MEASLES

WHAT IS
HOW IT SPREAD?
MEASLES?
SIGN AND SYMPTOMS?
INCUBATION PERIOD?
INFECTIVITY PERIOD?
COMPLICATION?
 WHAT IS MEASLES?
o An acute illness and one of the most infectious diseases
o Basic reproductive rate of 17 – 20 (i.e., one case of measles can generate 17 – 20
new cases in a completely susceptible community)
o Caused by measles virus, a member of the genus Morbillivirus of the
Paramyxoviridae family.
o Transmitted by:
o respiratory droplets or by direct contact with the nasal and throat secretion
of infected persons
oMeasles virus can live for up to two hours in an airspace where the infected
person coughed or sneezed
 days after rash.
4 days before rash to 4
Infectivity Period:
• Appear after 2 – 4 days after the prodromal symptoms begin.
• A maculopapular rash - started behind the ears, face and upper neck. APPEARANC
• Then, gradually spread to the trunk and extremities E OF RASH
• Lasted for 3 – 7 days.
• Lasted for 2 – 4 days (range 1 – 7 days). PRODROMA
• Symptom: fever, conjunctivitis, coryza, cough and presence of Koplik’s spot on the buccalL SYMPTOM
mucosa.
INCUBATION
• 10 – 12 days (range 7-21 days from exposure to the onset of fever) PERIOD
Clinical Features
• NO symptom
Figure 2: Time course of clinical events in measles disease
Conjunctivitis In Measles
(preceded By Cough & Coryza)
Koplik’s spots

Tiny white spots on

hard palate

Disappear by the time the rash is seen

 Miserly looking!
Measles rash

Maculopapular rash
-A macule is a flat blemish or discoloration
-A papule is as elevated lesion
Maculopapular rash - a smooth skin rash or
redness covered by elevated bump
 Measles Can Be Serious!!
 Children <5 years old and adult > 20 years old are more likely to suffer from measles
complications.

 Common complications:
 Ear infections
 Diarrhea - SSPE is a progressive,
disabling, and deadly brain
disorder related to measles
 Severe complications
infection.
 Pneumonia - Death usually occurs within 3
 Encephalitis years

 Long-term complications
 Subacute sclerosing panencephalitis (SSPE)

 Can cause DEATH

 IMMUNE RESPONSE TO
NATURAL INFECTION Virus
excretion

o Measles-specific IgM antibodies appear within 4 – 28 days

from onset of rash and decline rapidly after one month.
o The presence of IgM is accepted as evidence of primary
measles infection.
o However, absence of IgM does not exclude infection if
samples drawn within 3 days of rash onset.
 RUBELLA/ GERMAN
MEASLES

HOW TO DIFFERENTIATE WITH

MEASLES?
Time course of clinical events in Rubella
 Rubella

typical early rash, irritating conjunctivitis

& painful occipital LNpathy

confluent erythematous macules

on the face

rash spreading from face to trunk

 Is it measles or rubella?
Measles (Rubeola/morbilli)
viral agent paramyxovirus
age: before vaccination 5 - 9yrs
now <15mths or >10yrs
epidemics (pre- vaccine) every 2 - 3yrs
symptoms & signs highly contagious;
fever, cough + coryza,
conjunctivitis, Koplik’s spots,
reddish rash (confluent on
face, neck trunk)
‘CCCKR’
course & prognosis self limiting
complications:
• pneumonia
• otitis media
• laryngitis
• encephalitis
• myocarditis/pericarditis
Rubella (German/3-dy measles)
RNA, togaviridae
<15yrs
adults (>severe symptoms)
every 6 - 9yrs
moderately contagious;
pink rash, lymphadenopathy (post
auricle- post cervical);
asxs infections common (80%)
mild, self limiting
in non-immune pregnant ♀
 congenital rubella:
• heart defects(PDA/VSD)
• micropthalmia
• deafness
• micro/hydrocephalus
VACCINE ASSOCIATED
MEASLES

HOW TO DIAGNOSE?
Lima (5) kriteria VAM yang ditetapkan dalam Measles Elimination
Field Guide, WHO 2013:

