Measles

measlesMeasles

The Disease.

The highly contagious, Measles virus, a paramyxovirus, is spread by coughing and nasal droplets.
Incubation period 1-2 weeks.
WHO currently recognises eight clades of measles virus (A–H) with a total of 23 genotypes recognised within the clades, and viruses with related sequences within a genotype are referred to as clusters.
Features
The infection causes fever, sore throat, cough, runny nose, itchy eyes, and a red rash that starts on the face and spreads to the rest of the body.
Complications 1 in 25 children with measles develops pneumonia and 1 in 2,000 develops encephalitis (brain inflammation). For every 10 children who develop measles encephalitis, one dies and up to four have permanent brain damage. About 1 in 25,000 develops a brain degeneration called subacute sclerosing panencephalitis (SSPE), some 7-10 years (but up to 30 years) after the natural infection, which is always fatal.
The measles virus destroys white cell immunity learned from previous infections and immunisation and this may persist for 27 months. This effectively resets a child’s immunity to that of a newborn, thus increasing susceptibility to diseases (and death) caused by diarrhoea, pneumonia and meningitis.
Diagnosis
Serologic (Measles IgM) testing is required to confirm the diagnosis. In addition to serologic specimens, health departments should collect throat swabs and urine for viral isolation. Only laboratory confirmation is acceptable evidence of immunity.
Tips for GPs and patients
Never diagnose measles without serology.
Always notify any proven case.
Cases should be excluded for at least 4 days from the onset of the rash.
In Victoria, measles is a Group A notification and must be reported immediately.

Measles remains the leading cause of vaccine-preventable deaths
among children worldwide.

According to WHO, measles kills more than 134,000 people a year worldwide, or 15 deaths every hour – mostly children under five years – with the risk of dying increasing for children living in poverty. Before vaccines were available, there were 8 million deaths of children each year. Forty-five countries accounted for 95% of these deaths, and 31 of these 45 countries are in sub-Saharan Africa. Despite the availability of a safe and effective vaccine since 1963, measles has been a major killer of children in developing countries (causing an estimated 750,000 deaths as recently as 2000), primarily because of underutilisation of the vaccine.
In 2002, the United Nations General Assembly Special Session on Children set a goal to reduce global measles deaths by half (compared with 1999) by 2005.

From The Lancet 2007; 369:191200.
Between 1999 and 2005, measles-related deaths decreased 60% due to an increase in measles vaccinations and immunization coverage activities worldwide.
From Penn University Center for Bioethics
A global immunization drive has cut measles deaths by nearly half during the last six years, according to the World Health Organization and United Nations Childrens Fund. Deaths from measles dropped from 871,000 in 1999 to an estimated 454,000 in 2004, according to the UNICEF and WHO report, marking a 48 percent decrease in fatalities suffered from one of the most contagious diseases known.

Europe
Many more outbreaks of measles were reported in Germany, and in the UK and partly as a consequence of the irresponsible link to autism by a debunked researcher. Cases were also reported from Ukraine and Romania.
In 2006, cases were reported in France (550 cases),Denmark, Germany, Spain, Sweden and UK (740 cases). Some 60 cases of measles were reported from Poland, 87 from Belarus and 40 from Tuscany during the first half of the year.
During 2006-7, an extensive outbreak of measles was reported from Switzerland, mainly from the Canton of Lucerne and not far from Bavaria in southern Germany, where 24 cases were reported. 2007 saw the highest number of measles cases reported in England and Wales since 1995, with 971 confirmed cases reported, compared with 740 reported in 2006.
2008 Europe reported 8,145 cases of measles, the larger being in Austria, France, Switzerland (2000 cases), UK, Ireland, Romania, Germany, Italy and Spain. A small outbreak occurred in Netherlands in July. 49 cases were seen in Croatia.
Measles remained endemic in the UK and 276 clinical cases were reported in Gibraltar. Further extensive outbreaks are expected from around Europe as immunisation rates drop. Currently, only 10% of the population of Ukraine is immunised.

Asia
The World Health Organisation has a goal to eliminate measles from most parts of the world by 2020, with south-east Asian health ministers affirming this commitment in September 2013.

