Measles dr harivansh chopra

MEASLES
Dr. Harivansh Chopra,
DCH, MD
Professor,Community Medicine,
LLRM Medical College, Meerut.
harichop@gmail.com
DR. HARIVANSH CHOPRA-
(www.observerzparadise.com)

Objectives
1. To study the epidemiology of Measles.
2. To study the differential diagnosis of
Measles.
3. How Measles can be prevented.

Macule - A circumscribed flat area less
than 1 cm of discoloration without
elevation or depression of surface relative
to surrounding skin.

Papule - A
circumscribed,
elevated, solid lesion,
less than 1 cm.

Vesicle - A small,
superficial,
circumscribed
elevation of the
skin, less than 0.5
cm, that contains
serous fluid.

Pustule - A small (<
1 cm in diameter),
circumscribed
superficial elevation
of the skin that is
filled with purulent
material. Can also
be described as a
vesicle filled with
pus.

Measles
(Rubeola – Redspots)
1. Acute febrile eruption.
2. Communicable viral disease.
3. Stages –
i. Incubation stage.
ii. Prodromal stage.
iii. Final stage.

Problem Statement
1. Affects childhood population.
2. Causes malnutrition.
3. Breaks immunological barrier.
4. Flaring of existing T.B. Infection.

Problem Statement
5. Developing countries – 100-400 times
more mortality.
6. Major cause of morbidity & child hood
mortality.
7. Good vaccine is available.
Case fatality rate  1-3%

Problem staement
1.Measles occurs in endemic as well
as in epidemic forms.
2.Epidemic occurs after every three
to four years
3. Cyclic trend is present

WHO definition of elimination
of Measles
• Absence of endemic Measles for a
period of ≥12 months in the presence of
adequate surveillence.
• One indicator is : a sustained Measles
incidence of less than 1 per 1000000
population.

Measles in India
• During 1987 2.47 lakh cases were
reported.
• After the implementation of UIP, the
number of cases have decreased to
40840 with 44 deaths in the year 2009.
• ?

Agent Factors
1. Agent  RNA paramyxovirus.
2. Source of infection  Case.
3. Infective material  Secretions of Nose,
Throat & Respiratory tract of case.

Agent Factors
4. Communicability  Prodromal period &
at time of eruption.
5. Period of infectivity  4 days before +
5 days after appearance of rash.
6. Secondary attack rate  Over 80% in
susceptible contact.

Host Factors
1. Age 
 Developing countries – 6 mths to 3 yrs.
 Developed countries – over 5 years.
2. Sex  Equal incidence.

Host Factors
3. Immunity 
One attack – Life long.
Second attack – Rare.
Infants – Transplacentally from mother
(for 4-6 months).

Host Factors
4. Nutrition  400 times more mortality in
malnourished children.
Healthy Child
Severe Weight
Loss
Malnutrition
Measles

Environmental Factors
1. Any season.
2. More in winters  over crowding.
3. Population density & Movement.
4. Poorer the socio-economic condition 
lower the age of attack.

Transmission  Person to Person
by droplet infection & droplet nuclei.
Incubation period 
1.10 days from exposure to onset of
fever.
2. 14 days to appearance of rash.

Clinical Manifestations
Three stages in the natural history
of measles are:
(1) Prodormal or Pre-Eruptive stage.
(2) Eruptive stage.
(3) Post-measles stage.

Prodromal Stage
It begins 10 days after infection & last until
day 14.
Characterised by 
(1) Low grade to moderate fever.
(2) A hacking dry cough.
(3) Coryza.
(4) Conjunctivitis.
A day or two before the appearance of rash;
Koplik’s spots appear.

Koplik’s Spots
1.Occur opposite to lower molars, but may
spread irregularly over rest of the buccal
mucosa.
2.Grayish white dots usually as small grains
of sand.
3.With slight reddish areola occasionally
hemorrhagic.

Eruptive Stage
1.Temperature rises abruptly;
often reaches 40-40.5º C.
2.Rash starts on upper lateral parts of
neck behind the ears along hair line
& posterior part of cheek.

Eruptive Stage
3.Individual lesions become increasingly
maculopapulous as rash spreads rapidly –
1st 24 hrs. : Entire face  neck  upper
arm  upper part of chest.
Next 24 hrs. : Back  abdomen  entire
arms  thighs.

