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1. MEASLES (RUBEOLA)

2. TOP TEN CAUSES OF DEATH IN CHILDREN
AGED <5 YEARS, WORLDWIDE
0 500 1000 1500 2000 2500
Malnutrition
Tetanus
Pertussis
HIV
Congenital Anomalies
Measles
Malaria
Diarrheal Diseases
Lower Respiratory Infections
Perinatal Conditions
Number of Deaths (thousands)
Source: World Health Organization, Global Burden of Disease , 2010 Project

3. In an year (1980), before widespread use of measles
vaccine, around 2.6 million measles deaths occurred
worldwide.
WHO and UNICEF had developed an “Accelerated
Measles Mortality Reduction Strategy” of delivering two doses
of MCV (Measles Containing Vaccine) to all children through
Routine & SIA (Supplementary) activities and also to improve
disease surveillance system.

4. MEASLES - BASIC CHARACTERISTICS:
 Highly infectious, vaccine-preventable disease
 One of the most important causes of childhood mortality
worldwide.
 One case can infect 12- 18 children.
 More than 10 million cases and 0.25 million deaths occur
throughout the world, every year. (95% of deaths occur in
developing and under developed countries)

5. Endemic all over the world; tends to occur in
epidemics when the proportion of susceptible children
reaches about 40 pc.

6. PROBLEM STATEMENT
In 2014, measles killed around 114,900 worldwide.
Western Hemisphere and most of Europe:
 Vaccine strategies (2 shots) have interrupted the transmission.
Middle East, Arabian Peninsula:
 Decreasing with vaccination campaigns.
Africa:
 Poor control; most of the deaths occur every year.

7. In developing countries case fatality rate
ranges from 2 -15 % as compared to less than
0.02% in developed countries.

8. TRENDS
Pre-Vaccine Epidemics:
Every 1-3 years
Age: 3-15 months
More frequent epidemics, younger age
Urban > Rural
Post-Vaccine Small epidemics:
Every 5-10 years
Age of onset: Older Adolescents
Cause: Accumulation of unvaccinated population

9. DISTRIBUTION IN INDIA:
 In the year 2014, cases of measles reported were 23,348
with 33 deaths.
 In India, though overall immunization levels are high, many
districts have coverage far below the national average
 Vaccine coverage varies within the different states, which
leads to a pool of vulnerable target groups that are
susceptible to the disease.

10. EPIDEMIOLOGY
1. Agent factors:
Agent:
 Single stranded RNA virus of Paramyxovirus group.
 One serotype only.
 Very sensitive to drying and cannot survive outside the
human body .
 Can be stored at sub zero temperature.

11. Source of infection:
 A case / sub clinical case (recently observed).
 Carriers are not known to occur.
 No animal reservoirs were found.
Infective material:
Secretions of nose, throat & respiratory tract of a case
of measles during the prodromal period and at the time of
eruption.

12. Period of communicability:
 Highly infectious during the prodromal period and at the
time of eruption.
 Approximately 4 days before and 4 days after the
appearance of rash.
Secondary attack rate:
More than 90p.c.

13. Ongoing transmission
source
Index case

14. 2. Host factors:
Age:
Usually 6 months to 3 years of age in developing
countries and more than 5 years in developed countries.
Sex: Equal susceptibility.
Immunity:
One attack or vaccination generally confers life long
immunity.
Children below 6 months of age are protected due to
presence of maternal antibodies.

15. Nutrition:
 The disease tends to be very severe among
undernourished children.
 Mortality is 400 times more common among
undernourished when compared to normal nourished.
 An attack of severe measles may be followed by weight
loss, pushing the child into malnutrition.

16. 3. Environmental factors:
 The virus can spread in any season.
 Tropical countries: Most cases occur in dry season.
 Temperate climate: Winter
In India:
Common in winter and early spring (January to April)

17. 4. Transmission:
 Directly from person to person transmission by
droplet infection and droplet nuclei.
 Portal of entry is respiratory tract.
 Infection through conjunctiva is also considered.
 Humans are only reservoirs.
 Highly contagious & 90 p.c attack rate for close
contacts.
 Patients are contagious for 7-10 days.

18. It replicates initially in the upper/ lower respiratory
tract followed by replication in lymphoid tissues leading
to viraemia and growth in a variety of epithelial sites.

19. 5. Incubation period:
 Around 10 days from exposure to onset of fever and 14
days to appearance of rash.
 When bypassed the respiratory tract, as with vaccine the
incubation period is shortened to 7 days.

