- Measles, mumps, and rubella are viral infections that can be prevented through vaccination. Measles causes respiratory illness and is highly contagious. Mumps causes swelling of the salivary glands. Rubella infection during pregnancy can cause birth defects. - Vaccines for measles, mumps, and rubella are safe and effective. Two doses of the MMR vaccine are recommended for all children to provide long-lasting protection against all three diseases. While rare, vaccine-preventable outbreaks can still occur when vaccination rates decline. Maintaining high coverage is important for community immunity.

1. Update in Measles infection and MMR
vaccinations
By
Dr . Magdy Shafik Ramadan
Senior Pediatric and Neonatology consultant
M.S, Diploma, Ph.D of Pediatrics

2. Early History of Measles
• Reports of measles go back to at least 700
years, however, the first scientific
description of the disease and its distinction
from smallpox attributed to the Muslim
physician Ibn Razi(Rhazes) 860-932 who
published a book entitled "Smallpox and
Measles" (in Arabic: Kitab fi al-jadari wa-
al-hasbah).

3. • Measles is an infection of the respiratory
system caused by a virus, RNA viruses.
• More than 20 million people worldwide
are affected by measles each year.
• Only one antigenic type
• peak in late winter• and spring•
• Communicability – 4days before and 4
days after rash onset•
• Incubation period – 10-12 days (7-18 d
range)

4. Global burden
• • According to 2010 datas•
• 1,39,300 deaths globally due to measles•
Nearly 380 deaths/day•
• 15 deaths/hr•
• Of these most of the deaths belongs to
children < 5 years
• • >95% deaths occurs in low income
countries with weak infrastructures

5. • Comparing datas with 2000•
In the year 2000 there are 5,35,000 deaths due to
measles compared to 1,39,300 in 2010•
There is 74% reduction in deaths compared to
2000•
85% estimated MCV ( Measles coverage
Vaccination) in 2010 compared to 2000 with only
72%
• 65% countries reached >= 90% MCV coverage in
2010

6. 0
100
200
300
400
500
600
700
800
900
1950 1960 1970 1980 1990 2000
Cases(thousands)
Vaccine Licensed
Measles—United States, 1950-2005

7. How the Measles is Spread
• Measles is spread through respiration (contact
with fluids from an infected person's nose and
mouth, either directly or through aerosol
transmission), and is highly.
• incubation period of 10-12 days (7-18 d
range)
• infectivity lasts from 4 days prior to 4 days
following the onset of the rash.

8. Measles a Childhood Infection
• Age-specific attack rates may be highest in
susceptible infants
• younger than 12 months,
• school-aged children, or
• young adults,
• depending on local immunization practices
and incidence of the disease.

9. Clinical Aspect
• Prodrome
• High fever
• Cough , coryza and conjunctivitis (the "3 Cs").
• koplik Spots : 1-2 mm, blue-gray macules
on an erythematous base.

10. Koplik Spots

11. begins at the hairline and spreads caudally
over the next 3 days as the prodromal
symptoms resolve
lasts 4-6 days and then fades from the head
downward.
Desquamation
Complete recovery from the illness
generally occurs within 7-10 days from the
onset of the rash
Maculopapular
erythematous rash

14. • diarrhea 8%
• pneumonia 6%
• bronchitis
• , otitis media 7%
• very rarely SSPE—subacute
sclerosing panencephalitis) 0.1%
• corneal ulceration & blindness
Complications

15. • 1- Diagnosis
• 2- Clinical Assessment
• 3- Severity Status
• 4- Treatment
Case Management Guidelines

16. Diagnosis
• use standard standard Measles Case
Definition
• Whenever suspect always immediate report for
immediate complete investigation

17. Measles Case definition
1- Suspected Case of Measles :
any person with fever and rash
2- Clinical Case of Measles:
any person in whom a clinician suspect measles or
any person with fever and maculopapular rash & cough & coryza
& conjunctivitis .
3- Laboratory Confirmed Case of Measles :
any person meet the clinical case definition and laboratory
confirmed
- At least 4 fold increase in antibody titre
- OR isolation of Measles virus
- OR presence of Measles – specific Ig M antibodies
-OR epidemiologically linked to confirmed measles case

18. • 4- Clinical Confirmed Case of Measles:
A suspected case not completely invastigated
5- Discarded Case ( not Measles):
A completely investigated suspected case ,
including collection of an adequate blood
specimen, but lacks serological evidence of
measles virus infection

