Measles and Neonatal Tetanus: Measles and Neonatal Tetanus: Clinical Signs and TreatmentClinical Signs and Treatment

Prof. Pushpa Raj SharmaProf. Pushpa Raj SharmaInstitute of MedicineInstitute of Medicine

Kathmandu Kathmandu

Measles and Neonatal Tetanus: Measles and Neonatal Tetanus: Clinical Signs and TreatmentClinical Signs and Treatment

Measles Case definitionMeasles Case definition

Laboratory confirmation in the absence of Laboratory confirmation in the absence of recent immunization (1-14 days) with recent immunization (1-14 days) with measles containing vaccine:measles containing vaccine:– Detection of measles virus from urine or Detection of measles virus from urine or

throat/nasopharyngeal swabs throat/nasopharyngeal swabs oror– Significant rise in the measles antibody titre Significant rise in the measles antibody titre

between acute and convalescent sera between acute and convalescent sera oror– Positive serologic test for measles IgM Positive serologic test for measles IgM

antibody using a recommended assay.antibody using a recommended assay.

Measles: Basic CharacteristicsMeasles: Basic Characteristics

Also known as “dadura”/”bhosa kai” / rubeola / Also known as “dadura”/”bhosa kai” / rubeola / fourth day disease/ first feverfourth day disease/ first fever

Acute viral illnessAcute viral illness

Primarily affects childrenPrimarily affects children

Highly contagiousHighly contagious

ParamyxovirusParamyxovirus– RNA, single strandedRNA, single stranded

Vaccine preventableVaccine preventable– Potential to be eliminatedPotential to be eliminated

Measles: Signs and SymptomsMeasles: Signs and Symptoms

Incubation period: 10-12 days (8-16 range)Incubation period: 10-12 days (8-16 range)

ProdromeProdrome– CoughCough

NP, worsens over 4 days, then improvesNP, worsens over 4 days, then improves

Lasts through entire illness (7-10 days)Lasts through entire illness (7-10 days)

– Conjunctivitis (purulent), coryzaConjunctivitis (purulent), coryzaMay include photophobiaMay include photophobia

Lasts 6-8 daysLasts 6-8 days

– Fever: 38-40Fever: 38-40oo C: subsides after 1 week C: subsides after 1 week– DiarrheaDiarrhea

Chronic, serious if previously malnourishedChronic, serious if previously malnourished

Measles: Measles: Signs and Signs and SymptomsSymptoms

Koplik’s spotsKoplik’s spots– Part of prodrome: day 1-3 before rashPart of prodrome: day 1-3 before rash– Raised papules on buccal mucosa and conjunctivaRaised papules on buccal mucosa and conjunctiva– Usually adjacent to molarsUsually adjacent to molars– Often white on red baseOften white on red base– Disappear about time rash occursDisappear about time rash occurs

Measles: Signs and SymptomsMeasles: Signs and Symptoms

Erythematous papular Erythematous papular eruptioneruption

Travels inferior over 2-3 Travels inferior over 2-3 daysdays

Coalesces into macular Coalesces into macular “splotches”“splotches”

Often desquamates at end Often desquamates at end of illnessof illness

Hairline Behind Ears

Face

Trunk

Limbs

Rash

Measles: Signs and SymptomsMeasles: Signs and Symptoms

Peak of IllnessPeak of Illness– 2-4 days after onset of rash2-4 days after onset of rash

Other signs and symptomsOther signs and symptoms– Anorexia, malaise, hemorrhagic,Anorexia, malaise, hemorrhagic,

ResolutionResolution– Rapid improvement at end of febrile period (1 Rapid improvement at end of febrile period (1

week)week)– Complete recovery in 10-14 daysComplete recovery in 10-14 days

Summary: Diagnosis / ClinicalSummary: Diagnosis / Clinical

Clinical illness includes all of Clinical illness includes all of the following symptoms:the following symptoms:– Temperature of 38.3Temperature of 38.3°C or °C or

more.more.– Cough, coryza or conjunctivitisCough, coryza or conjunctivitis– Generalized maculopapular Generalized maculopapular

rash for at least three days rash for at least three days following temperature and following temperature and cough, coryza or conjunctivitis.cough, coryza or conjunctivitis.

Koplik’s spots can be classic, Koplik’s spots can be classic, but easily missedbut easily missed

Maculopapular Rash with Fever

Rubella

Roseola Infantum

Enteroviruses

Echoviruses

Mononucleosis

Reoviruses

Dengue

Kawasaki

Measles

Scarlet Fever

Six Case Studies

Low grade fever, headache and mild URI symptoms

Erythematous facial flushing.

“Slapped cheek appeaarence

High fever for three days.

Developed generalized seizure on the third day.

No specific localizing signs. Investigations including LP normal

Developed rash on the fourth day after the fever subsided. Rash first appeared on trunk sparing palm and sole

Presented with Jaundice and drowsiness, ascitis

Started ampicillin

Developed rash on 4th day.

