According to the WHO, in 2017, 15 countries with an outbreak of the disease were registered, including those with a high human development index (HDI).
The 3 most affected were Romania, Italy and Ukraine, with 5562, 5006 and 4767 cases diagnosed, respectively.
What is measles?
Measles is a highly contagious infection , transmitted by a virus in the Morbillivirus family . The signs mainly involve changes in the skin, called erythematous rash, accompanied by fever , cough , runny nose and malaise, for example.
Listed under ICD-10 B05, the infection can be further classified as:
- B05.0 – Measles complicated by encephalitis;
- B05.1 – Measles complicated by meningitis;
- B05.2 – Measles complicated by pneumonia;
- B05.3 – Measles complicated by otitis media;
- B05.4 – Measles with intestinal complications;
- B05.8 – Measles with other complications;
- B05.9 – Measles without complications.
The disease can also infect adults or children, but it is more prevalent in childhood.
The virus is transmitted when the person comes into contact with the infected patient’s secretions. It can occur through coughs, sneezes or droplets of saliva that spread through the air.
When the person is exposed and infected by the virus, an incubation period of approximately 12 days occurs. This means that the symptoms may take time to appear.
That is, even without any apparent symptoms or signs, the person has the virus and can transmit it.
There are still serious complications related to the disease, which can result in brain infections ( encephalitis ), pneumonia and brain damage.
Especially in untreated cases, in children under 5 years old or in patients with immunity problems, the condition can be fatal, representing between 5% and 20% of deaths due to the evolution of the condition.
In the world, there is an intense mobilization to fight the disease through the vaccination of children. But underdeveloped countries still have low success in fighting measles, due to low immunization and malnutrition.
What are viruses?
Several diseases can be caused by viruses, which are considered parasites. The word comes from the Latin and means “poison” or “toxin”.
The virus is considered a mandatory intracellular parasite, as it needs to be linked to a cell to reproduce (replicate its genetic material). It is composed of DNA or RNA, capsid, envelope, nucleocapsid and matrix, which together form the viral structure.
By attaching to a cell, the parasite is able to change its behavior and transmit its own genetic information, forming new viruses inside the cell.
The measles virus
The structure that transmits measles belongs to the Paramyxoviridae family , being classified in a subgroup called Morbillivirus .
Despite being highly contagious, outside the body the virus is considered fragile, as its life is relatively short.
Heat, light, acidic pH and some chemicals are able to neutralize the virus. That is, kill him.
Measles eradication certificate
In February, the Ministry of Health announced that Brazil is no longer free from measles.
Between 2015 and 2017, no cases were detected in Brazil. So much so that it was during this period that the measles eradication certificate was granted to Brazil. More specifically in the year 2016.
However, the drop in vaccination coverage was significant and allowed the disease to circulate again. In 2015, about 96% of the population was immunized, but in 2017 the number reached just 85%.
Also in February 2018, the first case was detected and, from that date, measles manifestations were monitored. That year, more than 10,000 cases were reported, characterizing an outbreak of the disease.
If in 12 months there was still circulation, the certificate would be withdrawn.
Due to the incidence of confirmed cases for the same virus during 12 months, Brazil lost the certificate.
In early 2019, the states of Amazonas, Roraima and Pará were in the group of regions with an outbreak alert. Among the most pointed causes is the drop in vaccination rates.
What are the stages of measles?
Measles can be divided into phases, according to the manifestation of symptoms.
In the first days after infection, the organism still does not show symptoms or signs, as the virus is in the incubation phase. The period lasts, on average, 10 days, but it can vary between 7 and 18 days after the infection of the organism.
Prodromal or prodrome stage
They represent the first manifestations of measles.
Initially, there is a manifestation of inflammation of the mucous membranes of the nose, pharynx, larynx and bronchi, in addition to eye irritation. This phase is called prodrome.
It is possible to notice red and sore eyes, often with a tendency to water. At this stage, the disease can even be mistaken for a cold or flu , because there is usually a cough, sneezing, runny nose and hoarseness.
In some cases, there may be cough with sputum and pain in the chest area.
About 3 days after the initial symptoms, the patient may experience fever, headaches and muscle pain, decreased appetite and malaise.
Between 12 and 72 hours, lesions appear on the roof of the mouth and on the inside of the cheek, but the condition usually occurs within the last 24 hours of the prodrome.
