Update on Measles, Mumps and Rubella

Burden of Disease and Its Prevention

Dr. dr. Sri Sofyani, M. Ked(Ped), Sp.A(K)
 WHO 2 JUNE ARTICLE

“Timely immunization against common childhood diseases not only save

lives but requires fewer resources than responding to outbreaks. It also
helps to reduce the burden on an already strained health systems.”
IDAI

IDAI
22 Mei 2020
 MEASLES IS A HIGHLY TRANSMISSIBLE VIRAL INFECTION1
Measles Pathogenesis and Clinical Features1–6

Transmission Incubation Communicability Disease

Aerosols generated during Incubation time of Highly communicable, Initial prodromal phase of:
coughing or by direct 2 weeks before the onset of with >90% secondary • Fever
contact with contaminated disease symptoms attack rates that can • Cough
respiratory secretions occur from 4 days • Coryza
before to 4 days after
the onset of rash
A few days later a generalized
maculopapular skin rash appears, often
in combination with conjunctivitis. At the
onset of rash, Koplik spots also develop
in the oral mucosa

▪ 1. Measles (Rubeola). Centers for Disease Control and Prevention Web site. https://www.cdc.gov/measles/about/transmission. html. Accessed March 5, 2019. 2. de Swart RL. Pediatr Infect Dis J. 2008;27(10 suppl):S84–S88. 3. World Health
Organization. Wkly Epidemiol Rec. 2009;84:349–360. 4. Public Health Image Library. Centers for Disease Control and Prevention Web Site. https://phil.cdc.gov/details.aspx?pid=1150. Accessed March 5, 2019. 5. Public Health Image Library.
Centers for Disease Control and Prevention Web Site. https://phil.cdc.gov/details.aspx?pid= 3187. Accessed March 5, 2019. 6. Centers for Disease Control and Prevention. Chapter 13: Measles. In: Hamborsky J, et al.
Epidemiology and Prevention of Vaccine-Preventab le Diseases. 13th ed. Washington D.C. Public Health Foundation. 2015; 209-230.
 WHILE THE GLOBAL INCIDENCE HAS DECREASED,
MEASLES REMAINS A THREAT1,2
Global Incidence of Measles, by WHO Region (2000 and 2018)1,2
Europe

37 K 54 K

2000
2018
Eastern Mediterranean
Western Pacific
Americas
39 K 19 K
177 K
19 K
1. 8 K
10 K 2000 2018
2000 2018
2000 2018
Southeast Asia
Africa
79 K 61 K
520 K
25 K
2000 2018
2000 2018

A total of 189,392 measles cases were reported worldwide in 20181,a

ACONFIRMED MEASLES CASES (CLIN+EPI+LAB) THROUGH NOVEMBER 2018.

WHO = WORLD HEALTH ORGANIZATION.

1. GLOBAL MEASLES AND RUBELLA UPDATE, NOVEMBER 2018. WORLD HEALTH ORGANIZATION WEB SITE.
5
HTTP://WWW.WHO.INT/IMMUNIZATION/MONITORING_SURVEILLANCE/BURDEN/VPD/SURVEILL ANCE_TYPE/ACTIVE/GLOBAL_ MR_UPDATE_NOVEMBER_2018.PDF?UA=1. ACCESSED MARCH
5, 2019. 2. MEASLES: REPORTED CASES BY WHO REGION. WORLD HEALTH ORGANIZATION WEB SITE. HTTP://APPS.WHO.INT/GHO/DATA/VIEW.MAIN.1520_62. ACCESSED MARCH 5, 2019.
 COMPLICATIONS FROM MEASLES CAN AFFECT
MULTIPLE ORGAN SYSTEMS1,2
Most measles-related deaths are caused by complications associated with the
disease3
Opportunistic Infections
Many complications are caused by disruption of the epithelial surfaces and
immunosuppression, which can increase susceptibility to opportunistic infections 1,2

Respiratory Complications
Including otitis media, mastoiditis, croup, tracheitis, and pneumonia1

