Population health and ethics for AMC MCQ

A 4 year old unvaccinated child presents with 4 days of high fever, cough, coryza and red eyes, and today a blotchy rash that started on the face and is spreading down the body. There are small white spots on the buccal mucosa. He has recently returned from overseas. He is sitting in a busy shared paediatric waiting room. What is the most likely diagnosis?

1. Measles correct Correct. The prodrome of fever, cough, coryza and conjunctivitis with Koplik spots and a descending maculopapular rash in an unvaccinated returned traveller is measles.
2. Enteroviral exanthem A non-specific viral rash without Koplik spots or the measles prodrome. Prodrome, Koplik spots and a descending rash in an unvaccinated returned traveller points elsewhere.
3. Kawasaki disease Prolonged fever with rash, conjunctivitis, mucosal and extremity changes in a young child. Prodrome, Koplik spots and a descending rash in an unvaccinated returned traveller makes it worth considering.
4. Rubella A milder illness with a rash and tender posterior cervical lymphadenopathy, dangerous in pregnancy. Prodrome, Koplik spots and a descending rash in an unvaccinated returned traveller points to it.
5. Scarlet fever A sandpaper rash with a strawberry tongue and sore throat from streptococcus. Prodrome, Koplik spots and a descending rash in an unvaccinated returned traveller raises it.

The point: Measles is a highly contagious notifiable disease and a model of population-health management. It presents with a prodrome of high fever, cough, coryza and conjunctivitis, then Koplik spots and a maculopapular rash spreading from the face down the body. It is diagnosed clinically and confirmed with a PCR and serology. Measles is a notifiable disease, so a suspected case is reported to the public health unit immediately, without waiting for confirmation, which triggers contact tracing and outbreak control. The infectious period runs from before the rash appears, so airborne isolation and keeping the patient away from waiting rooms are essential. Post-exposure prophylaxis for susceptible contacts is the MMR vaccine within 72 hours or normal human immunoglobulin within 6 days, with immunoglobulin for those in whom the vaccine is contraindicated, such as infants, pregnant women and the immunocompromised. The prevention is two doses of MMR, and low coverage is what allows outbreaks. Complications include pneumonia, encephalitis and the rare late subacute sclerosing panencephalitis.

Source: Australian Department of Health and Aged Care (CDNA) — Measles: national guidelines for public health units Australian Department of Health and Aged Care · tier 1, national regulator or guidance

A 4 year old unvaccinated child presents with 4 days of high fever, cough, coryza and red eyes, and today a blotchy rash that started on the face and is spreading down the body. There are small white spots on the buccal mucosa. He has recently returned from overseas. He is sitting in a busy shared paediatric waiting room. What is the most appropriate initial investigation?

1. Measles PCR and serology A nasopharyngeal or urine PCR and measles IgM confirm the diagnosis. Prodrome, Koplik spots and a descending rash in an unvaccinated returned traveller makes it confirmatory.
2. Airborne isolation on arrival The patient is isolated away from waiting areas because measles is airborne. Prodrome, Koplik spots and a descending rash in an unvaccinated returned traveller makes it immediate.
3. Assessment for complications Pneumonia and encephalitis are actively looked for. Prodrome, Koplik spots and a descending rash in an unvaccinated returned traveller makes it worthwhile.
4. Ascertainment of vaccination status Establishes susceptibility of the case and contacts. Prodrome, Koplik spots and a descending rash in an unvaccinated returned traveller makes it necessary.
5. Immediate notification to the public health unit correct Correct. Measles is notifiable and reported on suspicion, before confirmation, to start contact tracing and outbreak control.

The point: Measles is a highly contagious notifiable disease and a model of population-health management. It presents with a prodrome of high fever, cough, coryza and conjunctivitis, then Koplik spots and a maculopapular rash spreading from the face down the body. It is diagnosed clinically and confirmed with a PCR and serology. Measles is a notifiable disease, so a suspected case is reported to the public health unit immediately, without waiting for confirmation, which triggers contact tracing and outbreak control. The infectious period runs from before the rash appears, so airborne isolation and keeping the patient away from waiting rooms are essential. Post-exposure prophylaxis for susceptible contacts is the MMR vaccine within 72 hours or normal human immunoglobulin within 6 days, with immunoglobulin for those in whom the vaccine is contraindicated, such as infants, pregnant women and the immunocompromised. The prevention is two doses of MMR, and low coverage is what allows outbreaks. Complications include pneumonia, encephalitis and the rare late subacute sclerosing panencephalitis.

Source: Australian Department of Health and Aged Care (CDNA) — Measles: national guidelines for public health units Australian Department of Health and Aged Care · tier 1, national regulator or guidance

A 4 year old unvaccinated child presents with 4 days of high fever, cough, coryza and red eyes, and today a blotchy rash that started on the face and is spreading down the body. There are small white spots on the buccal mucosa. He has recently returned from overseas. He is sitting in a busy shared paediatric waiting room. What is the most appropriate next step in management?

1. MMR vaccine within 72 hours for susceptible contacts Post-exposure prophylaxis for eligible contacts given promptly. Prodrome, Koplik spots and a descending rash in an unvaccinated returned traveller makes it time-critical.
2. Supportive care for the case Fluids, antipyretics and rest, with vitamin A in specific settings. Prodrome, Koplik spots and a descending rash in an unvaccinated returned traveller makes it symptomatic.
3. Catch-up vaccination and coverage improvement Two doses of MMR and improving coverage prevent future outbreaks. Prodrome, Koplik spots and a descending rash in an unvaccinated returned traveller makes it preventive.
4. Normal human immunoglobulin within 6 days For contacts in whom the vaccine is contraindicated, such as infants, pregnant women and the immunocompromised. Prodrome, Koplik spots and a descending rash in an unvaccinated returned traveller makes it the alternative.
5. Notify the public health unit immediately correct Correct. The single most important population-health action, because it triggers the whole contact-tracing response.

The point: Measles is a highly contagious notifiable disease and a model of population-health management. It presents with a prodrome of high fever, cough, coryza and conjunctivitis, then Koplik spots and a maculopapular rash spreading from the face down the body. It is diagnosed clinically and confirmed with a PCR and serology. Measles is a notifiable disease, so a suspected case is reported to the public health unit immediately, without waiting for confirmation, which triggers contact tracing and outbreak control. The infectious period runs from before the rash appears, so airborne isolation and keeping the patient away from waiting rooms are essential. Post-exposure prophylaxis for susceptible contacts is the MMR vaccine within 72 hours or normal human immunoglobulin within 6 days, with immunoglobulin for those in whom the vaccine is contraindicated, such as infants, pregnant women and the immunocompromised. The prevention is two doses of MMR, and low coverage is what allows outbreaks. Complications include pneumonia, encephalitis and the rare late subacute sclerosing panencephalitis.

Source: Australian Department of Health and Aged Care (CDNA) — Measles: national guidelines for public health units Australian Department of Health and Aged Care · tier 1, national regulator or guidance