The wounds are small and whitish, as if they were small canker sores. Many patients experience a slight reduction in fever during this period, which can last between 2 or 3 days.
Exanthematic phase
The most characteristic symptom of measles is skin rashes, which are reddish in appearance and can cause burning or itching.
The lesions usually begin in the regions close to the ear and head, and continue to spread throughout the body. All regions of the skin can be affected, including the palms of the hands and the soles of the feet.
Symptoms may worsen, which is the acute phase of the disease. In addition, there may be other manifestations, such as:
- Increased secretions in the upper respiratory tract;
- High mucus production in the lungs;
- Hoarse voice;
- Inflamed pharynx and mouth;
- Elevated fever;
- Aggravated malaise.
Desquamative phase
At this stage, the stains darken, causing a fine flaking. However, fever and cough decrease considerably. Among the main signs are:
- Intense conjunctivitis.
- Pneumonia.
- Ear infection.
- Diarrhea.
- Encephalitis.
- It rarely progresses to subacute sclerosing panencephalitis.
Causes and transmission
Measles is caused by direct contact or with fluids from the infected person or by touching secretions or surfaces contaminated by the virus and bringing your hands to your mouth, eyes or nose.
It is possible that the infection also occurs through the use or sharing of cutlery or personal items that are not sanitized.
The virus is so widespread that, according to the organization Médecins Sans Frontières (MSF), more than 90% of people without immunity who share the same environment as an infected patient will catch the disease.
It is important to remember that the patient can transmit the virus even without showing symptoms. Therefore, it is not possible to know exactly who is sick.
Transmission occurs through the airways, through droplets in the nose, mouth or throat that are disseminated in the air when the infected person sneezes, coughs and speaks .
For this reason, closed environments, such as classrooms, schools and hospitals, are more prone to contamination, due to the low air circulation that can keep the virus suspended in the environment.
Groups and risk factors
People who have not been vaccinated and who have never been infected with the virus are susceptible to measles.
Health professionals, tourists and people who deal with foreigners (airport workers, for example) may be more subject to contamination.
Young children, less than 2 years old, have risk groups for the disease. However, even though measles is more frequent in childhood, adolescents and adults generally have more severe conditions.
In addition, pregnant women, immunocompromised and malnourished patients are more likely to develop complications of the disease.
Symptoms
The most obvious signs of measles are skin rashes, characterized by small reddish spots that affect the body.
The symptom is called erythematous maculopapular rash. Despite affecting a large part or all of the skin tissue, the spots are not harmful to health, being one of the most harmless symptoms of the disease.
In addition, small sores or whitish spots appear in the mouth, usually on the inside of the cheek and on the gums. Similar to thrush, these lesions are called Koplik’s spots and precede the appearance of skin lesions (rash).
Several manifestations may occur during the infection period, such as:
- High fever, above 38 ºC;
- Diarrhea;
- Persistent cough;
- Eye irritation and inflamed eyes;
- Runny nose (runny nose);
- Sensitivity to light;
- Infection in the nose;
- Conjunctivitis;
- Vomiting and nausea;
- Malaise;
- Ear infection;
- Seizures and stare;
- Brain injury.
But it is the symptoms and respiratory complications that can cause greater risks to the patient’s health, among them:
Breathing problems
Runny nose, cough and sputum are quite common manifestations of measles. The symptoms, which are similar to those of the flu, can confuse the initial diagnosis.
In most cases, respiratory problems are uncomplicated and evolve significantly well.
However, part of the patients may present complications of the pulmonary condition, otitis, sinusitis and central nervous system involvement.
Measles itch?
Measles causes less itching than other diseases, like chicken pox . However, it is possible that in the rash stage, when skin rashes occur, the patient will experience burning and itching.
How is the diagnosis made?
The disease was so frequent in the past that many parents or grandparents were able to make a previous diagnosis through the appearance of skin lesions.
It is like today when we get the flu and we know, or deduce, that the symptoms refer to the flu, even without consulting a specialist.
However, currently doctors, clinics and hospitals follow the procedure for detecting the infection. To perform the test, the presence of IgM antibodies in the blood is checked.
The antibodies appear because the body is producing defense cells to fight the disease.
The test is effective in the acute phase of measles, that is, from initial contamination to 4 days after the first signs on the skin (the rashes).