Neurologic Complications
Including febrile convulsions, encephalitis, and subacute sclerosing panencephalitis 1

Gastrointestinal Complications
Including diarrhea, appendicitis, hepatitis, pancreatitis, and stomatitis 1

Ophthalmic Complications
Including keratitis, corneal ulceration or perforation, central vein occlusion, and blindness 1

▪ 1. Perry RT et al. J Infect Dis. 2004;189(suppl 1):S4–S16. 2. de Swart RL. Pediatr Infect Dis J. 2008;27(10 suppl):S84–S88. 3. Measles. World Health
Organization Web site. http://www.who.int/mediacentre/ factsheets/ fs286/ en/. Accessed March 5, 2019.
 MUMPS PATHOGENESIS AND CLINICAL FEATURES
Mumps Pathogenesis and Clinical Features1−4

Transmission Incubation Communicability Disease

The mumps virus is The incubation period Contagiousness is Short prodromal phase of:
transmitted via the is ≈15−24 days similar to that of • Low-grade fever
• Anorexia
airborne spread of influenza and
• Myalgia
respiratory droplets rubella. Infected • Malaise
or direct contact patients are most • Headache
contagious
1−2 days before the Infection can remain localized to
onset of clinical the respiratory tract, but can
symptoms and for also affect other organs and
several days systems
afterward • Parotids
• Central nervous system
• Urinary tract
• Genital organs

▪ 1. Hviid A et al. Lancet. 2008;371:932–944. 2. Causes: mumps. National Health Service Web site. https://www.nhs.uk/conditions/mumps/causes/. Accessed March 5, 2019. 3. Public Health Image Library. Centers for Disease Control and
Prevention Web site. https://phil.cdc. gov/phil/details. asp?pid=130. Accessed March 5, 2019. 4. Centers for Disease Control and Prevention. Chapter 15: Mumps. In: HamborskyJ, et al. Epidemiology and Prevention of
Vaccine-Preventab le Diseases. 13th ed. Washington D.C. Public Health Foundation. 2015; 248-260.
 MUMPS CASES CONTINUE TO BE REPORTED WORLDWIDE WITH
THE GREATEST INCREASE IN THE WESTERN PACIFIC1
Global Incidence of Mumps, by WHO Region (2000 and 2017)
Europe

243 K
27 K

Eastern Mediterranean 2000 2017 Western Pacific

Americas
66 K 43 K 335 K
143 K

44 K 45 K 2000 2017 2000 2017

2000 2017
Southeast Asia
Africa

9K
62 K
39 K 41 K
2000
2000 2017
2017
7x increase in SE
ASIA

A total of 552,779 mumps cases were reported worldwide in 2017a

A
CONFIRMED MUMPS CASES (CLIN+EPI+LAB).

WHO = WORLD HEALTH ORGANIZATION.

8
1. GLOBAL HEALTH OBSERVATORY DATA REPOSITORY. WORLD HEALTH ORGANIZATION WEB SITE. HTTP://APPS.WHO.INT/GHO/DATA/. ACCESSED
MARCH 5, 2019.
 COMPLICATIONS FROM MUMPS CAN AFFECT
MULTIPLE ORGAN SYSTEMS1
≈97% of patients with mumps experience swelling of the parotid gland, the most
common complication of mumps

Glandular Complications
Including parotitis, submaxillary and/or sublingual gland
inflammation, epididymoorchitis a, mastitisb, oophoritis, and
pancreatitis

Neurologic Complications
Including meningitis and encephalitis

Other Complications
Including myocarditis, deafness (transient or permanent), and nephritis

a Male
▪ patients ≥12 years of age. bFemale patients ≥12 years of age.
▪ 1. Rubin SA et al. In: Plotkin SA et al. Mumps Vaccine. 7th ed. Elsevier Saunders; 2017:663−688.
 RUBELLA PATHOGENESIS AND CLINICAL FEATURES
Rubella Pathogenesis and Clinical Features1−3

