1. Measles

2. Measles is caused by the measles virus, a member of the family paramyxoviridae, genus Morbillivirus.

3. Occurrence Prior to widespread immunization
It was a common childhood disease.
There were an estimated 100 million cases and 6 million death each year.
It was endemic in large communities attained epidemic proportion every 2 or 3 years.
In small communities epidemics tended to be more widely spaced and more severe.
Over 80% reported cases are from southeast Asia and Africa.
Over 85% in children aged <5 years.

4. Occurrence
In temperate climates, it occurs in late winter and late spring.
In tropical climates, it occurs primarily in dry season
Effect of routine vaccination on the epidemiology of measles
Reduction of the incidence by 99% in many developed countries.
Reduction of the CFR.
Cases appeared among young unimmunized children or older children, adolescents or young adults who received one dose.

5. Occurrence Race: Measles affects people of all races. Sex:
Excess mortality following acute measles has been observed among females at all ages, but it is most marked in adolescents and young adults.
Age:
affect everyone in infancy or childhood between 6m-3 years in developing countries and children > 5years in developed countries .
Following the use of measles vaccine ,the disease now seen in older age groups

6. Chain of events Reservoir Human Mode of transmission Direct droplet
Air borne
Direct contact with nasal or throat discharge.
Articles soiled with nose & throat secretion (less common).
The incubation period days

7. Chain of events Period of communicability
signs and symptoms
one day before prodreomal period days after rash

8. Chain of events Susceptibility & resistance
Acquired immunity after illness is permanent.
Immunization at months induced immunity in 94-98% of recipients.
There is maternal immunity(6-9 months)depending on:
Amount of residual maternal antibodies at the time of pregnancy .
Rate of antibody degradation
Maternal antibodies interfere with the response to vaccination
Re immunization increases immunity level to 99%.

9. Clinical features Risk factors for infection
prodromal fever,cough, coryza, conjunctivitis
Koplik spots
followed by an erythematous maculopapular rash on the third to seventh day. It appears on the face then becomes generalized.
Risk factors for infection
Children with immunodeficiency(AIDS,steroid ....)
Travelers to areas where measles is endemic or contact with travelers to endemic areas.
Infants who lose passive antibody prior to the age of routine immunization

10. Clinical features

11. Risk factors for severe measles
Malnutrition
Underlying immunodeficiency
Pregnancy
Vitamin A deficiency.
Infants and adults

12. Complications
Respiratory complications (Otitis media,Interstitial pneumonitis,Bronchopneumonia and croup
Dehydration and diarrhoea
Blindness
Sever skin infection.
Rare complication include hemorrhagic measles, and protein losing enteropathy.
Encephalitis Encephalomyelitis.

13. Diagnosis
Diagnosis is usually on classic clinical picture and on epidemiological grounds.
Serological tests (IgM, IgG)
Isolation of measles virus from nasopharyngeal mucosa or blood

14. Prevention Public education Immunization
Live attenuated vaccine indicated to all persons not immune to measles ,unless otherwise contra-indicated.
Single injection of measles vaccine (MMR) which can be administrated concurrently with other inactivated vaccines or toxoid induces active immunity in 94-98% of susceptible (life long)
2 nd dose increases the immunity level to as high as 99%.

15. Prevention Vaccination schedule of measles in Iraq
Monovalent measles vaccine ⇒ 9 months.
MMR 1st dose ⇒ 15 months.
MMR 2nd dose ⇒ 4-6 years.

16. Prevention Side effects
5-15 % fever ,malaise within 5-12 days after immunization, lasts 1-2 days.
Occasionally rash, coryza, Koplik spots.
Infrequently febrile seizures .
1:10 6 dose Encephalitis & encephalopathy

17. Optimal age of vaccination
WHO recommend immunization at 9 months of age
Immunization before the age of 9 months run the risk the vaccine being rendered ineffective by natural antibodies through mother.
Age of vaccination can be lowered to 6 months if there is measles outbreak.
For infants immunized between 6-9 months, second dose should be gives as soon as possible after the child reach age of 9 months.

18. Contra-indication of vaccination
Immune deficiency.
Sever illness with or without fever, Delay the dose until recovery (minor illnesses such as diarrhea , upper respiratory infections are not a contra-indication).
Anaphylactic hypersensitivity to previous measles vaccine, gelatin or neomycin and egg hypersensitivity
Pregnancy

19. Control
Reporting is obligatory: early reporting means better control of the outbreak.
Isolation
At community level is impractical .
Children should be kept out of school for 4 days after appearance of rash.
Respiratory isolation for hospital cases.
Contacts
Live attenuated vaccine is effective if it given within 72 hrs of exposure.
IG should be used within 6 days of exposure for susceptible contacts or other contacts with high risk of complications.

20. Control 4. Specific treatment (essential steps)
The risk of complication is high in
<1 year of age
Pregnant women
Immunocompromised
If measles vaccine is contra indicated
4. Specific treatment (essential steps)
Relieve common symptoms
Provide nutritional support
Promote breast feeding
Giving vit A

21. Control
Giving vitamine A
It is the recommended for children with measles in the following situations :
Areas where measles CFR>1%.
Areas of known vit A deficiency.
In all cases of sever complicated measles.

22. Vit A
1st dose immediately on the Dx
2nd dose in the next day
If the child has any eye signs indicating vitamin A deficiency, then a third dose must be given 2-4 weeks later
Doses
Infant<6 months IU
Infant 6-11 months IU
Infant 12 months IU

23. Epidemic measures Rapid (within 24 h) reporting of suspected cases.
Comprehensive immunization program.
In institutional outbreaks new admission should receive Ig.
In many developing countries rapid immunization campaign is essential. If the vaccine supply is limited priority should be given to young children for whom the risk is greater.