Although the clinical examination (the one that the diagnosis is made only by observing the symptoms) is done, it is recommended that all suspected cases undergo the laboratory test.
For clinical diagnosis, the patient must have a cough, runny nose or conjunctivitis (at least 1 of these 3 symptoms), along with fever for more than 3 days.
The most qualified professionals to make the diagnosis of measles are the general practitioner, the infectologist, the pediatrician and the dermatologist.
Differential diagnosis
The physical manifestations and symptoms of measles can be quite wide, as several diseases have a high fever and skin rashes.
In this case, it is necessary to differentiate the condition from other infections or pathologies, mainly:
- Rubella;
- Infectious erythema;
- Sudden rash;
- Scarlet fever;
- Enteroviruses (coxsackie and echo);
- Dengue.
Exams
The Ministry of Health indicates that the test adopted by Brazil for the laboratory diagnosis of measles is the ELISA (Enzyme Linked Immunosorbent Assay).
The test consists of a traditional blood collection , in which the antibodies present in the sample will be analyzed.
In the first days after the appearance of skin lesions, IgM and IgG antibodies can be detected in the blood.
In general, IgM remains elevated in the blood for up to 6 weeks after signs of rash (skin rashes), whereas IgG can remain altered for many years.
However, all suspected measles cases should be examined within the indicated period (up to 4 weeks after the appearance of the skin spots).
Some of the procedures adopted in other countries involve:
- ELISA for IgM and IgG measurement;
- Hemagglutination (HI) inhibition for total antibody measurement;
- Immunofluorescence for measurement of IgM and IgG;
- Neutralization in plates.
They are all blood tests that check for the presence of the virus. The difference is the method used to detect the infection.
Is there a cure?
-Yeah . In general, the infection does not present severe complications for most patients, except in cases where there is HIV positive, malnutrition or other diseases that compromise the immune system.
After being infected, the body creates resistance, making the patient immune to other exposure to the virus.
There is a worldwide mobilization to reduce and deplete measles cases through vaccination. To that end, public policies in several countries encourage the measure, causing cases of contamination to be drastically reduced.
What is the treatment for measles?
There is no specific treatment for measles. After being contaminated, the organism needs to fight the infection.
Some measures can facilitate treatment and improve the body’s responses. For example, the use of anagenic and antipyretic medications can bring significant improvements during the recovery time, since the fever and malaise can be a major discomfort, especially for children.
In addition, medications for respiratory infections, eye drops or ointments to relieve itchy skin can be combined, when indicated by the doctor.
Generally, it is recommended that children use vitamin A supplementation to avoid worsening the condition, following dosages and determinations specified by the doctor.
The use of eye drops and saline to clean the eyes is usually prescribed, helping to ease the discomfort.
In cases where there is diarrhea , pneumonia and otitis media, treatment and specific monitoring for the conditions must be started.
Hot drinks, such as teas, can aid in throat discomfort. As the mucous membranes are usually irritated, fluid intake (at any temperature) is extremely recommended.
If there is cough with sputum, hot drinks can help clean the respiratory tract. Inhaling also favors breathing, which is often compromised (nose blocked or runny).
The patient needs to rest, hydrate properly and choose light foods. It is recommended to take care of the nutritional balance, avoiding deficiencies in the body, which can aggravate the symptoms.
Medicines
In cases of severe fever and pain, the doctor may prescribe the use of antipyretics, such as paracetamol .
Vitamin A can be administered, especially to children or newborns, helping to prevent the condition from worsening.
The saline and lubricating eye drops help in cleaning the lubrication of the eyes, easing discomfort and eye irritation.
Attention!
NEVER self-medicate or stop using a medication without first consulting a doctor. Only he will be able to tell which medication, dosage and duration of treatment is the most suitable for his specific case. The information contained in this website is only intended to inform, not in any way intended to replace the guidance of a specialist or serve as a recommendation for any type of treatment. Always follow the instructions on the package insert and, if symptoms persist, seek medical or pharmaceutical advice.
Prognosis
The prognosis of measles is generally good if the child or adult does not have malnutrition or immunological problems.
In general, the disease does not present itself seriously or with complications, unless the patient already has other diseases that affect immunity. In this case, the progress of measles can be quite aggressive and life-threatening.
Living together
When a person is diagnosed with measles, some measures need to be taken so that the period of infection results in less disturbance and discomfort to the patient.
