Transcript Skeleton slides

Objectives
 To recognize the signs and symptoms of a patient with




measles infection
To provide the most common differential diagnoses of
a patient presenting with fever and rash
To present the management of measles infection
To discuss the possible complications of measles
infection
To discuss the public health issues regarding the
current outbreak of measles in the country
IDENTIFYING DATA
 6 months old
FV
 6 months old
 Male
 Roman Catholic
 Filipino
 Fever
CHIEF COMPLAINT: Fever and rashes
 Rash
History of Present Illness
• Fever (Tmax 38.8oC)
• Intermittent
• Temporarily relieved by
paracetamol (Tempra) drops 100
mg/ml, 1ml every 4 hours
5 days PTA
(14mg/kg/dose)
• No cough, colds, difficulty of
breathing, rashes, loose stools,
decrease in appetite, or decrease in
activity
• Still with fever
• Erythematous maculopapular rashes
on the back of the ears and forehead
3 days PTA
• Spread of the maculopapular rashes to the
face and neck area
• Colds – watery nasal discharge
• Non-productive cough
• Consult at TMC satellite clinic
• CBC: Hgb 119, Hct 0.35, WBC 15.04, Neutrophil
2 days PTA
29.1, Lymphocytes 63.3, Platelet 305)
• Prescribed with ambroxol and cetirizine
• Advised to observe progression of rash
1 day PTA
• Progression in severity of the non-productive
cough
• Persistence of colds
• Eye redness and discharge (pagmumuta)
• Lysis of the fever
• Spread of the maculopapular rashes to the
trunk and lower extremities
• Irritable (increased crying)
• Fast breathing
Day of consult • Persistence of aforementioned symtpoms
ER consult and
admission
Temporal Profile
5 days
PTA
4 days
PTA
3 days
PTA
fever
rashes
colds
cough
eye redness & discharge
fast breathing
2 days
PTA
1 day
PTA
Admission
ROS
 GENERAL: No weight loss, no decrease
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in activity
HEENT: see HPI
CARDIOVASCULAR: No palpitations
RESPIRATORY: see HPI
GASTROINTESTINAL: No vomiting, no
diarrhea
EXTREMITIES: see HPI
 6 months old
 Fever
 Maculopapular
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



Rash
(cephalocaudal)
Cough
Coryza
Conjunctivitis
Decrease in oral
intake
Fast breathing
PMH
 No known allergies
 Previous illness:
 UTI at 2 mos


Given unrecalled dose of cefixime without
resolution of infection
At 4 mos, change of antibiotic to
cefuroxime with unrecalled dose with
subsequent resolution
• 6 months old
• Fever
• Maculopapular
Rash
(cephalocaudal)
• Cough
• Coryza
• Conjunctivitis
• Decrease in oral
intake
• Fast breathing
Birth History
 Born full term, via LTCS II, to a 28 year
old G3P3 (3003) at Unciano Medical
Center
 Birth weight of 3kg
 No complications during pregnancy or
delivery.
• 6 months old
• Fever
• Maculopapular
Rash
(cephalocaudal)
• Cough
• Coryza
• Conjunctivitis
• Decrease in oral
intake
• Fast breathing
Immunization History
 BCG:
 Penta:
 OPV:
 Hepa B:
 Measles:
 Varicella:
 Hib:
 PCV:
1 dose
3 doses
3 doses
1 dose
1 dose
1 dose
1 dose
1 dose
 6 months old
 Fever
 Rash






(Cephalocaudal)
Cough
Coryza
Conjunctivitis
Decrease in oral
intake
Fast breathing
Measles vaccine (6
days prior to
admission)
Nutritional History
 Breastfed exclusively until 3 months old
 Formula feeding (Enfalac) started at 3
months old
 Weaning at 6 months of age - started on
mashed vegetables and Cerelac
 Normally eats well consuming 2-4 oz per
feeding around 6x/day
• 6 months old
• Fever
• Rash
(cephalocaudal)
• Cough
• Coryza
• Conjunctivitis
• Decrease in oral
intake
• Fast breathing
• Measles vaccine (6
days prior)
enumerate the developmental milestones from birth to 6 mos, like at 2mos, what can he do, 3 mos, etc.
