diploma in clinical medicine student-mature entry

1. MEASLES
JAMES THUTHUWA
DCM-ME

2. OUTLINE
 Definition
 Epidemiology and Etiology
 Risk factors
 Pathophysiology
 Clinical features
 Diagnosis
 Treatment
 Complications

3. OBJECTIVES
By the end of this presentation you should be able to:
 Define measles.
 Know the etiology and epidemiology of measles.
 Understand the pathogenesis of measles.
 Understand the clinical features of measles.
 Know treatment and complications of measles.
 Know prevention of measles.

4. DEFINITION
 It is an acute viral infection characterized by a final stage with
a maculopapular rash erupting successively over the neck and
face, trunk, arms, and legs, and accompanied by a high fever.
 AKA rubeola

5. EPIDEMIOLOGY
WORLD WIDE
 From 2013 - 2018, 899 800 cases were reported
 57% cases occurred due to unvaccinated or under vaccinated
persons, 30% with an unknown vaccination history .
 66% cases were of lower-middle-income countries
 23% occurred in persons ≥15 years of age.
 As of 31 December 2018, a total of 82 countries have been
verified as having achieved elimination.

6. EPIDEMIOLOGY CT…….
 Even though a safe and cost-effective vaccine is available, in
2018, there were more than 140 000 measles deaths globally,
mostly among children under the age of five.
 Measles vaccination resulted in a 73% drop in measles deaths
between 2000 and 2018 worldwide
 In 2018, about 86% of the world's children received one dose of
measles vaccine by their first birthday through routine health
services – up from 72% in 2000.

7. EPIDEMIOLOGY CT…….
▸ During 2000- 2018, measles vaccination prevented an
estimated 23.2 million deaths making measles vaccine one
of the best buys in public health

8. EPIDEMIOLOGY CT…….
MALAWI
 Despite high coverage in immunization, in 2010 in Malawi, a
large measles outbreak occurred that comprised 134,000 cases
and 304 deaths.
 Highest attack rates were for young children
 2.3% : < 6M
 7.6% :6-8M
 4.5% :9-11M

9. EPIDEMIOLOGY CT…….
▸ Persons >15 years of age were also highly affected (1.0%
and 0.4% for persons 15–19 and >19 years, respectively;
28% of all cases).

10. AETIOLOGY
 Caused by a measles virus.
 RNA virus of the genus Morbillivirus in the
family Paramyxoviridae
 Spread by droplets from infected person.
INCUBATION PERIOD
 12-14 days but can vary 8-19 days

11. RISK FACTORS
 Unimmunized children
 Undernourished children
 Children over nine months of age
 Severely sick under 1 year children
 Children of mothers who did not suffer from measles or those who
were not immunized. 11

12. PATHOGENESIS
 The primary site of infection is the respiratory epithelium of the
nasopharynx
 This is followed by viremia mediated by infected monocytes.
 These may traffic the virus to the regional lymph nodes where they
can transmit the virus to lymphocytes, which during viremia
disseminate the virus throughout the body.

13. CLINICAL FEATURES:
 Characteristic rash, accompanied by inflammation of the
mucosa occurs the time immunity to the measles virus is
developing.
 Rash is preceded by fever, cough and sometimes diarrhea
 Skin rash appears macular or more often macula-popular with
a darker color than the normal skin.
13

14. CLINICAL FEATURES CT….
 There may be a transient
enathem (rash in the mouth,
which present as ‘Koplik’s spots’)
small white dots surrounded by a
narrow red rim on the inner
surface of the cheek.
Koplik spots
▸ .

