PPT

1. Presented by
Dr. Daulal Chouhan
2nd yr resident
PSM Dept.
Dr. SNMC, Jodhpur

2. Acute highly infectious disease of childhood
characterized by fever and catarrhal symptoms
of the URT (coryza, cough) followed by a typical
maculo-papular rash.

3. 1. Affects childhood population
2. Causes malnutrition
3. Breaks immunological barrier
4. Flaring of existing TB infection
5. Developing countries -> 100-400 times more
mortality
6. Major cause of morbidity and child mortality
7. Case fatality rate -> 1-3%

4. 1. Endemic as well as in epidemic forms
2. Epidemic -> Every 3-4 years
3. Cyclic trend is present
4. 1980 -> Before widespread vaccination, estimated
2.6 million deaths each year
5. 2015 -> 1,34,200 measles death, about 367 death
every day or 15 deaths every hour
6. 2000-2015 -> Vaccination prevented 20.3 million
deaths
7. Global measles death -> Decreased 79% from
6,51,600 in 2000 to 1,34,200 in 2015

5. 1. Third most common cause of death under - 5
2. 1987 -> 2.47 lakh cases were reported
3. 2013 -> 15,768 cases with 56 deaths, after
implementation of UIP
4. 2012 -> Measles mortality was highest from INDIA,
16,500 deaths out of 1,22,000 measles death globally
(14%)
5. 2005-2010 -> In Rajasthan , 2827 case were reported
with 5 deaths
6. Jodhpur -> 202 cases with zero death
(apr 2015- dec 2016)

6. Measles virus
RNA Paramyxovirus
One serotype
Human’s only host
Stable antigenicity
Rapidly inactivated by heat and light
Survival in low temperature

7. Agent Factors
1. Agent -> RNA paramyxovirus
2. Source of infection –> Case of measles
3. Infective material –> Secretion of Nose, Throat
and Respiratory tract of case
4. Communicability –> Prodermal period and at
time of eruption
5. Period of infectivity –> 4 days before and 4 days
after appearance of rash
6. SAR –> Over 80% in susceptible contacts

8. Host Factors
1. Age –
Developing countries -> 6 mths to 3 yrs
Developed countries - over 5 yrs
2. Sex – Equal incidence
3. Immunity -
One attack -> Life long
Second attack -> Rare
Infants -> Transplacentally from mother
(for 4-6 months)

9. 4. Nutrition -> 400 times more mortality in
malnourished children.
Healthy
Child
Malnutrition
Severe
weight Loss
Measles

10. Environmental Factors
1. Spread in any season
2. More in winters -> Over crowding
3. India -> Winter and early spring
4. Population density and Movement
5. Poor the socio-economic condition
-> Lower the age of attack

11. Transmission -> Person to person by
Droplet infection and droplet nuclei
Incubation Period -> 10 days from exposure
to onset of fever and 14 days to appearance
of rash

12. Portal of Entry
-> Respiratory tract and regional lymph nodes ->
Enters bloodstream (primary viraemia) ->
Monocyte-phagocyte system -> Target organs
(secondary viraemia)
Target organs
-> Skin, mucous membrane of nasopharynx,
bronchi, intestinal tract and conjunctivae

13. Three stages in the natural history of
measles are:
1. Prodermal or Pre-Eruptive stage
2. Eruptive stage
3. Post-measles stage

14. It begins 10 days after infection and last until
day 14.
Characterized 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.

15. 1. Appear on the buccal mucosa opposite the
first and second lower molars.
2. Like table salt crystals
3. Small, bluish-white spots on a red base
4. Smaller than the head of a pin
5. Pathognomonic of measles

16. 1. Temperatures rises abruptly; often
reaches 40-40.5° C
2. Rash starts on upper lateral parts of neck
behind the ears along hair line and
posterior part of cheek

17. 3. 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 -> Thigh
4. On 2-3rd day it finally reaches feet and
begins to fade in the same order of
appearance

