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Case
• A 12 months old child was brought to
RHTC, Rithora with c/o
Fever x 6 days
Running nose x 6 days
Appearance of r...
MEASLES
(Rubeola–Redspots)
Dr Deepak Upadhyay
Dept. 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 ...
 Agent  RNA paramyxovirus.
 Source of infection  Case.
 Infective material  Secretions of Nose,
Throat & Respiratory...
 Age 
• Developing countries – 6 mths to 3 yrs.
• Developed countries – over 5 years.
 Male = Female.
 Immunity 
• On...
 More in winters
 High Population density & Movement.
 Poorer the socio-economic condition lower the
age of attack.
 ...
 Incubation period 
 10 days from exposure to onset of fever.
 14 days to appearance of rash.
 Three stages in the na...
 It begins 10 days after infection & last until
day 14.
 Characterized by 
• Low grade to moderate fever.
• A hacking d...
 Occur opposite to lower molars, but may
spread irregularly over rest of the buccal
mucosa.
 Grayish white dots usually ...
 Temperature rises abruptly
(app.40 -40.5ºC).
 Rash starts on upper lateral parts
of neck behind the ears along hair
lin...
 Fading of the rash proceeds
down wards in the same
sequence in which it appears.
 As the rash fades, branny
desquamatio...
Complications
 Diarrhea 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 p...
Viral Others
German Measles. Meningococcemia.
Roseola Infantum. Typhoid fever.
Erythema Infectiosum. Scarlet fever.
Infect...
TYPICAL RASH OF MEASLES
• Maculopapulous rash of
Measles is often
slightly hemorrhagic.
May have Petechiae,
and Ecchymoses.
RUBELLA / GERMAN MEASLES
1.Tender lymph node  post-
cervical, post-occipital,
post-auricular region, post-
occipital & po...
ROSEOLA INFANTUM
• High fever (104-105OF);
no accompanying signs
• After 3-5 days Maculopapular
rash starting on trunk  a...
ERYTHEMA INFECTIOSUM
(Fifth Disease)
1) Usually in school going age group.
2)No prodromal symptoms; Fever absent or low
gr...
INFECTIOUS MONONUCLEOSIS
• Caused by Ebstein Barr Virus.
• Moderate fever (102OF).
• Pharyngitis, Lymphadenopathy
& Spleno...
MENINGOCOCCEMIA
The rash in acute
meningococcemia is
petechial purpuric.
It is due to presence
of organisms and
rupture of...
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 p...
Diagnosis
• The diagnosis is usually Clinical
• Leucopenia with relative lymphocytosis
• Measles IgM antibodies – ELISA / ...
Treatment
There is no specific antiviral therapy;
 Treatment is entirely supportive.
• Antipyretics (acetaminophen or ib...
Vitamin A Doses
• All the cases of measles should be given Vitamin
A megadose
Age Immediately Next Day
< 6 month 50,000 IU...
PREVENTION OF
MEASLES
1. In May 1974, W.H.O. officially launched a
programme to protect all children of world
against 6 va...
PREVENTION OF MEASLES
Prevention of measles is of
two types:
1) Active prevention:
(a) Measles vaccine.
(b) M.M.R. Vaccine...
Measles Vaccine
• Type – live attenuated freeze dried vaccine
• Composition – 5000 TCID-50 of Edmonsten
Zagreb Stain
• Dil...
Schedule of Measles
• According to NIS
• 1st dose – 9 months
• 2nd dose – 18 months
• Changes in schedule
• During epidemi...
• 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...
.• Catch -up is defined as a one-time, nation wide
vaccination campaign targeting usually all
children aged 9 months to <1...
Post-exposure prophylaxis
• Live measles vaccine - given within 72 hours of
exposure
• Immune globulin (IG) - given within...
• Measles control:
• reduction of measles morbidity and mortality
in accordance with targets; no longer a public
health pr...
MCQs
Q-1 Mortality in Measles is increased in
malnourished children upto
1. 100 times
2. 200 times
3. 300 times
4. 400 tim...