24. Rubella
German Measles

25. Epidemiology
Acute childhood infection ,usually mild, of short duration (approximately 3 days) caused by rubella virus.
Rubella occurs worldwide. The number of reported cases is high in countries where rubella routine immunization is either not available or was recently introduced.
It is endemic with epidemics every 5-9 years
Although the burden of congenital rubella syndrome is not well characterized in all countries, more than cases are estimated to occur in developing countries alone.

26. Epidemiology
In many countries, who sustained high levels of rubella immunization rubella and CRS is drastically reduced or practically eliminated.
The morbidity and mortality rates of rubella dropped remarkably since the licensing of the live attenuated vaccine in1969.
Race :no racial difference in the incidence has been clearly demonstrated

27. Epidemiology
Sex: No differences in infection rate in children, but in adults, more cases are reported in women than in men.
Age:
Before introduction routine vaccination it was a disease of school-age children, with a peak incidence in children aged 5-9 years.
Following the wide spread use of rubella vaccine in children, peak incidence has shifted to persons older than 20 years.

28. Mode of transmission Droplet spread
Direct contact with infected person
Direct contact with nasopharyngeal secretion
Infants with CRS continue shedding the virus in their urine & throat secretion for along period (months or year after birth)
Incubation period days

29. Period of communicability
Rash
week before days after

30. Susceptibility &resistance
General, after loss of transplacentally acquired maternal antibodies.
There is maternal immunity (6-9months).
Natural infection leads to permanent immunity.
Immunization produces life long or long term immunity (contact with endemic cases acts as a booster doses).

31. Clinical features
Prodromal symptoms: coryza, sore throat, conjunctivitis, mild fever.(1-5 days)
Lymphadenopathy: post-auricular, posterior cervical L.N, appear as early as 7 days before the appearance of rash.
Rash : Minute, discrete, pinkish maculopapular rash ,start in the face and spread rapidly to trunk and limbs. The rash disappear all together by third day.
In adults, rubella may be complicated by arthralgia, and arthritis particularly among females.
WHO case definition : Any person with fever, maculopapular rash and adenopathy.

33. Complications Pneumonia Arthralgia and arthritis (commoner in females)
Hemorrhagic manifestations due to thrombocytopenia,
Encephalitis
Congenital rubella syndrome.

34. Congenital Rubella Syndrome
Affects the fetuses of up to 80% of all women who contract the infection during the first trimester of pregnancy.
The incidence of congenital abnormalities diminishes in the second trimester and no ill-effects result from infection in the third trimester.
Congenital rubella syndrome is characterized by the presence of fetal cardiac malformations, especially patent ductus arteriosus and ventricular septal defect, eye lesions (especially cataracts), microcephaly, mental retardation and deafness.

35. Congenital rubella syndrome
Congenital rubella syndrome is considered to have occurred if infant have rubella IgM antibodies shortly after birth or if IgG persist for more than 6 months, by which time maternally derived antibodies would have disappeared

36. Diagnosis The diagnosis may be suspected clinically Serology
Achieved by the detection of rubella-specific
IgM by ELISA in an acute serum sample, preferably confirmed by the demonstration of IgG seroconversion(or a rising titre of IgG) in a subsequent sample taken 14 days later.
Viral genome can be detected in throat swabs (or oral fluid samples), urine and, in the case of intrauterine infection, the products of conception

37. Prevention Public education Mode of transmission.
Need of rubella immunization.
Risk caused by infection during pregnancy.
Rubella vaccination:
Live attenuated vaccine (MMR ,MR ,MMRV , Monovalent Vaccine)
Single dose confers long –term immunity in >90% of immunized persons.

38. Prevention
The primary purpose of vaccination is to prevent occurrence of congenital rubella infection including CRS.
Elimination of rubella as well as CRS, through
Universal immunization of infants
Ensuring immunity in women of childbearing age by immunization of women at childbearing age.
For increased impact men should also be vaccinated

39. Prevention
Vaccine Recommendation
Routine childhood immunization in Iraq
2 doses of MMR
1st dose at 15 months
2nd dose at 4-6 years

40. Prevention
In rubella immunization program, there is post pubertal female rubella immunization
Every female should be asked if they are pregnant or not
If pregnant excluded from immunization
If not pregnant immunization and explain the need to prevent pregnancy for one month after immunization

41. Adverse reaction to MMR
Fever in 5-15% , from 5-15 days post vaccination.
Rash in 5% of vaccine from 7-10 days post vaccination
Mild lymph adenopathy is common
Joint pain.
Transient arthritis in 10% of post pubertal females
CNS manifestation (no causal relationship)

42. Contra-indication to MMR vaccination
Immunodeficiency conditions (except HIV) .
Pregnancy .
Women planning to get pregnant in the next 3 months
Severe illnesses
Immediate anaphylactic reaction

43. Prevention
In case with infection early in pregnancy culturally appropriate counseling should be provided.
Intramuscular IG given in a dose of 20 ml within 72 hours of exposure may decrease
Clinical disease
Viral shedding
Rate of viremia in exposed susceptible .

44. Control Notification or reporting Isolation:
Contact isolation for hospital cases.
Prevent exposure of non immune pregnant women
Exclusion for 7 days after onset of rash
Infants with CRS should be put under contact isolation unless urine and pharyngeal virus culture are negative.

45. Control Epidemic measures
Protection of contacts. All contacts with infants with CRS should be protected. Passive immunization is not indicated.
Investigation of contacts and source of infection.
Epidemic measures
Active surveillance for infants with CRS should be carried out until 9 months after the last reported case of rubella.
Identify and protect susceptible pregnant women.
Prompt reporting of all confirmed cases.

46. Thanks