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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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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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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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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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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

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Dec

Jan

Feb

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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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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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Lab confirmed and Epi-linked measles cases, by age group and

vaccination status, Malaysia, January 2011-February 2012

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Laboratory confirmed and epi-linked measles cases by year of age and

vaccination status, Malaysia, January 2011-February 2012

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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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Indicators

No. INDICATORS TARGET 2009 2010 2011

INCIDENCE

1. Confirmed measles cases

(confirmed by lab,

epidemiologic linkage or

clinically)

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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

measles fm s 05072013

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