prevention and control of measles in India

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1. Measles Dr. Rajesh R. Kulkarni Associate Professor Dept. of Community Medicine, J. N. Medical College, KAHER, Belagavi 13-Sep-20 1 Dept of Community Medicine,J.N.M.C, Belagavi.

2. Lesson Plan Defn History Problem statement Elimination Epidemiology – agent, host & environment Transmission & incubation period Clinical features Complications of measles Prevention – Measles vaccine & Ig Eradication & Control

3. Measles (Rubeola) Defn: An acute highly infectious disease of childhood caused by a specific virus of the orthomyxoviruses, clinically characterised by fever and catarrhal symptoms of upper respiratory tract (coryza and cough), followed by a typical rash Measles - High mortality and morbidity in developing countries

4. History Rubeola = RED SPOTS Abu Bacr (Rhazes) described it first in 9 th century Panum studied epidemiology of measles in 1846 Enders isolated measles virus in 1954, USA 1958 Measles vaccine manufactured

5. Problem statement Endemic in most parts of globe, epidemics occur when 40% children become susceptible 90% infection when introduced into virgin community 100-400 times more deadly in developing countries CFR 2-15% compared to 2/100,000 in developed countries 7-8 million deaths before vaccination started

6. Incidence 242,000 measles deaths globally 1,200 deaths every day or 50 deaths /hour 95% deaths in poor countries Most common reason – failure to vaccinate all infants India in 2005 => 52,454 cases with 55 deaths Under-reporting is very common in India

7. Agent factors RNA Paramyxovirus, single serotype No survival outside human body, can be grown in cell cultures Source of infection – case of measles, NO carrier status Infective material – secretions of nose, throat Communicability – highly infectious during prodromal stage and eruptive stage; 4 days before and five days after appearance of rash One attack gives lifelong protection , No second attack

8. Host factors Age: 6 months - 5 yrs Sex: M=F Immunity: No age is immune. One attack gives lifelong immunity. Early infants are protected by maternal antibodies upto 6m Nutrition: Very severe in malnourished child Malnourished children excrete virus for a prolonged period Even in healthy child – wt. loss after measles

9. Environmental factors Virus can spread in any season Tropical areas - winter indoor overcrowding India - outbreaks common in January –April Poverty – early attack Density and Population movement affect incidence

10. Transmission & incubation period Person to person transmission by droplet infection & droplet nuclei Portal of entry Respiratory tract, conjunctiva Incubation period – 10 days from exposure to onset of fever/14 days for rashes Vaccine virus - 7 days

11. Clinical features Prodromal stage – Fever, Coryza, sneezing, cough, redness of eyes, lacrimation, photophobia, vomiting, diarrhoea Eruptive stage – dusky red macular, maculo-papular rash, Koplik’s spots on buccal mucosa opp. 1 st and 2 nd molar teeth, disappear by 3-4 days, brownish discoulouration Post-measles stage – Loss of wt, weakness, secondary bacterial infections, malnutrition, growth retardation, diarrhoea, pyoderma, candidiasis, reactivation of Pulmonary TB

12. Koplik’s spots

13. Measles pictures

14. Complications of Measles Diarrhoea Pneumonia Otitis media Febrile convulsions Encephalitis 1:1000 SSPE 1:300,000 – paralysis, involuntary movements, muscle rigidity, coma Pregnancy- spontaneous abortions, Prematurity Keratomalacia, Blinding due to Vit . A Deficiency

15. Corneal ulcer following measles

16. Encephalitis following measles

17. Measles vaccination HDCV Freeze dried powder Single strain (Edmonston - Zagreb) Highly sensitive to temp. variation 9months single dose 0.5ml sc at thigh 6-9m first dose + 2 nd dose after 4 wks Reconstituted vaccine given within 1 hr

18. Measles Vaccination Reaction - fever, rash Immunity – 11-12 days after immzn , lifelong Susceptible contacts of a case to be given vaccine within 3 days of exposure Contraindications – Pregnancy, acute illness, Immunocompromised status, steroid use Adverse effects – T.S.S. –diarrhoea, vomiting, fever Combined vaccine – MMR,MMRV, MR

19. Immunoglobulin Ig 0.25ml/kg within 3-4 days of exposure Measles vaccine should be given after 2-3 months of Ig admn.

20. Measles eradication & control Eradication –min. 96% primary vaccination Control - Isolation for 7 days after rashes Immunization of vaccine within 2-3 days If vaccine contraindicated, then Ig Prompt immunization at the beginning of an epidemic

