Indian Journal for the Practising Doctor

Parray SH, Gaash B, Ahmad M, Kadri SM

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ISSN : 0973-516X

Dr Muzaffar Ahmad, MD, FACP, FAMS, is Director Health Services, Kashmir. Dr Bashir Gaash, MD, DCH, (Principal) and Dr Shawkat Husain Parray, MBBS, MHA, (Tutor) are from the Regional Institute of Health and Family Welfare, Kashmir.
Syed Manzoor Kadri (MB, MPH) is currently in the Netherlands.
Correspondence: Dr Shawkat Hussain Parray, Tutor, Regional Institute of Health and Family Welfare, Tangmarg, Gulmarg Road, Kashmir.

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Abstract

Background: Measles is an acute, highly contagious infection, classically affecting infants and young children. Complete recovery is usual, but serious complications of respiratory and CNS may occur. A very effective vaccine is available, still measles outbreaks continue. The mean age of contracting infection is increasing, and more cases occur in the higher age group than before.
Aims: The epidemiologic investigation aimed to find the antigenic subtype responsible for the latest outbreak in Ladakh region and find some explanation for the upward age shift of measles.
Results: During a recent outbreak of measles in Leh and Kargil districts of Ladakh, 736 cases were studied, 281 (38.2%) being older than 10 years. Twelve blood and urine samples and throat swabs from different age groups were sent for serological confirmation and genotyping to NIV Pune. All the samples were reactive for measles antibodies and D4 strain of measles virus was isolated.
Conclusions: The study highlights the need for early measles vaccination of infants at 9 months of age, and a repeat dose (18-30 years) might be necessary at a higher age group to prevent adult measles as is being followed by some developed countries in the West.

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Introduction

Measles, caused by an RNA paramyxovirus, affects virtually everyone between 6 months and 3 years of age in developing countries. In the West, the peak age of infection is a bit higher – between 3 to 6 year. Classically, measles has behaved as an acute infection of infancy and young childhood. However, with effective vaccination programmes in developing countries, an upward shift in mean age of infection appeared. This was attributed to universal immunization during infancy, thus less chances of natural childhood infection. However, soon developing countries where vaccination is nowhere universal, too, started sharing this awful trend.

The measles virus can spread in any season, however, in temperate climates, measles is a cold-season disease, because of overcrowding which facilitates person to person transmission. Outbreaks are common in India in winter and early spring. The period of communicability is 4 days before and 5 days after the appearance of the rash. Isolation of the patient for a week from the onset of rash more than covers the period of communicability, yet it is not of any help in crowded conditions since transmission has occurred much before the typical features manifest in the primary/index case. Secondary attack rate is 80 percent among household contacts.

Table: Districtwise and Agewise Distribution of Measles Cases in Kashmir

District	Age Distribution of Measles Cases
	0-5yrs	5-10yrs	10-15yrs	15-20yrs	20-25yrs	>25 yrs	Total
Anantnag	4	1	1	3	Nil	Nil	09
Baramulla	15	3	3	Nil	Nil	Nil	21
Budgam	04	Nil	Nil	01	Nil	Nil	05
Kupwara	73	20	14	05	04	Nil	116
Ladakh	97	79	94	78	18	30	396
Pulwama	85	13	04	05	Nil	Nil	107
Srinagar	49	12	11	07	03	Nil	82
J&K State	327 (44.42%)	128 (17.39%)	127 (17.25%)	99 (13.45%)	25 3.39%	30 (4.04%)	736 (100%)

Complications are many, especially in malnourished children, those with poor immunity, and pregnant women, which include measles associated diarrhea, pneumonia, other respiratory complications, otitis media, subacute sclerosing panencephalitis (SSPE), etc.

Diagnosis is primarily clinical. IgM antibody titre by ELISA may be carried out where available. In vaccinated children, a four-fold increase in measles antibody titre can be demonstrated within 2-6 weeks.

Detection of measles antigen in saliva or urine, where resources permit, or where it is epidemiologically pertinent, should be carried out.

Material and Methods

A team from the Epidemiology and Disease Surveillance Cell surveyed all the affected areas and collected the data from the hospitals where patients received treatment.

Results

A total of 736 cases of measles occurred between March 2007 and May 2007, ie the 3 months of spring season in Kashmir.