Developmental History
At par with age
 Motor: able to sit with support
 Language: imitate sounds, babble
incomprehensible syllables
 Social: stretches arms when he wants to
be taken and indicates likes and dislikes
with actions
• 6 months old
• Fever
• Rash
(Cephalocaudal)
• Cough
• Coryza
• Conjunctivitis
• Decrease in oral
intake
• Fast breathing
• Measles vaccine (6
days prior)
Family History
 No hypertension, diabetes, asthma,
allergies, cancer
 No other family member with similar
symptoms
• 6 months old
• Fever
• Rash
(cephalocaudal)
• Cough
• Coryza
• Conjunctivitis
• Decrease in oral
intake
• Fast breathing
• Measles vaccine (6
days prior)
Personal, Social, and Environmental
History
 Lives at home with his parents in
Rosario, Pasig
 10 people at home (mother, father, 2
older siblings, maternal uncle and his
wife, the mother’s cousin, and great aunt,
nanny, patient)
 4-story aparment-type complex; each
family has their own room
 Father: property manager
 Mother: accounting assistant
 No smokers in the household
• 6 months old
• Fever
• Rash
(cephalocaudal)
• Cough
• Coryza
• Conjunctivitis
• Decrease in oral
intake
• Fast breathing
• Measles vaccine (6
days prior)
Maternal
grand-aunt
Nanny
Genogram
Maternal
uncle
Mother’s
cousin
Personal, Social, and Environmental
History
 Financial problems due to the increasing
length of the hospital stay and
medications
 Everyone in the household contributes to
the hospital expenses (mother’s older
brother shares a lot)
• 6 months old
• Fever
• Rash
(cephalocaudal)
• Cough
• Coryza
• Conjunctivitis
• Decrease in oral
intake
• Fast breathing
• Measles vaccine (6
days prior)
Stakeholder Analysis
Stakeholder
Role
Interest in
Issue
Level of
Influence
Father
Primary
Breadwinner
High
High
Mother
Primary
Caregiver
High
High
Uncle and wife
Breadwinner
Moderate
High
Nanny
Caregiver
Moderate
Low
High
Low
Moderate
Low
Low
Low
Siblings
Great aunt
Mother’s
cousin
Caregiver
Salient Features
SUBJECTIVE
•
•
•
•
•
•
•
•
•
6 months old
Fever
Rash (cephalocaudal)
Cough
Coryza
Conjunctivitis
Decrease in oral intake
Fast breathing
Measles vaccine (6 days prior)
OBJECTIVE
Temporal Profile
5 days
PTA
4 days
PTA
3 days
PTA
fever
rashes
colds
cough
eye redness & discharge
fast breathing
2 days
PTA
1 day
PTA
Admission
Physical Examination
General Survey: Awake, alert, not in
respiratory distress
Vital Signs:
BP 90/60 mmhg
CR 126 bpm
RR 31 cpm
T 39.9°C (febrile)
Anthropometric:
Wt 7.0 kg
(z score > -2)
Ht 86 cm
(z score < 3)
HC: 41cm
(z score > -2)
AC: 40cm
CC: 39cm
•High grade fever
Physical Examination
Skin
 Warm, moist
 (+) Erythematous maculopapular
rashes on the face and trunk
 Soft/supple skin
•High grade fever
•Erythematous
maculopapular
rashes on face
and trunk
Physical Examination
HEENT
 Head: No deformities of the head
 Eyes: eye redness with increased
tearing anicteric sclerae, hyperemic
conjunctivae, pupils 2-3mm, EBRTL
 Ears: Normal-looking pinnae, patent ear
canal with no swelling or discharge
 Nose: Midline, intact nasal septum,
patent nares and no nasal discharge
 Mouth: Pink, dry lips, tongue and
buccal mucosa
•High grade fever
•Erythematous
maculopapular
rashes on face and