• Q-2 Secondary attack rate is
• 1 Occurrence of second attack of a disease
• 2 Percentage of contacts developing the dise...
Q-3 Which of the following diseases have got a
cyclic trend
1. Chicken pox
2. Measles
3. Poliomyelitis
4. Hepatitis B
ANS 2
Q-4 The incubation period of Measles is
1. 10 days
2. 5 days
3. 15 days
4. 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 is
1. One week before & one week after the rash has appeared
2. 4 days before...
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. Trunk
2. Palm & Sole
3. Face
4. Behind the ears
ANS 4
Q-9 The most common complication
of measles in India is
1. Diarrhoea
2. Pneumonia
3. Encephalitis
4. S.S.P.E.
ANS 1
Q-10 Measles can occur below the age
of 6 months only if
1. Mother has not been immunized
2. Mother did not have measles i...
Q-11 Hemorrhagic Measles is
1. When rash is hemorrhagic
2. Synonym with Black Measles
3. When there is bleeding from mouth...
Q-12 Which of the following diseases can
exacerbate existing tuberculous process
1. Measles
2. Pertusis
3. HIV
4. All of t...
Q-13 Encephalitis due to Measles
can occur in
1.Pre-eruptive stage
2.Eruptive stage
3.Post-eruptive stage
4.All of the abo...
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.Pregnancy
2.Child with un...
MCQs
Q-16 The rash in Measles first of all appears on
1. Trunk
2. Palm & Sole
3. Face
4. Behind the ears
Answer – 4.
Q-17 The risk of S.S.P.E. after natural
infection of Measles is
1. One in one million
2. Seven in one million
3. One in se...
Q-18 Black Measles is
1. When measles is occurring in Blacks
2. When the colour of rash is black
3. When measles is occurr...
Measles
Measles
Measles
Measles
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Measles

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Problem based approach. Epidemiology of Measles along with brief of differential diagnosis and treatment.

Published in: Health & Medicine
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Measles

  1. 1. Case • A 12 months old child was brought to RHTC, Rithora with c/o Fever x 6 days Running nose x 6 days Appearance of rash on face x 2days • On examination Malnourish child Eye - Bitot spot bilateral
  2. 2. MEASLES (Rubeola–Redspots) Dr Deepak Upadhyay Dept. of Community Medicine Rohilkhand Medical College & Hospital
  3. 3. 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
  4. 4.  Agent  RNA paramyxovirus.  Source of infection  Case.  Infective material  Secretions of Nose, Throat & Respiratory tract.  Mode of transmission – Air borne transmission  Period of infectivity  4 days before + 5 days after appearance of rash.  Secondary attack rate  Over 80% in susceptible contact. Agent Factors
  5. 5.  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
  6. 6.  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
  7. 7.  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
  8. 8.  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
  9. 9.  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
  10. 10.  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
  11. 11.  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
  12. 12. Complications  Diarrhea is the most common complication of Measles in India. Otitis media Pneumonia Encephalitis
  13. 13. Other Complication • SSPE (Sub-acute Sclerosing Pan-Encephalitis) • Myocarditis • Exacerbation of an existing tubercular process • Vitamin A Deficiency
  14. 14. Viral Others German Measles. Meningococcemia. Roseola Infantum. Typhoid fever. Erythema Infectiosum. Scarlet fever. Infectious Mononucleosis. Live viral vaccine. Drug eruption. DIFFERENTIAL DIAGNOSIS
  15. 15. TYPICAL RASH OF MEASLES • Maculopapulous rash of Measles is often slightly hemorrhagic. May have Petechiae, and Ecchymoses.
  16. 16. RUBELLA / GERMAN MEASLES 1.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
  17. 17. 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)
  18. 18. 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
  19. 19. 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.
  20. 20. MENINGOCOCCEMIA The rash in acute meningococcemia is petechial purpuric. It is due to presence of organisms and rupture of small vessels in subcutaneous tissue.