19. • Clinical Assessment
• Ask if the child has had
-change in consciousness level, feeding or drinking.
- Cough, convulsion , diarrhea or ear pain
-Eye discharge or vision loss

20. - Examine the child for :
- Rapid pulse , wasting , sore red mouth
- Sign of dehydration
- Rapid breathing and chest in drawing
- Ear pus , red immobile drum
- Corneal ulceration , clouding , perforation

21. Severity status
Uncomplicated measles:
Measles + no symptoms nor signs of
complication
complicated measles:
Measles + at least one of sign and symptoms
of complications

22. Non complicated cases :
- Only supportive measures
-Treatment at home as long as no complication
- Provide nutritional support ( continue breast feeding or
give weaning foods and treat mouth ulcers
- Antipyrtics
Treatment

23. Treatment options in Developing Countries
All children in developing countries
diagnosed with measles should receive two
doses of vitamin A supplements, given 24
hours apart.
This can help prevent eye damage and
blindness. Vitamin A supplements have been
shown to reduce the number of deaths from
measles by 50%.

24. • Vitamin A schedule for measles treatment
Next dayImmediate on
diagnosis
Age
50 00050 000Less than 6 month
100 000100 0006-11 m
200 000200 00012 m plus

25. • Complicated Cases:
• -over 60% in developing country
• -Should be referred to other health
facility .
• -proper treatment of each
complication

26. Measles Vaccine
• Live Attenuated viral vaccine
• Efficacy :
85% at 9 month
95% at 12- 15 month
• Duration of immunity : life long
• 2 doses
• Should be administered with mumps and
rubella as MMR

27. Vaccine Storage and Handling
MMR Vaccine
• Store 35o - 46oF (2o - 8oC) (may be stored
in the freezer)
• Store diluent at room temperature or
refrigerate
• Protect vaccine from light
• Discard if not used within 8 hours
reconstitution

28. MMR indications
• All infant > 12 month
• 12month is the recommended and minimum
age
• MMR given before 12 month should not be
counted as a valid dose
• revaccination at > 12 months of age

29. Indications for Revaccination
• Vaccinated before the first birthday
• Vaccinated with killed measles
vaccine
• Vaccinated prior to 1968 with an
unknown type of vaccine
• Vaccinated with IG in addition to a
further attenuated strain or vaccine of
unknown type

30. MMR Adverse Reactions
• Fever 5%-15%
• Rash 5%
• Joint symptoms 25%
• Thrombocytopenia <1/30,000 doses
• Parotitis rare
• Deafness rare
• Encephalopathy <1/1,000,000 doses

31. MMR Vaccine and Autism
• Measles vaccine connection first
suggested by British gastroenterologist
• Diagnosis of autism often made in second
year of life
• Multiple studies have shown NO
association

32. Measles and Mumps Vaccines
and Egg Allergy
• Measles and mumps viruses grown in
chick embryo fibroblast culture
• Studies have demonstrated safety of
MMR in egg allergic children
• Vaccinate without testing

33. Measles Vaccine and HIV Infection
• MMR recommended for persons with
asymptomatic and mildly symptomatic
HIV infection
• NOT recommended for those with
evidence of severe immuno- suppression

34. MMR Vaccine
Contraindications and Precautions
• Severe allergic reaction to vaccine
component or following prior dose
• Pregnancy
• Immunosuppression
• Moderate or severe acute illness
• Recent blood product

35. MMR Vaccine Failure
• Measles , mumps, rubella disease in a
previously vaccinated person.
• 2% -5% do not respond to the 1st dose
• Failure caused by antibody, damage
vaccine , record errors
• Most patient with vaccine failure will
respond to the second dose

36. Mumps
• Acute viral illness
• Parotitis and orchitis described by
Hippocrates in 5th century BC
• Viral etiology described by Johnson
and Goodpasture in 1934
• Frequent cause of outbreaks among
military personnel in prevaccine era

37. Mumps Virus
• Paramyxovirus
• RNA virus
• One antigenic type
• Rapidly inactivated by chemical agents,
heat, and ultraviolet light

38. Mumps Pathogenesis
• Respiratory transmission of virus
• Replication in nasopharynx and regional
lymph nodes
• Viremia 12-25 days after exposure with
spread to tissues
• Multiple tissues infected during viremia

39. Mumps Clinical Features
• Incubation period 14-18 days
• Nonspecific prodrome of myalgia,
malaise, headache, low-grade fever
• Parotitis in 30%-40%
• Up to 20% of infections asymptomatic

