MEASLES Clinical review and Up-date A vaccine Preventable Disease Michigan Osteopathic Association 120th Annual Spring Scientific Convention Southfield Michigan May 16-19, 2019 ANTHONY OGNJAN DO FACP Metro Infectious Disease Consultants 43134 Dequindere Rd Sterling Heights, Michigan, 48314 Phone: 586 446-8688 Fax: 586 446-9994 Michigan Osteopathic Association Measles 120th Annual Spring Clinical review and Up-date: Scientific Convention A vaccine Preventable Disease Southfield Michigan May 16-19, 2019 SUMMARY Epidemic Measles In the United States eliminated 2000 v Airport Measles Sporadic Measles Still a threat among Groups of Unvaccinated / non-immune Measles is a highly contagious disease among the susceptible : 90% attack rate Complications v Immunosuppression v Neurological Can be Serious v Diarrhea v Pneumonia Symptomatic treatment: Fever control (No aspirin) : Hydration: NO ANTIVIRALS v Incubation 5-21 days Febrile illness: Koplik Spots Suspect v Out break with groups non-immune Morbilliform rash: Head- toe v Is safe and effective for protection Vaccine v 2 Shot series: Adults & Children ENCOURAGE VACCINATIONS v MMR® Is Preferred vaccine (MMR-V) Andrew T. Pavia, MD Never Seen Measles? 5 Things to Know May 02, 2019. Perspective/ Measles Medscape/ Infectious Disease https://www.medscape.com/viewarticle/912500_ Measles Re-emerges 5 things to remember Measles Re-emerges: 5 things to remember Certain Patient Groups Are Most Vulnerable v Children < 5 years of age v Malnourished children #1 v Especially infants v People with severely - Cancer chemotherapy, leukemia v Adults older >20 years compromised immune - Organ transplantation v Pregnant women systems - HIV infections - Immunosuppressive drugs People Who Think They Are Immune : May Not Be… v Born before 1957 v Are considered Immune #2 v Born 1957-1988 v Vaccinated: 1963-1963 Less effective vaccine v Vaccinated: 1962- 1989 Only single vaccine v Check vaccine records for administration of 2 doses of vaccine as evidence of immunity v Alternatively, measuring measles IgG titers can demonstrate immunity v Proof of immunity should be documented for all people working in the healthcare field. v Proof of immunity is recommended for people living in or traveling to areas with ongoing measles transmission. Andrew T. Pavia, MD Never Seen Measles? 5 Things to Know May 02, 2019. Perspective/ Measles Medscape/ Infectious Disease https://www.medscape.com/viewarticle/912500_ Measles Re-emerging 5 things to remember Measles Re-emerges: 5 things to remember The Most Important Diagnostic Tool Is Your H&P v Allows for quarantine v Important for contact tracing v vaccination of susceptible contacts v Other public health interventions #3 Diagnose v Patients vaccination status measles quickly History v Possible exposure to measles v Travel to areas of ongoing transmission. A careful history of disease progression & symptoms is critical. Physical v After an incubation period of 8-12 (“3Cs”) v Prodromal symptoms: Fever, Cough, Coryza, Conjunctivitis v During this period, Koplik spots Highly contagious. (Aerosols). If patients need to go to a lab to have blood drawn, you should #4 Labs notify the lab and infection control to help prevent exposing other patients. Serum IGM v 1-2 day : after rash PCR v Not generally available v Poor Specificity v Throat and nasopharynx are the preferred Andrew T. Pavia, MD Never Seen Measles? 5 Things to Know May 02, 2019. Perspective/ Measles Medscape/ Infectious Disease https://www.medscape.com/viewarticle/912500_ Measles Re-emerging 5 things to remember Measles Re-emerges: 5 things to remember Infants an Children: MMR Vaccine Doses Can Be Given Earlier Routine Childhood vaccinations v 1st 12-15 months v 2nd dose before school entry at age 4-6 years. During outbreaks or before travel v 2nd dose can be given 28 days after the first dose #5 v MMR vaccine can be given v Providing reasonable short-term protection. v However not considered a valid first dose: High risk : 6-11 months Another dose must be given after the child's first birthday. Outbreak situation: v Second dose aged 12 months or older v An early dose to children aged 6-11 months living in areas where transmission is ongoing or who will be traveling. Measles Epidemiology Comparison Of Morbidity-Mortality Historical Comparison Morbidity-Mortality For Vaccine Preventable Disease before 1980. (Measles-Mumps-Rubella) Estimated Annual Cases (Average) PEAK Diseases Cases Deaths Cases Deaths Measles 530,217 440 763,094 552 Years 1953-1962 1953-1962 1958 1958 Mumps 162,334 39 212,932 50 Years 1963-1968 1963-1968 1964 1964 Rubella 47,745 17 448,796 24 Years 1966-1968 1966-1968 1964 1968 JAMA, November, 14,2007. Vol.298, No 18 (2156) Ecology Measles Defined: Epidemics Impact US: How does being born