21. WHO Country staging Control Outbreak prevention Elimination WHO Measles elimination defn : absence of endemic measles for a period of more than 12 months in the presence of adequate surveillance i.e., incidence < 1/100,000 pop. WHA set a goal of 90% reduction in global measles by 2010 compared to 2000 level

22. W.H.O. Measles elimination strategy Catch up – one time, nationwide vaccination campaign in all 9m-14 yrs children Clean up – routine immunization of > 95% of each successive birth cohorts Follow up – subsequent nationwide vaccination campaign every 2-4 years for children born after catch up campaign Some countries – supplementary vaccination 2 nd dose of measles vaccine/MMR

23. Measles outbreaks Common in densely populated urban slums Vaccine efficacy only 85% Pockets of poorly immunized children Epidemiological shift – older children Interruption in health services Overcrowding in camps of refugees & internally displaced people

24. Priority action for measles control Routine vaccination > 90% Active coverage of catch up & follow up > 90% Case based surveillance with lab confirmation of suspected cases and virus isolation from all chains of transmission Conduct supplementary vaccination with Vitamin A in high risk areas

25. REFERENCES Preventive and Social medicine – K.Park (21 th edition) Principles of Internal medicine – Harrison (17 th edition) Robbins textbook of Pathology (8 th edition)

26. Acute Respiratory Infections Dr.Rajesh Kulkarni Associate Professor Dept of Community Medicine JNMC, Belgaum

27. Introduction Most common human ailment Substantial cause of morbidity and mortality ARI – URTI – common cold, pharyngitis , otitis media LRTI – epiglottitis , laryngotracheitis , bronchitis

28. Main clinical features Running nose, cough, sore throat, breathlessness, ear problems and fever PROBLEM STATEMENT: 3.9 million deaths Children < 5yrs suffer about 5 episodes /child/year 13% of inpatients deaths 987000 deaths in India annually

29. Introduction (contd..) Source: WHR 2007

30. PROPORTIONAL MORTALITY IN UNDER FIVE CHILDREN

31. Epidemiology Agent: Bacteria – Streptococcus, Corynebacterium, Bordetella, Klebsiella Viruses – Adenoviruses, Influenza, Rhinoviruses, Coronavirus Other agents: Chlamydia Coxiella burnetti Mycoplasma

32. Host factors Young children prone Malnourishment In adults 3 rd decade is more ( F > M ) Risk factors: Climate, poor housing, poor nutrition, LBW Maternal cigarette smoking, low SE status, school going child Day care centers, urban > rural

33. Mode of transmission Air borne ( MC ) Direct person to person contact Control of ARI : Basic measures: Primary medical care Early detection Treatment prevention

34. Classification of illness Children 2mth – 5yrs: Very severe disease: Cannot drink Convulsions, abnormally sleepy Stridor in calm child Severe malnourishment

35. Severe Pneumonia: Respiratory rate Chest indrawing Nasal flaring Grunting cyanosis

36. Pneumonia: Fast breathing only No Pneumonia: Cough and Cold No danger signs

37. Pneumonia

38. Child < 2months Any pneumonia is considered as severe RR ≥ 60 breaths per min Immediate referral Danger signs:- Convulsions, stridor, abnormally sleepy, stopped feeding well, wheezing, fever or Low body temperature

39. Treatment ( 2mth – 5yrs ) Pneumonia: Cotrimoxazole ( tab or syrup) Severe Pneumonia: First 48hrs- benzyl Penicilline: 50,000IU/KG – 6 th hrly or Ampicillin 50mg/kg – 6 th hrly or Chloramphenicol 25mg/kg – 6 th hrly If condition improves: for next three days continue the same If no improvement change the A/B

40. Very severe disease Oxygen therapy Intensive monitoring Chloramphenicol IM ( DOC )

41. Pneumonia infants < 2mths Inj Benzyl penicillin or Ampicillin & gentamicin ( 2.5mg/kg/dose BD ) Children without pneumonia: No need of A/B

42. Any general danger sign or Chest indrawing or Stridor in calm child SEVERE PNEUMONIA OR VERY SEVERE DISEASE Give first dose of injectable antiboitic . Refer URGENTLY to hospital. Fast breathing PNEUMONIA Give Cotrimoxazole for 5 days. Advise home care for cough or cold. Advise mother when to return immediately. Follow-up in 2 days. No signs of pneumonia or very severe disease. No pneumonia Advise home care for cough or cold. If coughing for more than 30 days, refer for assessment. Advise when to return immediately 42

43. Prevention Improve the living conditions Better nutrition Reduce indoor air pollution Better MCH care Immunization Community support Health education

44. Thank You