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M-M-R

M-M-R. A concern for all. The Three. M easles M umps R ubella. Measles – Shocking Facts. Measles is a leading cause of childhood deaths the world over Annually around 30 million cases of Measles are seen and about 9 lakh children die because of Measles

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M-M-R

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  1. M-M-R A concern for all

  2. The Three Measles Mumps Rubella

  3. Measles – Shocking Facts • Measles is a leading cause of childhood deaths the world over • 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

  4. 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

  5. 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

  6. Measles Rash - Evolution • Initial symptoms : high fever (103-105°F) & skin rash • Followed by cough, runny nose, and/or conjunctivitis • 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

  7. 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

  8. Measles affected children

  9. Objectives of Immunization • Eradicate Measles, Mumps and Rubella • Prevent aerosol transmission • Prevent trans placental transmission

  10. Who is immune to Measles? • The one born before early 1960s • The one with physician diagnosed Measles • 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)

  11. 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.

  12. Measles Vaccine Coverage (INDIA)

  13. Measles Vaccine Coverage (INDIA)

  14. Children 12- 23 mths. fully immunized

  15. 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

  16. 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

  17. 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 blockcompared to 12 cases of measles in the control group

  18. 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

  19. 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

  20. Recommendations • 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. • As per the recommendation of the IAP, • the first dose should be given at 9 months and • the second dose should be givenas MMR vaccine at 12-15 months • 3. Repeat dose at 4-5 years CDC; 12 yr AAP

  21. 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

  22. 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.

  23. 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.

  24. 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

  25. 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 (SN) deafness is a chronic compllication • Mumps can also cause Asceptic Meningitis, joint pain, pancreatitis, myocarditis and mastitis

  26. The treatment for Mumps • Unfortunately, there is no sure treatment available for Mumps. • Vaccination is the only way to prevent Mumps

  27. Mumps Orchitis Inflammation of Parotid Gland in mumps

  28. 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.

  29. 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.

  30. 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

  31. Chances of Deformity Hearing loss 92% Congenital Heart Disease 65% Eye defects56% Behavior disorders 32% Neurological deficit 26% Hearing and visual defect 19% Diabetes mellitus 1% Congenital Deformities Incidence

  32. Time of maternal infection Result 3-11 weeks100% infected fetus 12 weeks80% infected fetus 13-14 weeks54% infected fetus 15-16 weeks 35% infected fetus 23-26 weeks25% infected fetus The incidence of deformities in the various stages of pregnancy

  33. The incidence of deformities in India Several studies have clearly shown the link between congenital defects and Rubella in Indian Children Study Defect Incidence due to Rubella Chennai Congenital deafness 29% Madurai Congenital cataract 26.3% Delhi Congenital malformations 21% (12000 samples)

  34. 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

  35. 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.

  36. 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

  37. 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

  38. 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

  39. Rubella Congenital Cataract Deafness Microcephaly

  40. 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

  41. 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

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