Age distribution (Table 1, Fig 1) shows an upward age shift in measles cases. In India, majority of cases are expected to occur in children below 3 yrs of age; in our study, however, 55.6% of cases occurred beyond the 5th year of age, and as many as 20.88% cases were adults (>18 yrs age). Thirty cases were seen in adults aged 40 or above. Contrary to expectations, the severity of cases was milder in adults.

Though all the cases occurred between March and May 2007 (the s pring season), two thirds of cases were clustered in March, the number progressively halving in the following two months. This could be attributed to a warmer season which discourages confinement in overcrowded rooms and encourages outdoor activity.

Fig 1. Age distribution of Measles cases

Fig 2: Measles Cases in Spring Months

Vaccination status

Immunization cards were scrutinized to determine measles vaccine status of the cases. Where the cards were not available, parents, guardians or other family members were enquired in this regard.

Table 3. Vaccination status of the studied cases

District	Vaccinated	Un-vaccinated	Vaccination Status Not known	Total
Anatnag	13	01	15	29
Pulwama	82	03	12	97
Budgam	68	01	14	83
Srinagar	66	nil	07	73
Baramulla	54	01	04	59
Kupwara	94	19	23	136
Ladakh	145	36	78	259
TOTAL	522	61	153	736

Majority of patients (70.9%) had received vaccination in childhood, while 29.1% had either not received it or were not aware. It is noteworthy that measles vaccine was introduced into the National Immunization Schedule in 1985 under UIP, and affected adults more than 23 years old could not have received it during their infancy.

Discussions

Measles is one of the most infectious diseases known to man and remains the leading cause of vaccine preventable deaths in children worldwide. In most developing countries measles is still a formidable public health concern.^1-3 Complications include diarrhea, pneumonia, malnutrition, subacute sclerosing panencephalitis (SSPE), blindness, deafness, mental retardation or death.^2-5 Despite the easy availability of vaccination for its control, vaccination coverage has been suboptimal in some countries^4,5. In India, measles vaccine is one of the childhood vaccines with the least coverage. Our place shares this low coverage problem despite relatively colder climate which should otherwise be favourable for such thermo-sensitive vaccines.

Various studies carried out around the world have suggested that, in near future, there will be a three fold increase in measles mostly in developing countries like Africa and Asia. Large measles outbreaks continue to occur, and these outbreaks frequently have high case-fatality rates resulting in many measles deaths.⁷

The WHO/UNICEF Global Measles Strategic Plan seeks to reduce measles mortality worldwide by 50%. The strategies recommended for reducing measles deaths include:

1. providing a dose of measles vaccine to a very high proportion of infants (not less than 85%) at 9 months of age through routine immunization service, which will be the foundation of sustainable measles mortality reduction;
2. ensuring that all children have a second opportunity to receive measles vaccine providing measles immunity to those children who were previously vaccinated yet failed to develop measles immunity;
3. strengthening measles surveillance with integration of epidemiological and laboratory information and
4. improving the clinical management of measles cases.⁸

The National Institute of Communicable Diseases, Delhi, (NICD) has blamed low vaccine coverage and poor surveillance responsible for measles outbreaks in different parts of India.⁷

Though measles is mainly a public health problem of developing countries, developed world too is not without risk of outbreaks. A reported measles outbreak in Victoria, Australia in 1999 suggested that a substantial proportion of young adults (18-30 years old) may be susceptible to measles infection.⁹ A study by the Centers for Disease Control and Prevention (CDC) suggests that about 3 million Americans between the ages of 20 to 37 are at risk of catching measles. The grown ups are at risk because most of them never got a second dose of measles vaccine.⁵ The disease is considered to be more troublesome and dangerous to adults than children. However, in our investigations the adult cases were largely mild.

Table 4. Gender Distribution of Measles Cases

Males	199	78	93	58	06	12	446
Females	128	50	34	41	19	18	290

Conclusion

It is advisable that in any situation where measles is found to occur in adults measures are taken to rule out any adverse situations for the women, especially those who are, or planning to be pregnant. As there is now a changing pattern in age affliction of measles, i.e it is shifting towards the adult age groups, it indicates that immunity in the immunized individuals is waning with passing years, leaving aside the un-immunised and under-immunised children. Also, there is a large percentage of those who fail to develop immunity on standard immunisation procedure i.e. one dose of measles vaccine during infancy and a repeat dose might be necessary at a higher age to prevent adult measles as is being followed by some developed countries in the West.

Probably the time has come that we too think about the 2nd dose of measles to prevent outbreaks among adults.

References

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