Measles, Mumps and Rubella in Health Care Setting

1
Measles, Mumps and Rubella in Health Care Setting

• Nadia Abdel Aaty Abdel Kader
• Ass. Prof. Tropical Medicine
• Ain Shams University

2
Case (1)

• A child came to hospital with maculopapular,
  erythematous rash allover his body. He had
  history of fever and running nose 3 days ago. The
  resident examined him, he found ulcerated mucosal
  lesions inside his mouth.
• There is no staff health records for the past
  history of infectious diseases or vaccination.

3
What is the childs diagnosis?
4
Measles (Rubeola)

• IP is approximately 10 days (range 7-18 days).
  
  
• Infectivity
• from 24 days prior, until 25 days following the
  onset of the rash.
• Symptoms and signs
• The classical symptoms of measles include 4 day
  fever, the three Cscough, coryza (runny nose)
  and conjunctivitis. Koplik's spots seen inside
  the mouth are pathognomonic (diagnostic) for
  measles

5

• The characteristic measles rash is classically
  described as a generalized, maculopapular,
  erythematous rash.
• It starts on the head before spreading to cover
  most of the body, often causing itching. The rash
  is said to "stain", changing color from red to
  dark brown, before disappearing.
• The measles rash appears 2-4 days after initial
  symptoms and lasts for up to 8 days.

6

• Measles spreads through respiratory route (either
  directly or through aerosol transmission).
• Definition of Exposure
• 1) Same-room proximity to an infectious person
  for any amount of time.
• 2) Presence in a room previously occupied by an
  infectious patient. The virus can live on
  infected surfaces for up to 2 hours.
  

7
Who are the susceptible persons?

• Those with negative measles antibody titers
• When titers are not available, susceptible
  persons are those born after 1957 who do not have
  either documentation of physician-diagnosed
  measles or history of two doses of measles
  vaccine.

8
What are your instructions for this resident?
9

1- Post-exposure prophylaxis

• Measles vaccine is recommended (provided there
  are no contraindications) and should be given as
  soon as possible within 72 hours of exposure.
• If MMR vaccine is contraindicated, immune
  globulin (IG) should be offered within 6 days of
  exposure to prevent or modify measles disease.

10

2- Isolation precautions for susceptible
asymptomatic contacts

• Air borne isolation from day 5 through day 21
  post exposure or until 5 days after onset of
  rash.

11
3- Exclusion of Exposed, Susceptible,
Asymptomatic Personnel From Duty
12
Case (2)

• A nurse in pediatric ward is seeking your advice
  about her 4 years old child.
• Three days ago, he developed fever and malaise
  then today she noticed bilateral swelling in his
  face.

13
What is the childs diagnosis?
14
Mumps

• IP 12-25 days (usually 16-18 days).
• Communicability
• From 1 to 2 days before, until 5 days after
  onset of swelling.
• up to 20 of persons infected with the mumps
  virus do not show symptoms, so it is possible to
  be infected and spread the virus without knowing
  it. The disease is generally self-limited, needs
  no specific treatment.

15

• Tansmission
• Mumps spreads from person to person through
  contact with respiratory secretions such as
  saliva from an infected person.
• Mumps can also be spread by sharing food and
  drinks.
• Symptoms and Signs
• Fever and headache for few days are prodromal
  symptoms of mumps, together with malaise and
  anorexia.
• Unilateral or bilateral painful swelling of the
  salivary glands (classically the parotid gland)
  is the most typical presentation. Painful
  testicular swelling (orchitis) and rash may also
  occur.

16

• Definition of Exposure
• 1) Physical contact with respiratory secretions
  of an infectious person.
• 2) Close proximity (3-6 feet) to an infectious
  person for more than 5 minutes.
• 3) Same-room proximity to an infectious person
  for about an hour or more.
• Susceptible Persons
• Those with negative mumps antibody titers.
• When titers are not available, susceptible
  persons are presumed to be those born after 1957
  who have no history of mumps or history of mumps
  vaccination.

17
What are your advices for this nurse?
18
(No Transcript)
19

• Healthcare personnel who have presumptive
  evidence of immunity do not need to be excluded
  from work following an unprotected exposure.
• However, because 1 dose of MMR vaccine is about
  80 effective in preventing mumps and 2 doses is
  about 90 effective, some vaccinated personnel
  may remain at risk for infection. Therefore,
  healthcare personnel should be educated about
  symptoms of mumps and should notify occupational
  health if they develop these symptoms.
•  

20
Case (3)

• Female nurse in NICU, developed skin rash all
  over the body 3 days ago, diagnosed and treated
  as skin allergy.
• Three weeks ago she was caring for a baby with
  multiple purpuric spots and congenital cardiac
  and neurological defects.
• She had history of measles and mumps infections
  at 10 yrs age but no history for rubella
  infection or vaccination.

21
Rubella (German measles)

• IP 14-23 days (usually 16-18).
• Mode of transmission
• Infection is by droplet spread or direct contact
  with the patient (More prevalent in winter and
  spring).
• Any infant infected with rubella in utero can
  shed virus in pharyngeal secretions and urine
  for 1year, sometimes longer.
• Communicability From 7 days before, until 7 days
  after rash onset. About 20-50 of rubella
  infections are asymptomatic.

22

• Transmission
• Acquired rubella is transmitted via airborne
  droplet emission from the upper respiratory tract
  of active cases. The virus may also be present in
  the urine, feces and on the skin.
• Touching the infant with congenital rubella
  syndrome or come into contact with the infant
  secretions.

