health promotion

1. NIAS TRAINING
MEASLES DISEASE

2. outline
• Causative agent
• Transmission
• Standard case definition
– Fever and Rash Illness
• Prevention
• Investigation
Specimen taking and management

3. Measles Disease

4. Disease and causative organism
• Measles is a universal, highly infectious
disease affecting nearly every person in a
given population by adolescence in the
absence of immunization programmes.
• Is a viral disease (by morbillivirus)

5. Transmission
• Transmission is primarily person-to-person via
aerosolized droplets or by direct contact with
the nasal and throat secretions of infected
persons (coughing and sneezing).
• Man is the only reservoir

6. Standard Measles Case Definition
• Suspected Case
Any person with history of fever, skin rash, AND
any of the following: cough, runny nose,
and/or red eyes
• Confirmed Case
Suspected case with laboratory confirmation
(positive IgM antibody) or epidemiological link
to confirmed case(s) or outbreak

7. Measles “lay” case definition
to assist communities in notifying
health facilities
ANY PERSON
with
and
FEVER RASH

8. Rash+
Fever
Measles
Dengue Mononucleosis
Other Viral
Exanthems
Kawasaki
Meningococcemia
Toxoplasmosis
Roseola
Infantum
Scarlet Fever
Rubella

9. Infection & epidemiology
• In a non-immune person exposed to measles
virus, after an incubation period of about 10
to 12 days (range 7-18 days), prodromal
symptoms appear
• These include fever, malaise, cough, coryza
(runny nose), and conjunctivitis
• Koplik spots.

10. Infection & epidemiology..
• Within 2-4 days after the prodromal
symptoms rash made up of large, blotchy red
spots (maculopapular rash) appears behind
the ears and on the face accompanied by a
high fever.
• The rash spreads to the trunk and extremities
and lasts typically 3-7 days. Individuals with
measles are infectious 2-4 days before
through 4 days after rash onset.

11. Treatment for measles
• No specific antiviral treatment exists for measles virus.
Severe complications from measles can be avoided
though supportive care that ensures good nutrition,
adequate fluid intake and treatment of dehydration.
Antibiotics should be prescribed to treat eye and ear
infections, and pneumonia.
• Two doses of vitamin A during treatment of measles
have beneficial impact, a high dose of vitamin A given
immediately on diagnosis and repeated the next day. If
the child has clinical signs of vitamin A deficiency, a
third dose should be given 4–6 weeks later.

12. How is measles prevented?
• Measles is prevented by immunization with
measles vaccine. In Tanzania measles vaccine
is provided within routine immunization
schedule when a child has completed 9
months and 18 months the other
opportunities are provided through mass
immunization campaigns conducted every 3
years. The measles vaccine is safe, effective
and inexpensive.

13. Investigation of suspected
measles case

14. The process of investigating a
suspected measles and rubella that
has satisfied standard case definition
in case-based surveillance
Onset of rash and fever
Detection &
notification of
the case
Case investigation &
blood specimen
collection from a
suspect measles/
rubella case
Classification of
cases based on lab
results
Case investigation
form arrives at
national level,
along with serum
specimens to the
national lab
Serologic
investigation
results reported
< 30 days of onset
< 7 days of
receipt at lab
< 3 days of
being taken
Line listing of all
other cases in
the cluster*
Data analysis & interpretation
* In case of confirmed outbreaks

15. FRI specimen collection and handling

16. Outline
• Introduction
• Type of specimen
• Collection and handling of serology specimens
• Collection and handling of virus isolation
specimens

17. Introduction
Measles specimens are collected from patients who
meet the following case definition:
ANY PERSON
with
FEVER and RASH

18. 0 7 14 21 28 35 42
-7
-14
-21
0
2
4
6
8
10
Rash
onset
Days after rash onset
IgG
IgM
Infection
Relative levels of
antibody
Measles virus infection (wild or vaccine)
Essential dates:
•of last vaccination
•of rash onset
•of birth
IgM sensitivity
~70%
virus excretion
Collection of samples:
IgM: Single serum, 0-30 days post rash onset
Isolation: NP, Urine, T/S, 0-5 days post rash

