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Measles
Do we immunize earlier?
Tan Kah Kee MD
Dept of PediatricsHospital Tuanku Jaafar Seremban
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Outline
Measles infection
Measles vaccination
Measles vaccine strategies
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Measles infection
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Measles Infection
Highly contagious viral illness
First described in 7th century
Near universal infection of childhood inprevaccination era
Frequent and often fatal in developingcountries
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Paramyxovirus (RNA)
Hemagglutinin important surfaceantigen
One antigenic type
Rapidly inactivated by heat and light
Measles Virus
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Measles
Epidemiology
Reservoir : Human
Transmission : Airborne
Communicability : 4 days before to 4 days
after rash onset
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Measles Pathogenesis
Respiratory transmission of virus
Replication in nasopharynx and regional lymph
nodes
Primary viremia 2-3 days after exposure
Secondary viremia 5-7 days after exposure withspread to tissues
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Measles Clinical Case Definition
Generalized rash lasting >3 days, and
Temperature >38.30
C , and
Cough or coryza or conjunctivitis
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Measles
Clinical Features
Incubation period 10-14 days
Stepwise increase in fever to 390 C or higher
TRIAD : cough , coryza , conjunctivitis Koplik spots
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Measles Rash
History is unreliable! (unlike chickenpox)
2-4 days after prodrome, 14 days after
exposure
Maculopapular, becomes confluent
Begins on face and head
Persists 5-6 days Fades in order of appearance
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Measles Laboratory Diagnosis
Isolation of measles virus from a clinicalspecimen (e.g., nasopharynx, urine)
Significant rise in measles IgG by any standardserologic assay (e.g., EIA, HA)
Positive serologic test for measles IgM antibody: 75% +ve > 3 days & 100% +ve > 7 days (taken1st 3 days may have false ve in 20%)
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ConditionDiarrhea
Otitis media
PneumoniaEncephalitis
Death
Hospitalization
% reported8
7
60.1
0.2
18
Measles Complications
60% of deaths due to pneumonia
CFR of encephalitis 15% & high proportion
of permanent brain damage
Australian Immunization Guide 2013
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0
5
10
15
20
25
30
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Vitamin A for measles
Reduces mortality due to measles
At least two doses to reduce measles mortality
by 62% (95% CI 1982).
Infants younger than 6 months 50,000 IU/dayPO for 2 doses
Age 6-11 months - 100,000 IU/day PO for 2
doses
Older than 1 year - 200,000 IU/day PO for 2
doses
Sudfeld CR et al. Int J Epidemiol 2010;39
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Measles vaccines
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1963 Live attenuated and killed vaccines
1965 Live further attenuated vaccine
1967 Killed vaccine withdrawn
1968 Live further attenuated vaccine
(Edmonston-Enders strain)(Msia:1982)
1971 Licensure of combined measles-
mumps-rubella vaccine1989 Two dose schedule MMR(USA)(Msia:2002)
Measles Vaccines
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Measles Vaccine
Composition : Live virus
Efficacy : 95% (range , 90-98%) at 1 yr old
Duration of immunity : Lifelong Recommended schedule : 2 doses
Administered as MMR
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Measles, mumps, or rubella disease (or lack ofimmunity) in a previously vaccinated person
2%-5% of recipients do not respond to the first
dose
Caused by antibody, damaged vaccine
Most persons with vaccine failure will respondto second dose
MMR Vaccine Failure
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12 months is the recommended andminimum age
MMR given before 12 months shouldnot be counted as a valid dose
Revaccinate at >12 months of age
Measles Mumps Rubella Vaccine
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Second dose of Measles vaccine
Intended to produce measles immunity in
those who failed to respond to the first