41. CNS involvement
Orchitis
Pancreatitis
Deafness
Death
15% of clinical cases
20%-50% in post-
pubertal males
2%-5%
1/20,000
Average 1 per year
(1980 – 1999)
Mumps Complications

42. Mumps Outbreak, 2006
• Source of the initial cases unknown
• Outbreak peaked in mid-April
• Median age of persons reported with mumps
was 22 years
• Highest incidence was among young adults
18-24 years of age, many of whom were
college students
• Transmission of mumps virus occurred in
many settings, including college dormitories
and healthcare facilities
MMWR 2006;55(42):1152-3

43. Factors Contributing To Mumps
Outbreak, 2006
• College campus environment
• Lack of a 2-dose MMR college entry
requirement or lack of enforcement of a
requirement
• Delayed recognition and diagnosis of mumps
• Mumps vaccine failure
• Vaccine might be less effective in preventing
asymptomatic infection or atypical mumps than
in preventing parotitis
• Waning immunity

44. Mumps Vaccine
• Composition Live virus (Jeryl Lynn strain)
• Efficacy 95% (Range, 90%-97%)
• Duration of
Immunity Lifelong
• Schedule >1 Dose
• Should be administered with measles and rubella
(MMR) or with measles, rubella and varicella
(MMRV)

45. Rubella
• From Latin meaning "little red"
• Discovered in 18th century - thought to
be variant of measles
• First described as distinct clinical entity in
German literature
• Congenital rubella syndrome (CRS)
described by Gregg in 1941

46. Rubella Virus
• Togavirus
• RNA virus
• One antigenic type
• Rapidly inactivated by chemical agents,
ultraviolet light, low pH, and heat

47. Rubella Pathogenesis
• Respiratory transmission of virus
• Replication in nasopharynx and regional
lymph nodes
• Viremia 5-7 days after exposure with
spread to tissues
• Placenta and fetus infected during viremia

48. Rubella Clinical Features
• Incubation period 14 days
(range 12-23 days)
• Prodrome of low-grade fever
• Maculopapular rash 14-17 days after
exposure
• Usually quite mild

51. Epidemic Rubella – United States, 1964-1965
• 12.5 million rubella cases
• 2,000 encephalitis cases
• 11,250 abortions
(surgical/spontaneous)
• 2,100 neonatal deaths
• 20,000 CRS cases
–deaf - 11,600
–blind - 3,580
–mentally retarded - 1,800

52. Congenital Rubella Syndrome
• Infection may affect all organs
• May lead to fetal death or premature
delivery
• Severity of damage to fetus depends on
gestational age
• Up to 85% of infants affected if infected
during first trimester

53. Congenital Rubella Syndrome
• Deafness
• Cataracts
• Heart defects
• Microcephaly
• Mental retardation
• Bone alterations
• Liver and spleen damage

56. Rubella Epidemiology
• Reservoir Human
• Transmission Respiratory
Subclinical cases may
transmit
• Temporal pattern Peak in late winter and spring
• Communicability 7 days before to 5-7 days
after rash onset
Infants with CRS may shed
virus for a year or more

57. 0
10000
20000
30000
40000
50000
60000
70000
1966 1970 1975 1980 1985 1990 1995 2000 2005
RubellaCases
0
10
20
30
40
50
60
70
80
CRSCases
Rubella CRS
Rubella - United States, 1966-2005
Year

58. Rubella Vaccine
• Composition Live virus (RA 27/3 strain)
• Efficacy 95% (Range, 90%-97%)
• Duration of
Immunity Lifelong
• Schedule At least 1 dose
• Should be administered with measles and mumps as
MMR or with measles, mumps and varicella as MMRV

59. Rubella Vaccine Arthropathy
• Acute arthralgia in about 25% of vaccinated,
susceptible adult women
• Acute arthritis-like signs and symptoms
occurs in about 10% of recipients
• Rare reports of chronic or persistent
symptoms
• Population-based studies have not
confirmed an association with rubella
vaccine

60. Rubella Vaccine Arthropathy
• Acute arthralgia in about 25% of vaccinated,
susceptible adult women
• Acute arthritis-like signs and symptoms
occurs in about 10% of recipients
• Rare reports of chronic or persistent
symptoms
• Population-based studies have not
confirmed an association with rubella
vaccine

61. Vaccination of Women of
Childbearing Age
• Ask if pregnant or likely to become so in
next 4 weeks
• Exclude those who say "yes"
• For others
– explain theoretical risks
– vaccinate

62. THANK YOU