20. 6. Clinical manifestations:
Three stages in the natural history of measles.
1. Prodromal stage/ Catarrhal stage
2. Eruptive stage
3. Post – Measles stage

21. CLINICAL COURSE OF MEASLES:
-18-17 -16-15-14-13-12 -11 -10 -9 -8 -7 -6 -5 -4 -3 -2 -1 0 +1 +2 +3 +4 +5
+
6
+7 +8
Incubation Period
(7-18 days before Rash)
Prodrome
(about 4 days)
Rash
(about 4-8 days)
Rash minus 18
days is earliest
possible
exposure date
Rash minus 4
days is probable
start of
infectiousness
Onset of rash
Rash plus 4
days is probable
end of
infectiousness
Communicable Period

22. 1. Prodromal stage/ Catarrhal stage :
 Begins 10 days after infection, lasts until day 14.
 Characterized by fever, coryza, redness of eyes,
lacrimation, photophobia and koplik’s spots.
 There may be vomiting or diarrhoea also.

23. Koplik’s spots:
 Part of prodrome and their presence is pathognomonic of
measles.
 Can be observed 1-3 days before the appearance of skin
rash.
 Raised papules look like table salt crystals, appear on the
buccal mucosa opposite the first and second lower molars.
 Often bluish white spots on a red base.
 Disappear by the time skin rash appears.

24. Koplik’s spots:

25. 2. Eruptive phase:
 Appears, 3~5 days after fever but most common on 4th
day.
 Typical, dusky red, maculopapular, often confluent and
blotchy.
 Sequence: Begins behind the ear→ along the hairline→
face→ neck→ chest→ back→ abdomen→ limbs→ hand
and feet (palm and sole)
 The temperature rise is continuous and accompanied by
toxic symptoms.

27. 3. Post measles stage:
 Weight loss, may remain weak for few days.
 There may be growth retardation, diarrhoea, cancrum oris,
pyogenic infections, candidiosis and reactivation of
pulmonary tuberculosis, etc.
 Susceptibility to other bacterial and viral infections.
 Peak of Illness 2-4 days after onset of rash.
 Resolution- Rapid improvement at end of febrile period (1
week).
 Complete recovery is possible in 10-14 days.

28. LABORATORY DIAGNOSIS:
 The ELISA test for the detection of measles-specific IgM
antibodies is recommended by the WHO measles laboratory
network.
 It is a very sensitive test between days 4 and 28 after the
onset of rash.
 A single positive serum sample obtained with in 28 days
after the onset of measles is considered as confirmation for
measles.

29. 7. Complications:
Most common:
Diarrhoea, pneumonia & other resp complications, otitis
media, acute deficiency of vit ’A’ leading to keratomalacia,
corneal scarring, etc.
Rare & Serious:
Febrile convulsions, encephalitis (1 In 1000 Cases )
& SSPE (Subacute Sclerosing Pan-Encephalitis).
[SSPE is a very rare complication (1 In 3 Lac cases). Progressive
mental deterioration leads to paralysis, coma, and death (within 1 – 3
years) probably due to persistence of the virus in the brain.]

30. Corneal scarring causing blindness
Encephalitis
Pneumonia & diarrhoea
Severe measles complications:

31.  Measles during pregnancy may be associated
with spontaneous abortion and premature delivery.
 It is recommended that infants born to mothers who
suffer from measles at the time of delivery, be passively
immunized with immunoglobulins at birth.
 All cases of severe measles must be given a high dose
of Vitamin ‘A’ (50,000 IU to 200,000 IU as per age)
immediately on diagnosis and repeated the next day.
 If the child has clinical signs of vitamin ‘A’ deficiency a
third dose also should be given 4 weeks later.

32. 8. PREVENTION OF MEASLES
1. Achieving an immunization rate of over 95 p.c
2. On – going immunization against measles through
successive generations of children.
TWO APPROACHES:
1. Measles vaccination
2. Immunoglobulin

33. 1. Measles vaccination:
Vaccine:
Active immunization with Live attenuated & Freeze -
dried vaccine (Chick embryo or HDC culture).
Very sensitive to heat and must be stored in
freezer compartment.
Heat stable vaccine is commercially developed now.
Ideal age for vaccination: 9 months

34. Route: Subcutaneous, Dose: 0.5 ml.
Reactions: About 15- 20% of vaccinated children may get
mild fever & rash after 5 – 10 days.
Immunity: Develops 11- 12 days after vaccination.
Life long immunity in most cases,
(Vaccine efficacy: 85%).
Contacts:
Must receive within three days after exposure ( > 9
months old only).

