2. What are the Measles?
• A respiratory disease.
• Caused by a virus.
• Measles virus (MV) normally grows in the
back of the throat and lungs.
• Best known for its rash.
• AKA: Rubeola, morbilli, hard measles,
black measles (hemorrhagic), red measles,
first disease, and ten-day measles among
others.
4. It’s been around for a while…
• The human reservoir
threshold = 250,000 to
500,000 + 10% of non-
immune.
• This minimum population
threshold was achieved
permanently around 3000
B.C.
5. Measles Epidemiology
Reservoir(s) Humans
Transmission Respiratory droplets, formites
Communicability VERY
Immunity Vaccination or wild-type infection
Incubation Period 10 days (average)
Temporal Patterns • Winter and early spring in temperate areas
• Hot/dry season in tropical areas
6. Signs & Symptoms
CDC Clinical Case Definition:
1. Fever = >101°F or 38.3°C
2. Cough, coryza, or conjunctivitis
3. A generalized, maculopapular rash
that lasts more than 3 days
Pathognomic:
1. Koplik's spots
2. Malaise
8. Post-infection immune suppression
• Cascading effect on the immune system
• Weakened cells
• Limits replacement cells
• MV targets dendritic cells which activate T-cell response
• Tuberculosis and other auto-immune disorders came out
of remission
• Event occurs with vaccination as well as wild-type
infections.
9. Measles Vaccination
• Licensed live attenuated and
inactivated versions of measles
vaccines = 1963.
• Inactivated/”killed” vaccine pulled
• Waning immunity
• Atypical symptoms
• Combined Vaccination
• MMR & MMRV
• Same dosage requirements (2)
• Same transmission (airborne)
• Same storage needs (between -
58°F and +5°F)
First International Conference
on Measles Immunization
1961. John Enders, Tom
Peebles and Fellows.
10. Measles - Elimination
• 2000 Eliminated in US
• No native strains of the measles circulating during the
prior 12 months
• Only imported cases since that time.
• 2002 Eliminated in the Americas Region
11. Measles – USA
• January 1–August 21, 2015.
• 188 cases
• 111 linked to Disneyland
• Death in Washington State
• Not related to Disneyland Outbreak
• First US measles death since 2003.
12. Measles – Indiana
• No cases in 2015
• No native cases of measles in Indiana since 1994.
• Indiana 2011 Outbreak
• Index case, expatriate living in Indonesia
• Exposed 868 individuals
• Cost to the ISDH = $35,172.30
Notes:
What it is NOT is rubella or the German Measles or roseola
Source:
Centers for Disease Control and Prevention. (2014, January 24). Measles Overview. Retrieved March 23, 2014, from www.cdc.gov: http://www.cdc.gov/measles/outbreaks.html
Merriam-Webster. (2014, March 14). Dictionary - black measles. Retrieved from www.merriam-webster.com: http://www.merriam-webster.com/dictionary/black%20measles
Image source:
http://www.cdc.gov/measles/about/signs-symptoms.html
Notes:
Both canine distemper and rinderpest infect animals ONLY
Both are anatomically similar to MV; of the two, rinderpest is the closest structurally to morbillivirus. Rinderpest was eradicated in 2011.
Medicinenet.com definitions:
Non-segmented = the genome is all on one piece of RNA
Single-stranded, negative-sense = genetic information consists of a single strand of RNA that is the negative-sense strand which encodes mRNA (messenger RNA) and protein.
Sources:
Centers for Disease Control and Prevention. (2012). Genetic Analysis of Measles Virus. Retrieved from www.cdc.gov
Fenner, F. (1976). The Classification and Nomenclature of Viruses, Summary of Results of Meetings of the International Committee on Taxonomy of Viruses in Madrid, September 1975. Journal of General Virology, 31(3), 463-470.