Transmission Incubation Communicability Disease

Rubella is a viral It can take 2−3 weeks Rubella is only Symptoms of rubella include:
infection spread via for symptoms to moderately • A maculopapular rash, sometimes
droplets of moisture develop contagious. The pruritic
from the nose or throat disease is most • Swollen glands around the head and
neck
contagious when
• Fever
the rash first • Cold-like symptoms such as cough or
appears, but virus runny nose
may be shed from • Aching and painful joints (more
7 days before to common in adults)
5–7 days or more
after rash onset Infection is most serious in pregnant
women during the first 20 weeks of
pregnancy, as the virus can disrupt
fetal development

▪ 1. Rubella (German measles). National Health Service Web site. http://www.nhs.uk/Conditions/Rubella/Pages/Introduction.aspx. Accessed March 5, 2019. 2. Public Health Image Library. Centers for Disease Control and Prevention Web site.
https://phil.cdc.gov/Details.aspx?pid=712. Accessed March 5, 2019. 3. Centers for Disease Control and Prevention. Chapter 20: Rubella. In: HamborskyJ, et al. Epidemiology and Prevention of Vaccine-
Preventab le Diseases. 13th ed. Washington D.C. Public Health Foundation. 2015; 325-340.
 ACQUIRED RUBELLA INFECTION AND CRS CAN BE
ASSOCIATED WITH SERIOUS COMPLICATIONS AND BIRTH
DEFECTS1,2
Orthopedic Complications
Arthralgia or frank arthritis occurs in up to 60% of postpubertal women with
rubella infections 1

Neurologic Complications
Postinfectious encephalopathy occurs in 1 in 5,000 to 1 in 10,000 cases
of rubella1

Hematologic Complications
Transient thrombocytopenia is reported in 1 in 3,500 cases of rubella, and
purpuric rash occurs in 1 in 1,500 cases of rubella1

Complications to Pregnancies
When infection occurs during early pregnancy, the resulting CRS can have
serious consequences, including miscarriage, stillbirths, and a number of
birth defects2

▪ CRS = congenital rubella syndrome.

▪ 1. Banatvala JE et al. Lancet. 2004;363:1127–1137. 2. Congenital rubella syndrome. Centers for Disease Control and Prevention Web site. https://www.cdc.gov/vaccines/pubs/surv -manual/chpt15-crs.html. Accessed March 5, 2019.
 A Number of Measles, Mumps, and Rubella Outbreaks Have Been
Reported Recently1
Overview of Recent Selected Outbreaks of Measles, Mumps, and Rubella 1–14
Measles Mumps Rubella

Click to edit
142
Master title style England 2
Poland 4

USA: West
19
Coast 10 2016 Germ any3
2016
125 1,548
Portugal9 Rom ania5
2014−2015 USA: 2014−2015 Japan6
Ohio13 28 3,400
5,442
USA: Illinois 12 383 2017 Italy1 2016−2017 (5 CRS)
317 2014 4,487 2013
Israel7
2015−2016 2017 262 USA: Haw aii11
1,009
2017
Venezuela14 2017−2018
5,643
Brazil14
Madagascar8
2018 9,898
67,422
2018
2018−2019

CRS = congenital rubella syndrome; USA = United States of America.