18. 1. Lost weight
2. Failure to recover
3. Gradual deterioration into chronic illness
4. Growth retardation , diarrhoea , cancrum oris ,
pyogenic infection , candidosis , reactivation
of pulmonary TB

19. Condition Percent Reported
Diarrhea 8
Otitis media 7
Pneumonia 6
Encephalitis 0.1
Seizures 0.6-0.7
Death 0.2es
Others -> Respiratory tract infection,
Exacerbation of TB, Malnutrition and Vitamin A
deficiency, Myocaditis

20. Pneumonia
1. Measles virus itself
2. Bronchopneumonia is most common in India
(Secondary invading bacteria)
3. Pulmonary complication -> More than 90% of
measles related deaths
Encephalitis
1. Incidence -> 1 in 1000 of cases

21. (Sub-acute Sclerosing Pan-Encephalitis)
1. Rare complication
2. Develops many years after the initial measles
infection
3. Frequency is about 1 : 3,00,000 cases of
natural measles
4. Fatal within 1-3 year after onset
5. Progressive mental deterioration, paralysis,
involuntary movements, muscle rigidity, coma
6. Mortality rate -> 15-20%

22. 1. Isolation of virus from clinical specimen ->
Urine, nasopharynx, blood, throat swab
2. Significant rise in IgG titre by EIA or HA
3. Positive IgM antibody by measles

23. Control
1. Isolation of cases in a well ventilated room
2. Concurrent disinfection of nasal and throat
secretions
3. Tepid sponge bath, Antipyretics, Antibiotics,
Eye care
4. Terminal disinfection of room
5. Correction of malnutrition with high quality
diet
6. Vitamin A for measles case management

24. Dosage schedule of vitamin A for measles case
management
- If a child any signs of eye disease give a third dose 2-4
weeks after the second dose
Age At the time of
diagnosis
Following day
0-6 months 50000 IU 50000 IU
6-11 months 100000 IU 100000 IU
≥ 12 months 200000 IU 200000 IU

25. Active and Passive immunization
1. Active immunization -> Measles vaccine
2. Passive immunization -> Immunoglobulin
-> Measles vaccination was introduced through
UIP in 1985

26. 1. Live attenuated vaccine
2. Edmonston-Zagrab strain
3. Grown on Human diploid cells or purified
chick embryo cells
4. Each dose contain at least 1000 TCID50
5. Diluent – Sterile distilled water
6. Dose -> 0.5 ml SC/IM over the upper arm
7. Schedule -> 2 doses, MV1-: 9-12 months of
age, MV2-: 16-24 months of age
8. Measles vaccine of multiple antigen
-> MMR vaccine

27. 9. Store at 2-8°C (shelf life 2 years)
10. Reconstituted vaccine
-> Destroyed by light, heat labile, susceptible
to contamination (No preservative)
-> Protected from light, kept at 2-8°C and used
within 4 hrs of reconstitution
11. Immunity -> 10 to 12 days after vaccination
and lasts lifelong
12. One dose confers 95% protection
13. Reaction in 15-20% of vaccines

28. 1. Fever
2. Rash
3. Rarely SSPE
4. Toxic shock syndrome (TSS)
- Contamination of vaccine by staphylococci
- Delay in using the vaccine after opening the vial
- Sudden onset of high fever , vomiting and sever
watery diarrhea
- Death may occur within 48 hrs
- Case fatality rate is high
- Reflects the poor quality of immunization services

29. 1. Impaired cell mediated immunity
2. Convulsions
3. Patient on steroid
4. Pregnancy
5. Active TB
6. Acute infectious disease
7. Generalized allergy

30. 1. Human normal immunoglobulin
2. Given to contact with a case of measles and are
not immunized
3. Prevents or modifies attack of measles, if given
within 1 week of exposure
4. Dose -: 0.25 to 0.50 ml /kg bw
5. Intramuscularly
6. Immunity lasts for 3 weeks , afterwards
contact is immunized actively

31. 1. Disease of human beings only
2. No animal reservoir
3. Neither subclinical state nor carrier state
4. Potent , live vaccine is available
5. Double dose administration
6. Life long immunity