15. CLINICAL FEATURES CT….
▸ Skin rash (exanthema),
appears first behind the ears,
and spread onto the face and
upper trunk, then the lower
trunk and proximal parts of
the limb
Macula papular rash

16. DIAGNOSIS:
 Based on the following clinical features:
 fever,
 conjunctiva infection,
 often with puffiness of the eye lids,
 cough and
 rash.
 Often a history of exposure to measles 2-3 weeks previously
will be found 16

17. LABORATORY INVESTIGATIONS
▸ Sample from serum and a throat swab (or nasopharyngeal
swab) from the suspects
▸ Urine samples may also contain virus.
▸ Detection of measles-specific IgM antibody in serum and
measles RNA by real-time polymerase chain reaction (RT-
PCR) in a respiratory specimen are the most common methods
for confirming measles infection.

18. DIFFERENTIAL DIAGNOSIS
 Rubella
 Roseola infantum (human herpesvirus 6);
 Infections resulting from echovirus, coxsackievirus,
 and adenovirus;
 Infectious mononucleosis; toxoplasmosis;
meningococcemia; scarlet fever; rickettsial diseases;
Kawasaki disease; serum sickness; and drug rashes.

19. TREATMENT:
There is no specific treatment for measles.
It is often over treated.
Supportive treatment is important, this requires education on
the mother or guardian on the following
 Management of fever.
 Management of diarrhea (with extra oral fluids),
 Children feeding (including spoon feeding of expressed
breast milk where there is stomatitis, and more frequent
feeding and high energy food after recovery to achieve catch
up growth), and 19

20. TREATMENT CT..
 eye care with boiled and cooled water without the use of
local medicine.
 Identification of signs of complications, especially dyspnea,
dehydration, ear discharge and convulsions, which require
return to hospital

21. TREATMENT CT..
 Give vitamin ( (100,000 units) stat under 1 year, 200,000 over 1
year) to all cases and repeat the next day and a week later, if
there is exophthalmia or early keratomalacia.
 Admit the child with complications or who is under weight
(below the green path).
 Give antipyretics, extra fluids and eye care.
21

22. TREATMENT CT..
 Give antibiotics for pneumonia and otitis media.
 Treat laryngitis, for which intubation or tracheostomy may
be needed, though IM dexamethasone 0.3mg/kg stat,
repeated six hourly for 24 hours, may be effective, and is
worthy trying first, with careful monitoring of response.
 Give IV fluids for severe dehydration.
 Give anticonvulsants if there are fits.
 Give extra feeds if there is weight loss

23. COMPLICATIONS:
▸ Secondary bacterial or viral infections of the lungs, larynx, and
middle ear.
▸ Malnutrition and activation of tuberculosis.
▸ Uncommon complications include: subcutaneous emphysema,
febrile convulsions 23

24. ▸ Keratomalacia (corneal
damage) may occur due
to vitamin A metabolism
upset.

25. PREVENTION:
 Measles vaccine :
25
1ST DOSE SECOND DOSE
9M 15M

26. ▸ Children admitted to the hospital or NRU
who have passed 6 months of age, even
before reaching 9 months of age, should be
given vaccine – and later be immunized at
standard time.

27. SUMMARY
 Measles is a viral infection spread by droplets of infected perso
with an incubation period of 12-14 days
 Macula popular rash occur at the time immunity to the virus is
developing, and the child is usually non-infectious 48 hours
after the rash has developed
 Mortality rate has declined due to immunization
 Diagnosis is based on clinical features
 Treatment is based on symptoms
 Measles may be complicate to secondary bacterial or viral
infection of lungs, larynx, and middle ear.

28. REFERENCES
1. S Yamaguchi 1, A Dunga, R L Broadhead, B J Brabin
https://pubmed.ncbi.nlm.nih.gov/12403112/
2. https://www.who.int/news-room/fact-sheets/detail/measles
3. The Journal of Infectious Diseases, Volume 222, Issue 7, 1
October 2020, Pages 1117–
1128, https://doi.org/10.1093/infdis/jiaa044
4. A pediatric Handbook for Malawi JA Phillips,PN Kazembe,EAS
Nelson 4th edition 2015
5. Nelson textbook for pediatrics 18th edition, Richard
E Behrman, MD,Robert M Kliegman, MD, Elsevier Science
(USA), by W.B. Saunders Company.

29. ▸ Any questions?