• Kes mengalami ruam + demam, tetapi tiada batuk atau simptom respiratori
yang berkaitan dengan measles
• Ruam muncul antara 7 hingga 14 hari selepas imunisasi measles (KKM ambil 7-
21 hari)
• Sampel darah yang positif IgM diambil antara 8 hingga 56 hari selepas
imunisasi measles
• Siasatan lapangan yang menyeluruh gagal menemui kes measles lain
• Siasatan lapangan dan makmal gagal mengenalpasti sebab-sebab lain

Kes disyaki measles yang mempunyai virus genotype A (strain vaksin) dalam
isolat juga dikategorikan sebagai VAM.
 Vaccine Associated Measles (VAM)

o
CASE DEFINITION
 Jika GAGAL notify kes dalam
tempoh yang ditetapkan 

Tindakan kompaun atas

kesalahan di bawah
Subseksyen 10(2), Akta
Pencegahan Dan Pengawalan
Penyakit Berjangkit 1988.

 In the elimination phase, the classification of

measles cases as CLINICAL CASE IS NOT ALLOWED.
 SPECIMEN FOR
VIRAL MEASLES
WHAT?
WHEN TO TAKE?
HOW TO TAKE?
WHERE TO SEND?
SEROLOGY
WHAT?

BLOOD WHEN TO TAKE?

IF POSITIVE?
IF
OUTBREAK
IF NEGATIVE?
SPECIMEN WHERE TO SEND? ???

2 SAMPLE
WHAT?
ND WHEN TO TAKE?
IF POSITIVE?
IF NEGATIVE?
WHERE TO SEND?
 SPECIMENS COLLECTION
• MUST be taken
• All clinical specimens should be sent to the Makmal Kesihatan Awam
Kebangsaan (MKAK), Sungai Buloh
• For blood samples for serological tests, the blood must be taken within 28
days after onset of the rash (preferable 4 to 28 days). It is an indicator of
adequate sample for each case of measles. Our target is at least 80%
achieved.
Duration Onset of Rash Type of specimen Investigation
Viral isolation Serological test
1-5 Days Blood √

Urine / throat swab/ √

nasopharyngeal swab

4/6 – 28 Days Blood √

 COLLECTION OF SECOND
SAMPLE
Indication:
1) Result of Measles or Rubella (IgM) is equivocal.

2) Negative result for Measles or Rubella (IgM) for specimen collected

within 5 days.

 2nd. specimen should be collected within 10 to 20 days from collection of the first
specimen.
 VAKSINASI
WHAT?

WHEN IT STARTED?

WHEN TO GIVE?
 PERUBAHAN JADUAL IMUNISASI KANAK-KANAK DI
MALAYSIA PADA TAHUN 2016

A. Pelalian measles MCV 1 dari 12 bulan dipinda ke umur 9 bulan.

B. Dos kedua (MCV 2) pula diberi pada umur 12 bulan
C. Kedua-dua dos pelalian 9 dan 12 bulan menggunakan vaksin MMR.
D. Pelalian measles pada umur 7 tahun diteruskan sehingga kohot yang lahir 2015
mencapai umur 7 tahun pada tahun 2021.
E. Pada tahun 2022 imunisasi measles di sekolah diberhentikan. Pelalian measles 6
bulan di Sabah dan beberapa kumpulan berisiko di Semenanjung akan diteruskan.

Pelalian pada umur 9 bulan akan beri serocenversion 85% dan pemberian dos kedua
selepas lebih satu bulan dan pada umur 12 bulan ke atas akan memberi
seroconversion hampir 100% (99%).
PENGENDALIAN KES
MEASLES
PENGENDALIAN KES MEASLES DI
LAPANGAN
DIBUAT NOTIFIKASI
DLM MASA 24 JAM

Pastikan kes berada di

dalam Sistem Maklumat
Siasatan Measles (SM2)