trunk
•Eye redness with
increased
tearing,
hyperemic
conjunctiva, dry
lips, tongue and
buccal mucosa
Physical Examination
Cardiovascular
 Adynamic precordium; no deformities;
good S1/S2; regular rate and rhythm; no
heart murmur;
Pulmonary
 (+) Intercostal retractions; equal chest
expansion; (+) bilateral rales, no
wheezing
•High grade fever
•Erythematous
maculopapular
rashes on face and
trunk
•Eye redness with
increased tearing,
hyperemic
conjunctiva, dry
lips, tongue and
buccal mucosa
•Intercostal
retractions
•Bilateral rales
Physical Examination
Abdomen
 Non-distended, no lesions; normoactive
bowel sounds; soft, non-tender, no
organomegaly
Extremities
 No edema, no cyanosis, full and equal
pulses, CRT <2sec
•High grade fever
•Erythematous
maculopapular
rashes on face and
trunk
•Eye redness with
increased tearing,
hyperemic
conjunctiva, dry
lips, tongue and
buccal mucosa
•Intercostal
retractions
•Bilateral rales
Physical Examination
Neurological Exam
Appropriate for age
 Cranial nerves:
I: Not tested
II: Pupils 2-3 mm bilaterally reactive to light
III, IV, and VI: Full range of motion of extraocular
muscles
VI: not assessed
VII: No facial asymmetry
VIII: not assessed
IX and X: (+) gag reflex
XI: not assessed
XII: Tongue midline
 Motor: exhibits spontaneous movement on all
extremities
 Cerebellar: cannot be assessed
 Reflexes: 2+ on all extremities
 Sensory: reacts to pain
•High grade fever
•Erythematous
maculopapular
rashes on face and
trunk
•Eye redness with
increased tearing,
hyperemic
conjunctiva, dry
lips, tongue and
buccal mucosa
•Intercostal
retractions
•Bilateral rales
Salient Features
SUBJECTIVE
•
•
•
•
•
•
•
•
•
6 months old
Fever
Rash (cephalocaudal)
Cough
Coryza
Conjunctivitis
Decrease in oral intake
Fast breathing
Measles vaccine (6 days prior)
OBJECTIVE
•High grade fever
•Erythematous maculopapular
rashes on face and trunk
•Eye redness with increased tearing,
hyperemic conjunctiva, dry lips,
tongue and buccal mucosa
•Intercostal retractions
•Bilateral rales
Differentials
 Differential #1: MEASLES
Fever
Rashes
Colds
Cough
Conjunctivi
tis
Irritability
(+) Measles
Vaccine
Harsh
breath
sounds
Bilateral
crackles
Rule In
Rule Out
Presents with:
Fever
Rash (Cephalocaudal
spread)
Coryza
Cough
Conjunctivitis
Complication of Pneumonia
Measles IgG/IgM results
Cannot be totally ruled out
Laboratory findings:
Diagnosis of measles is mainly clinical and laboratory
exams are not routinely ordered.
CBC: Slightly decreased hemoglobin, hematocrit, RBC
with slightly increased WBC
Measles Rash
Differentials
 Differential #2: Varicella
Fever
Rashes
Colds
Cough
Conjunctiviti
s
Irritability
(+) Measles
Vaccine
Harsh breath
sounds
Bilateral
crackles
Rule In
Rule Out
Presents with:
Low grade fever
Anorexia
Headache
Rash (vesicle on an
erythematous base, with
significant pruritus) “dew on a
rose petal”
Emerge in various
asynchronous crops
Rash lasts 12-21 days
 Does not present with:
Same description of rash
(pustule with erythematous
base)
Trunk to extremities
Laboratory findings:
CBC: Non-specific CBC findings. May show a decrease in WBC
with lymphocytic predominance as found in other viral illnesses.