before 1957 confer immunity to measles? • People born before 1957 lived through several years of epidemic measles before the first measles vaccine was licensed in 1963. • Surveys suggest 95% - 98% of those born before 1957 are immune to measles. Therefore: Persons born before 1957 can be presumed to be immune. ECOLOGY* Measles … Defined “Measles is one of the most important infectious diseases of humans…. Has caused millions of deaths since its emergence as a Zoonotic disease thousands of years ago….. For infectious disease epidemiologists… measles has served as a model of an acute infectious disease, particularly for understanding the nature of epidemics” ” -Kenneth Maxcy Johns Hopkins University School of Public Health, 1948 *Ecology is the branch of biology which studies the interactions among organisms and their environment Ecology Measles Defined: Clinical “What is Measles?” “Highly contagious” viral illness characterized by Fever, Malaise, Rash, Cough, Coryza, and Conjunctivitis that occurs worldwide…. Natural measles infection is thought to confer lifelong immunity. Immunity due to Measles vaccination is also highly protective against clinical infection. Measles Measles Morbidity Viral Human Ecology Hospitalized 1 : 4 Encephalitis 1 :1,000 (0.1%) Death 1-2 :1,000 Prodrome* 0 0 VIRAL LOAD VIRAL v FEVER 104 f (40 C) v COUGH v RHINORHEA v CONJUNCTIVITIS Immune Response Exposure TIME INCUBATION PRODOROME* EXANTHEM RECOVERY 5-21 days Median 2-4 days ~3-5 days After fever Cough may persist (Asymptomatic) Koplik Spots Resolves 5-6 days 1-2 weeks Contagious ~4 days before 4 days after the rash appears Measles Measles Clinical First day Third day of rash of rash Exanthems Koplik’s spots Confluent Search carefully for Koplik spots in patients with On Buccal mucosa Maculopapules suspected measles, since they can improve the accuracy of clinical diagnosis ….. However, this enanthem does not appear in all Rash patients with measles. Discrete Measles Exanthem: v Arises approximately 2- 4 days after onset of fever v Erythematous, Maculopapular, Blanching rash v Classically begins face - And spreads cephalocaudally and centrifugally - To involve the neck, upper trunk, lower trunk, and extremities v Early on, the lesions are blanching; v Later stages….they are not Discrete v May include petechiae Maculopapul v Severe cases, may appear hemorrhagic es Children: the extent of the rash and degree of confluence generally correlate with the severity of the illness. v The palms and soles are rarely involved. Development and distribution of measles rash. Reproduced from Perry RT and Halsey NA. The clinical significance of measles. J Infect Dis 2004;189(Suppl 1):S5 MEaSLES CENTRAL NERVOUS SYSTEM COMPLICATIONS v Febrile Convulsions v Guillain-Bare syndrome v Corneal Ulceration v Reye’s Syndrome v Corneal Perforations v Transverse myelitis v Encephalitis v Central Vein Occlusion v Acute Disseminated Encephalomyelitis v Subacute Sclerosing Panencephalitis v Myocarditis v Pericarditis Respiratory Infections* S v Otitis Media IMMUNE SYSTEM v Mastoiditis Reticuloendothelial or v Bronchopneumonia Macrophage system: v Laryngotracheobronchitis (croup) v Dysfunction v Bronchiolitis v Suppression v Giant cell pneumonia v TTP v DIC Gastrointestinal *Bacterial Superinfections ~5% v Diarrhea (Most common) v Mesenteric Enteritis S. pneumoniae H influenzae v Appendicitis S pyogenes S. aureus v Hepatitis v Pancreatitis v Stomatitis Symptoms v Cancrun Oris) v severity ranges from mild and less serious v First 4–6 wks. after an acute phase (and upon the immune functions are disturbance) v Complications are usually more severe in adults CASES v And malnourished and immune compromised individuals. Measles In immunology, the mononuclear phagocyte system (also known as the reticuloendothelial Virology system or macrophage system) is a part of the Measles morbillivirus immune system that consists of the phagocytic Pathology IMMUNOSUPRESSION cells located in reticular connective tissue. Measles Virus: IMMUNOSUPRESSION Multiple organ systems Mononuclear phagocyte Targets v Epithelial tissues v Monocytes v Reticuloendothelial tissues* v Macrophages v T-Lymphocytes Multinucleated giant cells Pathological studies of (typical of measles virus infection) children dying during acute measles Throughout v Respiratory v Most Lymphoid v Gastrointestinal tract tissues Measles Mump Rubella Vaccine Vaccine Options IMPACT OF : “MMR VACCINE” MEASLES VACCINATION INPACT United states Post MMR VaCCINE 1969: v Measles : Endemic Disease Elimination: 2000 v Rubella : Endemic Disease Elimination: 2004 v Mumps : 99% Endemic Disease Elimination Measles Classic measles infection in Virology immunocompetent patients Measles morbillivirus ●Modified measles infection in patients with