PENYIASATAN KES DALAM MASA

48JAM DARI TARIKH
PENERIMAAN NOTIFIKASI

Maklumat yang diperlukan

sepertiyg
Kontak ygterdedah
terdapat semasa
dalam
Siasatan di dalam
borang siasatan
infectivity period lokaliti
kes
perlu
dalam
ditemui lingkungan
measles.
utk 1 km
mencari punca
dari tempat
jangkitan tinggal saiz
& mengetahui kes
sebaran jangkitan
PENGENDALIAN WABAK
MEASLES
• Definisi wabak measles
• Notifikasi melalui sistem e-wabak
• Laporan awal wabak ke JKNP
• Siasatan kes dalam tempoh 48 jam
• Siasatan kontak
• Aktiviti imunisasi tambahan
 DEFINITION OF MEASLES OUTBREAK

Two or more locally transmitted with laboratory

confirmed case/s of measles notified in one
locality.

During measles elimination programme:

One confirmed case of measles was considered
as epidemic. It is to ensure the investigation,
prevention and control is carried out
immediately.
Supplementary Immunisation Activity (SIA)

Hendaklah dirancang sekiranya terdapat lebih 10% kanak-kanak

berumur 12 bulan hingga bawah 7 tahun yang tidak menerima
pelalian measles.
Hasil SIA hendaklah diisikan dalam format di Lampiran 2 dan
dimasukkan sebagai satu komponen dalam pengendalian wabak.
Laporan hendaklah dihantar kepada Jabatan Kesihatan Negeri
untuk disemak sebelum dihantar ke Bahagian Kawalan Penyakit.
PROGRAM ELIMINASI
MEASLES, RUBELLA
DAN CONGENITAL
RUBELLA SYNDROME
 KRITERIA VERIFIKASI BAGI
ELIMINASI MEASLES
1) Tiada kes measles akibat jangkitan oleh virus endemik dalam
tempoh 3 tahun atau 36 bulan

2) Disahkan berdasarkan sistem survelan yang berkualiti tinggi.

3) Analisa genotype virus measles membuktikan tiada virus endemik

di persekitaran.
 Program Eliminasi Measles (MEP)
2002 – Malaysia mensasarkan untuk mencapai status eliminasi
measles menjelang tahun 2012.

Tidak tercapai kerana:

Terdapat kawasan dengan liputan imunisasi measles < 95%.
Measles kekal endemik
genotaip virus measles lazim
genotaip yang diimport
PROGRAM ELIMINASI MEASLES
PAHANG

Sasaran : Tiada kes tempatan (indigenous)

Pencapaian :
2014 2015 2016 2017 2018

2.5/ 14.8/ 22.4/ 17.9/

AL ! ! !!
14.7/
1,000,000 1,000,000 1,000,000 AG
1,000,000
G 1,000,000

25 kes tempatan
Program Eliminasi Rubella dan
Congenital Rubella Syndrome (CRS)
• Tahun 2014- Malaysia telah membuat komitmen kepada WHO untuk
Eliminasi Rubella dan CRS.
• Tahun 2017, WHO di Manila menetapkan sasaran Eliminasi Measles,
Rubella dan CRS di rantau ini adalah pada tahun 2025.
 SITUASI
MEASLES DI
MALAYSIA
 MEASLES INCIDENCE IN MALAYSIA;
1980 – 2018

Cases Death
2013: 195 cases (6.6) 2013: 0
2014: 235 cases (7.8) 2014: 1
2015: 1,316 cases 2015: 2
(43.2) 2016: 1
2016: 1,587 (51.4) 2017: 2
2017: 1,693 (52.3) 2018: 6
2018: 1,958 (59.5)
Source: SM2 (rash
2018)
Input range: 1 Jan 2018
– 1 March 2019
DL: 19 March 2019
MMR @ 7yo,
Intensive
Monovalent Measles Nationwide SIA
Vaccination @9 mo MMR @12 mo targeted SIA MMR 1@9m
-8-16yo MMR2@12m
 MEASLES CASES BY RASH ONSET,
MALAYSIA
2013 – 2018