33. Vision
-> Achieve and maintain a world without measles,
rubella and CRS
Goals
By end 2015
-> Reduce global measles mortality by at least
95% compared with 2000 estimates
-> Achieve regional measles and rubella/CRS
elimination goals

34. By end 2020
-> Achieve measles and rubella elimination in at
least 5 WHO regions
Milestones
By end 2015
-> Reduce annual incidence to <5 cases/million
and maintain that level
-> Achieve at least 90% coverage with the first
routine dose of MCV nationally

35. -> Exceed 80% vaccination coverage in every
district
-> Achieve at least 95% coverage with M, MR or
MMR during SIAs in every district
-> Establish a target date for the global eradication
of measles

36. By end 2020
-> Sustain the achievement of the 2015 goals
-> Achieve at least 95% coverage with both the
first and second routine doses of measles
vaccines in each districts and nationally

37. 1. Country ownership and sustainability
-> National governments and civil society to
work together
2. Routine immunization and health
system strengthening
-> Robust and effective health and
immunization systems, particularly a strong
national EPI

38. 3. Equity
-> Specifically target children missed by routine
services , including underserved, migrant
and poor children
4. Linkages
With polio eradication
-> Providing polio vaccination during measles
SIAs, facilitate both polio eradication and
measles control and elimination

39. With other proven child survival interventions
-> The routine measles vaccinations visit at nine
months is widely used to provide Vitamin A
supplementation

40. -> The strategy for 2012-2020 builds on the
experiences in the America and in countries in
other WHO regions that successfully
eliminated indigenous transmission of measles
-> High coverage with two doses of MCV serves as
the foundation required to ensure high
population immunity against measles
-> There are 5 components in this strategy

41. 1. Achieve and maintain high levels of
population immunity
-> Vaccination coverage >=95% with each of 2
doses of MCV
-> Unvaccinated children old enough to receive
MCV1 (9 or 12 months)
-> Strengthening RI
-> 2nd dose via RI (15 to 18 months)
-> Catch up and follow up

42. 2. Monitor disease using effective
surveillance and evaluate to ensure
progress
-> Effective surveillance needed to provide
information
a) To set priorities
b) Plan activities
c) Allocate resources
d) Implement prevention programmes
e) Respond to outbreaks
f) Evaluate control measure

43. 3. Develop and maintain outbreak
preparedness and respond rapidly
-> In elimination setting :
Single case -> outbreak -> rapid investigation
and response
-> In emergency setting :
Urgent coordinated SIAs include
Vitamin A supplementation -> prevent
outbreaks and child mortality

44. 4. Communicate and engage to build
public confidence
-> Community awareness regarding
a) Immunization rights
b) Benefits
c) Safety
d) Available sources
-> Will promote public acceptance and
participation

45. 5. Perform research and development
-> CDC in may 2011 highlighted critical research
area necessary to achieve measles eradication
a) Measles epidemiology
b) Assessing vaccine efficacy and effectiveness
c) Needle free vaccine delivery methods
d) Improved methods for laboratory testing for
measles

46. -> Accelerated measles control strategy
-> Update on accelerated measles control
- MCV2 in routine services
- Catch-up campaigns
- Laboratory supported measles surveillance
-> Linkage with RI

47. Principles of accelerated measles control
strategies in India
1. Improve and sustain RI coverage (MCV1)
2. Provide a second opportunity for measles
immunization to all eligible children
3. Sensitive, laboratory supported measles
outbreak surveillance for case/outbreak
confirmations
4. Fully investigate all detected measles outbreak
and ensure appropriate case management

48. Global Context: Worldwide measles
vaccination delivery strategies, mid-2010
MCV1 & MCV2, no SIAs (40 member states or 21%)
MCV1 & regular SIAs (59 member states or 31%)
MCV1, MCV2 & one-time catch-up (36 member states or 19%)
MCV1, MCV2 & regular SIAs (57 member states or 28%)
India

49. SIA: MCV1 <80%
RI: MCV1 > 80%
2nd Dose of Measles vaccine:
State specific delivery strategies
MCV1: Coverage of Measles containing vaccine
per DLHS-3; CES-06 for Nagaland