Moss, W. J., & Ota, M. O. (2007). Measles. In K. E. Nelson, & C. M. Williams, Infectious Disease Epidemiology: Theory and Practice (2nd ed., pp. 601-636). Sudbury, Massachusetts: Jones and Bartlett Publishers.
http://www.reference.com/browse/wiki/Paramyxovirus
Picture Sources:
http://media.historyofvaccines.org/images/000504_265.jpg
http://previewcf.turbosquid.com/Preview/2010/12/04__14_36_00/2.jpgd889c5a9-0332-4cf2-b31c-3820e2c35e64Larger.jpg
Notes:
Originally a zoonotic disease
Monkeys in captivity can get the measles, but the disease runs its course and is over. They do not have the social structure in the wild to maintain a reservoir for the disease.
Image source:
http://i.telegraph.co.uk/multimedia/archive/01602/silkroad_1602133c.jpg
Transmission Notes:
People are infectious BEFORE signs and symptoms appear.
If you are sharing air space with a measly person, you are going to be sick, too.
Respiratory Droplets:
Somebody sneezes or coughs, sends respiratory droplets flying.
Droplets can survive up to 2 hours
Measles virus cannot tolerate UV light or heat.
Incubation Notes:
Incubation range can be less than a week or up to nineteen days
Typical infectious range is 4 days before the appearance of the rash and 4 days after.
Infectivity peaks during the rash
Temporal Patters:
Being indoors facilitates transmission
UV rays which can kill the virus are less prevalent in the wintertime.
Sources:
American Public Health Association. (2008). Measles. In D. L. Heymann (Ed.), Heymann, David L; (19th ed., pp. 402-408). Washington, DC.
Babbott, F. L., & Gordon, J. E. (1954, September). Modern Measles. American Journal of the Medical Sciences, 228(3), 334-361.
Centers for Disease Control and Prevention. (2009, August 31). Transmission of Measles. Retrieved March 19, 2014, from Centers for Disease Control and Prevention: http://www.cdc.gov/measles/about/transmission.html
Centers for Disease Control and Prevention. (2012, July 19). Manual for the Surveillance of Vaccine-Preventable Diseases.
NIH (n.d.) National Institute of Allergy and Infectious Diseases. http://science.education.nih.gov/supplements/nih1/diseases/activities/activity5_measles-database2.htm
Sun Safety Alliance (n.d.). When and Where are UV Rays Strongest? Retrieved from, http://www.sunsafetyalliance.org/uv_rays.html
Notes:
Coryza = snotty nose
Conjunctivitis = inflammation of the eye
First set are CDC clinical case definitions
Koplik’s spots = pathognomonic, but not always present
Source:
Roush SW & Baldy LM (2015). Manual for the Surveillance of Vaccine-Preventable Diseases. Centers for Disease Control and Prevention. Retrieved from, http://www.cdc.gov/vaccines/pubs/surv-manual/
Image Sources:
CDC (2015). Signs and Symptoms. Retrieved from, http://www.cdc.gov/measles/about/signs-symptoms.html
www.cartoonbrew.com/wp-content/uploads/spongebobrectal1.jpg
NOTES:
PP studied measles in the Faroe Islands. The islanders had not been exposed to measles in 70 years, and many otherwise healthy adults died.
Most of what is known about the epidemiology of measles is due to Dr. Panum’s research during an outbreak on the remote Faroe Islands.
Sources:
Babbott, F. L., & Gordon, J. E. (1954, September). Modern Measles. American Journal of the Medical Sciences, 228(3), 334-361. Retrieved February 2014
Panum, P. L. (1939). Observations Made During the Epidemic of Measles on the Faroe Islands in the year 1846. In Medical Classics (A. S. Hatcher, Trans., Vol. 3, pp. 829-886). Williams & Wilkins. Retrieved March 2014
Image sources:
http://www.denstoredanske.dk/@api/deki/files/22287/=421333.501.jpg?size=webview
http://cruisingoutpost.com/2013/06/lost-islands-faroe-islands-denmark/
http://health.mo.gov/training/epi/HostFactors-b.html
Pneumonia (5% -- leading killer of kids < 5)
Several types of pneumonia
Warthin-Finkeldey giant cell/Syncytial giant cells = measles pathaganomic
Hypoxemic, shock
Blindness:
Leading cause of preventable blindness in Africa
When the eye fails to produce enough tears to moisten the cornea, it is called xerophthalmia.
