Download Measles (Rubeola) Disease Report

Measles(Rubeola)DiseaseReport
By:JeannaReed
EtiologicalAgent
! MeaslesVirus:Measlesvirus(MeV)isamemberofthegenusMorbillivirusofthefamilyParamyxoviridae.(1)
Transmission
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DirectContact/Airborne:Measlesiswellknownasacontagious,infectiousdisease;90%ofsusceptiblepersons
withclosecontacttoameaslespatienttypicallydevelopmeaslesinfection.Thevirusistransmittedbydirectcontact
withinfectiousdropletsbutcanalsoinfectvianondirectcontact.MeVcanalsobespreadthroughtheairwhenan
infectedpersonbreathes,coughs,orsneezes.Airborne,themeaslesvirusiscapableofinfectionforuptotwohours
afteraninfectedpersonexitsthearea.(2)
Reservoirs
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Humans:Measlesisahumandisease.Thereisnoknownanimalreservoir.(3)
MicroorganismGeneralCharacteristics
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SinglestrandedRNAvirus:“Measlesvirusisanegative-sense,singlestrandedRNAvirus.Itconsistsofahelical
nucleocapsid,100-300nmindiameter,surroundedbyanenvelope.Theenvelopeislinedbymatrixproteinsand
carriestransmembranehemagglutininandfusionglycoproteinswhicharethevirulencefactors.”(4)
IdentificationKeyTests
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LaboratoryConfirmation: Measles-specificIgMantibodyandmeaslesRNAdetectionbyreal-timepolymerase
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chainreaction(RT-PCR)aretypicalmethodsusedtoconfirmmeaslesinfection.Insuspectedpatients,serumsamples
andthroatswab(ornasopharyngealswab)shouldbecollectedatfirstcontact.(2)
TheCDCusesassaysintheirreferencelabspecificformeaslesserologictestingofIgMandIgG.Theassaysusea
recombinantmeaslesnucleoprotein(NP)antigenintheEIA(enzymeimmunoassay).(5)
Urinesamplesmayalsodetectthemeaslesvirus.(2)
MolecularAnalysiscanalsobecompleted.Genotypingisusedtomapthetransmissionpathwaysofmeaslesviruses.
Thegeneticdatacanhelptolinkorunlinkcasesandcansuggestasourceforimportedcases.“Genotypingistheonly
waytodistinguishbetweenwild-typemeaslesvirusinfectionandarashcausedbyarecentmeaslesvaccination.”(2)
OccasionallyfalsepositiveIgMresultsareproduced.Noassayis100%specific.Whenwarranted,theCDCprovides
additionalserologicaltestingtoaidinconfirmationofdiagnosis.(5)
SignsandSymptomsofDisease
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Prodromalfever.Canbeashighas105°Fahrenheit.(1)
Cough.(6)(1)
Coryza(runnynose).(1)
Conjunctivitis(redeyes).(6)
Sorethroat.(1)
Redorreddishbrownrash.(7)(8)
Koplikspots.(7)(8)
1to2dayspriortotherashdevelopment,Koplikspotsmayappear.Theyaretypicallywhiteincolorandasandtype
appearance.Thespotscanbefoundintheliningofthecheeks,roofofmouthandinsidethelips.(9)
3to5daysfollowingsymptoms,arashtypicallydevelops.Flatredspotsaloneorwithsmallraisedbumpsontop
becomevisibleonthefaceatthehairlineandspreaddownwardtowardsthefeet.Thespotsmayspreadandjoin
together.Inaddition,whentherashappears,aperson’sfevercanrisetomorethan104°Fahrenheit.Afterafew
days,therashwillfadeoncethefeversubsides.(8)
HistoricalInformation
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900CE:APersianphysiciandescribedsmallpoxandmeaslesinawrittenpublicationtryingtodifferentiatebetween
thetwodiseases.(10)
1657-1757:Duringthisperiod,measlesisnotedtomakeanappearanceincoloniesoftheU.Swithdeaths
reported.(10)
1757:AScottishphysicianshowedmeaslescanbecausedbyaninfectiousagentinthebloodofhumans.(11)
1861:TheCivilWarsawitsfairshareofmeaslesoutbreaksandsecondaryinfectionsresultingincasualtiesonboth
sidesofthewar.(10)
1912:Measles(ifcontractedintheUS)mustnowbereportedbyhealthcareprovidersandlaboratories.(11)
1920:PerMMWR(MorbidityandMortalityWeeklyReport)thisyear469,924measlescaseswerereported,and
7575patientsdied.(13)
1954:JohnEndersandDrThomasPeeblesweresuccessfulinisolatingmeaslesvirusfromaninfectedthirteenyear
oldpatientnamedDavidEdmonston.(11)
1958-1962:503,282measlescasesand432measles-associateddeathswerereportedonaverageoverthisfive
yearperiod.(13)
1963:“Edmonston-Bstrain”oftheMeaslesvirusisdevelopedbyJohnEndersandteamtobecomeavaccineandis
licensedwithintheUnitedStates.(11)
1968:MauriceHillemanPhDandhisteamdevelopandimprovethecurrentmeaslesvaccinebymakingaweaker,
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moreattenuatedstrainrenamed“Moraten”.Thisvaccinewaswidelydistributedandcontinuestobetheonly
measlesvaccineusedwithintheUnitedStatessince1968.(11)
1971:FirstMMR(MeaslesMumpsRubella)combinationtrivalentvaccineislicensedintheUS.(10)
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1978:CenterforDiseaseControldeclaresgoalstoeliminatemeaslesintheUSby1982.(11)
1981:ReportedUSmeaslescaseswerenoteliminatedcompletely,butgreatlyreduced(80%)comparedto1980.
