M-M-RM-M-R

A concern for all

Measles

Mumps

Rubella

Measles

Mumps

Rubella

The Three

Measles – Shocking FactsMeasles – Shocking Facts

Measles is a leading cause of childhood deaths the world over

Annually around 30 million cases of Measles are seen and about 9 lakh children die because of Measles

Measles still kills about million people, annually

Indian medical textbook estimates 45 million cases annually

In India, more that 500 children die due to measles, everyday

India alone contributes 27% of global measles deaths

Measles – Shocking FactsMeasles – Shocking Facts

Measles – The diseaseMeasles – The disease

Also called “Rubeolla” or red spots.

A paramyxo-virus infection.

Measles – an acute systemic viral illness.

Two types – Typical and Atypical

Respiratory prodrome 2-4days, High fever

Koplick’s spots, then skin rash – typical pattern

More severe in adults (modified) than in children

Measles Rash - EvolutionMeasles Rash - Evolution

Initial symptoms : high fever (103-105°F) & skin rash

Followed by cough, runny nose, and/or conjunctivitis

Rash usually appears about 14 days after exposure and lasts 5 - 6 days

It begins at the hairline, then involves the face and upper neck

Over next 3 days, rash gradually proceeds downward & outward, reaching hands & feet – becomes confluent

Four Groups of complications

1. Respiratory Otitis media, pneumonia, sec. bact.

pneumonia Laryngitis, croup, bronchitis

2. CNS Encephalitis – head ache, convulsions,

coma SSPE – slow, months after, MR

3. Gastro-intestinal Gastro-enteritis, Heapatitis,

mescentric adenitis.

4. Rare complications – Myocarditis, AGN, TPP

Complications of MeaslesComplications of Measles

Measles affected childrenMeasles affected children

Objectives of ImmunizationObjectives of Immunization

Eradicate Measles, Mumps and Rubella

Prevent aerosol transmission

Prevent trans placental transmission

Who is immune to Measles?Who is immune to Measles?

The one born before early 1960s

The one with physician diagnosed Measles

The One with laboratory evidence

The one with documented vaccination

The one who was administered the 1st dose of Measles at or after 9 months of age (dose received before 9th months of age should not be considered as 1st dose)

Measles VaccineMeasles Vaccine

There is no treatment for measles and vaccination is the best solution

As per the WHO, minimum 95% coverage is required for eradication of disease

This coverage should be complemented by regular doses of measles vaccine every 4-5 yrs

A two-dose schedule is the best way to ensure adequate protection

Vaccine coverage against Measles in India is only 66.5% and even below 50% in some states.

Measles Vaccine Coverage (INDIA)

Measles Vaccine Coverage (INDIA)

Measles incidence and Vaccine Coverage (%)

51

78

0

37

96

9

22

23

6

21

01

333

99

0

6756

898784

0

10000

20000

30000

40000

50000

60000

1998 1999 2000 2001 2002

No

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f C

ases

0

10

20

30

40

50

60

70

80

90

100

Vac

cin

e co

vera

ge

Measles cases Vaccine coverage (%)

Measles Vaccine Coverage (INDIA)

Measles Vaccine Coverage (INDIA)

Children 12- 23 mths. fully immunizedChildren 12- 23 mths. fully immunized

How to eradicate measles How to eradicate measles

The WHO has recommended a 2-dose strategy as the only reliable way to reduce

measles deaths

WHO is making concerted efforts to eradicate Measles. Set goal is to reduce deaths due to measles by half by 2005

Provides another opportunity for children to get vaccine.

Ensures that, in case a child has missed the first dose he gets at least one dose of Measles vaccine.

About 10-15% of children do not get adequate protection in spite of vaccination due to various reasons. Such children can also get protected with second dose.

It provides an chance of strengthening immunity in those cases where it has waned

Advantages of two-dose scheduleAdvantages of two-dose schedule

How does the second dose ensure protection:

A study in Maharashtra to evaluate the efficacy of second dose of measles vaccine

Study design: an urban slum block of population of 50,000 irrespective of immunization status

3985 children below 5 yrs was administered second dose of measles vaccine

an identical block of 4000 children served as control

Zero incidence of measles in the vaccinated block compared to 12 cases of measles in the control group

The use of MMR vaccine as 2nd doseThe use of MMR vaccine as 2nd dose

Protection against two additional diseases i.e. Mumps and Rubella in a single shot.

Mumps is a cause of complications like deafness, meningitis, encephalitis and infertility in adults and children. Also causes an estimated loss of 50-60 lac school days annually

Rubella is a proven cause of congenital disabilities like deafness, cataract, heart defects and mental retardation.

Provides a booster dose of measles vaccine

The MMR vaccine as 2nd doseThe MMR vaccine as 2nd dose

Several countries use the 2-dose schedule for measles vaccine as it is the only reliable way to control measles.

These countries include USA, Central and South America, many European countries including Sweden, Norway, Finland and Portugal, Middle East countries like Bahrain, Iran, Qatar Tunisia, UAE and Saudi Arabia, China and New Zealand

Countries using the 2 dosesCountries using the 2 doses

1. To ensure adequate protection against Measles to all children, the WHO, American Academy of Paediatrics (AAP) and also the Indian Academy of Paediatrics (IAP) recommend use of two doses of Measles vaccine.

2. As per the recommendation of the IAP,

• the first dose should be given at 9 months and

• the second dose should be given as MMR vaccine at 12-15 months

3. Repeat dose at 4-5 years CDC; 12 yr AAP

RecommendationsRecommendations

Vaccine schedule Vaccine schedule

Measles Vaccine at the age of 9 months

MMR Vaccine at 12-15 months

If missed any time up to 13 years of age

Usually two doses against Measles (first at 9 months and followed by MMR at 12-15 months) offers long term protection.