Schedule
change 9 mo

2013 2014 2015 2016 2017 2018

MEASLES INCIDENCE BY STATE (PER
1 MILLION POPULATION), 2014 – 2018

Six (7)
from 14
states
increasin
g trend
in
measles
IR per
mill
populati
ons over
5 years
 Measles Mortality, 2018
N State District Age Vaccination Status Date of COD
o. Death
1 Selangor Kuala 4 mths Not eligible, other 26/3/2018 HIE secondary to pneumonia with bilateral
Selangor vacc up to date pneumothorax underlying measles pneumonitis

2 WPKL Titiwangsa 5 mths Not eligible, other 16/4/2018 Pneumonia with underlying measles
vacc up to date Known congenital pontocerebellar hypoplasia

3 Selangor Hulu 1 yr Incomplete – only up 22/1/2018 Severe measles with secondary invasive
Langat 3 mths to 1 month old pneumococcal disease (pneumococcal septicemia
(logistic issue) with para-pneumonic effusion)

4 Sabah Kudat 1 yrs None 27/6/2018 Measles

(Sea gypsy)

5 Selangor Gombak 4 yrs Incomplete (no birth 29/7/2018 MRO sepsis, severe ARDS, measles pneumonitis
cert, Indonesian
parents)

6 Terengganu Dungun 5 mths Not eligible, other 6/12/2018 Measles Pneumonitis

vacc up to date
Measles Cases By Age Group, Malaysia,
2016- 2018

65% of
cases 7
yo and
below
Measles: Status Imunisasi
• Measles, Malaysia, 2018 (data up to 9 Jan 2019)
• 481 cases had history of measles vaccination
• With record 285
• Verbal 180
• Unknown 5
• Blank 11
• 341 cases with unknown history of vaccination; 72 cases were born before
1982, 30 cases aged <7 years old
• Bukti sejarah imunisasi
• Sejarah lisan
Measles Cases By MCV Vaccination Status
2017 2018

Source; SMM Disease

Control Division
Distribution of Measles Virus genotype,
Jan-July 2017; Jan – Jun 2018

2
D8
2 D8
21
1 B3 1 D8 B3
1 B3 2 B3 2 B3
1 D8 2 D8 3 D8
1 D8 2 D9
1 D9 1 B3
1 B3 10 D8
2 D8 1 D9
1 D8
26 D8 38 B3 3 D8 1 B3
7 D9 13 D8 1 D9 1 D8
12 B3 1 B3
7
2 D8 5 B3 2 D9 2017 2018
D9
6 D9 3 D8 4
• D8 (46)
• D9 (22) D8 (35)
D8
2 • B3 (41) B3 (49)
3 B3 D8
Data Source : NPHL
 Genotyping Data 2010-
June2018
2017 2018
Year 2010 2011 2012 2013 2014 2015 2016 (Jan- (Jan
July) -June)

D8 D8
D8
A (1) D8 D8(1 D8 (7) (33) (66) D8
A (1) (46)
B3 (1) G3 (1) (45) 0) D9 (3) D9 D9 (35)
Measles D8 (4) D9
G3 (4) D9 D9 H1 (28) (86) B3
D9 (1) D9 (22)
(37) (51) (5) (5) B3 B3 (49)
B3(41)
(10) (64)

2B(27
2B(8 )
2B 2B(12) 1A(1)
Rubella 0 5) 2B (1) 0 0
(10) 1E(1) 1E(4) 2B(2)
1E(4)
1A (1)

Data Source : NPHL

 SITUASI
MEASLES DI
NEGERI PAHANG
TREN 10 TAHUN KES MEASLES DI NEGERI PAHANG
TAHUN 2008-2018
 TREN KES DISYAKI MEASLES NEGERI PAHANG
B il. k e s d is y a k i m e a s le s TAHUN 2014-2018

