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MEASLES                  UPDATE  Dr.T.V.Rao MD            1
Early History of MeaslesReports of measles go back to atleast 700 years, however, the firstscientific description of the d...
Serious disease as Per        WHO.              It remains a leading              cause of death among              young ...
Measles - ParmyxoviridaeMeasles is an infectionof the respiratory systemcaused by a virus,specifically aParamyxoviruses of...
Measles VirusThe measles virus is aspherical, nosegmented, single-stranded RNA virus inthe Morbillivirus family,closely re...
Fusion Protein         The F (fusion) protein is         responsible for fusion of         virus and host cell         mem...
Measles      More than 20 million      people worldwide are      affected by measles      each year. Measles      outbreak...
How the Measles is Spread  Measles is spread through  respiration (contact with fluids from  an infected persons nose and ...
Measles threat to Developing           World In developing countries, measles affects 30 million children a year and cause...
Measles a Childhood Infection Age-specific attack rates may be highest in susceptible infants younger than 12 months, scho...
Patients on Physical        examinationPatients tend to appear moderately ill anduncomfortable because of their viralprodr...
A rash is leading manifestations                   Typically begins at the hairline                   and spreads caudally...
Rash is a Prominent Feature                     Dr.T.V.Rao MD
Risk factors for infection                Children with                immunodeficiency                due to HIV or      ...
Spread of VirusThe highlycontagious virus isspread bycoughing andsneezing, closepersonal contactor direct contactwith infe...
Early Symptoms in MeaslesThe incubation period from exposureto onset of symptoms ranges from 8-12 days. The prodromal phas...
Beginning of Illness in      MeaslesApproximately 10 days after the initial exposureto the virus, the classic viral prodro...
Koplik Spots leading clue to Measles  With in 2-3  days, the  pathognomonic  Koplik spots  typically arise on  the buccal,...
Risk factors for severe MeaslesMalnutritionUnderlyingimmunodeficiencyPregnancyVitamin Adeficiency                 Dr.T.V.R...
Mortality Rate in Measles                The mortality rate                associated with                uncomplicated me...
Modified MeaslesModified measles occurs inchildren who have receivedserum immunoglobulin after theirexposure to measles. T...
Atypical MeaslesWhen they are exposed to the measles virus, a mild ornon-existent prodrome of fever, headache, abdominalpa...
Sub acute sclerosing pan encephalitis                SSPESSPE is a neurodegenerative diseasecaused by persistent infection...
Sub acute sclerosing pan      encephalitis Sub acute sclerosing pan encephalitis (SSPE) is a rare chronic, progressive enc...
Clinical Presentation of           SSPECharacterized by a history of primarymeasles infection usually before the age of 2y...
The Progress of SSPEThe initial symptoms of SSPE usually involveregressive changes in intellect and personality.Within sev...
Diagnosis of MeaslesMost cases ofMeasles arediagnosed clinically,usually in patient’shome or in GeneralpracticeDirect Viro...
Diagnosis by Microscopy              Production of              multinucleate giant cells              with inclusion bodi...
Diagnosis withImmunofluorescence          Direct and indirect           immunofluorescence           have been used       ...
Diagnosis by Viral IsolationMeasles virus can beisolated form a varietyof sources, e.g. throator Conjunctivalwashings, spu...
Diagnosis by Serology             Diagnosis of measles             infection can be made if             the antibody titre...
Diagnosis of SSPEThe presence ofmeasles specificantibodies in the CSF isthe most reliable meansof laboratory diagnosisof S...
TreatmentSevere complications from measlescan be avoided though supportive carethat ensures good nutrition, adequatefluid ...
Treatment options in Developing           CountriesAll children in developingcountries diagnosed withmeasles should receiv...
VACCINATIONThe Vaccines areLive attenuatedcontainingEdmonston B orSchwartz strainswhich will giveseroconversionrate of 90%...
Measles vaccine is given as      MMR Vaccine                 The measles vaccine is                 often incorporated wit...
