Measles: Epidemiology and Control

District Measles Surveillance Workshop

 Measles virus

• RNA virus
• Family: Paramyxoviridae.
• Genus: Morbillivirus
• Humans are the only reservoir
• Multiplies in the respiratory tract
• Transmitted via respiratory secretions
or aerosols
 Measles disease
- An acute highly infectious disease:
• Everyone exposed gets the disease if not immune

- Classic manifestations:
• Fever AND
• Maculopapular rash AND
• One or more of the 3C:
• Cough / Coryza (runny nose) / Conjunctivitis (red eyes)

- Mortality
• Very High in children <2 yrs and in adults
• High in malnourished children
 Clinical course of measles
- Incubation period (to rash): 14 days (range, 7 – 18
days)
- Prodrome: begins 10 – 14 days after exposure
 High fever, cough, coryza, conjunctivitis
 Period of greatest infectiousness (virus shedding)
- Rash begins: 2 – 4 days after prodrome starts

- Complications: occur mostly in 2nd and 3rd weeks

 Any disease or death not clearly due to another cause (e.g., trauma)
during the 30 days following rash onset
- Case Fatality Ratio (CFR) 0.1 – 10 %
-
Up to 30% in humanitarian emergencies
 Clinical course of measles

incubation period prodrome rash

( 7–18 days before rash) (about 4 days) (about 4–8 days)

-18-17 -16-15 -14 -13 -12 -11 -10 -9 -8 -7 -6 -5 -4 -3 -2 -1 0 1 2 3 4 5 6 7 8

rash 4 days
18 days before 4 days before after rash
rash rash Is the probable
Exposure happened Is the probable start end of
the earliest 18 days of infectiousness infectiousness
before rash The case can
be identified
here
 Measles complications (1)
Corneal scarring
causing blindness
Vitamin A deficiency

Encephalitis
Older children, adults
≈ 0.1% of cases
Chronic disability

Pneumonia &
diarrhea
Diarrhea common in developing countries
Pneumonia ~ 5-10% of cases, usually bacterial
desquamation
 Measles complications (2)
- Sub-acute Sclerosing Panencephalitis
(SSPE)
- Delayed complication: avg. 7 years after
measles infection
- Rare (1 in 100,000 cases)
- Degenerative CNS disorder with personality
changes, seizures, motor disability,
progressing to coma and death
 Measles Epidemiology: Key points

- Caused by a virus and highly infectious

- Infants and adults at high risk of complications

- Most complications in 2nd and 3rd weeks after rash

- Blood sample for IgM serology should be collected 4-28 days

after rash onset

- Goal of measles vaccine program is to reduce measles mortality

by achieving and maintaining ≥95% population immunity
Measles vaccine

District Measles Workshop

 Measles vaccine properties
 Composition: live virus - freeze dried powder
 Requires reconstitution (diluent from
manufacturer)
 Vaccine Efficacy (VE) depends on age
 At 9 months of age 85%
 At >12 months of age 95%
 For those who sero-covert, vaccine provides long-
lasting immunity (lifelong)
 India UIP schedule for Measles first dose at
9 months
 Dose 0.5 ml all ages
 Route sub-cutaneous
Contraindications and precautions
 Severe allergic reaction to prior dose of
vaccine or vaccine component
• Neomycin, Gelatin most allergenic
 Immunosuppression
 Temporary contraindications
 Pregnancy
 Moderate or severe illness
 Recent receipt of blood product
 Storage of measles vaccine
 Long term storage: Before reconstitution
 frozen -15º to -25º C up to 2 years
 At Health facility: Before reconstitution
 refrigerated at +2 to +8º C (up to 1 month at
CHC/PHC & 3 months at district)
 After reconstitution, becomes extremely heat-
and light-sensitive (discard after 4 hours)
 VVM on cap has no utility after reconstitution
 Reconstitution of measles
vaccine
 Reconstitute just before use
 Always check the expiration date and VVM
 Use diluents kept at +4 to +kprovided by
same manufacturer
 Place diluent in the refrigerator few hours before
use
 Diluent vials must not be frozen
 Keep reconstituted vial of vaccine cold and
protected from sunlight
 discard after 4 hours of reconstitution or at the
end of vaccination session, whichever comes first
 VVM of no use after reconstitution

 Reconstitute vaccine only with diluent supplied by

manufacturer
 Prepared vaccine should be placed in slit in foam cushion that
fits over opening of vaccine carrier
 Protect vaccine from sunlight
 Check vaccine vial monitor (VVM)
 Stage 1 or 2 = vaccine is ok
 Stage 3 or 4 = discard vial
Measles vaccination
 Adverse reactions with measles-
containing vaccines (1)
 Common Adverse Reactions
 Fever > =39.4° C (>103°F) in 5-15% of
persons vaccinated, usually 7-12 days after
vaccination, lasts 1-2 days
 Rash in 5-15% of persons vaccinated 7-12
days after vaccination
 Rare Adverse Reactions
 Thrombocytopenia <1/30,000 doses
 Anaphylaxis 1 per million doses
 Adverse reactions with measles-
containing vaccines (2)

 Avoid Program errors: Ensure that

health workers note time of
reconstitution and discard vaccine after
4 hours or at end of session whichever
is earlier.
 Measles Vaccine: Key points
 Measles vaccines is safe and effective
 Dose: 0.5 ml; Route: sub-cutaneous
 Vaccine efficacy at:
 9m = 85%
 ≥12 m = 95%
 “Second opportunity” because vaccine is
not 100% effective and all children not
reached by routine vaccination
 Serious AEFI associated with the vaccine
very rare
 Measles Vaccine: Key points
 Live virus - freeze dried powder that must
be reconstituted before use
 Only diluent supplied with vaccine must be used
 Check VVM to rule out heat damage before
reconstitution
 Once diluted, vaccine is very sensitive to heat
and light: keep cold protected from light and
DISCARD AFTER 4 HRS
 Strategies
Measles Control and Surveillance
India is in Mortality Mortality Elimination
Reduction Phase
Reduction
1st dose coverage >90% >95%

2nd Opportunity All children All children

(routine 2nd dose or SIAs)

Surveillance Aggregate or Case-based

case-based
Case Vitamin A Vitamin A
Management Supportive Rx Supportive Rx
 Summary
 Measles is a major cause of childhood
morbidity and mortality

 Common complications are: Pneumonia,

diarrhoea, eye problems, ear infections and
encepahlitis

 Safe and effective vaccine available

 Four pronged strategy for control and

elimination tested in other regions
Thank You!