  21. 21. TYPHOID • Macular rose spots involving primarily the anterior trunk are seen in typhoid. • Associated with prolong fever
  22. 22. 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
  23. 23. 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
  24. 24. Treatment There 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
  25. 25. 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 IU 6 month – 12 month 1,00,000 IU 1,00,000 IU 1 year – 5 year 2,00,000 IU 2,00,000 IU
  26. 26. 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.
  27. 27. PREVENTION OF MEASLES Prevention of measles is of two types: 1) Active prevention: (a) Measles vaccine. (b) M.M.R. Vaccine. 2) Passive prevention: by Gamma globulin.
  28. 28. 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
  29. 29. 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
  30. 30. • Side effect • Fever and rash • SSPE • Toxic Shock Syndrome • Efficacy • After 1st dose – 85% • After 2nd dose – 95%
  31. 31. 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
  32. 32. .• 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
  33. 33. 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
  34. 34. • 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)
  35. 35. MCQs Q-1 Mortality in Measles is increased in malnourished children upto 1. 100 times 2. 200 times 3. 300 times 4. 400 times Answer – 4.
  36. 36. • 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
  37. 37. Q-3 Which of the following diseases have got a cyclic trend 1. Chicken pox 2. Measles 3. Poliomyelitis 4. Hepatitis B ANS 2
  38. 38. Q-4 The incubation period of Measles is 1. 10 days 2. 5 days 3. 15 days 4. 20 days ANS 1
  39. 39. Q-5 Secondary attack rate in Measles is 1 >50% 2 >60% 3 >70 % 4 >80% ANS 4
  40. 40. Q-6 The period of communicability in Measles is 1. One week before & one week after the rash has appeared 2. 4 days before & 5 days after the rash has appeared 3. 5 days before & 4 days after the rash has appeared 4. 5 days before & 5 days after the rash has appeared ANS 2
  41. 41. Q-7 The rash in Measles is 1 Macculo-papular 2 Exanthems 3 Enanthems 4 All of the above ANS 4
  42. 42. Q-8 The rash in Measles first of all appears on 1. Trunk 2. Palm & Sole 3. Face 4. Behind the ears ANS 4
  43. 43. Q-9 The most common complication of measles in India is 1. Diarrhoea 2. Pneumonia 3. Encephalitis 4. S.S.P.E. ANS 1
  44. 44. Q-10 Measles can occur below the age of 6 months only if 1. Mother has not been immunized 2. Mother did not have measles in childhood 3. Mother is HIV positive 4. All of the above ANS 4
  45. 45. Q-11 Hemorrhagic Measles is 1. When rash is hemorrhagic 2. Synonym with Black Measles 3. When there is bleeding from mouth, nose, or bowel 4. All of the above 5. 2 &3 are correct 6. 1 &3 are correct ANS 5
  46. 46. Q-12 Which of the following diseases can exacerbate existing tuberculous process 1. Measles 2. Pertusis 3. HIV 4. All of the above ANS 4
  47. 47. Q-13 Encephalitis due to Measles can occur in 1.Pre-eruptive stage 2.Eruptive stage 3.Post-eruptive stage 4.All of the above . ANS 4
  48. 48. Q-14 The efficacy of Measles vaccine is 1 >80% 2 < 80% 3 95% 4 100% ANS 3
  49. 49. Q-15 Which of the following condition is not a contraindication for the use of Measles vaccine 1.Pregnancy 2.Child with untreated tuberculosis 3.Child with Leukaemia 4.Child with H.I.V. infection ANS 4
  50. 50. MCQs Q-16 The rash in Measles first of all appears on 1. Trunk 2. Palm & Sole 3. Face 4. Behind the ears Answer – 4.
  51. 51. Q-17 The risk of S.S.P.E. after natural infection of Measles is 1. One in one million 2. Seven in one million 3. One in seven million 4. Seven in seven million MCQs Answer – 2.
  52. 52. Q-18 Black Measles is 1. When measles is occurring in Blacks 2. When the colour of rash is black 3. When measles is occurring in Whites & color of rash is black 4. None of the above MCQs Answer – 4.

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