Measles

1. Measles

2. History • The earliest description of measles- Arab physician, Abubacr (865-925 A.D.) • Classical studies on the epidemiology of measles- Panum, 1846 • Measles virus isolated- Enders and his colleagues, USA(1954) • Measles vaccine first used in a clinical trial-1958 • Live measles vaccine licensed for use-1963

3. Introduction • A distinct clinical disease associated with high morbidity and mortality rates in early childhood. • Also called RUBEOLA (red spot) • A highly acute viral infectious disease affecting nearly every person in a given population in the absence of immunization • More than 30 million cases/year • 875000 deaths/year from measles or its complications

4. Kills more children than any other vaccine preventable diseases; represents 50 to 60% of estimated deaths attributable to childhood vaccine preventable diseases • More severe in infants and adult than in children • Crowding and poverty in close contact with large numbers of non-immunized people – contributing factors for measles outbreaks.

5. Case definition • any person with fever of 38 degree Celsius or more (hot to touch) and Maculo-papular rash and at least one of the following: Cough, Coryza or conjunctivitis or any person in whom a health professional suspects measles”.

6. Characteristics • Fever • Dry cough • Runny nose • Inflamed eyes (conjunctivitis) • Sensitivity to light • Tiny red spots with bluish-white centers on the inner lining of the cheek, called Koplik's spots

7. Complications • Varies from country to country; occurs in 10-15% of cases • Common in Nepal - Otitis media, pneumonia, diarrhea followed by malnutrition, Corneal ulcer and post infection encephalitis (rarely). • Others:- Orchitis (13-15% of adult male cases; rare in childhood) - sterility, oophritis & mastitis (occasionally) - pancreatitits (very rarely) - meningoencephatitis (without involvement of salivary gland.)

8. Measles infection during pregnancy is associated with spontaneous abortion and delivery of LBW infants Rare reports of congenital malformation associated with measles during the first trimester No evidence for the congenital measles syndromes Approx.1/1,00,000 cases can result in degenerative disorders of CNS known as sub-acute sclerosing panencephalitis (SSPE)

9. Risk factors • Age: higher CFRs in younger age group ( 6-18 mth) • Gender: In two studies from Asia, CFRs for females > males In Bangladesh CFR for Male (0.98%) < females (2.64%) but no differences documented in African studies (see below) • Socio economic status: poverty, over-crowding • Intensity of exposure: Increased rates of mortality in secondary cases at home.

10. Nutritional status: High mortality in under nourished population but no studies have proven individual nutritional status as a reliable predictor of mortality (?) • Absent or delayed medical care: -most mortality be prevented through timely and appropriate medical care. -rare in developing countries • Local treatment: -Measles normal event work of Witches or sorcerers (cultural concept). -local treatments, restrictions on fluids/food, delay in access to effective chemotherapy and use of potential toxic substances potential contributors to increased mortality.

11. Non- vaccination: Vaccination status-the single most important determinant of measles morbidity and mortality Almost all unprotected children eventually be infected with measles and 1-5% will die.

12. WORLD SITUATION • In 2007, there were 197 000 measles deaths globally - nearly 540 deaths every day or 22 deaths every hour. • More than 95% of measles deaths occur in low-income countries with weak health infrastructure. 85% of deaths occur in SEAR.

13. 50-60% of estimated deaths attributable to childhood vaccine preventable diseases • Measles vaccination has caused 74% drop in measles deaths between 2000 and 2007 worldwide - a drop of about 90% in the eastern Mediterranean and Africa regions. (WHO, 2007)

14. SITUATION IN NEPAL • Measles affects 1,50,000 children every year in Nepal, causes about 5000 deaths annually, renders thousands others blind and cause mental disability. (UNICEF, 2009) • Measles remain endemic in Nepal with epidemics occurring every 2-3 years

15. EPIDEMIOLOGY • Agent factors: -Single strained RNA virus of paramyxo virus group -Only 1 serotype known -Very sensitive to acid conditions, drying, and light but can survive well in aerosolized droplets -Virus can remain viable for at least 34 hours at room temperature -During the prodeermal period and for a short time after the rash appears, virus sheds in nasopharyngeal secretion, blood and urine.

