Measles and Rubella/CRS

Disease Epidemiology and case management

 Measles virus
• RNA virus (100-200 nm)
– Family: Paramyxoviridae.
– Genus: Morbillivirus
• Humans are the only
reservoirs
• Invades and multiplies in the
respiratory tract
• Spreads by airborne
transmission via respiratory
secretions or aerosols
 Measles disease
• An acute disease
– Caused by measles virus
– Highly infectious: everyone exposed
gets the disease if not immune
– Mortality highest in children < 2 yrs
and in adults

• Classic manifestations:
– Fever
– Maculopapular rash
– The 3 Cs:
• Cough,
• Coryza (runny nose),
• Conjunctivitis (red eyes)
 Transmission
• Droplet infection

• Portal of entry- respiratory tract or conjunctivae

• Face to face contact not necessary

• Virus is viable in suspended air even 1-2 hour after

patient leaves the room

• Secondary spread can occur from airplanes,

hospitals, clinics

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 Clinical course of measles

Incubation period Prodrome Rash

( 7–21 days max before rash) period ( about 4–8 days)

-18 -17 -16 -15 -14 -13 -12 -11 -10 -9 -8 -7 -6 -5 -4 -3 -2 -1 0 +1 +2 +3 +4 +5 +6 +7 +8

Communicable period

-18 -4 0 +4
Rash minus 18
days is earliest Rash minus 4 days is Rash plus 4 days
possible probable start Onset is probable end
exposure date of infectiousness of rash of infectiousness
 Clinical course of measles
• Incubation period: 14 days avg (range: 7 – 21 days)
• Prodrome: begins 10 – 14 days after exposure
– High fever, cough, coryza, conjunctivitis
– Period of greatest infectiousness (virus shedding)
• Rash duration: 4 - 8 days after rash appearance
• Complications: mostly in 2nd and 3rd weeks
• Case Fatality Ratio (CFR):
– 0.1 – 10 %
– Up to 25- 30% in humanitarian emergencies
– India: Median CFR from review of outbreaks – 1.63%
 Clinical features contd..
• Characteristic erythematous
(red) maculopapular (blotchy)
rash appears ,starting behind
the ears and spreading to rest
of body.

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Maculo-papular rash
Koplik’s spot pathognomonic of measles
 Measles - differential diagnosis

Measles
Rubella Other viral exanthemas

Dengue
Kawasaki

Fever + Rash
Scarlet fever Meningococcemia

Toxoplasmosis Mononucleosis

Chickungunya scrub typhus

 Laboratory Diagnosis
• IgM antibodies appear 1-2 days after the onset of
rash and persists upto 1 month

• Four fold rise in IgG titer( paired sera in 2-4 weeks )

• Viral culture and isolation from secretions (blood,

respiratory secretions, nasopharyngeal secretion
and urine)

• Molecular detection by PCR (polymerase chain

reaction)
 Measles complications
Corneal scarring
causing blindness
Vitamin A deficiency

Encephalitis
Older children, adults
≈ 0.1% of cases
Chronic disability

Pneumonia &
diarrhea
Diarrhea common in developing countries
Pneumonia ~ 5-10% of cases, usually bacterial
desquamation
 Measles Complications
Measles can be serious in all age groups
Children < 5 years and adults > 20 years old more likely to suffer from measles
complications

S.No Complication Incidence

1 Ear Infection 1 in 10 with measles ( Most common

complication)
2 Diarrhea 1 in 10 with measles

3 Pneumonia 1 in 20 with measles ( Most common cause

of death from measles in young)

4 Encephalitis 1 in 1000 with measles

5 Subacute sclerosing pan 1 in 100,000 with measles

encephalitis
Mouth ulcers
Pus draining from eye
 Clouding of cornea

Figure - 1 Figure - 2
 Basic Principles of management
• Anticipate complications
• Encourage breast feeding
• Provide nutritional support to all children
• Administer vitamin A – 2 doses
• Give paracetamol if temp > 39°C
• Give ORS-Zinc for diarrhea
• Treat eyes promptly to prevent blindness
• Use antibiotics if indicated
• Admit severely ill children
• Monitor growth regularly
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 Measles and vitamin A

• Low vitamin A levels: ~ higher rates of

complications & deaths
• Synergy of measles & vitamin A deficiency
have additive effect on epithelia and
immune system leading to ~ 1 million deaths
• Measles itself may lead to severe acute
depletion of vitamin A
• Precipitates keratomalacia & blindness
Vitamin A schedule for treatment of measles

Immediately on
Age Next day
diagnosis

< 6 months 50,000 IU 50,000 IU

6 – 11 months 1,00,000 IU 1,00,000 IU

> 12 months 2,00,000 IU 2,00,000 IU

2 dose schedule is more effective than single dose schedule

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 Rubella

• An acute, mild, self limiting viral illness affecting

both susceptible children and adults (~ 90% rubella
cases are < 15 years of age)

• Rubella infection occurring before conception and

during early pregnancy may result in miscarriage,
fetal death or congenital defects known as CRS
(congenital rubella syndrome)

• Public health importance of rubella due to

teratogenic potential of the virus
 Rubella Disease
• 20-50% of Rubella infections are mild/
without rash / asymptomatic

• Mild Prodrome
 Rare in children
 Adolescents and adults -Low grade
fever, malaise, cervical group of
lymph node enlargement, upper
respiratory symptoms,(lasts1- 5
days)
• Mild Rash
 Maculopapular non-coalescent
 Begins on face and head
 Usually persists 3 days
 Mild Joint pain
 Rubella - Complications
• Lymphadenopathy

• Arthritis
 Children: rare
 Adult female up to 70%

• Thrombocytopenic purpura
 1/3000 cases

• Encephalitis
 1/6,000 cases
However, increased frequency has
been noted in some of the Pacific
Islands, Hong Kong and Tunisia
 CRS
• Occurs if a susceptible pregnant mother is infected in early
pregnancy.

• Severe congenital anomalies

Ophthalmic, auditory, cardiac, cranio-facial and neurological

anomalies causing congenital cataract ,deafness, cardiac defects,
hepato-spleeno-megaly, diabetes, thrombocytopenia and mental
retardation etc.)

• Infection of the the fetus in utero causes these multiple

anomalies leading to missed abortion, fetal deaths ,premature
delivery and serious life long disabilities.
 Congenital Rubella Syndrome

• Hearing Impairment
• Cataracts
• Heart defects (particularly PDA )
• Microcephaly
• Developmental Delay
• Bone alterations
• Liver and spleen damage
 Summary
• Infants and adults at high risk of Measles complications/death
• Most Measles complications in 2nd and 3rd weeks after rash
• As population immunity increases, measles transmission reduces, period
between outbreaks increases and outbreak size decreases
• Goal of measles elimination is to stop measles transmission by achieving
and maintaining ≥95% population immunity
• Measles and Rubella vaccines are safe, effective and affordable
• Simple supportive measures along with Vitamin -A (two doses) to prevent
complications are the mainstay of Measles case management and
treatment
• Rubella is a self limiting mild disease that can cause CRS (Congenital Rubella
Syndrome) if infected during pregnancy
• Rubella/CRS control/elimination is feasible along with Measels elimination
by use of RCV in the form of MR vaccine.
Thank you