine at age

of 18 month• Keeping high immunization coverage

• In states with routine immunization coverage≤80% • 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 <10 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 vaccination campaign conducted every 3 -5 years targeting usually all children born after the catch-up campaign

Post-exposure prophylaxis

• Live measles vaccine - given within 72 hours of exposure

• Immune globulin (IG) - given within 6 days of exposure

• IG may be especially indicated • Child younger than 6 months of age• Immunocompromised child

• Measles control: • reduction of measles morbidity and

mortality in accordance with targets; no longer a public health problem.

• Measles elimination: • In a large geographical area in which

endemic transmission of measles has stopped (< 1 per 10,00,000 population)

• Measles eradication: • Agent no longer exist in country (No cases

for 3 years in presence of good surveillance)

MCQsQ-1 Mortality in Measles is increased

in malnourished children upto 1. 100 times2. 200 times3. 300 times4. 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 efficacy 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

MCQsQ-16 The rash in Measles first of all

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

Answer – 4.

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

1. One in one million2. Seven in one million3. One in seven million4. Seven in seven million

MCQs

Answer – 2.

Q-18 Black Measles is1. When measles is occurring in Blacks2. When the colour of rash is black3. When measles is occurring in Whites &

color of rash is black4. None of the above

MCQs

Answer – 4.