Fever and rash for three day

Forehead and cheeks flushed

Non itchy, maculo-papular, punctate, granular generalized, first noticed over neck.

Bilateral periorbital edema not associatedwith generalized edemaMaculopapular rash

Mild fever and cough for two days

Developed rash on the second day of fever which appeared on face first and spread allover in one day.

Fever: 99.2 axillary; enanthem on the soft palate; tender discrete lymph nodes over retro auricular, sub occipital and posterior cervical region.

Rash cleared on third day.

Exanthem a common clilnical manifiestation

Nonspecific febrile illness (no coryza and conjunctivitis)

Rubeolliform rash

Rash and fever same time

Rash last 3-5 days

Case history:Case history:Five years , child Five years , child – moderate fever, a hacking cough, moderate fever, a hacking cough,

runny nose, red eyes for three runny nose, red eyes for three days. days.

On examination On examination – enanthem was present on the enanthem was present on the

hard and soft palate. Grayish hard and soft palate. Grayish white dots were seen opposite the white dots were seen opposite the lower molars.lower molars.

On fourth day On fourth day – temperature: 104temperature: 104ºF. Faint ºF. Faint

macules on the upper lateral parts macules on the upper lateral parts of neck, behind the ears, along the of neck, behind the ears, along the hair line, and on the posterior hair line, and on the posterior parts of neck was noticed.parts of neck was noticed.

Major ComplicationsMajor Complications

Acute Post-infectious EncephalitisAcute Post-infectious Encephalitis– Occurs in 1-4/1000, 2-6 days after rashOccurs in 1-4/1000, 2-6 days after rash– Mild to fulminant (death in 24 hours)Mild to fulminant (death in 24 hours)– 25% morbidity; 15% mortality 25% morbidity; 15% mortality

Subacute Sclerosing Panencephalitis–SSPESubacute Sclerosing Panencephalitis–SSPE– 2-15 years after infection2-15 years after infection– Progressive behavioral changesProgressive behavioral changes

Secondary infections: Pneumonia; flaring of Secondary infections: Pneumonia; flaring of tuberculosis.tuberculosis.MyocarditisMyocarditisCorneal ulcerCorneal ulcer

Measles: PrognosisMeasles: Prognosis

Mortality varies by age / nutritional statusMortality varies by age / nutritional status– Historically 1-5%Historically 1-5%

Higher with close contact secondary cases from Higher with close contact secondary cases from presumed high viral exposurepresumed high viral exposure

– West Africa/Asia: 25%West Africa/Asia: 25%– Death: pneumonia, malnutrition, diarrheaDeath: pneumonia, malnutrition, diarrhea

Risk factorsRisk factors– Immune compromise, Vitamin A deficiencyImmune compromise, Vitamin A deficiency

Measles: TreatmentMeasles: TreatmentSupportive CareSupportive Care– Rest, hydration, nutrition, prn medsRest, hydration, nutrition, prn meds– Look for and treat bacterial super-infectionsLook for and treat bacterial super-infections– Rinse eyes daily (saline or sterile water)Rinse eyes daily (saline or sterile water)

Vitamin AVitamin A– May decrease mortality by 40%May decrease mortality by 40%– Benefit may be independent of deficiencyBenefit may be independent of deficiency– WHO recs for both hospitalized and less illWHO recs for both hospitalized and less ill

RibavirinRibavirin– Inhibits viral replication in cell cultureInhibits viral replication in cell culture– Limited benefit in immune compromised patientsLimited benefit in immune compromised patients– High cost makes = impractical in developing worldHigh cost makes = impractical in developing world

Measles: Treatment*Measles: Treatment*

Vit-A Vit-A AgeAge

Initial DoseInitial Dose Final DoseFinal Dose

2 weeks later2 weeks later

0 – 50 – 5

MonthsMonths

50,000 IU / day50,000 IU / day

X 2 daysX 2 days

50,000 IU50,000 IU

6 – 116 – 11

MonthsMonths

100,000 IU / day100,000 IU / day

X 2 daysX 2 days

100,000 IU100,000 IU

>12 >12

MonthsMonths

200,000 IU / day200,000 IU / day

X 2 daysX 2 days

200,000 IU200,000 IU

*WHO Recommendations

Some MythsSome Myths

Over clothing is essential.Over clothing is essential.Do not use antipyretics.Do not use antipyretics.Do not give meat / egg / fruits / oil.Do not give meat / egg / fruits / oil.Keep in a room with windows closed.Keep in a room with windows closed.Religious Puja.Religious Puja.Herbal medicines in eye.Herbal medicines in eye.My child has three episodes of measles My child has three episodes of measles within one year.within one year.