Skin rashes can usually itch and become a constant nuisance. In addition to the medications and ointments indicated by the doctor, it is recommended to keep the temperature of the environment pleasant (not too heated), and if possible to avoid smothering the skin with tight clothing.
The lighter and more comfortable the fabrics used, the less the friction with the skin. In addition, cold compresses can help reduce itching and burning. Hydration of the body is also essential, so it is necessary to drink plenty of fluids, especially if the condition presents with fever.
The diet should be regular, light and nutritious. In this sense, it is necessary to maintain a balanced intake of nutrients.
It is recommended to avoid environments with strong or irritating smells, as they can cause allergic reactions, due to the sensitivity of the organism.
As measles requires the patient to stay away from social life temporarily, it is necessary to organize activities for daily needs. For example, keep food, emergency phones and medicines accessible.
The bedding, blankets, pajamas or other fabrics used by the patient must be washed separately. It is recommended to heat the water to perform the washing.
For friends or family members who live with the patient, it is necessary to intensify hygiene care, washing their hands frequently and using alcohol gel.
Objects used by the patient, such as glasses and cutlery, must be maintained and handled separately.
For fathers and mothers of young children, it may be more difficult to maintain the distance, due to the necessary care for the patient. In this case, the use of gloves and masks may be recommended, always keeping the environment well ventilated.
Complications
When the disease has more severe symptoms, breathing problems can occur, such as:
- Purulent rhinitis;
- Laryngitis;
- Pharyngitis;
- Otitis;
- Bronchitis;
- Meningitis;
- Strabismus;
For pregnant women, complications involve a high risk of miscarriage during the first trimester of pregnancy, in addition to causing premature birth . There are also increased risks of malformation of the fetus.
In immunosuppressed people, severe interstitial pneumonia and blindness due to corneal injuries are more likely. It is still possible to worsen the infection, which can lead the patient to death.
The most severe complications associated with measles are:
Encephalitis
For every 1,000 and 2,000 children diagnosed with measles, about one case of encephalitis occurs. The condition is a brain infection that can be brief, having a good recovery, or prolonged, resulting in brain damage and even death.
Neuritis
Neuritis is an inflammation of the nerve that causes pain, decreased sensitivity, atrophy and reduced vision. The condition can lead to blindness as well. Factors such as trauma, eye damage, degenerative diseases and infections or intoxications can trigger the condition.
Excessive bleeding
After the body fights the infection, the levels of platelets in the blood can drop dramatically, causing thrombocytopenia . Platelets are responsible for blood clotting when injuries occur.
In this case, purple spots are observed on the patient’s skin, in addition to bleeding or difficulty in clotting.
Subacute sclerosing panencephalitis
The condition causes progressive brain damage, usually representing severe life-threatening conditions, but it is a rare condition.
The measles virus can infect the brain and cause encephalitis. It is possible that the virus remains in the organ for years and does not show any symptoms.
However, years later, it can be reactivated, causing subacute sclerosing panencephalitis. The condition has a tendency to manifest between 7 and 10 after measles diagnosis, but can occur in other periods.
In addition, there is a higher prevalence in people who were infected before the age of 2.
Pneumonia
The condition occurs when there is severe pulmonary impairment. On average, 5% of patients develop the condition, being one of the main causes of death for babies and young children.
How to prevent measles?
The most effective method of prevention is the vaccine against measles. Approximately 97% of vaccine people are immune to measles.
Immunization occurs between 14 and 21 days after the vaccine is administered. Therefore, people who are going to travel to regions with measles outbreaks must have the injection in advance.
Even if immunized, it is recommended that there is no direct exposure to the infected patient, especially without protection (such as masks).
Pregnant women or women who may become pregnant within 90 days should not be vaccinated. Adults who have not been vaccinated as children, however, can and should take doses.
Vaccine
The vaccine proves to be effective in 97% of patients, being a worldwide recommendation. In Brazil, the Brazilian Immunization Society recommends that two applications be made.
Private clinics offer the vaccine, however, in Brazil, the Basic Health Units carry out the application, offering the two dosages according to the vaccination schedule.
Women up to 49 years old and men up to 39, who are not up to date with the dosages, can also receive the dosage in the units free of charge.
Until 2013, children received 2 doses of the triple viral (dosage that included protection against measles, mumps and rubella ).