Measles Vaccine is cheap and         EffectiveThe measlesvaccine (in use for40 years) is safe,effective andinexpensive. It...
Epidemiological Trends              Measles epidemics              occur every 2 year in              developed countries ...
Two doses of Measles VaccineContinued progressdepends on ensuringthat all children receivetwo doses of measlesvaccine incl...
Changing trends for a Booster Dose About 15% of vaccinated children fail to develop immunity from the first dose.)        ...
Autism and VaccinationIn UK vaccineuptake has fallenrecently due tofear over itssafety, particularlyas cause ofAutism.Thes...
CDC disproves Autism            Theory The official perspective ofthe CDC is that there is noproven connection betweenlive...
WHO and UNICEF are                collaboratingStrong routine immunization: for children by theirfirst birthday.A second o...
Global InitiativesThe Measles Initiative - acollaborative effort of WHO,UNICEF, the American Red Cross,the United States C...
Global EpidemiologyApproximately 30 millionmeasles cases are reportedannually. Most reported casesare from Africa. In 1998...
Tropics and MeaslesIn tropical areasparticular in Africachildren under 1year of age suffermore attacks, andmortality ratei...
Vaccination for MeaslesContinues to be a Top Priority                        Dr.T.V.Rao MD
Programme Created by Dr.T.V.Rao MD for Medical and Paramedical  Students in Developing World               Email       doc...
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Measles - update

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  1. 1. MEASLES UPDATE Dr.T.V.Rao MD 1
  2. 2. Early History of MeaslesReports of measles go back to atleast 700 years, however, the firstscientific description of the diseaseand its distinction from smallpoxattributed to the Muslim physicianIbn Razi(Rhazes) 860-932 whopublished a book entitled "Smallpoxand Measles" (in Arabic: Kitab fi al-jadari wa-al-hasbah). Dr.T.V.Rao MD
  3. 3. 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. Dr.T.V.Rao MD
  4. 4. Measles - ParmyxoviridaeMeasles is an infectionof the respiratory systemcaused by a virus,specifically aParamyxoviruses of thegenus MorbillivirusMorbilliviruses, like otherparamyxoviruses, areenveloped, single-stranded, negative-sense RNA viruses. Dr.T.V.Rao MD
  5. 5. Measles VirusThe measles virus is aspherical, nosegmented, single-stranded RNA virus inthe Morbillivirus family,closely related to therinderpest and caninedistemper viruses. Itcontains six structuralproteins, three that arecomplexed to the RNAand three that areassociated with theviral membraneenvelope. Dr.T.V.Rao MD
  6. 6. 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
  7. 7. 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 Dr.T.V.Rao MD
  8. 8. How the Measles is Spread Measles is spread through respiration (contact with fluids from an infected persons 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. Dr.T.V.Rao MD
  9. 9. 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. Dr.T.V.Rao MD
  10. 10. 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. Dr.T.V.Rao MD
  11. 11. Patients on Physical examinationPatients tend to appear moderately ill anduncomfortable because of their viralprodromal symptoms.The Koplik spots are 1-2 mm, blue-graymacules on an erythematous base.The measles rash is a Maculopapularerythematous rash that involves thepalms and soles.Lesion density is greatest above theshoulders, where macular lesions may Dr.T.V.Rao MDcoalesce
  12. 12. 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 Dr.T.V.Rao MD
  13. 13. Rash is a Prominent Feature Dr.T.V.Rao MD
  14. 14. 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 Dr.T.V.Rao MD
  15. 15. Spread of VirusThe highlycontagious virus isspread bycoughing andsneezing, closepersonal contactor direct contactwith infected nasalor throat secretion Dr.T.V.Rao MD