However, clinical data is available showing the antibody titers well above the minimal limits up to 16 years after vaccination.

Duration Vaccine protection Duration Vaccine protection

MumpsMumps

More than 85% of children become susceptible to mumps by the age of 9-12 months and continue to be so in the first 5 years of life

It is estimated that about 8.5 - 9 lakh cases of mumps occur in our country every year.

Obvious sign of mumps is swelling of parotid region, because of Acute parotitis.

Swelling usually lasts for 10 days with fever, Ear-ache, difficulty to talk, eat, open the mouth for 1-6 days.

Affects various organs like salivary glands - Parotid glands, kidneys, testicles (Males), ovaries (females), pancreas, breast and joints 

Loss of 55 to 60 lakh school days / year – morbidity is considerable

The symptoms- signs of MumpsThe symptoms- signs of Mumps

About 20% people who get mumps develop a painful swelling of testicles (Orchitis) and 50% will end up with testicular atrophy. Only 15% of cases of orchitis are bilateral in which case may leads to infertility.

Mumps can also affect reproductive organs in females.

Sensori-neural (SN) deafness is a chronic compllication

Mumps can also cause Asceptic Meningitis, joint pain, pancreatitis, myocarditis and mastitis

The consequences of MumpsThe consequences of Mumps

Unfortunately, there is no sure treatment available for Mumps.

Vaccination is the only way to prevent Mumps

The treatment for MumpsThe treatment for Mumps

MumpsMumps

Inflammation of Parotid Gland in mumps

Orchitis

RubellaRubellaRubella is a togo viral infection – German measles

When a pregnant woman gets infected in her first trimester, the virus causes congenital defects in the developing foetus

In fact, over 2 lakh babies are born with birth defects because of Rubella infection during pregnancy in Indian sub-continent

This causes a great social and economic burden on the family and society at large

Around 40-45% of women are susceptible to Rubella.

Rubella - PNARRubella - PNAR

Sub-clinical, very mild viral illness, Dx. often missed

Post auricular, sub occipital or cervical adenopathy

Rash mainly face, never confluent, later extends – body

Fever may or may not occur, usually low grade, mild

Complications – rare – arthritis, TPP, Haeg., Encephalt.

Rubella in during pregnancy may lead to miscarriage.

Rubella- CRSRubella- CRS

Congenital cataract

Congenital heart diseases – PVS, PDA, ASD, VSD

Sensory neural deafness

Glaucoma, Chorioretunitis

Hepato-splenomegaly, Low BW, DM,

Microcephaly, Mental retardation, Behavioural problem

Hearing loss 92%Congenital Heart Disease 65%Eye defects 56%Behavior disorders 32%Neurological deficit 26%Hearing and visual defect 19%Diabetes mellitus 1%

Congenital Deformities IncidenceCongenital Deformities Incidence

Chances of Deformity Chances of Deformity

The incidence of deformities in the various stages of

pregnancy

The incidence of deformities in the various stages of

pregnancy

3-11 weeks 100% infected fetus12 weeks 80% infected fetus13-14 weeks 54% infected fetus15-16 weeks 35% infected fetus23-26 weeks 25% infected fetus

Time of maternal infection ResultTime of maternal infection Result

The incidence of deformities in India

The incidence of deformities in India

Several studies have clearly shown the link between congenital defects and Rubella in Indian Children

Study Defect Incidence due to RubellaChennai Congenital deafness 29%Madurai Congenital cataract 26.3%Delhi Congenital malformations 21%

(12000 samples)

The treatment for Rubella The treatment for Rubella

Unfortunately there is no treatment for Rubella.

Vaccination is the only way to prevent all these complications

In fact, 123 countries i.e. more than 57% of the countries include Rubella vaccine in their schedule

Sri Lanka has already included the vaccine in their EPI program

Rubella vaccine should be given to Rubella vaccine should be given to 

All girls at puberty (9 years and above)

All women of child bearing age and Hospital workers

After vaccination at least of 3 months of contraception

if missed, Post delivery to protect subsequent pregnancies

Should not be given during pregnancy

400 pregnant women inadvertently given vaccine in USA – no serious problems occurred.

Who is immune to Rubella?Who is immune to Rubella?

The one with serological evidence of infection (non clinical)

The one with documented vaccination

The one who was administered the 1st dose of Rubella above 9-12 months of age

Vaccine against Rubella offers long term protection.

Clinical reports state that sufficient antibodies are present in the blood even after 21 years of vaccination

The length of protectionThe length of protection

Primary emphasis on children of both sexes

Secondary emphasis on susceptible adolescents and young adults

Prenatal screening followed by post natal vaccination

Vaccination of women in abortion cases

Vaccination Strategy for RubellaVaccination Strategy for Rubella

RubellaRubella

Microcephaly

Congenital Cataract

Deafness

1 dose schedule of Measles has failed to protect population against Measles and hence 2 doses considered and recommended

1 dose of Mumps not adequate as Mumps occurred in densely populated areas

In spite of 1 dose MMR at 15-18 months children with CRS continued to be born which clearly indicated women attending age of puberty were not protected through out their reproductive life and some women were exposed to Rubella during pregnancy, Hence 2nd dose of Rubella

ConclusionConclusion

Routine Childhood schedule2 doses of MMR

1st dose at 15 months2nd dose at 4-6 yrs (school entry)

Colleges and other educational institutes require documentation of receipt of 2 doses or other evidence of Immunity

Medical personnel before employment require documentation of receipt of 2 doses or other evidence of Immunity

Recommendations in USARecommendations in USA