Currently, the vaccination schedule foresees that 12-month-old children will be vaccinated with a dose of the triple viral, and at 15 months of age they will receive a second dose called tetra viral, which includes immunization for measles, mumps , chickenpox and rubella .
| Vaccine | At what age do | What does it protect against? |
| Triple Viral | 12 months | Measles, mumps and rubella |
| Viral tetra | 15 months to 4 years | Measles, mumps, rubella and smallpox |
For children who were unable to receive the dosage at 15 months, immunization can be done, within the period of the vaccination calendar, up to 4 years, 11 months and 29 days.
Adults who have not received the vaccine at the age indicated should receive it at any age. Pregnant women and immunosuppressed people, on the other hand, do not have the indication to receive the vaccine, as soon as they have the weakened virus, but they are still alive.
The national measles scenario has changed dramatically with vaccination. Before immunization entered the vaccination schedule, it was considered that almost all children would be infected with measles.
As the contamination was great, many of them had complications from the disease. In addition, the number of victims was also quite high.
It was in the 1960s that the vaccine was launched in Brazil. Immunization lasts for a lifetime, being a safe and very effective method to fight infections.
Vaccination campaign: D-day
It is important to remember that measles vaccines are offered throughout the year to people within the age range indicated in the vaccination schedule.
The so-called D-Day promotes a day, within the vaccination campaign, to reinforce the immunization of specific diseases.
For measles, even children who have already received the doses should take it again, as there are no health risks.
In addition, the date allows those who were unable to receive the vaccine to update the passbook.
Contraindications
Not everyone can get the vaccine, and some cases need to be evaluated by a doctor.
Among the groups are pregnant women, people with immunodepressive illnesses, who use medications that affect immunity or who are allergic to components of the vaccine.
As the compound has traces of chicken egg protein, the vaccine can cause allergic reactions, especially in children.
However, it is observed that the reactions are moderate, not compromising the child’s health, even those who have severe allergies.
However, it is necessary that the allergy is known by the health professional who will administer the dosage so that, if severe reactions occur, the care is done quickly.
Reactions and side effects
Up to 10% of patients may experience redness and burning at the application site, in addition to fever above 38 ºC.
Between 1% and 10% of vaccinees may experience respiratory infections, swelling at the application site and skin reactions such as rashes and injuries.
Skin changes usually occur in 3% of patients, appearing approximately 12 days after the vaccine.
High fever, above 39.5 ºC, can occur in up to 15% of vaccinees, and some isolated cases (between 0.01% and 0.1%) develop into a febrile seizure, but the condition has no sequelae or damage severe.
Cases of inflammation in the ear (otitis media), swollen lymph nodes, especially in the neck, armpits and groin (lymphadenopathy), loss of appetite, conjunctivitis, bronchitis , cough, swelling of the salivary glands, diarrhea and vomiting occur in up to 1 % of vaccinated.
In addition to these episodes, rare reactions (less than 0.1%) were observed after the injection:
- Meningitis;
- Measles-like syndrome;
- Mumps-like syndrome;
- Epididymitis (inflammation of the epididymis);
- Difficulty in coagulation and bruising;
- Serious allergic reactions;
- Encephalitis (inflammation of the brain);
- Cerebelitis (inflammation of the cerebellum);
- Transient gait disorders (difficulty or inability to move)
- Guillain Barré syndrome (generalized disease of the nerves);
- Inflammation of the spinal cord;
- Swelling of the arms and legs with the presence of severe pain;
- Vasculitis (inflammation of blood vessels);
- Severe skin rashes;
- Pain and swelling in the joints.
Vaccination recommendations
Although the vaccine is on the vaccination schedule, being indicated for all children, except in specific cases, some groups must redouble their attention during periods of outbreak or spread of the disease.
Health professionals
Due to the intense flow of people and direct contact with various diseases, health professionals are encouraged to check the conditions of immunization.
Workers from different health areas who are not committed to immunization campaigns can bring risks to their own health and that of others, and can transmit and disseminate the infection to patients who, in general, already have compromised immunological conditions.
Travelers and tourists
Tourists or people traveling to regions with measles cases should be aware of immunization.
When the vaccination card does not guarantee that the patient, older than 6 months, has been immunized, it is necessary to warn about the need to take the dosage at least 2 weeks before the trip.