700

600 592

500
445
400

300

200
132 143
106
100
24 37 30 25
4
0
2014 2015 2016 2017 2018

Tahun
KES MEASLES MENGIKUT DAERAH DI NEGERI PAHANG
TAHUN 2014-2018
25

20
Bilangan kes

15

10

0
BTG BR CH JRT KTN LPS MRN PKN RB RPN TML
2014 0 0 0 0 3 0 0 0 0 0 1
2015 0 0 0 1 14 7 1 0 0 0 1
2016 2 1 1 2 23 3 1 0 1 1 2
2017 1 0 0 0 9 1 0 8 0 11 0
2018 4 4 0 0 8 0 3 2 0 4 0
PERBANDINGAN KES DAN WABAK MEASLES BAGI TAHUN
2017 DAN 2018 MENGIKUT DAERAH DI NEGERI PAHANG
DAERAH 2017 2018

Bentong 1 4 (1)
Bera 0 4
C. Highland 0 0

Jerantut 0 0

Kuantan 9 8
Lipis 1 0
Maran 0 3
Pekan 8 (3) 2
Raub 0 0
Rompin 11 (2) 4
Temerloh 0 0
JUMLAH 30 (5) 25 (1)

NOTA : ( ) BILANGAN WABAK

KES MEASLES MENGIKUT KUMPULAN UMUR DAN STATUS IMUNISASI
DI NEGERI PAHANG BAGI TAHUN 2018 N=25
12

Tiada suntikan - 1%
10
Tidak diketahui - 8%

Telah disuntik (lisan) - 20%

8

Telah disuntik (rekod)- 44%

Bilangan kes

6
Belum layak - 24%

0
-
<9 bln 9 bln - 1 thn 2 -7 thn 8- 16 thn 17 - 25 thn 26 - 34 thn >35 thn

Kategori umur
KES DISAHKAN MEASLES MENGIKUT WARGANEGARA DI
NEGERI PAHANG BAGI TAHUN 2018, N=25
1; 4%
1; 4%

Malaysia
Indonesia
Thailand

23; 92%
 WABAK MEASLES DI NEGERI PAHANG
TAHUN 2015-2018
BIL TAHUN DAERAH LOKALITI BIL. KES BIL. TERDEDAH ATTACK RATE

1 2015 KUANTAN MAAHAD TAHFIZ DARUL FIKRI 6 211 2.8%

2 2016 LIPIS KUARTERS GURU MRSM KUALA LIPIS 2 108 1.9%

RUMAH KANAK-KANAK SULTANAH HAJJAH KALSOM,

3 2016 KUANTAN PENOR, KUANTAN 19 198 9.6%

4 2017 PEKAN MRSM TUN ABDUL RAZAK 5 785 0.6%

5 2017 PEKAN KG KALONG(OA) 2 22 9.1%

6 2017 PEKAN KG TANJUNG 2 22 9.1%

7 2017 ROMPIN KG.LANGKAP 14 273 5.1%

8 2017 ROMPIN KG DESA SEMARAK 2 350 0.6%

9 2018 BENTONG KOLEJ KOMUNITI BENTONG 3 294 0.7%

KES MEASLES MENGIKUT DAERAH DI NEGERI
PAHANG BAGI TAHUN 2018, N=25
KATEGORI KES DISYAKI MEASLES NEGERI PAHANG
TAHUN 2018 N=594
8% 4% 2% 4%

Lab-Confirm Measles (25)

Vaccines-Assosiated (12)

Rubella (20)

Valid Discard (489)

Non-Valid Discarded (48)

82%
 KATEGORI KES DISCARD DISYAKI MEASLES NEGERI
PAHANG TAHUN 2018
Kategori Kes Discard (n= 527)

48, 8

479, 92%

Valid Discard Non-valid Discard

*discard berdasarkan sampel urin/
throat swab
 TREN KES RUBELLA DI NEGERI PAHANG
TAHUN 2014 – 2018
25

20 20
B ilang an kes

15

11
10

6
5
4
1
0

Tahun
INDIKATOR MEASLES YANG DIPANTAU
 PENCAPAIAN INDIKATOR PROGRAM ELIMINASI
MEASLES NEGERI PAHANG TAHUN 2018
INDIKATOR
KLASIFIKASI KES