50. Updates on accelerated measles control
-> 17 states (MCV1 > 80%)
introduced measles 2nd
dose in their RI program
-> 45 district, who completed
measles campaign in
phase-1 are in process of
introducing 2nd dose in
their RI program

51. MCV2 introduction through Supplementary
Immunization Activity (SIA) in Phases
Phase 1
-> Initiated in Nov. 2010
-> 45 districts from 13 states
- 9 states from Chhattisgarh
- 5 district from each of the 6
states(Bihar , Jharkhand
Rajasthan, MP, Gujarat
and Haryana)
- 1 district from each of the 6
North-East states
-> Approximately 14 million target
children 9 months – 10 years

52. Coverage achieved: Administrative and
RCA monitoring
11,963,663 of 13,845,686 vaccinated (86.4%)
18 of 45 districts with >= 90% coverage (40%)
Data as on 12 July 2011
0
10
20
30
40
50
60
70
80
90
100
Arunachal Pr.
Assam
Bihar
C
hhattisgarh
G
ujarat
H
aryana
Jharkhand
M
adhya
P
radesh
M
anipur
M
eghalaya
N
agaland
R
ajasthan
Tripura
percentage(%)
Reported Coverage RCA Coverage

53. Enhanced AEFI surveillance during the
Measles catch-up campaigns
 304 minor AEFIs and 40 serious AEFIs reported
 All serious AEFIs reported and correctly managed
 NO DEATHS – VACCINE OR PROGRAMME RELATED

54. Measles SIA plan, India
Phase 2 A (144 districts)
Phase 1, 45 districts covered
Phase 2 B (81 districts)
Phase 3 (91 districts)
Total target- 135 million
children
Districts- 361

55. Expansion of measles outbreak
surveillance  Reporting of clinical
measles cases linked
with AFP weekly
reporting in these
states
 One state level lab
strengthened in
each state testing
for measles and
rubella IgM
2006
2007
2010
2009
2011

56. 0
200
400
600
800
1000
1200
1400
1600
1800
2000
2200
2400
2600
2800
3000
3200
3400
3600
3800
4000
< 1 year 1-4 years 5-9 years 10-14 years >= 15 years
Total cases = 9,221
Vaccinated Not Vaccinated Unknown
* Serologically and epidemiologically confirmed cases
** Data from 8 states (Andhra Pradesh, Gujarat, Karnataka, Kerala, Madhya Pradesh,
Rajasthan, Tamilnadu and West Bengal* data as on 15th Jun, 2011
 61 % no or unknown
vaccination status
 86 % < 10 yrs of age
Serologically confirmed measles outbreaks:
Age and vaccination status of measles cases*, 2011

57. Serologically confirmed# measles, rubella and
mixed outbreaks
(Andhra Pradesh, Gujarat, Karnataka, Kerala, Madhya Pradesh, Rajasthan, Tamil Nadu and West Bengal)
129 outbreaks
Measles outbreaks confirmed
Rubella outbreaks confirmed
Mixed outbreaks confirmed
109
10
10
2011*
# Outbreak confirmation for Measles: 2011 ≥ 2 cases IgM positive for measles and rubella* data as on 15th Jun, 2011
2010
#
198
16
5
219 outbreaks
Widespread measles virus transmission
indicating gaps in RI
2011* 2010
#

58. RI – Measles synergies
Measles catch-up campaigns has helped, RI
-> By augmenting AEFI surveillance (reporting
and management
-> By improving injection safety practices on
large scale
-> By enforcing waste management practices
-> By optimizing cold-chain space and efficient
vaccine stock management practice at various
levels (state/district/block)
-> Encouraging fixed-day , fixed-site session based
approach

59.  Controls efforts have reduced measles related
morbidity and mortality , especially due to
availability of an effective vaccine
 Selected region of the world like INDIA need
concentrated efforts
 Measles eradication is a real possibility but will
require greater commitment from all
stakeholders

60. 60