16. Host Factors: • Age:6 mths-3 yrs (developing countries) >5 yrs (developed countries) • Sex: Incidence equal in both male and female • Immunity: No immunity unless immunized/natural immunity • Nutrition:-very severe in malnourished child -mortality 400 times higher in malnourished -Severely malnourished children excrete virus for longer periods than better-nourished indicating prolonged risk to them and of intensity of spread to other

17. Environmental factors: • Can spread in any season if suitable climate but in temperate climates, it is a winter disease (coz) Mode of transmission • Droplet infection • Droplet nuclei (4 days before onset of disease till 5 days thereafter ) • Infection through conjunctiva (likely) The portal of entry - respiratory tract. Rate of infection depends on • his/her immune status • population size and density of the community and • frequency of individuals contact with other infectious persons(90% of contacts develop disease)

18. Incubation period -approx. 10-12 days to the first prodromal symptoms and another 2-4 days to the appearance of the rash. -When measles infection artificially induced, the incubation period somewhat shortened, i.e. 7 days Clinical features Measles has three clinical stages: - • Prodromal stage • Eruptive stage • Post measles stage

19. Measles elimination Campaign • WHO has proposed to eliminate measles . • This refers to the interruption of transmission in a sizeable geographical area. • The global eradication of measles is technically plausible with currently available vaccines because it is very unlikely that non-human reservoirs could sustain measles transmission. However, for eradication of measles, more than one dose vaccine is recommended as a strategy. WHO categorizes countries in three “Phases” of elimination and Nepal falls into the lowest rank, some innovative strategy need to be developed and implemented. • High level of immunization coverage important factor.

20. Following measures have been recommended • Children with measles should be kept out of school for 4 days after appearance of the rash. In hospital respiratory isolation from onset of catarrhal stage of the prodromal period through 4th day of rash to reduce the exposure of other patients at high risk. • Usually quarantine not practical but sometimes quarantine of institution ward or dormitories can be of value, strict segregation of infants if measles occur in institutions. • Investigation of the contracts and source of infection: a search for an immunization of exposed susceptible contract be carried out to limit the spread of disease.

21. National policy and strategy: Goal: To reduce the infant and child morbidity and mortality associated with measles disease. Objectives: To reduce measles cases by 30% and measles death by 95% from previous levels by the year 2005 (according to child heath profile of Nepal 2003 or WHO, UNICEF, Global measles strategic plan 2001-2005 seeks to reduce measles mortality worldwide in a sustainable way by 50% relative to 1999 estimates.

22. Strategies for measles mortality reduction • Improved routine immunization 90% or more • Strengthen measles surveillance with integration of epidemiological and laboratory information. • Improved case management with Vitamin A supplementation. • Supplemental measles immunization

23. WHO measles elimination strategy • Catch-up: One time nation wide vaccination campaigning targeting usually all children aged 9 months to 14 years regardless of history of measles disease or vaccination status. • Keep-up: Routine services aimed at vaccinating more than 95% of each successive birth cohort. • Follow-up: Subsequent nation wide vaccination campaign every 2-4 years targeting all children born after the catch-up campaigning.

24. Challenges in Measles Eradication • Increasing measles immunization coverage to a level of at least 95%. • Rescheduling or two-dose policy in measles immunization. • Addressing missed opportunity adequately. • Cold chain maintenance for securing vaccine potency/efficacy. • Safe injection practices in immunization. • Better case management of measles cases. • Active surveillance of measles cases. • Clear guidelines on “Outbreak Response Immunization”: Vaccination during outbreak of measles.

25. Constraints: - • Very difficult to maintain cold chain due to the various topographical situation. • Lack of motivation or willingness in the side of health workers. • Poor inter and intra-sectoral co-ordination. • Lack of KAP on measles vaccination of the general population, which has caused high dropout rates in the vaccination.

26. RECOMMENDATIONS • Effective co-ordination between different sectors be maintained. • Good governance of the program be made. • Reporting system be strengthened. • Effective training for the health workers be conducted regularly. • Effective surveillance system be conducted. • Motivation and follow-up mechanisms to be developed for VDCs to support FCHVs.

27. References • Preventive and Social Medicine. Park and park 17th edition. • Annual Report-2002/03.p.25- DHS • Child health situation in Nepal: - CHD • Polio Eradication Nepal-hands out. • Control of Communicable Disease Manual 2003;EDCD/MOH/DHS.

28. Thank you