Eruptive Stage
4.On 2-3rd day it finally reaches feet
& begins to fade on face.

Eruptive Stage
Measles rash as seen in a dark skinned child.
In severe cases, with confluent rash
Petechiae may be present in large
numbers. There may be extensive
Ecchymoses.
Fading of the rash proceeds down
wards in the same sequence in which
it appears.

Eruptive Stage
Complete absence of rash is
rare except in patients 
1) Those who have received human
antibodies during incubation period.
2) Some patients with AIDS.
3) In infants less than 8 months of age.

Eruptive Stage
Lymph nodes at the angle of jaws
& in the posterior cervical region
are usually enlarged & slight
splenomegaly may be noted.

Eruptive Stage
Mesentric Lymphadenopathy
may be noted. Symptoms
of Appendicitis appears when
there is
obliteration of lumen of appendix.

Complications
1. Diarrhea is the
most common
complication of
Measles in India.

Complications
2. Otitis media
3. Pneumonia
4. Encephalitis

1.Pneumonia may be caused by
the measles
virus itself.
2.Bronchopneumonia is most
common
complication in India.
3. It is due to secondary invading
bacteria
particularly
Pneumococcus, Streptococcus,
&
Pneumonia

Encephalitis
Encephalitis may present in
the incubation
period,
or may be post measles.
Incidence is 1 in
1000 cases
of measles.

SSPE –
Sub-acute Sclerosing Pan-Encephalitis
Rare complication.
Develops many years after the
initial measles infection.
Incidence 7 cases for each
1 million cases of natural
measles.

Other Complications
1. Exacerbation of an existing
tubercular process is one of
potential
danger of measles.
2. Myocarditis is an infrequent
complication.

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

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
& 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.

RASH OF RUBELLA
• Evolution of rash in
Rubella is very rapid
and not associated
with fever.

ROSEOLA INFANTUM
1)High fever (104-105OF);
no accompanying signs.
2)No photophobia or conjunctivitis & little
cough may be present.
3)After 3-5 days Maculopapular rash
starting on trunk  arm & neck &
slightly involves face & leg.

ROSEOLA INFANTUM
4)As soon as rash appears fever disappears.
5) Duration of rash is hardly 24 hrs.
6) Caused by Human Herpes Virus 6 (HHV-6).

RASH OF ROSEOLA INFANTUM
• Fever disappears as soon as maculopapular
rash of Roseola Infantum appears.

ERYTHEMA INFECTIOSUM
(Fifth Disease)
1)Usually in school going age
group.
2)No prodromal symptoms;
Fever absent or low grade.
3)Slapped face appearance.

ERYTHEMA INFECTIOSUM
(Fifth Disease)
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.

RASH OF ERYTHEMA INFECTIOSUM
• Maculopapular lesions of
Erythema Infectiosum
give Slapped Face
appearance. The rashes
remain for longer time.

INFECTIOUS
MONONUCLEOSIS
1)Moderate fever (102OF).
2)Pharyngitis, Lymphadenopathy &
Splenomegaly.

INFECTIOUS
MONONUCLEOSIS
3)Lymphocytosis & presence of atypical
lymphocytes.
4)Caused by Ebstein Barr Virus.

RASH OF INFECTIOUS
MONONUCLEOSIS
5) Enanthema at junction of hard & soft palate.
6) Maculopapular rash in Infectious Mononucleosus
appears on treatment with Ampicillin.

MENINGOCOCCEMIA
1.Rash similar to measles, but cough
& conjunctivitis are usually absent.
2.In acute meningococcemia rash is
characteristic – Petechial Purpuric.

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

RASH OF TYPHOID
• Macular rose spots
involving primarily
the anterior trunk are
seen in typhoid.

SCARLET FEVER
1.Caused by Streptococci
elaborating one of three
pyrogenic toxins.
2.Incubation Period  1-7 days.
3.Onset  Acute.

SCARLET FEVER
Characterized by 
1.Fever, Vomiting, Headache.
2.Toxicity, Pharyngitis, Chills.
3.White strawberry tongue; followed
by Red Strawberry Tongue.