Children under 6 months, lactating women, pregnant women and people with immune deficiency should avoid traveling during periods of risk.
Measles in babies
The first dose of the measles vaccine should occur at 12 months. Therefore, before that age, the baby is more sensitive to infection.
If the baby needs to travel to areas at risk or has been exposed to the virus or if outbreaks of the disease occur, the vaccine can be administered before the scheduled period under medical advice.
According to the General Directorate of Health, a dose can be administered between 6 and 12 months, being considered an extra vaccination. That is, it does not replace the two doses that appear in the official calendar, and the next vaccine must respect a period of 4 months.
Care for sick babies is the same as that recommended for adults and should follow medical recommendations.
In this case, frequent and intense crying is common due to the discomfort of skin lesions and fever. Cold ointments and compresses can relieve discomfort.
It is necessary to avoid the patient’s contact with other children, maintaining attention to food, hydration and hygiene.
Measles epidemic
It is estimated that, before the implementation of immunization programs, measles outbreaks occurred every 3 to 6 years, according to the Ministry of Health.
In Brazil, the last measles epidemic occurred in 1997 and accounted for 53,000 cases of infection and 61 deaths. At the time, the vaccine was already available for sale.
Most cases affected patients who were not immunized or who took only one dose of the vaccine.
In 1991, Brazil launched the Measles Eradication Plan, aiming to reduce cases of infection and eradicate the disease until the 2000s.
Common questions
What to do when measles are suspected?
The patient should see a health professional when there is discomfort and skin rashes for an assessment of his condition. If measles are suspected, tests will be requested to confirm the diagnosis.
Even cases of suspicion that have not yet been confirmed must be reported to the State Department of Health.
The patient should be removed from his activities, remaining isolated from other people until the diagnosis is made. If confirmed, isolation should remain until the infection is no longer transmissible.
Does the measles vaccine cause autism?
No. There is a dissemination of incorrect information about numerous vaccines, causing a disincentive to immunization. The determined dosage is safe and does not pose any risk to the population, except pregnant and immunocompromised people.
The rumor that the vaccine can cause autism stems from a study published in 1998 by British physician Andrew Wakefield, who pointed out autism as a consequence of the triple viral vaccine.
Some time later, it was verified that the researcher, in fact, defrauded the reports of the studied patients and adulterated the results.
Andrew Wakefield lost his medical record and was accused of misconduct in exchange for money. The doctor received about 435,000 pounds (more than 2 million) to defraud the results.
Who should get the measles vaccine?
Everyone should be immunized against measles.
The vaccination scheme offered by the Ministry of Health indicates that children between 12 months and 5 years receive 2 doses. Adults between 30 and 49 years old need to take just one.
Who has not been vaccinated or is not sure, can receive a booster too. And they are all found free of charge at health centers or units.
Measles kills?
-Yeah . Especially in patients with low immunity or impairment of the organism (for example, associated diseases or malnutrition), measles can trigger severe complications and lead to death.
What are the reasons for the new cases?
Although there are policies for vaccination, 2017 and 2018 show an increase in the diagnosis of the infection.
Countries with a low HDI present risks related to the increase of the disease, since the vaccinated population rate is still low.
Even in developed countries, it is in the poorest population that measles is most affected. This is due to poor diet and malnutrition combined with the lack of immunization.
However, a recent outbreak of anti-vaccine people has worried the medical community and authorities. In these cases, parents and family decide not to immunize children because they are against vaccination.
The groups’ justification is, above all, the spread of false news (such as thinking that the measles vaccine causes autism), and the belief that drugs and vaccines would harm health.
In 2017, of the 1,600 measles cases diagnosed in Europe, 88% had not taken the vaccine.
Measles is a disease well known to the population, being classically attributed to childhood.
In the past, there was a popular belief that the sooner the child was infected, the less dangerous the disease would be. In addition to being quite mistaken, the belief caused mothers to promote contact between their children and an infected patient, causing the virus to circulate more intensely.
After a few years, studies have shown that the condition is exactly the opposite, as the baby’s immune system can be more fragile, making the infection more dangerous and aggravated.
Today, there are worldwide campaigns that aim to reduce and deplete measles cases, reducing the aggravating factors of the disease.
Immunization is safe, simple and part of the national vaccination calendar, being the most effective measure to prevent infection.
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