Vitamin A deficiency is the cause of keratomalacia, cornea deteriorates
Vitamin A is both a primary and secondary treatment for measles
SSPE
Always fatal
Average = presents between 7-10 years post-measles, but RANGE can be almost 30 years after getting infection
Garg (2002) “children infected with measles under the age of one year carry a risk of 16x greater than those infected at age five years or later”
Degenerative, change in personality, spasms, loss of motor function, death
Connection to measles was made in 1969 during autopsy.
Sources:
Centers for Disease Control and Prevention. (2012). Manual for the Surveillance of Vaccine-Preventable Diseases. Retrieved from www.cdc.gov: http://www.cdc.gov/vaccines/pubs/surv-manual/chpt07-measles.html
Garg, R. K. (2002). Subacute sclerosing panencephalitis. Postgraduate Medical Journal, 78, 63-70. Retrieved March 22, 2014, from www.postgradmedj.com
Jain RS, Sannegowda RB, Srivastava t, Jain R, Mathur T, Gandhi P (2013) A rare presentation of subacute sclerosing panencephalitis with acute fulminant course and atypical radiological features, Annals of Indian Academy of Neurology, 16(4), 732-733. Retrieved from: http://www.annalsofian.org/article.asp?issn=0972-2327;year=2013;volume=16;issue=4;spage=732;epage=733;aulast=Jain
Janigan, DT (1961) Giant Cell Pneumonia and Measles: An Analytical Review, Canad. M. A. J., 85, 741-749.
Notes:
Infected dendrites do not stimulate naïve CD4+T cells to mature
Measles vaccination is not recommended for individuals who are immunosuppressed
Rotuma outbreak in 1911: “50% of Rotumans born in 1910 or 1911 died within two years of the epidemic . . . . Only 24% survived to adulthood.”
Sources:
Grosjean, I., Caux, C., Bella, C., Berger, I., Wild, F., Banchereau, J., & Kaiserlian, D. (1997). Measles Virus Infects Human Dendritic Cells and Blocks Their Allostimulatory Properties for CD4+T Cells. J. Exp. Med., 186(6), pp. 801-812.
Moss, W. J., & Ota, M. O. (2007). Measles. In K. E. Nelson, & C. M. Williams, Infectious Disease Epidemiology: Theory and Practice (2nd ed., pp. 601-636). Sudbury, Massachusetts: Jones and Bartlett Publishers.
Siegel, M. M., Walter, T. K., & Ablin, A. R. (1977). Measles Pneumonia in Childhood Leukemia. Pediatrics, 60(1), 38-40. Retrieved from http://pediatrics.aappublications.org/content/60/1/38
Shanks, D., Lee, S.-E., Howard, A., & Brundage, J. F. (2011). Extreme Mortality After First Introduction of Measles Virus to the Polynesian Island of Rotuma, 1911. American Journal of Epidemiology, 173(10), 1211-1222. doi:10.1093/aje/kwq504
Pictured: First International Conference on Measles Immunization. 8 November 1961 at the National Institutes of Health, Bethesda Maryland. Left to right : Samuel Katz (fellow), Ann Holloway (fellow), Kevin McCarthy (fellow), Anna Mitus (fellow), Milan Milovanovic (fellow), John Enders, Gisele Ruckle, Frederick Robbins, Ikuyu Nagata
Sources:
CDC (2014). Vaccine Storage & Handling Toolkit. Retrieved from: http://www.cdc.gov/vaccines/recs/storage/toolkit/storage-handling-toolkit.pdf
Katz, S. L. (2009). John F. Enders and Measles Virus Vaccine--A Reminiscence. In D. E. Griffin, & M. B. Oldstone (Eds.), Measles--History and Basic Biology. p. 3-11. Berlin Heidelberg: Springer-Verlag.