SCARLET FEVER
Characterized by 
4.Exanthem is red, punctate & finally
papular.
5.May be palpated more readily than seen
(Goose Flesh Texture or Coarse Sand
paper).
6. Rash initially in Axilla. Involves groin
and neck within 24hrs.

SCARLET FEVER
7.There is circumoral pallor
8.In severe disease  small vesicular
lesions (Miliary syndrome) – may
appear over abdomen; hands & feet

SCARLET FEVER
9.Disappearance of the rash is followed
by desquamation of skin – which begin
by the end of first week & starts on face
& proceed to trunk & finally to hands &
feet
10.Desquamation is directly proportional
to intensity of rash & it may continue
for as long as 6 wks.

RASH OF SCARLET FEVER
• Exanthem is red, punctate & finally papular
(goose flesh texture or coarse sand paper). Red
Strawberry tongue is a typical feature of this
disease.

RASH OF DRUG ERUPTION
Patient receiving
Penicillins,
Sulphonamides,
Captopril, Phenytoin
or Gold may develop
maculopapular rash.

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.

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.

MEASLES VACCINE
1)Freezed dried vaccine contains live
attenuated virus 1000 T.C.I.D.50; Stored
at 2-8oC.
2)Dose  0.5 ml; Route  Subcutaneous.

MEASLES VACCINE
3.Time of administration  9 months in India.
According to W.H.O if child is
malnourished,
1st dose is b/w 6-8 months;
2nd dose after 1 year.
4.Efficacy of Vaccine – 95%
5.Duration of immunity– Lifelong.

Measles vaccine
6.It is freezed dried
vaccine
7.Has to be
reconstituted with
distilled water
8.Reconstituted
vaccine must be
used as early as
possible

Measles vaccine
9.It has shell life for 2
years
10.Must be stored
between
2-8 degree
centirgade

MEASLES VACCINE
Recent W.H.O. recommendation –
1st dose of measles 9 months.
2nd dose of M.M.R. – 15 months.
This vaccine may also be given to
contacting person.

Complications of vaccine
1. Fever
2. Rash
3. Rarely S.S.P.E
4. T.S.S

CONTRAINDICATIONS
TO MEASLES VACCINE
1.Impaired cell-mediated immunity.
2.Convulsions.
3.Patient on steroids.
4.Pregnancy.

CONTRAINDICATIONS
TO MEASLES VACCINE
5.Active T.B.
6.Acute infectious disease.
7.Generalized allergy.

Vaccination strategy
• catch-up, keep-up and follow-up, two
of which are supplementary
vaccinations.
• Catch -up is defined as a one-time,
nation wide vaccination campaign
targeting usually all children aged 9
months to 14 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 nation
wide vaccination
campaign conducted
every 2 -4 years
targeting usually all
children born after the
catch-up campaign

TREATMENT OF MEASLES
1.Ribavirin (10mg/kg/day) X 5 days.
2.PCM (10mg/kg/dose) 4 – 6 hourly.
3.Codeine (1 mg/ kg/ day).

TREATMENT OF MEASLES
4.Humidification of room for
laryngitis & irritating cough.
5.Protect from exposure to light.
6.Extra nutrition to child.

VITAMIN A
The recommended regimen is
a single dose of 100,000 IU
orally for children 6 mo to 1
yr, and 200,000 IU for children
1 yr of age or older.

Children with
ophthalmologic
evidence of vitamin A
deficiency should be
given additional doses
the next day and 4 wk
later.As per BSPM 2ND
DOSE I MONTH LATER.

Conclusion
1. Important Vaccine preventable
disease.
2. Number of illnesses resemble
measles.
3. High suspicion index is required to
make a diagnosis.
4. Making a right diagnosis will remove
the myths related to non-acceptance of
measles vaccine.

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.

• 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

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 & 5 days after the rash has appeared
ANS 2

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 in childhood
3. Mother is HIV positive
4. All of the above
ANS 4

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

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

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

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 untreated
tuberculosis
3.Child with Leukaemia
4.Child with H.I.V. infection
ANS 4

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.

MCQs
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
Answer – 2.

MCQs
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
Answer – 4.

Measles dr harivansh chopra

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