Diagnosis is mainly clinical.
Varicella Rash
Differentials
 Differential #3: Rubella
Fever
Rashes
Colds
Cough
Conjunctiviti
s
Irritability
(+) Measles
Vaccine
Harsh breath
sounds
Bilateral
crackles
Rule In
Rule Out
Presents with:
Low grade fever
Rash
 Does not present with:
Same description of rash
Anorexia
Maculopapular rash appears on
face and neck and spreads to the
rest of the body
Spares the palms and soles
Fades after 3 days
Tender posterior acuricular
adenopathy
Laboratory findings:
CBC: Non-specific CBC findings. May show a decrease in
WBC with lymphocytic predominance as found in other
viral illnesses.
Diagnosis is mainly clinical.
Rubella Rash
Differentials
 Differential #4: Roseola
Fever
Rashes
Colds
Cough
Conjunctiviti
s
Irritability
(+) Measles
Vaccine
Harsh breath
sounds
Bilateral
crackles
Rule In
Rule Out
Presents with:
Fever
Diffuse macular or
maculopapular rash
 Does not present with:
Presentation of fever
Same description of rash
“Well looking baby”
Condition improves with
appearance of rash
Laboratory findings:
CBC: Slightly decreased hemoglobin, hematocrit, RBC
with slightly increased WBC
Roseola Rash
Differentials
 Differential #5: Hand Foot & Mouth Disease
Fever
Rashes
Colds
Cough
Conjunctiviti
s
Irritability
(+) Measles
Vaccine
Harsh breath
sounds
Bilateral
crackles
Rule In
Rule Out
Presents with:
Low-grade fever
Rash
 Does not present with:
Same description of rash
malaise, anorexia, and posterior
pharyngeal ulcerations
Oral lesions on whole
palate/tongue
Maculopapular lesions on
hands and feet (progresses to
vesicles and then ulcerations)
Laboratory findings:
CBC: Non-specific CBC findings. May show a decrease in WBC
with lymphocytic predominance as found in other viral illnesses.
Diagnosis is mainly clinical.
Hand, Foot, and Mouth Rash
Differentials
 Differential #6: Dengue
Fever
Rashes
Colds
Cough
Conjunctiviti
s
Irritability
(+) Measles
Vaccine
Harsh breath
sounds
Bilateral
crackles
Rule In
Rule Out
Presents with:
Fever
Defervescence rash (isles of
white in a sea of red)
 Does not present with:
Same description of rash
Anorexia
Abdominal pain
Bleeding episodes
CBC results  decreasing
platelet count with
hemoconcentration
Laboratory findings:
CBC: Decrease in WBC, hemoconcentration, and decrease in platelet.
Lymphocytic predominance as found in other viral illnesses.
May request for Dengue NS1 and Dengue Blot test to confirm diagnosis.
Dengue Rash
Differentials
 Differential #7: Chikungunya
Fever
Rashes
Colds
Cough
Conjunctiviti
s
Irritability
(+) Measles
Vaccine
Harsh breath
sounds
Bilateral
crackles
Rule In
Rule Out
Presents with:
Fever
Rash
Conjunctivitis
 Does not present with:
Presentation of rash
Anorexia
Vomiting
Joint pains
Laboratory findings:
CBC: CBC: Decrease in WBC and slight decrease in platelet.
Lymphocytic predominance as found in other viral illnesses.
Chikungunya Rash
Primary Working Impression
 Rubeola
Complications
•Otitis media – most common
 Pneumonia, Severe
•Generalized•(All ages less than 5 years)
Strep, H. influenza, M.