Notes:
India joined the initiative in 2011
Guinea = 2 098 829 kids reached for MV, combined with polio in 2012. MV outbreak in Conakry Jan 2014. UNICEF to help supply vaccinations but ebola hem. fever OB is the immediate priority.
Sources:
Centers for Disease Control and Prevention. (2014). Global Control and Regional Elimination of Measles, 2000-2012. Retrieved March 22, 2014, from www.cdc.gov: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6305a5.htm?s_cid=mm6305a5_w
World Health Organization. (2014). www.who-measles.org/Public. Retrieved from www.who-measles.org: http://www.who-measles.org/Public/Web_Front/recordsListPublic.php?&sort_mtd=ASC&sort_field=means_who_name&offset=105
World Health Organization (2014) Four Western Pacific countries and areas are the first in their Region to be measles-free. Retrieved from: http://www.wpro.who.int/mediacentre/releases/2014/20140320/en/
UNICEF. (2014). http://www.unicef.org/media/media_71798.html
Notes:
2001 – 2011 = 83 measles cases on average/year.
2013 = 189 cases
Jan-Feb 2014 = 54 cases
Index case at Disneyland was not identified. Strain had same genotype from a 2014 outbreak in the Philippines
Death in Washington State (not related to Disneyland outbreak)
647 cases reported in US during 2014.
Sources:
Centers for Disease Control and Prevention. (2015). Measles Cases and Outbreaks . Retrieved from, http://www.cdc.gov/measles/cases-outbreaks.html
Centers for Disease Control and Prevention. (2015). Measles--United States, January 4 – April 2, 2015. Morbidity and Mortality Weekly Report, 64(14), p. 373-376. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6414a1.htm
Centers for Disease Control and Prevention. (2015). Notifiable Diseases and Mortality Tables. Morbidity and Mortality Weekly Report, 62(8), p. 128-145. Retrieved from http://www.cdc.gov/mmwr/pdf/wk/mm6408md.pdf
Washington State Department of Health (2015). Measles led to death of Clallam Co. woman; first in US in a dozen years. Retrieved from: http://www.doh.wa.gov/Portals/1/Documents/1500/NewsReleases/2015/15-119-WA-MeaslesRelatedDeath.pdf
Notes:
2 cases in 2013
1 case in 2014 (email from ISDH)
Sources:
Centers for Disease Control and Prevention. (2015). Measles Cases and Outbreaks . Retrieved from, http://www.cdc.gov/measles/cases-outbreaks.html
Centers for Disease Control and Prevention. (2014). Global Control and Regional Elimination of Measles, 2000-2012. Retrieved March 22, 2014, from www.cdc.gov: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6305a5.htm?s_cid=mm6305a5_w
Centers for Disease Control and Prevention. (2013). Measles--United States, January 1-August 24, 2013. Morbidity and Mortality Weekly Report, 62(36), p. 741-743. Retrieved March 17, 2014
Collier, M. G., Cierzniewski, A., Duszynski, T., Munson, C., Munson, C., Wenger, M., Beard, B., Gentry, R., Duwve, J., Kutty, P. K., & Pontones, P. (2013). Measles Outbreak Associated With International Travel, Indiana, 2011. Journal of the Pediatric Infectious Diseases Society, 2(2), 110-118. Retrieved February 7, 2014, from 10. J093/jpids/pis132
Indiana State Department of Health (n.d.). Measles. Retrieved August 23, 2015, from http://www.in.gov/isdh/23849.htm
Parker Fiebelkorn, A., & Goodson, J. L. (2013). Yellowbook. Retrieved March 17, 2014, from www.cdc.gov: http://wwwnc.cdc.gov/travel/yellowbook/2014/chapter-3-infectious-diseases-related-to-travel/measles-rubeola