  16. 16. Early Symptoms in MeaslesThe incubation period from exposureto onset of symptoms ranges from 8-12 days. The prodromal phase ismarked by malaise, fever, anorexia,and conjunctivitis, cough, andcoryza (the "3 Cs"). The entirecourse of uncomplicated measles,from late prodrome to resolution offever and rash, is 7-10 days. Coughmay be the final symptom to appear Dr.T.V.Rao MD
  17. 17. Beginning of Illness in MeaslesApproximately 10 days after the initial exposureto the virus, the classic viral prodrome occurs.FeverNon-productive coughCoryzaConjunctivitisAdditional prodromal symptoms may includemalaise, myalgias, photophobia, and periorbitaloedema. Dr.T.V.Rao MD
  18. 18. Koplik Spots leading clue to Measles With in 2-3 days, the pathognomonic Koplik spots typically arise on the buccal, gingival, and labial mucosa Dr.T.V.Rao MD
  19. 19. Risk factors for severe MeaslesMalnutritionUnderlyingimmunodeficiencyPregnancyVitamin Adeficiency Dr.T.V.Rao MD
  20. 20. 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. Dr.T.V.Rao MD
  21. 21. Modified MeaslesModified measles occurs inchildren who have receivedserum immunoglobulin after theirexposure to measles. Themeasles symptom complex maystill occur, but the incubationperiod is as long as 21 days,with the same symptoms asmeasles but milder. Dr.T.V.Rao MD
  22. 22. Atypical MeaslesWhen they are exposed to the measles virus, a mild ornon-existent prodrome of fever, headache, abdominalpain, and myalgias precedes a rash that begins on thehands and feet and spreads centrally.The rash is most prominent in the body creases andmay be macular, haemorrhagic vesicles, petechial, orurticarial.Complications may include pneumonia, pleural effusion,hilar lymphadenopathy, Hepatosplenomegaly,hyperesthesia, or paraesthesia.Atypical measles occurs in individuals whowere previously immunized with the killedmeasles vaccine between 1963 and 1967 andwho have incomplete immunity. Dr.T.V.Rao MD
  23. 23. Sub acute sclerosing pan encephalitis SSPESSPE is a neurodegenerative diseasecaused by persistent infection of the brainby an altered form of the measles virus.Neither the biology underlying the viralpersistence nor the triggering mechanismfor viral reactivation is well understood. Inmost cases, infected children remainsymptom-free for 6-15 years after acutemeasles infection[ Dr.T.V.Rao MD
  24. 24. 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. Dr.T.V.Rao MD
  25. 25. Clinical Presentation of SSPECharacterized by a history of primarymeasles infection usually before the age of 2years, followed by several asymptomatic years(6–15 on average), and then gradual,progressive psycho neurological deterioration,consisting of personality change, seizures,myoclonus, ataxia, photosensitivity, ocularabnormalities, spasticity, and coma. Dr.T.V.Rao MD
  26. 26. The Progress of SSPEThe initial symptoms of SSPE usually involveregressive changes in intellect and personality.Within several months, the psychologicalsymptoms are compounded by neurologicalones, most often consisting of myoclonic jerks. Arelentless mental and motor deterioration thenensues, culminating in extreme neurologicdysfunction and death within several years of theonset of symptoms. Our patients clinical coursereflected this typical natural history. Dr.T.V.Rao MD
  27. 27. Diagnosis of MeaslesMost cases ofMeasles arediagnosed clinically,usually in patient’shome or in GeneralpracticeDirect Virologicalconfirmation isdifficult in most of theDeveloping countries Dr.T.V.Rao MD
  28. 28. 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 Doctortvrao’s ‘e’ learning series Dr.T.V.Rao MD
  29. 29. Diagnosis withImmunofluorescence 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 Dr.T.V.Rao MD
  30. 30. Diagnosis by Viral IsolationMeasles virus can beisolated form a varietyof sources, e.g. throator Conjunctivalwashings, sputum,urinary sediment cellsand lymphocytes.Primary human kidney(HEK) cells are thebest, although primarymonkey kidney can beused as well.Continuous cell linessuch as Vero cells canalso be used Dr.T.V.Rao MD
  31. 31. 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 measles- specific IgM is found. The methods that can be used include HAI, CF, neutralization and ELISA tests. Dr.T.V.Rao MD