inflammation
catarrhalis
•Epithelial cells
(skin,
•Pneumonia – Leading
conjunctivae, and the mucous
cause of mortality
membranes of the nasopharynx,
•H.influenza, Strep
bronchi, and intestinal
tract)
•May be
viral or due to
bacterial lung infection
•Encephalitis
•From measles virus itself
•Laryngotracheobronchitis
Hospital Day 1
Subjective
Objective
Assessment
•Day 6 of illness
•crying but
consolable, weak
looking
•Fever (39.9C)
•slightly sunken
eyeballs, bilateral
conjunctivitis, dry
lips
•bilateral rales and
shallow subcostal
retractions
•generalized
maculopapular rash
•Measles
•Pneumonia
Plan
•CBC with PC
•Measles IgG and
IgM
•Chest Xray AP Lat
Stages of Measles
•IVF: D5LR 350ml to
•Incubation stage
run at 44ml/hour
•Paracetamol
•Prodromal stage
100mg/ml
•With enanthem
•Salbutamol +
•Final stage
Ipratropium neb
•Cefuroxime
•Maculopapular
200mg/IV every 8
rash
hours (86 mg/kg/day
•High fever
CBC
Hemoglobin
Hematocrit
RBC Count
WBC Count
MCH
MCHC
MCV
RDW
Platelets
Differential Count
Neutrophil
Lymphocyte
Monocyte
Eosinophil
Basophil
Blast cells
Erythrocyte Morphology
Normal Values
137-170
0.40-0.54
4.60-6.20
4.50-10.00
27-32
0.32-0.36
80-96
11.5-16.0
140-440
0.56-0.66
0.22-0.40
0.04-0.06
0.01-0.04
0.00-0.01
01/15
119
0.35
16.04
305
29.1
63.3
Differentials
 Measles Immunoglobulin G and Immunoglobulin M
Measles IgM (ELISA)
Measles IgG
0.541
0.217
<0.9 negative
0.9-1.1 borderline pos.
>1.1 positive
Laboratory findings:
Measles IgG/IgM: IgG (+): past infection IgM: current
infection
Chest Xray: Interstitial Pneumonia, bilateral
Hospital Day 1
Subjective
Objective
Assessment
•Day 6 of illness
•Fever management
(39.9C)
•Measles
•Supportive
•crying but
•slightly sunken
•Pneumonia
therapy
is not
consolable,•Antiviral
weak
eyeballs,
bilateral
looking effectiveconjunctivitis, dry
lips
•Prophylactic
•bilateralantimicrobial
rales and
therapy shallow
- notsubcostal
indicated
retractions
•Goals of•generalized
therapy:
maculopapular rash
Hydration
Oxygenation
Comfort
Plan
•CBC with PC
•Measles IgG and
IgM
•Chest Xray AP Lat
•IVF: D5LR 350ml to
run at 44ml/hour
•Paracetamol
100mg/ml
•Salbutamol +
Ipratropium neb
•Cefuroxime
200mg/IV every 8
hours (86 mg/kg/day
Recommendations for Vitamin A
Treatment of Children with Measles
INDICATIONS:
 Children 6 mo to 2 yr of age hospitalized with measles and
its complications (e.g., croup, pneumonia, and diarrhea)
 Children >6 mo of age with measles who are not already
receiving vitamin A supplementation and who have any of
the following risk factors:
 Immunodeficiency
 Clinical
evidence of vitamin A deficiency
 Impaired intestinal absorption
 Moderate to severe malnutrition
 Recent immigration from areas where high mortality rates attributed to
measles have been observed
From the American Academy of Pediatrics, Committee on Infectious Disease:
Vitamin A treatment of measles. Pediatrics
REGIMEN
 Parenteral and oral formulations of vitamin A are
available in the USA. The recommended dosage,
administered as a capsule, is:
 Single dose of 200,000 IU orally for children ≥1 yr of age
(100,000 IU for children 6 mo to 1 yr of age)
 The dose should be repeated the next day and again 4
wk later for children with ophthalmologic evidence of
vitamin A deficiency
From the American Academy of Pediatrics, Committee on Infectious Disease:
Vitamin A treatment of measles. Pediatrics
Hospital Day 2-3
Subjective
Objective
Assessment
•Day 7 of illness
•Irritable
•Cough
•Soft stools x2
