Transcript MMR Update by Dr Sarma

M-M-R
A concern for all
The Three
Measles
Mumps
Rubella
Measles – Shocking Facts
Measles is a leading cause
childhood deaths the world over
of
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
Measles – Shocking Facts
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 – 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 - Evolution
Initial symptoms : high fever (103-105°F) & skin
rash
Followed by
conjunctivitis
cough,
runny
nose,
and/or
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
Complications of Measles
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
Measles affected children
Objectives of Immunization
Eradicate
Rubella
Measles,
Mumps
and
Prevent aerosol transmission
Prevent trans placental transmission
Who is immune to Measles?
The one born before early 1960s
The one
Measles
with
physician
diagnosed
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 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 (%)
60000
84
87
100
89
90
67
56
40000
70
10000
51780
37969
20000
22236
30000
21013
60
50
40
30
20
10
0
0
1998
1999
Measles cases
2000
2001
Vaccine coverage (%)
2002
Vaccine coverage
80
33990
No. of Cases
50000
Children 12- 23 mths. fully immunized
How to eradicate measles
WHO is making concerted efforts to eradicate
Measles. Set goal is to reduce deaths due to
measles by half by 2005
The WHO has recommended a 2-dose strategy
as the only reliable way to reduce measles
deaths
Advantages of two-dose schedule
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
The use of MMR vaccine as 2nd dose
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 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
Countries using the 2 doses
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
Recommendations
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
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
Duration Vaccine protection
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.
Mumps
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.
The symptoms- signs of Mumps
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 consequences 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
compllication
(SN)
deafness
is
a
chronic
Mumps can also cause Asceptic Meningitis, joint pain,
pancreatitis, myocarditis and mastitis
The treatment for Mumps
Unfortunately, there is no sure treatment
available for Mumps.
Vaccination is the only way to prevent
Mumps
Mumps
Orchitis
Inflammation of Parotid Gland
in mumps
Rubella
Rubella 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 - 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- 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
Chances of Deformity
Congenital Deformities
Incidence
Hearing loss
Congenital Heart Disease
Eye defects
Behavior disorders
Neurological deficit
Hearing and visual defect
Diabetes mellitus
92%
65%
56%
32%
26%
19%
1%
The incidence of deformities in the
various stages of pregnancy
Time of maternal infection
3-11 weeks
12 weeks
13-14 weeks
15-16 weeks
23-26 weeks
Result
100% infected fetus
80% infected fetus
54% infected fetus
35% infected fetus
25% infected fetus
The incidence of deformities in India
Several studies have clearly shown the link between
congenital defects and Rubella in Indian Children
Study
Chennai
Madurai
Delhi
Defect
Incidence due to Rubella
Congenital deafness
29%
Congenital cataract
26.3%
Congenital malformations 21%
(12000 samples)
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
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?
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
The length of protection
Vaccine against Rubella offers long
term protection.
Clinical reports state that sufficient
antibodies are present in the blood
even after 21 years of vaccination
Vaccination Strategy for Rubella
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
Rubella
Congenital
Cataract
Deafness
Microcephaly
Conclusion
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
Recommendations in USA
Routine Childhood schedule
2 doses of MMR
1st dose at 15 months
2nd 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