dose(primary vaccine failure)
May boost antibody titers(secondary vaccine
failures due to waning immunity)
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2nd dose MMR
1st dose of MMR at 12-15 mth
2nd dose at 4-6 yrs
2nd dose may be given > 28 days after 1st dose
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MMR Adverse Reactions
Fever : 5-15%
Rash : 5%
Joint Sx : 25% Thrombocytopenia : < 1 per 30,000 doses
Parotitis : rare
Encephalopathy : < 1 per 1,000,000 doses
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Measles vacccine strategies
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Ministry o f Health Malaysia
0
20
40
60
80
100
120
0
100
200
300
400
500
600
700
Incidence per 1mil. pop Vaccination coverage
National SIA:
8-15 y; 93%
Measles Incidence vs MCV1 vaccination coverage,
Malaysia (1970 2011)
i ib i f l
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Ministry o f Health Malaysia
Distribution of Measles
Virus genotype, 2010 & 2011
1G3
1D9
14D9
5D8
1B3
1D9
5D9
1G3
2D8
1G3
1G3
1A
2010 D9, B3, G3
2011 D9, D8
1A
1G3
A case import from
Indonesia 2010
A case import from
Singapore 2011
1D9
6D9
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Ministry o f Health Malaysia
Measles Incidence*
Western Pacific Region 2008
* per million population
Source: WPRO measles-rubella monthly country reports and WHO-UNICEF Joint Reporting Form (data for 2008)
< 1.0 (22)
1.0 4.9 (4)
20.0 29.9 (0)
LEGEND:
10.0 19.9 (4)
5.0 9.9 (3)
50.0 (3)
40.0 49.9 (0)
30.0 39.9 (0)
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Ministry o f Health Malaysia
Measles Incidence*
Western Pacific Region 2012
* per million population
< 1.0 (30)
1.0 4.9 (1)
20.0 29.9 (0)
LEGEND:
10.0 19.9 (2)
5.0 9.9 (1)
50.0 (1)
40.0 49.9 (1)
30.0 39.9 (0)
Source: WPRO measles-rubella monthly country reports, data through February 2012
Annualized Incidence = 3.5
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Ministry o f Health Malaysia
0
50
100
150
200
250
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
2008 (lab & Epi-linked = 93;clinically = 222)
2009 (Lab & Epi-linked = 50;clinically = 1)
2010(Lab & Epi-linked = 68;clinically = 4)
2011(Lab & Epi-linked = 1378;clinically = 92)
2012
numberof
cases
Lab-confirmed Epi-linked Clinically c onfirmed
Confirmed Measles Cases, by Month of Onset
Malaysia 20082012*
2012
Lab & Epi-Linked=267,Clinically=33
fi d l b
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Ministry o f Health Malaysia
Confirmed Measles Cases, by State
Malaysia 20112012*
* Source: WPRO measles-rubella monthly country reports, data through February 2012
1 dot = 1 case
2011
2012
2
1.0 - 1.9
< 1
Discarded measles per 100K population:
No suspected measles cases
b fi d d i li k d l b d
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Ministry o f Health Malaysia
Lab confirmed and Epi-linked measles cases, by age group and
vaccination status, Malaysia, January 2011-February 2012
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Ministry o f Health Malaysia
Laboratory confirmed and epi-linked measles cases by year of age and
vaccination status, Malaysia, January 2011-February 2012
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Ministry o f Health Malaysia
Accumulation of susceptible pop
MCV1
Coverage
ELB Est 1 - 2 yo Recipent Missed
No. %
=95% 276113 258129 279828 -21699
510853 490900 471354 19546 4.0
Based on coverage 2011
95% seroconversion rate was not taken into account
Indicators
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Ministry o f Health Malaysia
Indicators
No. INDICATORS TARGET 2009 2010 2011
INCIDENCE
1. Confirmed measles cases
(confirmed by lab,
epidemiologic linkage or
clinically)
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Ministry o f Health Malaysia
Recommendations
Retain 1st dose of MMR at 12 months
Advanced 2nd dose MMR to 18 months ,
instead of Standard 1
Giving additional dose of measles
monocomponent vaccine to hot spots at
6 months old not beneficial
Efficacy of measles vaccine at 6 mth =
35.7 %
Kurubi J et al. Trop Med & Int Health 2009;14
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Conclusions
Measles is a highly transmissible infection
Death mainly due to pneumonia
Sequalae due to encephalitis significant Shifting 2nd dose of MMR to 18 mth old
may be practical & useful