•Adequate urine
output
•Tachypneic 60s-80s •Measles
•Tachycardic 145-204 •Pneumonia
bpm
•O2 sat 90-91% 
96% after O2
support
•Hyperemic
conjunctiva,
hyperemic posterior
pharyngeal walls
•bilateral rales and
shallow subcostal
retractions
•generalized
maculopapular rash
Plan
•Paracetamol,
Cefuroxime,
•Shifted Salbutamol +
Ipratropium neb to NSS
neb q2hrs
•Zinc drops BID
•O2 support via facemask
at 5 lpm  10-15 lpm
•Advised PICU admission,
family refused due to
financial limitations
Hospital Day 4-7
Subjective
Objective
Assessment
Plan
•Day 9 of illness
•Febrile episodes +
chills
•able to tolerate oral
feeding every 2-3
hours
•Adequate urine
output and bowel
movement, formed
stools
•Tachypneic episodes
noted; no
desaturations
•Hyperemic
conjunctiva,
hyperemic posterior
pharyngeal walls
•bilateral rales and
shallow subcostal
retractions
•generalized
maculopapular rash
•Measles
•Pneumonia
•Referred to Infectious
Disease
•Cefuroxime shifted to
Piperacillin-Tazobactam
500mg/IV every 6 hours (258
mg/kg/day)
•Multivitamins started
•Paracetamol
•O2 support via facemask 
nasal cannula at 3 lpm
•Requested transfer to
Unciano Medical Center due
to financial constraints
CBC
Normal Values
01/15
01/17
Hemoglobin
Hematocrit
RBC Count
WBC Count
MCH
MCHC
MCV
RDW
Platelets
Differential Count
Neutrophil
Lymphocyte
Monocyte
Eosinophil
Basophil
Blast cells
Erythrocyte
Morphology
137-170
0.40-0.54
4.60-6.20
4.50-10.00
27-32
0.32-0.36
80-96
11.5-16.0
140-440
119
0.35
100
0.33
4.21
11.20
24
0.31
77
14.9
325
0.56-0.66
0.22-0.40
0.04-0.06
0.01-0.04
0.00-0.01
16.04
305
29.1
63.3
Laboratory findings:
Slightly decreased hemoglobin, hematocrit, RBC with
slightly increased WBC (predominance of lymphocyte)
0.56
0.36
0.08
0.00
0.00
0.23
Chest Xray: Interval progression of bilateral pneumonia
Hospital Day 5
Subjective
Objective
Assessment
Plan
•Day 10 of illness
•Febrile episodes +
chills
•able to tolerate oral
feeding every 2-3
hours
•Adequate urine
output and bowel
movement
•Tachypneic episodes
noted; no
desaturations
•Hyperemic
conjunctiva,
hyperemic posterior
pharyngeal walls
•bilateral rales and
shallow subcostal
retractions
•generalized
maculopapular rash
•Measles
•Pneumonia
•Referred to Infectious
Disease
•Cefuroxime shifted to
Piperacillin-Tazobactam
500mg/IV every 6 hours (258
mg/kg/day)
•Paracetamol
•O2 support via facemask 
nasal cannula at 3 lpm
WHAT IS THIS PICTURE?
Case Definition
 Clinical case definition
 Any person in whom a clinician suspects measles
infection
 Any person with fever, maculopapular rash, cough,
coryza, conjunctivitis
 Laboratory criteria for diagnosis
 4x increase in antibody titer, isolation of measles virus,
or presence of IgM antibodies
What is considered an outbreak?
 DOH:
 1 case, suspected or confirmed, in a community where
there was no case in the past
 1 case per 2 weeks for 2 consecutive weeks
 WHO
 Number of cases observed is greater than the number
normally expected in the same geographic area for the
same period of time
Outbreak Timeline (Metro Manila)
Only 6% of the reported
Cases are confirmed
416 % increase
760cases
Jan 11 2014
716% increase
179 cases
Dec 10 2013
25 cases
2012
DOH statistics
DOH Declared
Outbreak
Jan 4, 2014
21 barangays
In 9 cities
Philippines
Year
Confirmed
measles
cases
Incidence
(per 1
million)
Deaths due
to measles
2008
874
9.8
8
2009
1490
16.6
10
2010
6388
68.2
34
2011
6555
69.1
28
2012
1499
15.5
5
2013
1724
17.97
21
Source: WHO. Country Profile-Measles Elimination.