19. Types of Specimen
• Specimens for Serology:
– Serum [Standard Specimen]
– Dried Blood spots
– Oral fluid
• Specimen for Virus detection/ Isolation:
– Nasopharyngeal specimens (nasal aspirates, throat
washes, swabs): [Throat swabs= recommended Specimens
in Africa Region surveillance guidelines
– Oral fluid
– Urine
– Lymphocytes

20. Serological Specimens
• Collect within 30 days of rash onset (ideally 4-
28 days after rash onset)
• May obtain false negative results if specimen
taken within 72 hours rash onset

21. Serological Specimen: Serum
• Observe universal sterile procedures
• 3- 5 mls whole blood by venipuncture
• Centrifuge at 1000g for 10 min OR
• Hold in refrigerator for 24 hours OR
• Place at an angle at room temperature,
and wait for the clot to retract
• Transfer serum to sterile labeled vial tube
• AVOID extracting red cells
• Label vial (Name, date of collection, district)
• Store at 2-8oC ready for shipment

22. Serological Specimens : Serum
• Prepare transport to National Laboratory
• Place in ziplock or plastic bags containing
absorbent material eg. Cotton wool
• Use specimen carriers and ice/icepacks
< 8oC to deliver to lab
• Carry the completed case form
• Important dates: rash onset, last measles
vaccination, date of specimen collection
(useful in interpretation of results)
• Deliver to lab within 72 hours

23. Specimen storage
• Serum specimens received for IgM should
be tested as soon as possible.
• Short term storage(1-7days) should be at
4oC
• Long term storage of sera should be at or
below -20oC
• Avoid Freeze thaw before testing (harmful
to the IgM)

24. Specimen condition
A good serum specimen:
• In cold chain
• Not leaking
• Adequate amount for the tests
• Not obviously contaminated
A hemolysed specimen is not a bad specimen

25. Confirming Suspected Measles cases
IgM
 Requires single blood sample taken at first contact with
health facility
 Blood sample can be collected anytime between onset
and 28 days post onset
 High efficiency for confirming cases if serum collected
between 4 and 28 days after rash onset
 Measles negative samples can be tested for rubella

26. Detection of virus from cases
 Virus excreted for very short period after onset
 Pharyngeal sample –throat swab (PREFERABLY).
 Can detect by isolation using cell culture or RT-PCR
 Oral fluid (OF) samples can be also be used for virus
detection using RT-PCR
 Helpful for molecular epidemiology
 Not useful for routine measles diagnosis
 Not every case needs to be sampled: 5-10 samples from
outbreaks or chains of transmission sufficient

27. Nasopharyngeal Aspirate
• Collect specimen soon after rash onset (<5days)
• Introduce sterile saline into nostril
• Aspirate using nasal tube fitted with
syringe, vacuum pump
• Place aspirate into Virus Transport Medium (PBS with
100 units/ml penicillin, 100 ug/ml streptomycin and
2% fetal bovine serum)
• Transport within 48hrs at 4-8oC on wet ice

28. Virus Isolation: Throat swab
• Collect specimen soon after rash onset (within 5days)
• Use throat swab provided
• Ask patient to say “ah”
• Depress the tongue with a tongue depressor
• Firmly swab throat and nasopharynx
• Place the specimen /swab into labeled container with
Virus Transport Medium and refrigerate
• Transport within 48hrs at 4-8oC in specimen carrier
with ice packs
• Recommended specimen of choice (AFR guidelines)
for virus isolation

29. Taking a Throat swab

31. Specimen storage
• Short term storage(1-7days) should be at 2-
8oC
• Long term storage of sera should be below -
0oC
• Avoid Freeze & thaw before testing (harmful
to the quality of samples)

32. Interpretation of results
 Case Notification (investigation) Form, completely
filled in all spaces
 Information NEVER to be skipped include:
-patient identification data (name, place of residence,
age)
-basic clinical information (date of onset of rash)
-immunization history (number of measles vaccine
doses, date of last vaccine dose)
-date of collection of specimen

33. In summary --
 Specimens are to be collected from all suspected
measles cases (SCD)
 At district level accumulate specimens collected
from different areas and store in the laboratory,
notify appropriately when five or more samples
have been collected
 If there are many cases, collect specimens from
the first 5 cases, use quickest means of
notification should it be a suspected outbreak
 Inform regional and national levels before
transportation
 FREEZE specimens collected on cumulative basis
 NEVER TRAVEL without clearance from the region

34. Asanteni!