  32. 32. Diagnosis of SSPEThe presence ofmeasles specificantibodies in the CSF isthe most reliable meansof laboratory diagnosisof SSPE. Demonstrationof MV-specific antibodiesin the CSF may besufficient with, ifnecessary,demonstration of MV-specific restrictedheterogeneity byisoelectric focusing Dr.T.V.Rao MD
  33. 33. TreatmentSevere complications from measlescan be avoided though supportive carethat ensures good nutrition, adequatefluid intake and treatment ofdehydration with WHO-recommendedoral rehydration solution (to replacefluids and other essential elements lostfrom diarrhoea or vomiting). Antibioticsshould be prescribed to treat eye andear infections, and pneumonia. Dr.T.V.Rao MD
  34. 34. Treatment options in Developing CountriesAll children in developingcountries diagnosed withmeasles should receivetwo doses of vitamin Asupplements, given 24hours apart. This canhelp prevent eyedamage and blindness.Vitamin A supplementshave been shown toreduce the number ofdeaths from measles by50%. Dr.T.V.Rao MD
  35. 35. VACCINATIONThe Vaccines areLive attenuatedcontainingEdmonston B orSchwartz strainswhich will giveseroconversionrate of 90%.The immunityproduce may belife long. Dr.T.V.Rao MD
  36. 36. 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 Dr.T.V.Rao MD
  37. 37. Measles Vaccine is cheap and EffectiveThe measlesvaccine (in use for40 years) is safe,effective andinexpensive. Itcosts less thanone US dollar toimmunize a childagainst measles. Dr.T.V.Rao MD
  38. 38. Epidemiological Trends Measles epidemics occur every 2 year in developed countries in the absence of widespread use of vaccine Poverty and overcrowding increases epidemics Dr.T.V.Rao MD
  39. 39. Two doses of Measles VaccineContinued progressdepends on ensuringthat all children receivetwo doses of measlesvaccine including onedose by their firstbirthday, strengtheningdisease surveillancesystems, and providingeffective treatment formeasles. Dr.T.V.Rao MD
  40. 40. Changing trends for a Booster Dose About 15% of vaccinated children fail to develop immunity from the first dose.) Dr.T.V.Rao MD
  41. 41. Autism and VaccinationIn UK vaccineuptake has fallenrecently due tofear over itssafety, particularlyas cause ofAutism.These fears have nowbeen confirmed asUnsubstantiated. Dr.T.V.Rao MD
  42. 42. CDC disproves Autism Theory The official perspective ofthe CDC is that there is noproven connection betweenlive-virus vaccines andautism. 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. Dr.T.V.Rao MD
  43. 43. WHO and UNICEF are collaboratingStrong routine immunization: for children by theirfirst birthday.A second opportunity for measlesimmunization through mass vaccinationcampaigns, to ensure that all children receive atleast one dose.Effective surveillance in all countries to quicklyrecognize and respond to measles outbreaks.Better treatment of measles cases, to includevitamin A supplements, antibiotics if needed, andsupportive care that prevents complications. Dr.T.V.Rao MD
  44. 44. Global InitiativesThe Measles Initiative - acollaborative effort of WHO,UNICEF, the American Red Cross,the United States Centres forDisease Control and Prevention,and the United Nations Foundation -and other public and private partnersplay key roles in advancing theglobal measles strategy Dr.T.V.Rao MD
  45. 45. Global EpidemiologyApproximately 30 millionmeasles cases are reportedannually. Most reported casesare from Africa. In 1998, thecases of measles per 100,000total population reported to theWorld Health Organization Dr.T.V.Rao MD
  46. 46. Tropics and MeaslesIn tropical areasparticular in Africachildren under 1year of age suffermore attacks, andmortality rateincreasesMalnutrition is amajor contributingfactor. Dr.T.V.Rao MD
  47. 47. Vaccination for MeaslesContinues to be a Top Priority Dr.T.V.Rao MD
  48. 48. Programme Created by Dr.T.V.Rao MD for Medical and Paramedical Students in Developing World Email doctortvrao@gmail.com Dr.T.V.Rao MD
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