KES DISAHKAN SECARA KLINIKAL

VACCINE ASOSIATED MEASLES

KES DISAHKAN MAKMAL
KES
SASARAN INSIDEN DISIASAT
INSIDEN

EPID LINK

DISCARD

PENDING
RUBELLA
DAERAH POPULASI KES KES BUKAN DALAM 48
KES
DINOTIFIKASI NOTIFIKASI MEASLES JAM
(<1/1 juta)
(≥2/100,000) (≥2/100,000) NOTIFIKASI
(≥80%)

BTG 125,400 3 21 4     1   16   31.9 12.8 100.0%

BR 119,800 2 45 4     1   40   33.4 33.4 95.6%
CH 45,800 1 9           9   0.0 19.7 100.0%
JRT 94,900 2 38           38   0.0 40.0 100.0%
KTN 580,400 12 183 8     3 2 170   13.8 29.6 100.0%
LPS 99,700 2 14       1   13   0.0 13.0 100.0%
MRN 119,400 2 118 3     9 3 104   25.1 89.6 100.0%
PKN 116,600 2 16 2     2 1 11   17.2 10.3 100.0%
RB 104,400 2 26       2 2 22   0.0 23.0 100.0%
RPN 120,600 2 105 4       3 98   33.2 83.7 100.0%
TML 176,000 4 19       1 1 17   0.0 10.2 100.0%
PHG 1,703,000 34 594 25     20 12 538   14.7 32.3 99.70%
UJI MINDA
KES 1
• AS, 11 m/o baby, 1st MMR on 26.11.2018
• Fever on 6.1.19, maculopapular rash on 9.1.19, had cough, no
coryza or conjunctivitis.
• No Koplik’s spot
• 1st blood sample on D7 of rash - +ve for measles, negative for
rubella
• No throat swab or urine taken
• Not identify any secondary cases

• DIAGNOSIS?
Kes 2
• AR, 10 m/o baby, 1st MMR on 5.12.2018
• Fever on 10.1.19, maculopapular rash on 13.1.19, had cough but no
coryza or conjunctivitis.
• No Koplik’s spot
• 1st blood sample on D3 of rash - +ve for measles, rubella not done (not
enough sample)
• No throat swab or urine taken
• Not identify any secondary cases

• DIAGNOSIS?
KES 3
• NRS, 9 m/o baby, 1st MMR on 31.12.18.
• Fever on 1.1.19, maculopapular rash on 5.1.19, had cough and
conjunctivitis, but no coryza.
• No Koplik’s spot
• 1st blood sample on D2 of rash - +ve for measles, negative for rubella
• No throat swab or urine taken
• Not identify any secondary cases

• DIAGNOSIS?
Kes 4
• MSI, 10 m/o baby, 1st MMR on 20.2.2018
• Fever on 8.3.18, maculopapular rash on 8.3.18, had cough on
5.3.18, no coryza or conjunctivitis.
• No Koplik’s spot, no lymphadenopathy
• 1st blood sample on D8 of rash - +ve for measles, negative for
rubella
• Not identify any secondary cases
• Field investigation failed to identify other causes

• DIAGNOSIS?
Kes 5
• SM, 9m/o baby, 1st MMR 15.2.18
• Fever on 15.2.18, maculopapular rash on 19.2.18, had cough and coryza but no
conjunctivitis.
• No Koplik’s spot
• 1st blood sample on D3 of rash -> -ve for measles
• 2nd blood sample on D21 of rash -> +ve for measles

• No throat swab or urine taken

• Not identify any secondary cases

• DIAGNOSIS?
 Key Message……
1) SEMUA KES FEVER & RASH (TANPA DIAGNOSIS LAIN) WAJIB
DINOTIFIKASI SEBAGAI SUSPECTED MEASLES
2) SEMUA KES SUSPECTED MEASLES WAJIB DINOTIFIKASI
DALAM TEMPOH 24 JAM
3) SEMUA KES DISYAKI MEASLES DIKEHENDAKI MENGAMBIL
SPESIMEN YANG BETUL DAN MENCUKUPI
4) WALAUPUN HANYA 1 KES POSITIF MEASLES, PERLU DIBUAT
SIASATAN DAN ACD SEPERTI WABAK
5) PLEASE UPDATE SM2 AS SOON AS POSSIBLE
ANY QUESTION??