1. Communicable disease threats report, 10-16 September 2017, week 37. European Centre for Disease Prevention and Control Web site. ecdc.europa.eu/en/public ations-data/c ommunicable-dis eas e-threats-report-10-16-september-2017-week-37. Accessed March 5, 2019. 2. Laboratory confirmed cases
of measles, mumps and rubella, England: October to December 2016. Public Health England Web site. https://www.gov.uk/governme nt/uploads /system/uploads /attachm ent_data/file/594801/hpr0817__mmr.pdf. Accessed March 5, 2019. 3. Measles and rubella monitoring: July 2015. European Centre for
Disease Prevention and Control Web site. http://ecdc.europa.eu/en/public ations/Publicati ons/m easles-rubella- quarterly-surveillanc e-july-2015.pdf. Accessed March 5, 2019. 4. Measles and rubella monitoring: July 2017. European Centre for Disease Prevention and Control Web site.
https://ecdc.europa.eu/sites/portal/files/docum ents/m easles %20-rubell a-monitoring-170424.pdf. Accessed March 5, 2019. 5. Measles outbreaks across Europe threaten progress towards elimination. World Health Organization Web site. http://www.euro.who.int/en/medi a-centr e/secti ons/press-
releases/2017/measles-outbreaks-across-europe-threaten-progress-tow ards-eliminati on. Accessed March 5, 2019. 6. Nationwide rubella epidemic−Japan, 2013. Centers for Disease Control and Prevention Web site. https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6223a1.htm. Accessed March 5, 2019.
7. Indenbaum V et al. Euro Surveill. 2017;22:pii: 30605. 8. Outbreaks and Emergencies Bulletin, Week 07: 11-17 February 2019. WHO Web site. https://www.afro.who.int/publicati ons/outbreaks-and-emergenci es-bulletin-week- 07-11-17-february-2019. Accessed March 5, 2019. 9. George F et al. Euro
12 Surveill. 2017;22:pii: 30548. 10. Measles outbreak―California, December 2014-February 2015. Centers for Disease Control and Prevention Web site. https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6406a5.htm. Accessed March 5, 2019. 11. Hawaii State Web site.
http://health.hawaii.gov/doc d/advisories/m umps/. Accessed March 5, 2019. 12. Mumps outbreak at a university and recommendation for a third dose of measles-mumps-rubella Vaccine—Illinois, 2015–2016. Centers for Disease Control and Prevention Web site.
https://www.cdc.gov/mmwr/volumes/65/wr/mm6529a2.htm. Accessed March 5, 2019. 13. Measles cases in 2019. Centers for Disease Control and Prevention Web site. https://www.cdc.gov/measles/cases-outbreaks.html. Accessed March 5, 2019. 14. Pan American Health Organization/World Health
Organization. Epidemiological Update: Measles. 30 November 2018, Washington, D.C.: PAHO/WHO; 2018.
 MEASLES OUTBREAK IN ASIA

17Jan2021 13

1. HTTPS://PAPUANEWS.ID/2018/02/08/THE-MEASLES-OUTBREAK-AND-MALNUTRITION-ENDANGERING-PAPUAS-CHILDREN/.

2. HTTPS://WWW.PASSPORTHEALTHUSA.COM/2018/05/MEASLES-CASES-SPREAD-THROUGH-MULTIPLE-ASIAN-COUNTRIES/
 THE WHO STRONGLY ENCOURAGES THE USE OF
AN MMR VACCINE1
• Immunization against measles is recommended for all susceptible children and
Measles adults in whom measles vaccination is not contraindicated2

M • The standard for all national vaccination programs should be 2 doses of the
measles vaccine in childhood2
Eliminate

• Routine mumps vaccination is recommended in countries with a well-established,

childhood vaccination program and the capacity to maintain high levels of coverage
with routine measles and rubella vaccination, and where the reduction of mumps
Mumps incidence is a public health priority1 The Global

M
Measles and
Rubella Strategic
• The first dose of the mumps vaccine should be given at the age of 12−18 months,
Plan, launched by
and countries still using a 1-dose schedule are encouraged to add a routine second
dose1 the Measles &
Rubella Initiative in
2012, aims to
achieve measles
and rubella
• The integration of rubella vaccination into measles-vaccine delivery strategies (eg, the elimination in
MMR vaccine) is recommended to interrupt rubella virus transmission and eliminate
Rubella both rubella and CRS3 ≥5 WHO regions
by 20204,5,a

