DISCLOSURES. I have no actual or potential conflicts of interest in this presentation.

Transcription

1 OVERVIEW ON MEASLES Oneka B. Marriott, DO, MPH, FAAP, FACOP Assistant Professor of Pediatrics and Public Health Nova Southeastern University College of Osteopathic Medicine Presentation to FSACOFP Annual Meeting, Orlando July 30, 2015

2 DISCLOSURES I have no actual or potential conflicts of interest in this presentation.

3 OBJECTIVES By the end of this presentation participants should be able to: Identify the mode of transmission, clinical manifestations, and complications of measles infection Describe the current state of measles in the United States Recommend measles vaccination as per CDC recommendations Identify contraindications and adverse reactions to the measles vaccine Outline a plan of action to help stop the spread of measles

4 Measles is one of the most infectious human diseases and can cause serious illness, lifethreatening complications and death. Global Measles and Rubella: Strategic Plan World Health Organization. Retrieved from:

5 MEASLES: THE VIRUS AKA: Rubeola, Hard measles, Red measles Measles is caused by a singlestranded, enveloped RNA virus with 1 serotype. It is classified as a member of the genus Morbillivirus in the Paramyxoviridae family. Humans are the only natural hosts of measles virus. Virus is rapidly inactivated by heat, sunlight, & acidic ph. Virus survives less than 2 hours in the air or on objects/surfaces.

6 MEASLES A HISTORICAL PERSPECTIVE Dates back to as early as the 7 th century Most infections occurred in children during the pre-vaccine era Nearly 90% of persons were infected before age 20 Estimated 100 million cases and 6 million deaths per year Measles outbreaks typically involved a large proportion of the population with a high case-fatality rate Heyman, D.L. (2008). Measles. (19 th Ed.), Control of Communicable Diseases Manual (pp ). American Public Health Association.

7 EPIDEMIOLOGY Measles is one of the most highly contagious directly transmitted pathogens Requires human to human transmission and an outbreak will last as long as there are susceptible individuals Newborns are highly susceptible due to loss of maternal antibodies and unvaccinated status. In higher vaccination areas measles is a disease of adolescents and adults (as in the US) Infectious period occurs several days before symptoms are present and after the onset of rash when the viral load is the highest Children may present to the healthcare facility during the prodromal period and pass the infection to others in the waiting area or to the healthcare workers who can then pass it on to other patients. Moss, WJ. (2012). Measles (Rubeola).In Longo, D.L., et al (18 th Ed.), Harrison s Principles of Internal Medicine (pp ). McGraw Hill Companies.

8 PATHOGENESIS Human reservoir Respiratory transmission Replicates in the nasopharynx and regional lymph nodes Primary viremia occurs 2-3 days after exposure Secondary viremia occurs 5-7 days after exposure with spread to tissues Viral shedding occurs 4 days before to 4 days after the rash onset Incubation period days Photo courtesy of Microbiology Online Measles. (13 th Ed.), Epidemiology and Prevention of Vaccine-Preventable Diseases (pp ). American Public Health Association.

9 SIGNS AND SYMPTOMS Prodrome: 2-4 days High fever ( F) 3 C s: Cough, Coryza (runny nose), Conjunctivitis Koplik spots may appear: 1-2 days before the rash to 1-2 days after the rash Rash: 3-5 days after start of symptoms rash appears, persists for 5-6 days Maculopapular rash; discrete confluent; blanches initially, then no blanching Begin as flat red spots on face at the hairline Cephalocaudal spread Fever subsides and rash fades after a few days in order of appearance Fine desquamation may occur Measles. (13 th Ed.), Epidemiology and Prevention of Vaccine-Preventable Diseases (pp ). American Public Health Association.

10 CLINICAL MANIFESTATION Photos courtesy of

11 KOPLIK SPOTS Photos courtesy of

12 DIAGNOSIS Diagnosis is mainly clinical Routine isolation is not recommended but is useful for molecular epidemiologic surveillance data Isolate measles virus from urine, nasopharyngeal aspirates, throat swabs, or heparinized blood Ship all specimen to the state public health laboratory or the CDC Measles. (13 th Ed.), Epidemiology and Prevention of Vaccine-Preventable Diseases (pp ). American Public Health Association.

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14 MEASLES COMPLICATIONS BY AGE GROUP Measles. (13 th Ed.), Epidemiology and Prevention of Vaccine-Preventable Diseases (pp ). American Public Health Association.

15 Measles Complications Diarrhea 8% Otitis Media 7% Pneumonia 6% Encephalitis 0.1% Seizures % Death 0.2% Based on surveillance data Adapted from: Measles. (13 th Ed.), Epidemiology and Prevention of Vaccine-Preventable Diseases (pp ). American Public Health Association.

16 Before the widespread use of measles vaccine, it was estimated that measles caused between 5 million and 8 million deaths worldwide each year. Moss, WJ. (2012). Measles (Rubeola).In Longo, D.L., et al (18 th Ed.), Harrison s Principles of Internal Medicine (pp ). McGraw Hill Companies.