Asian countries report the deaths of many thousands every year and represent a common source of infections for the unimmunised traveller. Pakistan launched a new phase of the largest-ever national measles vaccination campaign, with a goal of reaching more than 63 million children by March 2008. This campaign will be a significant step toward reaching the global goal of reducing measles deaths by 90 percent by the year 2010 (compared to 2000).
A similar campaign in Nepal has drastically reduced the numbers of reported cases.
In 2017, Indonesian government’s support for the combined measles-rubella (MR) vaccine will be a game changer in fighting these infections. This landmark campaign which commences from the beginning of August aims to vaccinate nearly 70 million children, aged between nine months and 15 years, and replace the measles vaccine in the routine immunisation schedule.

Africa
Since the beginning of 2005, a measles epidemic has killed about 600 children in Nigeria and 115 in Chad.

An epidemic of measles in Ethiopia killed many people in late 2005.
Measles has killed 42 people in Kenya in early 2006 and 25 have died in Angola in mid-2006.
In Sudan, despite an extensive vaccination campaign, about 500 people with 14 deaths, were reported in April 2007.

North America
Prior to the introduction of the MMR vaccine into the USA many thousands were hospitalised every year (with 300-400 deaths).
Although measles was thought to have been eliminated in 2001, some 34 cases (mainly unvaccinated children) occurred in an outbreak in Indiana, during the northern summer of 2005. A multi-state outbreak occurred in 2007 and apparently imported cases were reported in Arizona, California, Honolulu, New York, Michigan and Virginia in 2008 (more than 100 in the first half). Many people in the US (and also in the UK) refuse to protect their children, either through ignorance or negligence. See the CDC report.
There were 17 confirmed cases in Toronto and 30 in Ontario, Canada by the end of May 2008.
Australia
Small outbreaks of measles occur in Australia from time to time and are usually introduced by travellers returning from South East Asia. The group most at risk are those born between 1966 and 1980, which missed out on mass vaccination programs.
Shepparton case
A confirmed case was notified on July 1st.

Travellers
Adequate vaccination against measles is recommended for all travellers to Asia, Mexico and those parts of Europe with low immunisation coverage (see above).
From The Australian Immunisation Handbook 9th Ed.:
Those born during or since 1966 should be encouraged to complete the MMR vaccination schedule (using MMR or MMRV, when appropriate) before embarking on international travel if they do not have evidence of receipt of 2 doses of MMR.

Vaccine Information

In Australia, the first measles-containing vaccine was introduced in 1968 and had an immediate impact on the number of cases reported. It was not until 1994 that a two-dose immunisation schedule was introduced.

Monovalent vaccine is not available in Australia. The currently available measles vaccines in Australia are all live and attenuated:
Trivalent vaccines (mumps, measles and rubella) – M-M-R II (CSL/Merck) and Priorix (GSK)
Quadrivalent vaccines (mumps, measles, rubella, varicella) – Priorix-tetra (GSK) and ProQuad (CSL/Merck)

Two doses are recommended – usually at 12 months and at 4 years, prior to starting school. Catch-up doses are available to those born since 1966 who do not have two documented doses.
Side effects:
About 10% of vaccine recipients have discomfort, local inflammation or fever. Of those children receiving the vaccine, about 1% develop a noninfectious rash, about 1% develop parotid gland swelling and febrile convulsions occur in 0.1%. No vaccine recipients develop encephalitis (inflammation of the brain).
Contraindications
Measles, mumps, rubella and varicella vaccines are contraindicated in
– people with impaired immunity (eg due to HIV/AIDs, high dose steroids, immunosuppressive treatment and certain malignancies),
– people having had a previous anaphylaxis reaction to a vaccine or component of a vaccine,
– pregnancy should be avoided for 28 days.

Travellers, especially to Asia, should be vaccinated (see above).

Uncertain about MMR? The NCIRS Decision Aid should help.

All health care workers should have evidence of two doses of MMR, regardless of their year of birth.

Caution:
Vaccination with Priorix or M-M-R II interferes with Mantoux testing for up to one month. It should not be given within one month of another live vaccine, such as yellow fever.

History
An account of significant events in measles, mumps and rubella immunisation practice in Australia is available at the NCIRS site.