DOH National Epidemiology Center
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Jan 1 – Dec 14, 2014
1,724 cases and 21 deaths
Majority came from Metro Manila (744 cases)
13/17 regions of the Philippines have measles case increase
 2013 (NCR)  416 confirmed cases
 1568 % increase!
 2012 (NCR)  25 confirmed cases
 Las Pinas (78), Manila (72), Muntinlupa (65), Caloocan (45),
Paranaque (32), Malabon (31)
 Urbanized, congested area
 High mobility of the residents
 Supposedly good EPI coverage
Source: WHO. Country Profile-Measles Elimination.
Population at Risk
 Children under age 5 years old
 Higher percentage of death due to measles complication
 158,000 people died from measles in 2011
 Pregnant women
 Immunocompromised
MCV2 routine coverage: the level of coverage by the second
dose of the measles-containing vaccine, as reported in the annual
WHO/UNICEF Joint Reporting Form on Immunization.
Goals
 Herd Immunity
 Vaccination coverage of no less than 95%
 The “Iligtas sa Tigdas ang Pinas” program in 2011 only
covered 84% of the population (15,649,907) – MR
vaccine

16% (~3million) were unvaccinated or in 2 years since at 84%
coverage, 6 million were unvaccinated
 Measles Free by 2017 (WHO)
 1 case per 1 million population
Vaccination
 Measles
 At 9 months
 At 6 months during
outbreaks

Maternal antibodies may
have dwindled already
 MMR
 2 doses
 1 dose  90% immunity

Booster at 12-18 (15) months
 2 doses  almost 100%
immunity

At 4-6 years of age
 Some children who have
been vaccinated still got
infected

2-3% may not develop
antibodies
 Some parents refuse
vaccination
 Religious belief
 Transfer of residence
Government Response
 Vaccination
 It will take a couple of weeks before they develop
immunity
 Mass Immunization Campaign that aims to cover
children <5 years old (11.7 million)
 Door to Door approach
 All (6mo-59 mo) will be vaccinated regardless of prior
vaccination (unless does is <1 month ago) or if recently
had measles
 DepEd and DOH advise voluntary quarantine
Government Response
 Mandatory Nutrition Program
 FNRI: underweight children 0-5 years (3.35 million)
 Significant increase in prevalence among 6-10 years old
from 22.8% in 2005 to 25.6% in 2008
 Those who are malnourished are at increased risk of
dying from measles complication
 Vit A supplementation can reduce mortality risk by 50%
 Tayag: “infants and children with measles should be
hospitalized”
 Panic among parents
Government Response
 Checking for new strain
 DOH declared no new strain for this measles outbreak
What can we expect?
 A further rise in measles cases in the coming months
peaking during the summer where virus replication is
faster
TMC Number
Statistics
of Measles Cases (Admissions) from
October 2013 to January 15, 2014
60
50
40
30
20
10
0
October
November
December
January
Number of Measles Cases (Admissions) per Age
Group
40
35
30
25
20
15
10
5
0
<1 year old
1-4 years
5-9 years
10-14 years
15-18 years
Vaccination Status
Vaccinated
50%
50%
Non-vaccinated
Number of Doses
29%
38%
1 dose
2 doses
3 doses
5 doses
Unknown
17%
2%
14%
Reasons for Non-vaccination
Mother was busy
8%
21%
Ineligible to receive
vaccine
Forgot schedule
6%
35%
Baby was sick
11%
Others
19%
Unknown
Development of Complications
Yes
No
12%
88%
Exposure History
3%
27%
School
Community
Home
Unknown
66%
4%