17 PRE-VACCINE ERA ~500,000 cases and 500 deaths annually in the United States Epidemic cycles occurred every 2-3 years Gross under-reporting actual numbers closer to 3-4 million cases annually Over 90% of children infected before they reach age 15 years More than 5 million deaths worldwide 15,000 16,000 cases of blindness (#1 cause of blindness in African children) Global Measles and Rubella: Strategic Plan World Health Organization. Retrieved from:

18 VACCINE DISCOVERY 1846 incubation period of measles and lifelong immunity described by Peter Panum 1954 virus isolated from human and monkey kidney tissue (Enders and Peebles) 1963 first live attenuated vaccine was licensed for use in the United States Because the measles virus has one antigenic type the measles vaccine developed decades ago from a single strain of measles virus remains protective worldwide to date. Measles. (13 th Ed.), Epidemiology and Prevention of Vaccine-Preventable Diseases (pp ). American Public Health Association.

19 MEASLES VACCINE Live virus 95% efficacy at 12 months of age, 98% efficacy at 15 months of age Lifelong immunity 2 dose schedule administered with mumps and rubella (MMR) and possibly varicella (MMRV) 2-5% of recipients do not respond to the first dose, but most will respond to the second dose Measles. (13 th Ed.), Epidemiology and Prevention of Vaccine-Preventable Diseases (pp ). American Public Health Association.

20 MEASLES VACCINE RECOMMENDATIONS First dose: months of age Second dose: at 4-6 years, may be given as early as 4 weeks after the first dose Adults born after 1957, without proper vaccination documentation should be vaccinated All healthcare workers should have documented evidence of vaccination or immunity to measles Measles. (13 th Ed.), Epidemiology and Prevention of Vaccine-Preventable Diseases (pp ). American Public Health Association.

21 CONTRAINDICATIONS Severe allergy to vaccine components (e.g. gelatin, neomycin) Pregnancy Immunosuppression Recent blood product History of seizures (MMRV only) Moderate of severe acute illness

22 MEASLES VACCINE NOT Contraindications Egg allergy Penicillin allergy Close contact with pregnant woman Breastfeeding HIV infection without evidence of immunosuppression Minor illness (OM, URI, concurrent antibiotic therapy) Adverse Reactions Generally occur 5-12 days postvaccination Fever Rash Thrombocytopenia Lymphadenopathy (rare) Allergic reactions (rare)

23 With effective childhood immunization programs, measles cases in many industrialized countries have dropped by 99% Heyman, D.L. (2008). Measles. (19 th Ed.), Control of Communicable Diseases Manual (pp ). American Public Health Association.

24 MEASLES TRENDS Measles. (13 th Ed.), Epidemiology and Prevention of Vaccine-Preventable Diseases (pp ). American Public Health Association.

25 MEASLES RESURGENCE Measles. (13 th Ed.), Epidemiology and Prevention of Vaccine-Preventable Diseases (pp ). American Public Health Association.

26 MEASLES ELIMINATED Elimination declared in the US in 2000 After the resurgence in , number of measles cases dropped dramatically due to aggressive vaccination campaign. Most reported cases of measles now in the region are imported from other countries or linked to imported cases and occur among unvaccinated groups or among those whose vaccination status is unknown

27 MODERN DAY OUTBREAKS DUE TO: FAILURE TO VACCINATE Continued high measles burden in India Prolonged outbreaks in Europe and Africa Global community Funding deficits Global Measles and Rubella: Strategic Plan World Health Organization. Retrieved from:

28 Washington State Department of Health News Release. July 2, Retrieved from:

29 MEASLES OUTBREAKS SINCE : Large, multi-state outbreak linked to an amusement park in California. No source was identified. 2014: 23 outbreaks, including one large outbreak of 383 cases, occurring primarily among unvaccinated Amish communities in Ohio. Many of the cases in the U.S. in 2014 were associated with cases brought in from the Philippines, which experienced a large measles outbreak. 2013: 11 outbreaks in 2013, three of which had more than 20 cases, including an outbreak with 58 cases. 2011: France was experiencing a large outbreak. Most of the cases that were brought to the U.S. in 2011 came from France. 2008: Increase resulted from spread in communities with groups of unvaccinated people. 3 Large outbreaks reported in the US Measles Outbreaks. 2015, Centers for Disease Control and Prevention. Retrieved from:

30 Measles Outbreaks. 2015, Centers for Disease Control and Prevention. Retrieved from:

31 Measles Outbreaks. 2015, Centers for Disease Control and Prevention. Retrieved from:

32 MEASLES VACCINE WORKS Photo courtesy of:

33 GLOBAL ERADICATION STRATEGIC PLAN 1. Achieve and maintain high levels of population immunity by providing high vaccination coverage with two doses of measles- and rubella-containing vaccines. 2. Monitor disease using effective surveillance and evaluate programmatic efforts to ensure progress 3. Develop and maintain outbreak preparedness, respond rapidly to outbreaks and manage cases. 4. Communicate and engage to build public confidence and demand for immunization. 5. Perform the research and development needed to support cost-effective operations and improve vaccination and diagnostic tools. Global Measles and Rubella: Strategic Plan World Health Organization. Retrieved from:

34 THE PRACTITIONER S ROLE Get educated Promote vaccination Maintain a high degree of clinical suspicion to promote early detection Early reporting to public health authorities

35 THANK YOU!