Authors affiliations:
*Royal Tropical Institute (KIT), Amsterdam, The Netherlands
** Department of epidiomology.Directorate of Health Services, Srinagar.,Kashmir India
** Department of Anatomy, Govt.Medical College, Srinagar

Correspondence to:
SM Kadri
Rode Kruislaan 1418 C, 1111 XD, Diemen,
Amsterdam, The Netherlands
gsm: +31630292620
e mail: kadrism@gmail.com, kadrism@hotmail.com

Measles is caused by an RNA paramyxovirus of which only one serotype is known. It contains a single strand of RNA, is highly pleomorphic, and ranges from 100 to 300 nm in diameter¹.

It affects virtually everyone in infancy or childhood, between 6 months and 3 years in developing countries, while in the developed countries of the West; children between the ages of 3 to 6 years are infected. There is a current trend of measles occurrence in adult age groups, especially in the developed countries, but developing countries are not exempt (e.g. Thailand).

The virus can spread in any season. In temperate climates, measles is a winter disease, because of overcrowding. Epidemics are common in India in the months of winter and early spring.

Cases of measles are the major source of infection, while the subclinical cases are more numerous and are also a source of infection. Infective material is the secretions from the nose, throat and respiratory tract of a case of measles in the prodromal stage and at the time of eruption. Droplet nuclei can remain in the environment for 1 hour.

Communicability declines after appearance of a rash. 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. Secondary attack rate is 80 percent among household contacts. The incubation period is 10 days. The incubation period with vaccine is shortened to 7 days

Clinical features include a Prodromal phase (day 10-14), eruptive phase (day 14 -18) + post-measles stage.

Complications are many, especially in malnourished persons, those with poor immunity, and pregnant women. They include Measles associated diarrhoea, pneumonia, other respiratory complications, otitis media, Sub acute Sclerosing Pan Encephalitis (SSPE),

Encephalitis and Severe acute deficiency of vitamin A
Diagnosis is primarily clinical. IgM antibody titer by ELISA can also be carried out. Detection of measles antigen in saliva or urine, where resources permit, or where it is epidemiologically important should be carried out. In vaccinated children, a four-fold increase in measles antibody titre can be demonstrated within 2-6 weeks.

Special Concerns for women:
Women who get measles during pregnancy may be at risk for a miscarriage, stillbirth or pre-term (early) delivery. If someone who is pregnant develops measles or has been exposed to a case of measles she should talk with her health care provider. Although in adults, the measles vaccine is usually given in combination with mumps and rubella vaccine (MMR), it cannot however be given to pregnant women. Thus, depending on the situation, the healthcare provider should administer immunoglobulin, or IG, as soon as possible after known exposure. Immune globulin can either prevent development of measles or result in a milder infection. Immune globulin (IG) is ideally administered within 6 days of exposure to decrease severity of measles. If someone is planning to get pregnant and is not sure if she has had measles or the measles vaccination, the healthcare provider may suggest an MMR vaccine. However, a woman should not get the vaccine if they plan to become pregnant within the next four weeks or may already be pregnant. There are no concerns if a man wishes to receive this vaccine and is planning to have a child. Breast-feeding does not interfere with the response to MMR vaccine and poses no risk to the infant being breastfed.

Background:
Kashmir (the Switzerland of India), its natural beauty, the glorious climate and other attractions of the Kashmir valley have been so much appreciated that the new-comer is apt to picture themselves to be in a paradise on earth.

A team from the Department of Epidemiology, Directorate of Health Services surveyed all the areas and assessed the cases for the clinical manifestation of measles and randomly took blood samples from 147 cases i.e. (20% of cases) for serological confirmation and genotyping.

Findings:
During a recent outbreak of measles epidemic in J&K state, a total of 736 cases of measles occurred within a period of 3 months (March 2007-May 2007) Spring season. Figure 2.

The age breakup of measles cases in Kashmir is tabulated below:

Figure 1 PIE CHART SHOWING PERCENTAGE DISTRIBUTION OF CASES IN VARIOUS AGE GROUPS.

The age breakup of cases shows that measles is shifting from its traditional age group (below 3 years), and affecting higher age groups. In India the majority of cases occur in children below 3 years of age, while we see here that although the maximum number of cases (44.42%) are still occurring in children (0-5 years of age), a good percentage of cases are occurring in higher age groups (55.58%). Out of these, 20.88% are occurring in adults also (>18 years of age). Even cases above 40 years of age have occurred (30 cases). The severity of cases was mild in adults.

Figure 2 showing total no. of cases by Month.