Measles: PreventionMeasles: Prevention

Maternal antibodiesMaternal antibodies– Protect for 3-12 months; usually 6 monthsProtect for 3-12 months; usually 6 months– Presence of Ab’s makes vaccine less effectivePresence of Ab’s makes vaccine less effective

Passive ImmunizationPassive Immunization– Gamma globulin (0.25mg/kg)Gamma globulin (0.25mg/kg)– For: high risk pts and exposure within 6 daysFor: high risk pts and exposure within 6 days

Pregnant, immune suppressed, children too young Pregnant, immune suppressed, children too young for vaccine, active TB, leukemia, known HIVfor vaccine, active TB, leukemia, known HIV

– Impractical for developing worldImpractical for developing world

Measles: PreventionMeasles: PreventionVaccine ImmunizationVaccine Immunization– Live attenuated vaccineLive attenuated vaccine– Efficacy (seroconversion)Efficacy (seroconversion)

Lifelong immunityLifelong immunity

9 months9 months: 80-85%: 80-85%

Second dose with MMR at 16 months: >90%Second dose with MMR at 16 months: >90%

– Contraindications (live vaccine)Contraindications (live vaccine)Immune suppressed, leukemia, lymphoma, Immune suppressed, leukemia, lymphoma, pregnancy, anaphylaxis to neomycin or gelatinpregnancy, anaphylaxis to neomycin or gelatin

Most recommend vaccinating HIV patientsMost recommend vaccinating HIV patients

Measles: PreventionMeasles: Prevention

Vitamin AVitamin A– National Vit. A programmeNational Vit. A programme– Targets children >= 6 Targets children >= 6

months oldmonths old– Decrease mortality by Decrease mortality by

improving nutritionimproving nutrition– Benefit likely involves Benefit likely involves

many infections, but many infections, but measles is at the topmeasles is at the top

Neonatal TetanusNeonatal Tetanus

First described by HippocratesFirst described by Hippocrates

Etiology discovered by Carle and Rattone Etiology discovered by Carle and Rattone in 1984in 1984

Passive immunity used for treatment and Passive immunity used for treatment and prophylaxis during World War Iprophylaxis during World War I

Tetanus toxoid first widely used during Tetanus toxoid first widely used during World War IIWorld War II

Tetanus PathogenesisTetanus Pathogenesis

Anaerobic condition helps to germinate Anaerobic condition helps to germinate spores and production of toxins.spores and production of toxins.

Toxins binds to the central nervous systemToxins binds to the central nervous system

Interferes with the neurotransmitter Interferes with the neurotransmitter release to block inhibitory impulses.release to block inhibitory impulses.

Leads to unopposed muscle contraction Leads to unopposed muscle contraction and spasm.and spasm.

Clinical FeaturesClinical Features

Incubation period: 8 days (3-21 days).Incubation period: 8 days (3-21 days).Three clinical forms:Three clinical forms:–Local (not common)Local (not common)–Cephalilc (rare)Cephalilc (rare)–Generalised most commonGeneralised most common

Descending symptoms of trismus, difficulty Descending symptoms of trismus, difficulty swallowing, muscle rigidity and spasm.swallowing, muscle rigidity and spasm.

Spasm continues ( consciousness Spasm continues ( consciousness retained)retained)

Neonatal tetanus

A conscious spasm

Tetanus: complicationsTetanus: complications

LaryngospasmLaryngospasm

HypoglycemiaHypoglycemia

Nosocomial infectionsNosocomial infections

MyoglobinuriaMyoglobinuria

Aspiration Aspiration

Iatrogenic apnoeaIatrogenic apnoea

DeathDeath

Management: PrinciplesManagement: Principles

Eradication of C. tetani.Eradication of C. tetani.– Penicillin G 100,000 U / kg / 24 hrs.Penicillin G 100,000 U / kg / 24 hrs.

Neutralizing the toxinNeutralizing the toxin– Human tetanus immunoglobulin: 500 IU IMHuman tetanus immunoglobulin: 500 IU IM– TAT: 10,000 – 100,000 U (I/2 IM and ½ IV)TAT: 10,000 – 100,000 U (I/2 IM and ½ IV)

Prevent spasm:Prevent spasm:– Diazepam: 0.1 – 0.2 mg every 3 – 6 hourly Diazepam: 0.1 – 0.2 mg every 3 – 6 hourly

intravenously.intravenously.– Dantrolene; chlorpromazine; baclofenDantrolene; chlorpromazine; baclofen– Vecuronium and pancuronium with Vecuronium and pancuronium with

Mechanical ventilation (best survival rate)Mechanical ventilation (best survival rate)

Management: contd.Management: contd.

IV line.IV line.

Nasogastric tube feeding.Nasogastric tube feeding.

Minimal handling.Minimal handling.

A separate room. A separate room.

PreventionPrevention

An entirely preventable diseaseAn entirely preventable disease– Mortality <10% (intensive care treatment) Mortality <10% (intensive care treatment)

> 70% without intensive care treatment.> 70% without intensive care treatment.

Antenatal Tetanus ToxoidAntenatal Tetanus Toxoid

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