R • Countries should achieve and maintain immunization coverage of ≥80% with at least 1
dose of a rubella vaccine delivered through routine services or regular supplementary
immunization activities, or both3

aThe Measles & Rubella Initiative is a global partnership led by the American Red Cross, United Nations Foundation, CDC, UNICEF, and WHO.4
WHO = World Health Organization; MMR = measles, mumps, and rubella; CRS = congenital rubella syndrome; CDC = Centers for Disease Control and Prevention; UNICEF = United Nations Children's Fund.
1. World Health Organization. Wkly Epidemiol Rec. 2007;82:49−60. 2. World Health Organization. Wkly Epidemiol Rec. 2017;92:205−228. 3. World Health Organization. Wkly Epidemiol Rec. 2011;86:301−316. 4.
Measles. World Health Organization Web site. http://www.who.int/mediacentre/factsheets/fs286/en/. Accessed March 5,
2019. 5. Rubella. World Health Organization Web site. http://www.who.int/mediacentre/factsheets/fs367/en/. Accessed March 5, 2019.
 PI M-M-R II MENYATAKAN BAHWA VAKSIN DAPAT DIBERIKAN
DARI 15 BULAN
JADWAL IDAI 2020: VAKSINASI MMR PADA USIA 18 BULAN,
httpwww.idai.or.idartikelklinikimunisasijadwal-imunisasi-2020
DOSIS KEDUA PADA USIA 5 TAHUN
 THE SAFETY AND IMMUNOGENICITY OF MMR VACCINE AS A
FIRST AND/OR SECOND DOSE HAS BEEN STUDIED EXTENSIVELY
IN CLINICAL TRIALS1

Studied Extensively in Clinical Trials

At least 23 clinical trials from 1988 to 2009 have been conducted,
postlicensing of MMR Vaccine, demonstrating that MMR Vaccine
is well-tolerated and immunogenic

More Than 14,000 Children Received MMR Vaccine in

Trials
14,221 children, from 10 months to 6 years of age, received
MMR Vaccine as a first or second dose in these studies

▪ 1. Kuter BJ et al. Pediatr Infect Dis J. 2016;35(9):1011−1020.

 EFFICACY OF MMR VACCINE AND CONCOMITANT USE WITH
OTHER VACCINES
Established Efficacy
The efficacy and duration of immunity of the individual M-M-RII components have been established in a
series of double-blind controlled trials1

Seroconversion
Studies have also established that seroconversion in response to vaccination against MMR paralleled
protection from those diseases1

Long-lasting Protection
Antibodies associated with protection against all 3 MMR viruses, measured by neutralization assays or
ELISA tests, were still detectable in most individuals
11−13 years after primary vaccination1

Concomitant Use With Other Pediatric Vaccines

There is evidence to support the concomitant use of M-M-RII with other pediatric vaccines: varicella,
diphtheria, tetanus, pertussis, Haemophilus influenzae type B, hepatitis B, and/or oral polio vaccine 2

▪ MMR = measles, mumps, and rubella; ELISA = enzyme-linked immunosorbent assay.

▪ 1. International Physicians Circular, M-M-RII, Worldwide Product Labeling, MRL. Whitehouse Station, NJ: Merck & Co., Inc.; 2016. 2. Kuter BJ et al. Pediatr Infect Dis J. 2016;35:1011−1020.
 MMR VACCINE DEMONSTRATED SEROCONVERSION RATES OF >92%
AFTER 1 DOSE ACROSS MEASLES, MUMPS, AND RUBELLA IN CLINICAL
TRIALS1
Range of Seroconversion Rates After
Vaccination Across 20 Studies

Measles
92.8%−100%
M

Mumps
97.7%−100%
M

Rubella
92.8%−100%
R
▪ 1. Kuter BJ et al. Pediatr Infect Dis J. 2016;35:1011−1020.
 EFFICACY OF THE INDIVIDUAL MMR VACCINE
COMPONENTS
Efficacy

Measles From the CDC

Enders’ attenuated • 93% effective after 1 dose2
M Edmonston strain1
• 97% effective after 2 doses2

Mumps From the CDC

Jeryl Lynn (B-level) • 78% effective after 1 dose2,3
M mumps strain1
• 88% effectiveness after 2 doses2,3

Rubella
Wistar RA 27/3
Vaccine highly effective (95% −100%)4
R rubella strain1,4

▪ CDC = Centers for Disease Control and Prevention.