35. Contraindications:
High fever/ serious disease
Pregnancy
Severely immunocompromised
Severe HIV infection
History of allergy to Neomycin/ Sorbitol/ Gelatin
Advanced Leukaemia/ lymphoma
Malignancies
Treatment with steroids, immuno-suppresents &
On Chemotharapy

36. Adverse effects of vaccine:
Toxic Shock Syndrome (TSS):
Most dangerous complication.
Reflects poor quality of services.
Cluster of cases occur due to sharing of a
contaminated vaccine vial. (Vaccine must not be used if 4
hours are over, after reconstitution.)
Symptoms:
Severe watery diarrhoea, vomiting and high fever
usually resulting in death within 48 hrs.
Case fatality rate is very high.

37. Second dose of Measles vaccine is given at 18
months of age in India (Since India has achieved > 80%
coverage of the vaccine for three consecutive years).
Measles vaccine should be given to asymptomatic HIV
positive children and adults.
In areas where there is a high incidence of measles
and in special conditions, the vaccine may be given early, i.e.,
6 months but two additional doses should be given as per
UIP.

38. Combined vaccines:
The combinations are also highly effective.
Ex: MR, MMR & MMRV, etc.

39. 2. Passive immunization:
Administration of Human immunoglobulin
Early in the incubation period.
The dose recommended by WHO is 0.25ml/ kg body
weight; should be given within 4 days of exposure.
The person passively immunized should be given a
live measles vaccine, 8- 12 weeks later.

40. Elimination of measles (WHO):
“The absence of endemic measles for a period of > 12
months in the presence of adequate surveillance”.
Measles elimination indicator:
Sustained measles incidence of < 1/ 10,00000
population.

41. WHO’S MEASLES ELIMINATION STRATEGY
THREE PART VACCINATION STRATEGY
a. Catch – up: One – time, nationwide vaccination
campaign targeting all 9 months – 14 years children
regardless of history of measles disease or their
vaccination status.
b. Keep – up: Routine services aimed at vaccinating >95% of
each successive birth cohort.
c. Follow – up: Subsequent nation wide vaccination
campaign conducted every 2- 4 years targeting
usually all children born after the catch – up campaign.

42. Outbreak - Control measures:
1. Isolation for 7 days after onset of rash.
2. Immunization of contacts within 2 days of exposure.
3. If vaccine is contraindicated, immunoglobulin should be
given.
4. Prompt immunization at the beginning of an epidemic is
essential to limit the spread.

43. TARGETS TO BE ACHIEVED BY 2015
(WORLD HEALTH ASSEMBLY’ 2010)
1. Raise routine coverage with the first dose of Measles
Containing Vaccine (MCV) to > 90 p.c nationally, and > 80
p.c in every district or equivalent administrative unit.
2. Reduce and maintain annual measles incidence to < 5
cases per million.
3. Reduce measles mortality by > 95 p.c in comparison with
the estimated level in the year 2000.

44. PRIORITIES OF COUNTRIES IN MEASLES CONTROL
1. Improve Routine Immunization coverage to at least 90
p.c.
2. Active coverage of > 90% In Catch Up & Follow Up
Campaign.
3. Establish case based surveillance with Lab confirmation
of suspected cases and virus isolation from all chains of
transmission.
4. Supplementary vaccination campaign along with vit ‘A’
administration.

45. GLOBAL MEASLES AND RUBELLA STRATEGIC PLAN
( 2012 – 2020)
1. Achieve and maintain high level of population immunity
through high coverage with 2 doses of measles and
rubella – containing vaccines.
2. Establish effective surveillance
3. Development of outbreak preparedness
4. Communicate and engage to build public confidence
5. Improve research on vaccination and diagnostics.

46. ELIMINATION OF MEASLES
Amenable for eradication.
1. Human beings are the only natural host to measles virus.
2. Carriers are not known to occur.
3. Only one vaccine dose is needed.
4. Heat stable vaccine has been developed now.
5. Achieving an immunization of at least 96% of children
under one year of age.

47. 1. Weak immunization systems
2. High infectious nature of measles
3. Inaccessible conflict of the population
4. Changing epidemiology (Increased transmission among
adolescents and adults)
5. Need to provide catch – up measles vaccination
6. Gap in human and financial resources
CHALLENGES FOR MEASLES ELIMINATION: