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Measles

General childhood infections


Gert van Zyl Tel. 021 9389691 guvz@sun.ac.za

Family: Paramyxoviridae Ss RNA genome, helical nucleocapsid, nucleocapsid, 150150-200 nm diameter, membrane

Pathogenesis
Droplet spread Primary replication in respiratory tract Viraemic spread Generalised infection Virus infects most epithelial surfaces of the body Incubation period 1010-14 days
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Pathogenesis continue
Rash due to cytoxic T cells against antigen as well as antibodyantibody-antigen complexes Circulating antibody appears simultaneously with onset of the rash Virus is shed in body fluids, including respiratory secretions and also replicates in leucocytes causing leukopenia

Clinical
Incubation period: 1010-14 days Prodromal illness: 22-3 days with fever and Koplik spots on the buccal mucosa. Rash starts on the face and then spreads to the trunk and limbs within the next 2 days. Rash fades over the next 44-5 days with desquamation
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Measles: Complications
Site
Respiratory

Complications
Croup, bronchitis, pneumonia Conjunctivitis, corneal ulceration, blindness Otitis media Stomatitis, enteritis with diarrhoea Convulsions, encephalitis, SSPE

Eye

Ear Gastrointestinal tract

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CNS

Epidemiology
Highly infectious, almost 100% of susceptible contacts Occurs worldwide: elimination in certain areas through vaccination programs In developing countries: early infection < 2 years is common associated with high case fatality rate 33-6% Infective up till 7 days after rash appears

Laboratory diagnosis
Detection:
Direct fluorescence antibody (DFA) assay PCR

Isolation:
pharyngeal swab, urine Intracytoplasmic and intranuclear inclusions, syncytia Shell vial culture with immunofluorescence

Serology:
IgG: IgG: previous infection - immunity IgM: IgM: current infection (some false positive or negative tests)

Prevention
Live attenuated vaccine Developed countries: At 15 months as part of MMR Developing countries at 9 and 18 months. In high risk areas (hospitals) may vaccinate at 6 months. Mass vaccination and case reporting are parts of measles elimination strategies.

Measles case definition


Fever > 38.3 degrees C Cough or Coryza or Conjunctivitis Maculopapular rash for 3 days Collect blood Measles IgM Urine and or Pharyngeal swab - culture

Rubella
Family: Togaviridae Genus: Rubivirus + SS RNA Membrane icosahedral capsid

http://www.lib.uiowa.edu/hardin/md/pictures22/cdc/PHIL_712_lores

Pathogenesis:
Respiratory transmission Viraemic spread Generalised infection: mucosal membranes, skin, joints, transplacental

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Epidemiology
Occurs worldwide Droplet spread, respiratory transmission Prior to vaccination 80% of women of child bearing potential were immune Incubation period: 1010-21 days Infective until 5 days after rash appears

Clinical
Milder than measles 1/3 infections asymptomatic Prodrome: Prodrome: low grade fewer <38.5 Fine maculopapular rash starts on face and neck spreads to body, fades 11-4 days and does not desquamate Lymphadenopathy: Lymphadenopathy: post auricular and occipital Complications: Arthritis, encephalitis, thrombocytopenia Congenital rubella syndrome: maternal infection first 16 weeks of pregnancy

Congenital rubella syndrome


Spontaneous abortion Transient

Low birth weight, Trombocytopenic purpura, Hepatosplenomegaly Bone lesions

Developmental
Permanent

Sensorineural deafness, Mental retardation, Language defects, Severe myopia Peripheral pulmonary stenosis, Patent ductus arteriosus, Ventricular septal defect, Cataract, Retinopathy, Microcephaly, Microphthlalmia Diabetes mellitus, Progressive rubella panencephalitis (PRP)

Late

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Laboratory diagnosis
Isolation: throat swab, urine sample Serology:
Acute infection: IgM IgG avidity: high avidity > 50% past/ rere-infection; low avidity <30% recent infectioninfection- indication for termination of pregnancy

Congenital rubella syndrome:


Cord blood IgM, IgM, PCR on amniotic fluid Neonate - diagnosis: IgM within 22-3 weeks of birth or isolation of virus within 3 weeks of birth Virus can be isolated for months/ years from affected babies
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Prevention
Live attenuated vaccine as part of MMR at 15 months (not part of EPI in SA) Immunise all nonnon-immune adult females Vaccination contracontra-indicated during pregnancy

Mumps
Family: Paramyxoviridae Subfamily: Paramyxovirinae Genus: Rubulavirus

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Pathogenesis
Spread in saliva and secretions in respiratory tract Incubation: 1414-21 days Infection: respiratory route, big droplets, hand contact Viraemia Generalised spread: including parotid gland Virus shed for several days before and after symptoms: respiratory tract and urine
http://www.kcom.edu/faculty/chamberlain/Website/lectures/lecture/IMAGE/MUMPS.GIF

Epidemiology
Worldwide distribution, infects mainly children 55-14 years. Highest incidence in winter, 80% of adults immune Infective until 9 days after onset of parotitis

Clinical
Unapparent infections common. Typical symptoms: fever, painful enlargement of one or both parotid glands

Complications:
Aseptic meningitis (and encephalitis) Deafness Orchitis (sterility rare) Oophoritis Pancreatitis Mastitis Thyroiditis

Laboratory diagnosis
Isolation
Throat swabs or urine samples Syncytia and Intracytoplasmic inclusions in monkey cells Shell vial culture with IMF detection

Serology
Acute infection: IgM

Prevention
Live attenuated vaccine: Jeryl Lynn/ Urabe strain. Vaccinate children at 15 months: MMR

Enteroviruses
Family: Picornaviridae RNA viruses 1818-30 nm in diameter Icosahedral capsid No membrane

Group

Number serotypes

Disease/ symptoms

Poliovirus

Respiratory tract infection, meningitis, paralysis

Coxsackie A

23

Meningitis, encephalitis, myocarditis, pleurodinia, acute haemorrhagic conjunctivitis, herpangina, hand-foot-and-mouth disease, rash, paralysis, respiratory tract infection

Coxsackie B

Meningitis, encephalitis, myocarditis, pleurodinia, rash, pancreatitis, orchitis, respiratory tract infection

Echovirus

30

Encephalitis, meningitis, myocarditis, pleurodynia, herpangina, rash, paralysis, conjunctivitis, respiratory tract infection

Enterovirus

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Respiratory tract infection, hand-foot-andmouth disease, meningitis, paralysis

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Pathogenesis: Polio
Acquired via the faecal oral and respiratory routes After primary replication virus spread via blood stream to CNS Lytic infecion of the anterior horn cells of the spinal cord - lower motor neuron paralysis Infection is asymptomatic in 90% of cases

Epidemiology
Enteroviruses: Enteroviruses: majority of viral meningitis cases Children 3 months to 14 years Peak incidence in summer months

Laboratory diagnosis
Detection: PCR - on stool samples or throat swabs, nonnon-polio enterovirus on CSF Isolation: Stool samples. Isolation in monkey cells (polio, Coxsackie B, ECHO, Enterovirus) Enterovirus) and baby mice (Coxsackie A and B) Serology:
Polio 11-3, Coxsackie B 11-6 Neutralising antibody assay. For acute infection show a 4 fold rise in antibody titre on two specimens taken 1010-21 days apart

Prevention
Vaccines only available for polio Worldwide eradication campaign underway date was 2005 but largely due to outbreak originating in Kano Nigeria it was delayed. Eradication strategies: interrupt transmission
Routine infant vaccination Supplementary vaccination: National immunisation days Acute flaccid paralysis surveillancesurveillance- detect polio MopMop-up campaigns

Comparison of vaccines: Salk and Sabin

Inactivated (Salk)

Attenuated (Sabin) Developing world

Used
Administered Cost Temperature Immunity Back mutation Secondary spread Breast feeding

Scandinavia, Netherlands, USA Injection More expensive Room IgG No No No influence

Oral Cheaper 4C IgG and IgA Yes Yes Not contra-indicated, possible effect on vaccine success

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Parvovirus
Family: Parvoviridae Genus: Erythrovirus Virus: Human parvovirus B19 Morphology: ss DNA, 22 nm diameter, icosahedral capsid, capsid, no membrane

Pathogenesis
Primary infection of the upper respiratory tract Viraemia Virus replicates in rapidly dividing cells (foetal cells and red blood cell precursors)

Epidemiology
Worldwide Spread is by respiratory route Occasionally via blood transfusion Majority of infections are subsub-clinical

Clinical
Erythema infectiosum: infectiosum: fifth disease. Fever and maculopapular rash in children. Rash starts on face slapped cheeks cheeks. 80% of adult women with rash suffer from arthropathy

Aplastic crisis:
Patients with chronic haemolytic anaemias (sickle cell, thalassaemia, thalassaemia, spherocytosis, spherocytosis, etc.)

Congenital infection
Infection in early pregnancypregnancy- foetal loss laterlater- severe anaemiaanaemia- hydrops foetalis

Chronic infection: immunosuppressed patients


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Laboratory diagnosis
Detection:
Viral DNA blood or foetal material Electron Microscopy

Serology: IgM

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