23

• Symptoms and Signs
• German measles causes symptoms that are similar
  to the flu.
• The primary symptom of rubella virus infection is
  the appearance of a rash on the face which
  spreads to the trunk and limbs and usually fades
  after three days (that is why it is often
  referred to as three-day measles).
• The facial rash usually clears as it spreads to
  other parts of the body.

24

• Other symptoms include low grade fever, swollen
  glands (sub occipital posterior cervical
  lymphadenopathy), joint pains, headache and
  conjunctivitis.
• The rash of German measles is typically pink or
  light red, causes itching and disappears after a
  few days with no staining or peeling of the skin.
  When the rash clears up, the patient may notice
  that his skin sheds in very small flakes wherever
  the rash covered it.

25
(No Transcript)
26
Susceptibilty and Resistance

• -Rubella can affect anyone of any age and is
  generally a mild disease, rare in infants or
  those over the age of 40.
• -Susceptibility is general after loss of
  transplacentlly acquired maternal antibodies.
• -Active immunity is acquired by natural infection
  and thought to be long term(probably lifelong)
  after immunization.
• -Rubella reinfection is rare but has been
  documented.

27

• Although rubella transmission is usually
  associated with repeated exposure, transmission
  has been documented after a single exposure.
• Susceptible Persons
• Those with negative rubella antibody titers.
• When titers are not available, susceptible
  persons are presumed to be those who have no
  history of rubella or history of rubella
  vaccination.

28
What are your advices for this nurse?
29
(No Transcript)
30
(No Transcript)
31
Measles, Mumps, Rubella Vaccine (MMR)

• It is a live attenuated vaccine, usually in
  combined form (MMR).
• -Rubella vaccine had been licensed in 1969 in
  United States.
• -In 1979, a new formulation has been determined
  to induce higher antibody titers and produce an
  immune response more closely paralleling the
  natural infection than the previous vaccine.

32

• Age
• Immunization of all children is recommended at
  12-15 months of age. A second dose at school
  entry or at adolescence.
• The second dose is not a booster Revaccination
  is intended to seroconvert those who do not
  respond to the first dose (i.e small number of
  persons 25.
• About 21-28 days are required for development of
  protection following vaccination.

33

• Effectiveness of the Vaccine
• For rubella single dose of vaccine( 0.5ml,
  s.c.) elicits a significant antibody response in
  approximately 98-99 of susceptible persons.
• For measles 95 of those who receive the vaccine
  at 12 months of age or older are immune after the
  first dose. After the second dose, 99.7 of those
  immunized are protected. Immunity is lifelong.
• For mumps 1 dose of vaccine is about 80
  effective in preventing mumps and 2 doses is
  about 90 effective

34
DOSAGE AND ADMINISTRATION

• The dose for any age is 0.5 mL administered
  subcutaneously, preferably into the outer aspect
  of the upper arm.
• Without proof of immunity, ideally all HCWs , in
  particular those who are in contact with patients
  in prenatal clinics should receive 2 doses of MMR
  separated by a minimum of 1 month between doses.
• Immunization with MMR is not harmful to a
  recipient already immune to one or more of these
  viruses (i.e Vaccine can be given safely to
  immune person).

35

• Adverse reactions
• Rarely serious, may occur from each component of
  the MMR vaccine.
• 10 of children develop fever, malaise and a rash
  521 days after the first vaccination.
• 5 develop temporary joint pain.
• Anaphylaxis is an extremely rare.

36
CONTRAINDICATIONS

• Hypersensitivity to any component of the vaccine
• Do not give MMR to pregnant females the possible
  effects of the vaccine on fetal development are
  unknown at this time. If vaccination of
  postpubertal females is undertaken, pregnancy
  should be avoided for three months following
  vaccination
• Severe febrile respiratory illness or other
  active febrile infection.
• Patients receiving immunosuppressive therapy.
• Primary and acquired immunodeficiency states

37
Use With Other Vaccines

• Routine administration of DTP (diphtheria,
  tetanus, pertussis) and/or OPV (oral poliovirus
  vaccine) concurrently with MMR vaccine is not
  recommended because there are limited data
  relating to the simultaneous administration of
  these antigens.
• Co-administration with other live viral vaccines
  (other than oral polio vaccine or varicella)
  should be avoided, and separated by at least 30
  days.
• MMR has been administered concurrently with
  Varicella virus vaccine and Haemophilus b
  conjugate vaccine using separate injection sites
  and syringes.

38
Use in contolling nosocomial transmission

• Immunization health care workers (HCWs) against
  Measles, Mumps, Rubella prevents nosocomial
  transmission of the virus from (HCWs) to patient
  and vice versa.
• Post vaccination serologic testing
• Not usually done. Testing for MMR antibody can be
  done to document immunity in HCWs who do not wish
  to receive a second dose of vaccine.

39
Post-Exposure Vaccination

• Vaccination of individuals exposed to measles may
  provide some protection if the vaccine can be
  administered within 72 hours of exposure.
• If, however, vaccine is given a few days before
  exposure, substantial protection may be afforded.
  There is no conclusive evidence that vaccination
  of individuals recently exposed to wild-type
  mumps or wild-type rubella will provide
  protection.

40

• Should I administer MMR and varicella vaccines or
  the MMRV vaccine for the first and second dose?
• Why is a history of recent receipt of blood
  products important to know before immunizing
  someone with MMR vaccine?
• I am 3 months pregnant, should I administer MMR
  vaccine to my little child?
• Can I receive MMR vaccine with breast feeding?

41
THANK YOU