Vaccinecoverageiscreditedforthisachievement.(11)
1986:NCVIA(NationalChildhoodVaccineInjuryAct)ispassedbyUSCongresstoaddressgrowingpublicconcernsof
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adversereactionsfollowingvaccineadministration.NVICP(NationalVaccineInjuryCompensationProgram)wasalso
includedintheNCVIAtoallowcompensationtoindividualsfortableinjuryandnon-tableinjuryclaims.Measles
(MMR),Mumps(MMR,MR,M)islistedasacompensablevaccine.(14)(15)
1988:Measles,mumps,rubellaoranyofitscomponentsarelistedontheVaccineInjuryTablewithillness,injury,
disability,andconditionscoveredincludingdeath.Thetimeframeinwhichthesymptom,significantaggravation,or
manifestationofonsetmayoccurisalsoestablished.(16)
1989:“Measlesoutbreaksamongvaccinatedschool-agedchildrenpromptedtheAdvisoryCommitteeon
ImmunizationPractices(ACIP),theAmericanAcademyofPediatrics(AAP),andtheAmericanAcademyofFamily
Physicians(AAFP)torecommendaseconddoseofMMRvaccineforallchildren.Followingwidespread
implementationofthisrecommendationandimprovementsinfirst-doseMMRvaccinecoverage,reportedmeasles
casesdeclinedfurther.”(11)
2000:Measlesconfirmed“eliminated”pertheUS.Nocasesreportedwithinoneyear.(11)
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2005:MMRV(Measles,Mumps,Rubella,Varicella/ProQuad)vaccineapprovedbyFDAandmarketedasan
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alternativetomonovalentvaccinesandMMRalone.(17)
2007:WHO/UNICEFreportsthateffortstoachieveareductioninmeaslesmortalitywereverysuccessfulandhad
reducedmeaslesmortalityby60%,fromanestimated873,000deathsin1999to345,000deathsin2005.(18)
2010:ApaperpublishedinajournalcalledVirologyinvestigateddivergencetimessuggestingMeVpossiblycame
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fromanonhumanspeciesandwasresponsiblefortheinfectiousdiseasearoundthe11 to12 century.(12)
2011-2013:PertheCDC,collectively464measlescaseswerereportedintheUS.(19)
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2014-2016:AccordingtotheCentersforDiseaseControl,2014sawthebiggestincreaseinmultiplestatesof
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measlescases(667confirmed)reportedsincetheCDCdeclaredmeasleseliminatedin2000fromtheUS.Multiple
outbreakshaveoccurredworldwideduringthistime.(20)
VirulenceFactors
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Portalofentry=Respiratorymucousmembranes.(21)
Attachment=Humagglutinin(H)proteinfoundonthesurfaceofthevirusandFusion(F)protein.Bothinteractin
ordertoestablishattachmentandfusionoftheviralenvelopewiththehostcellularreceptors.(M)proteinisalso
involvedinviralassembly.(21)
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MeVquicklyspreadstothelymphsystemandentersthebloodstreamwheremultipleorgansystemscanthenbe
infected.ComplicationsfrommeaslesvirushasbeenreportedineveryorganincludingRespiratory,Gastrointestinal,
Neurological(includingCentralNervousSystem),andOcularsystems.Themostcommoncauseoflongtermsequelae
isencephalitis.(22)
Immunesuppressionoccurslongenoughtoevadeimmunedefensesallowingmeaslesvirustoestablishitself.Asthe
diseaseprogresses,destructionoftissuecancausesignificantneutropeniaandsecondarybacterialinfectionswhich
canalsobedeadly.(21)(22)
Agecanaffecttherateofcomplicationsandunderlyingconditionsresultinginmild,modifiedandatypicalMeV.(21)
ControlandTreatment
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4daysbeforeto4daysafterthemeaslesrashappearspatientsareconsideredtobeinfectious.Onceconfirmed,
promptisolationishighlyrecommendedandtreatmentforMeVismainlysupportive.(23)
Postexposureprophylaxisisavailable(typicallybestifgivenwithin72hours)tothoseexposedtoMeVbutcannot
showimmunitytomeaslesintheformofMMRvaccination.Immunoglobulin(IG)administeredviaIMorIVcanalso
begivenwithin6daysofexposuretoselectpatients.(2)
WHO(WorldHealthOrganization)recommendssupplementingVitaminA(dosingagedependent)tohelpreduce
complications.Alsoantibiotictherapiesforsecondaryinfectionscanhelpwithreductioninmeaslesassociateddeaths
indevelopingcountries.(22)
Factorsthataffectmeaslesmorbidityandmortalityincludesex,age,crowding,immunosuppression,malnutritionand
VitaminAdeficiency.(22)
PreventionandVaccines
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Preventionofmeaslesvirusinfectionispossiblewithameasles-containingvaccine.IntheUnitedStates,theCenters
forDiseaseControlareadvisedbyACIP(AdvisoryCommitteeonImmunizationPractices)andarecommendedvaccine
scheduleispublishedannually.(24)
MonovalentmeaslesvaccineisnolongeravailableintheUSandhasbeenreplacedwithtwocombinationvaccines.
