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Measles

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Measles

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Measles is a highly contagious infection caused by a measles virus which presents with a characteristic maculopapular rash, cough, coryza, conjunctivitis and Koplik spots 
( pathognomonic of measles )

Back ground – Caused by Paramyxovirus It is an RNA virus – humans are the natural host and reservoir Incubation period is 10-14 days Highly contagious illness -spread is via respiratory droplets In fact it is the most infectious of all diseases transmitted through the respiratory route The virus replicates in the epithelial cells of the respiratory tract- spreads subsequently to the lymphoid tissue and blood leading to viremia Measles can be severe in
○ Immunocompromised individuals
○ young infants
○ pregnant women – increased risk of miscarriage , stillbirth or preterm delivery Season- late winter to spring Infectiousness – maximal in 4 days before and 4 days after the rash develops Measles has been around for over 1000 yrs

How common- Widespread use of vaccination has reduced incidence worldwide UK MMR vaccination was introduced in 1988 Most effective way to control measles is via vaccination It still accounts for substantial morbidity and mortality
○ particularly in regions of Africa and SE Asia
○ 6 th leading cause of death worldwide ( 1997 )
○ incidences have risen lately ( Measles cases in Europe tripled from 2017-2018 BMJ 2019 ) due to suboptimal immunization
○ Vaccination uptake peaked in 2017 in the EU
○ WHO target is > 95 % vaccination Measles is a notifiable disease in most countries It can affect people of all ages

Vaccination –WHO recommends > 95 % 2 dose-vaccination to maintain high levels of population immunity MMR is freeze-dried preparation containing live , 
attenuated ( modified ) strains of measles , mumps and rubella viruses Two doses are recommended for satisfactory protection MMR vaccine can be given irrespective of a h/o measles , mumps , or rubella infection for vaccination- no ill effects from immunising such individuals as they have pre-existing immunity that inhibits replication of the virus Unimmunized individuals should be offered vaccination If already received one dose – offer 2nd dose for protection Vaccine effectiveness
♦ single dose ia around 90 %
♦ two doses around 95 %

Presentation-Starts with a 2-4 day illness – prodromal phase before the rash starts Prodromal symptoms include
♦ high fever
♦ coryzal symptoms e.g nasal congestion
♦ cough
♦ conjunctivitis
 Fever – increases during the prodromal phase
peaks around rash onset – generally > 39° 
 Rash 
♦ red blotchy and maculopapular
♦ starts at the forehead , hairline , and behind the ears to the trunk and limb 
over 3-4 days
♦ become confluent as it progresses
♦ starts to fade around the 5th day- in the same order as it had appeared
♦ fever resolves after appearance of rash
♦ rash is not itchy
 Koplik spots – pathognomonic for measles , may develop on the buccal mucosa about 1-2 days before the rash and may persist 1-2 after the rash onset
( not always seen – unreliable marker )


Other causes which can cause rash and fever- Roseola ( HHV 6 infection ) Fifth disease ( parvo-virus B19 ) Streptococcal infection for e.g scarlet fever Rubella Early meningococcal disease Rash and lymphadenopathy- consider Kawasaki disease and infectious mononucleosis Drug eruption

history-ask about vaccination history close contact with a possible case previous h/o measles travel to an area where measles is endemic typical features contact public health- measles is a notifiable disease if there is any suspicion of measles infection

Complications – Otitis media – 7 to 9 % of cases Pneumonia 1 to 6 % cases Diarrhoea – 8 % Convulsions 1 in 200 cases reduced immune response in the few weeks
following the infection

Rare complications include 
 encephalitis blindness sub-acute pan-encephalitis ( SSPE )

investigations- Measles specific IgM and IgG serology Measles RNA by real time polymerase chain reaction ( RT- PCR ) Throat or nasophrayngeal swab Urine sample can also contain virus FBC may show leukopenia , particularly lymphopenia

management –Management is supportive No specific antiviral therapy As a GP – clinical suspicion and isolation in surgery – First steps Vitamin A – low levels are associated with ↑ measles related morbidity and mortality hence recommended for children by WHO Supportive measures ( for e.g paracetamol and ibuprofen ) Exclude from school atleast 4 days after the initial development of rash – can advise to stay at home till recovered fully to reduce risk of infective complications
 Seek advise if
○ child younger than 1 year
○ pregnant
○ immunocomppromised
 Consider admission if any complications present as
♦ pneumonia
♦ neurological problems
 Advice the infected person to avoid contact with immunosuppressed individuals and other vulnerable people for e.g pregnant women and infants 
 Exposure prophylaxis – seek advice from Public health
♦ live vaccine provides permanent protection and may prevent disease if given within 72 hrs of exposure
♦ IG may prevent or modify disease and provide temporary protection if given within 6 days of exposure
 Do not wait for confirmation of diagnosis – notify all suspected cases to PHE
Oral fluids kit are send by the PHE.
 Most people make a full recovery after around 7 days of symptoms with supportive management

 

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