Vaccination status;
Immunization cards were assessed to find the measles vaccination status status. If cards were not available parents/family members were questioned in this regard. Table 3

Serology
A total of 147 blood samples were subjected to serological tests in our Regional laboratory. 83 cases were reactive and 64 cases were non reactive for IgG and IgM antibodies to measles virus in ELISA. 12 blood samples and throat swabs were sent to NIV Pune for genotyping. (D4 strain)

Measles is one of the most infectious diseases known to man and remains the leading cause of vaccine preventable deaths in children worldwide. In many countries measles is still a great public health concern.^1-7 despite the easy availability of vaccination for its control, vaccination uptake has been sub -optimal in some countries⁸.

The diagnosis of measles is often based on the signs and symptoms (fever, malaise, conjunctivitis, coryza and tracheo-bronchitis). Kopliks spots appear on the buccal mucosa 1-2 days before the onset of rash. The rash is typically an erythematous maculopapular rash.⁴
The most definitive method of diagnosis of measles is either isolating the virus from the throat or by serologic test for antibodies.

Complications include diarrhea, pneumonia, subacute sclerosing pan encephalitis (SSPE), deafness, mental retardation or death.^11,13

It has been postulated through various studies carried out around the world that there will be a three fold increase in measles mostly in the 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 death.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 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.12

A study of the Centers for Disease Control and Prevention says that about 3 million Americans between the ages of 20 to 37 are at risk of catching measles. The disease is more dangerous to adults than children. The grown ups are at risk because most of them never got a second dose of measles vaccine.^3,6,7

A reported measles outbreak in Victoria, Australia in 1999 has suggested that a substantial proportion of young adults (18-30 years old) may be susceptible to measles infection.⁵
NICD has pointed out low vaccine coverage and poor surveillance responsible for measles outbreaks in different parts of India.¹⁴

Eberhart-Phillips JE, Frederick PD, Baron RC, Mascola L.at Division of Field Epidemiology, Centers for Disease Control and Prevention, Atlanta, Georgia carried out research where 58 pregnant women with measles were identified by county health department records, and their hospital and clinic records were reviewed. It was concluded that the incidence of death and other complications from measles during pregnancy might be higher than expected for age-comparable, non-pregnant women. Measles in pregnancy may lead to high rates of fetal loss and prematurity, especially in the first 2 weeks after the onset of rash.

In this study, a total of 736 cases of measles occurred during the period of three months (March 007 to May 2007). All of these cases were diagnosed on the basis of clinical signs and symptoms like fever, maculopapular rash, cough, conjunctivitis and coryza.

Complications, such as pneumonia and diarrhea were encountered. The pregnant women who was included in the study delivered a healthy male.
However no death was noted in this study.

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 are 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 there is waning immunity in the immunized individuals, 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 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.

1. Centers for disease control and prevention: Measles-USA, 2000.
   M.M.W.R.Morb.Mortal.Wkly.Rep.51 (6):120-123, 2002.
   
2. Chalmers, I.: Why we need to know whether prophalytic antibiotics can reduce measles-related morbidity, Pediatrics 109:312-315, 2002.
   
3. Dales, L<Hammer, S.J, Smith, N.J Time trends in autism and in MMR immunization coverage in California. J.A.M.A. 285:1183-1185, 2001.
   
4. Koplik, H: A new diagnostic sign of Measles.Med.Rec.53:505, 1898.
   
5. Kelly HA, Riddell MA, Lambert SB Measles immunity among young adults in Victoria, Common Dis Intell 1999; 25(3): 129-132
   
6. Miller M, Williams WW,Redd SC,Measlesa among adults United States,1985-1995.Am J Prev Med 1999,17(2);114-119.
   
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8. King a, Varughese P, De Serres G, Tipples GA, Waters J. Measles elimination in Canada. J Infect Dis. 2004; 189(Suppl 1):S236-42. [PMID: 15106117].[Medl
   
9. Papania MJ, Seward JF, Redd SB, Lievano F, Harpaz R, Wharton ME. Epidemiology of measles in the United States, 1997-2001. J Infect Dis. 2004; 189(Suppl 1):S61-8.
   
10. Vukshich Oster N, Harpaz R, Redd SB, Papania MJ. International importation of measles virus-United States, 1993-2001. J Infect Dis. 2004; 189(Suppl 1):S48-53.
    
11. The State of the World's Children 2006. New York: UNICEF; 2005.
    
12. World Health Organization. WHO vaccine-preventable diseases: monitoring system: 2004 global summary. Geneva: World Health Organization; 2004.
    
13. Technical instructions to panel physicians for vaccination requirements. Atlanta: Centers for Disease Control Division of Global Migration and Quarantine Health. Accessed at http://www.cdc.gov/ncidod/dq/pdf/TI.pdf on 5 November 2005.
    
14. NICD, CD Alert, Measles continuing to remain a major public problem in India, 2000, 4(5); 2-4.