A 12-month-old child was brought to a health center with fever for 6 days, running nose for 6 days, and a rash on the face for 2 days. On examination, the child was malnourished and had Bitot's spots bilaterally. Measles was diagnosed based on the clinical presentation and history of exposure. Measles is a highly contagious viral illness spread through the air. Complications can include diarrhea, pneumonia, and encephalitis. Treatment focuses on supportive care and vitamin A supplementation. Vaccination is the most effective prevention strategy.

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

4. MEASLES
(Rubeola–Redspots)
Dr Deepak Upadhyay
Dept. of Community Medicine
Rohilkhand Medical College & Hospital

5. 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

6.  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

7.  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

8.  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

9.  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

10.  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

11.  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

12.  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

13.  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

14. Complications
 Diarrhea is the most
common complication of
Measles in India.
Otitis media
Pneumonia
Encephalitis

15. Other Complication
• SSPE (Sub-acute Sclerosing Pan-Encephalitis)
• Myocarditis
• Exacerbation of an existing tubercular process
• Vitamin A Deficiency

16. Viral Others
German Measles. Meningococcemia.
Roseola Infantum. Typhoid fever.
Erythema Infectiosum. Scarlet fever.
Infectious
Mononucleosis.
Live viral vaccine.
Drug eruption.
DIFFERENTIAL DIAGNOSIS

17. TYPICAL RASH OF MEASLES
• Maculopapulous rash of
Measles is often
slightly hemorrhagic.
May have Petechiae,
and Ecchymoses.

18. 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

19. 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)

20. 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

21. 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.

22. MENINGOCOCCEMIA
The rash in acute
meningococcemia is
petechial purpuric.
It is due to presence
of organisms and
rupture of small
vessels in subcutaneous
tissue.

23. TYPHOID
• Macular rose spots
involving primarily the
anterior trunk are seen in
typhoid.
• Associated with prolong
fever

24. 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

25. 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

26. 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

27. 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

28. 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.

29. 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.

30. 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

31. 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

32. • Side effect
• Fever and rash
• SSPE
• Toxic Shock Syndrome
• Efficacy
• After 1st dose – 85%
• After 2nd dose – 95%

33. 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

34. .• 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

35. 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

36. • 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)

38. 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.

39. • 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

40. Q-3 Which of the following diseases have got a
cyclic trend
1. Chicken pox
2. Measles
3. Poliomyelitis
4. Hepatitis B
ANS 2

41. Q-4 The incubation period of Measles is
1. 10 days
2. 5 days
3. 15 days
4. 20 days
ANS 1

42. Q-5 Secondary attack rate
in Measles is
1 >50%
2 >60%
3 >70 %
4 >80%
ANS 4

43. 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

44. Q-7 The rash in Measles is
1 Macculo-papular
2 Exanthems
3 Enanthems
4 All of the above ANS 4

45. Q-8 The rash in Measles first
of all appears on
1. Trunk
2. Palm & Sole
3. Face
4. Behind the ears
ANS 4

46. Q-9 The most common complication
of measles in India is
1. Diarrhoea
2. Pneumonia
3. Encephalitis
4. S.S.P.E.
ANS 1

47. 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

48. 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

49. 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

50. 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

51. Q-14 The efficacy of
Measles vaccine is
1 >80%
2 < 80%
3 95%
4 100%
ANS 3

52. 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

53. 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.

54. 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.

55. 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.