CurrentlyMMR(MeaslesMumpsRubellaIIbyMerckandCo.,Inc.)andquadrivalentvaccineProQuad(Measles,
Mumps,Rubella,VaricellabyMerckandCo.,Inc.)arerecommendedtopreventmeaslesinfection.Bothare
administeredsubcutaneouslyandareindicatedforpatientstwelvemonthsorolder.However,certaincircumstances
mayallowforearlieradministrationofthevaccinedependingonthechoiceofcombinationvaccineselectedandthe
conditionofthepatient.(24)
Forpreventionofmeaslesinfection,onedoseofeitherMMRorMMRVisrecommendedforpreschoolagedchildren
(12-15monthsold)andadultsnotathighriskforexposureandtransmission.Twodosesarerecommendedfor
schoolagechildren(Kindergartenthrough12 years)andadultsinahighrisksetting.MMRV(ProQuad)isnotlicensed
foranyoneundertheageof12months.(24)(17)
LocalCurrentOutbreaks/Cases
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In1958measlesincidencepeakedat85,862casesinthestateofTexas.Asmeaslesvaccineswereintroduced,these
casesdroppedconsiderablyto99.9%.MeaslesexposureresultinginoutbreaksintheUSandTexassince2000have
primarilyoccurredduetopeopleexposedduringtraveltocountrieswheremeaslesisconsideredendemic.(25)
2013recordsindicate27casesofmeaslesinfectionwerereportedstatewidewithadecreasein2014to10cases.No
deathshavebeenreportedsince2000pertheTexasDepartmentofStateHealthServicesdatabaseforMeasles.(25)
GlobalCurrentOutbreaks/Cases
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In2015theUnitedStatesreportedalargemeaslesoutbreakovermultiplestatesthatweretracedbacktoan
amusementparkinCalifornia.Furtherinvestigationsuggestedoneofthecaseshadrecentlytraveledinternationally
andbecameinfectedwiththemeaslesvirus.Detectionofthemeaslesviruswasimplementedimmediatelybut
identificationofthesourceisstillunknown.However,“AnalysisbytheCentersforDiseaseControlshowedthatthe
measlesvirustypeinthisoutbreak(B3)wasidenticaltothevirustypethatcausedthelargemeaslesoutbreakinthe
Philippinesin2014.”(20)
WhilemeaslescaseshavedeclinedconsiderablyintheUnitedStates,measlesanddeathsgloballyarestillreported.
Measlesoutbreakscanoccurespeciallywheregapsinvaccinationprogramsexist.WHO(theWorldHealth
Organization)supportschangesinpoliciesandpracticesinordertoensurehighaccessandcoverageoflifesaving
vaccines.In2001multipleorganizationsjoinedtogethertoformtheMeaslesandRubellaInitiative.Aprogram
creditedwithpreventing17.1millionmeaslescases.(26)
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In2014,theAmericasandWesternPacificregionssawincreasednumbersofreportedcasesdueinparttolarge
outbreaksinChina,thePhilippinesandVietNam.InAngola,Ethiopia,India,theRussianFederationandSomalialarge
outbreaksalsooccurredalthoughtheoverallnumberofcasesdeclinedinsomeregions.PerWHOin2014,
approximately114,900peoplediedgloballyfrommeaslesandthemajorityofthecaseswerechildrenundertheage
offive.(26)(27)
“Despitethewelcomereductioninmeaslesdeaths,thishighly-infectiousdiseasecontinuestotakeaterribletollon
thelivesofchildrenaroundtheworld,”saidDrSethBerkley,CEOofGavi,theVaccineAlliance.“Acoordinated
approachthatputsstrongerroutineimmunizationatitscorewillbecentraltogettingmeaslesundercontroland
securingfurtherreductionsinmortalityfromthisvaccine-preventabledisease.”(27)
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