▪ 1. International Physicians Circular, M-M-R II, Worldwide Product Labeling, MRL. Whitehouse Station, NJ: Merck & Co., Inc.; 2016. 2.Vaccines and preventable diseases. Centers for Disease Control and
Prevention Web site. https://www.cdc.gov/vaccines/vpd/mmr/hcp/about.html. Accessed March 5, 2019. 3. Epidemiology and prevention of vaccine-preventable diseases. Centers for Disease Control and
Prevention Web site. https://www.cdc.gov/vaccines/pubs/pinkbook/mumps.html. Accessed March 5, 2019. 4. Rubella. World Health Organization Web site. https://www.who.int/ith/vaccines/rubella/en/.
Accessed March 5, 2019.
 WIDESPREAD USE OF A 2-DOSE VACCINATION SCHEDULE OF
MMR VACCINE IN COUNTRIES SUCH AS FINLAND HAS LED TO A >99% REDUCTION IN
THE INCIDENCES OF THE 3 DISEASES, COMPARED WITH THE PRE VACCINE ERA1,2

In 1982, a 2-dose vaccine program was instituted in Finland with the aim of eliminating indigenous measles, mumps, and
rubella. Measles was effectively eliminated in 1996, while mumps and rubella elimination followed in 19972,3
Measles
25,000
Mean Num ber of
Cases per Year

20,000 Vaccination
Measles

15,000

10,000

5,000

0
* *

Mumps
15,000
Mean Num ber of
Cases per Year

12,500 Vaccination
Mumps

10,000
7,500
5,000
2,500
0
* *

7,000 Rubella
Mean Num ber of
Cases per Year

6,000 Vaccination
Rubella

5,000
4,000
3,000
2,000
1,000
0 * *

Year

MMR = measles, mumps, and rubella.

1. Lievano F et al. Vaccine. 2012;30:6918−6926. 2. Peltola H et al. Lancet Infect Dis. 2008;8:796−803. 3. Peltola H et al. N Engl J Med. 1994;331:1397−1402.
 Post-Licensure Study: Global Safety Surveillance Data for M-M-R :
32 tahun pengamatan (1978-2010) menunjukkan Vaksin M-M-R memiliki
profil keamanan yang baik dan dapat ditoleransi dengan baik.

• 17,536 AEs voluntarily reported/~575 million doses distributed

• ~31 AEs/1 million doses distributed
Kesimpulan:
“Vaksin MMR memiliki profil keamanan yang baik dan dapat ditoleransi dengan baik ”
Lievano et al Vaccine 2012
Isu tentang Vaksin MMR
• Brian Deer dkk 200 : wakefield MEMALSUKAN
riwayat Pasien agar pengacara menuntut
produsen Vaksin.
• Dari 12 anak : 5 anak ada masalah perkembangan
sebelum divaksinasi, 7 anak tidak pernah Autis.
• Lancet Mar.3, 2004 : 10 dari 12 co-authors
menarik pendapatnya : karena data tidak cukup.
• Lancet Feb. 2, 2010 : Editor menarik artikel
wakefield dkk 1998 karena beberapa bagian
makalah terbukti tidak bener.
• British Journal of Medicine. Jan 5, 2011 :
Wakefield menerima $674.000 dari pengacara
yang menangani tuntutan orang tua.
• May 24, 2011 : Ijin praktek Wakefield dicabut
karena menyalahgunakan posisi dan profesinya.
 TAKE HOME MESSAGES
• Measles, Mumps dan Rubella adalah penyakit yang sangat menular yang terjadi di
seluruh dunia dan mempengaruhi semua kelompok umur, terutama anak-anak1-3
• Vaksinasi MMR memberikan dampak signifikan terhadap upaya pencegahan
terhadap penyakit measles, mumps dan rubella di berbagai negara dan sejalan dengan
goals dari WHO.
• Studi klinis menunjukkan vaksin M-M-R mempunyai nilai serokonversi yang tinggi
setelah pemberian dosis pertama
• Global Safety Surveillance Data for M-M-R Vaccine : 32 year review (1978-2010)
menunjukkan M-M-R memiliki profil keamanan yang baik dan juga ditoleransi
dengan baik.
 Click to edit Master title style

24 17Jan2021