Sections View Full Chapter Figures Tables Videos Full Chapter Figures Tables Videos Supplementary Content + Print Section ++ For further information, see CMDT Part 32-02: Major Vaccine-Preventable Viral Infections + Key Features Print Section ++ ++ Essentials of Diagnosis ++ Exposure 7–18 days before onset of prodrome in an unvaccinated patient Prodrome: Fever Coryza Cough Conjunctivitis Malaise Irritability Photophobia Koplik spots Rash Brick red, irregular, maculopapular Appears 3–4 days after onset of prodrome Begins on the face and proceeds "downward and outward," affecting the palms and soles last Leukopenia ++ General Considerations ++ Transmitted by inhalation of infective droplets Highly contagious Communicability is greatest during the preeruptive and catarrhal stages, continuing for 4 days after the appearance of rash Illness confers permanent immunity ++ Demographics ++ The 2019 outbreak of measles is associated with 268 cases between January 1, 2019 and March 14, 2019 in 15 states The highest recent number of cases was 667 persons in 27 states in 2014 followed by 372 cases in 2018 Globally, measles continues to affect large numbers, with WHO estimating 7 million infections for 2016, the year with most recently compiled data + Clinical Findings Print Section ++ ++ Symptoms and Signs ++ Prodromal phase Fever Malaise may be marked Coryza (nasal obstruction, sneezing, and sore throat) Persistent and nonproductive cough Conjunctivitis manifests as redness, swelling, photophobia, and discharge These symptoms intensify over 2–4 days before onset of the rash and peak on the first day of the rash Characteristic measles rash appears on the face and behind the ears Initial lesions are pinhead-sized papules that coalesce to form a brick red, irregular, blotchy maculopapular rash Spreads to the trunk and extremities, including the palms and soles Lasts for 3–7 days and fades in the same manner it appeared Koplik spots Small, irregular, and red with whitish center on the mucous membranes Appear about 2 days before the rash and last 1–4 days as tiny "table salt crystals" on the palatal or buccal mucosa opposite the molars or on vaginal membranes Other findings Pharyngeal erythema Tonsillar yellowish exudate Coating of the tongue in the center with a red tip and margins Moderate generalized lymphadenopathy Splenomegaly ++ Differential Diagnosis ++ Kawasaki disease May be mistaken for other exanthematous infections + Diagnosis Print Section ++ ++ Koplik spots are pathognomonic Leukopenia usually present unless secondary bacterial complications exist Thrombocytopenia is common Proteinuria is often observed Real-time reverse transcriptase-polymerase chain reaction (RT-PCR), available from the CDC and some public health laboratories, can help establish a diagnosis Detection of IgM measles antibodies with ELISA or fourfold rise in measles antibody titer is diagnostic IgM assays can be falsely negative the first few days of infection and falsely positive in the presence of rheumatoid factor or with acute rubella, erythroparvovirus (parvovirus B19), or HHV-6 infection + Treatment Print Section ++ ++ Administer antipyretics and fluids as needed Vitamin A supplementation for all children 200,000 units/day orally for 2 days to children with measles more than 1-year-old 100,000 units/day for children 6–12 months old 50,000 units/day for children younger than 6 months) A third dose is recommended 2–4 weeks later for children with vitamin A deficiency Ribavirin is used in selected severe cases of pneumonitis, but insufficient data prevent recommending antiviral use Zinc has a role in the maintenance of normal immune functions, but insufficient data are available to recommend zinc supplementation to children with measles + Outcomes Print Section ++ ++ Complications ++ Otitis media (the most common complication) Postinfectious encephalomyelitis Inclusion body encephalitis Subacute sclerosing panencephalitis (SSPE) is very rare Bronchopneumonia or bronchiolitis Bronchiectasis may occur in up to one-quarter of nonvaccinated children Cervical adenitis Pneumonia Diarrhea and protein-losing enteropathy are significant complications among malnourished children Conjunctivitis, keratitis, and otosclerosis ++ Prevention ++ See Table 30–7 Vaccine coverage rates must exceed 95% to prevent outbreaks One vaccine dose is about 93% effective Two doses of vaccine are estimated to be 97% protective MMR and MMRV vaccine should not be administered to pregnant women, patients with anaphylactic reactions to neomycin, and patients with known primary or acquired immunodeficiency Asymptomatic patients living with HIV with CD4 counts higher than 200 cells/mcL should receive MMR vaccine, but not MMRV vaccine. ++Table Graphic Jump LocationTable 30–7.Recommended adult immunization schedule—United States, 2019.View Table|Favorite Table|Download (.pdf)Table 30–7. Recommended adult immunization schedule—United States, 2019. Table 30–7: Recommended adult immunization schedule—United States, 2019. ++ Prognosis ++ During 2000–2016, annual estimated measles deaths decreased by 84% In the United States, the case fatality rate is around 2 per 1000 reported cases, with deaths principally due to respiratory and neurologic complications Deaths in the developing world are mainly related to diarrhea and protein-losing enteropathy Pregnant women with measles may be at increased risk for death ++ When to Refer ++ Any suspect cases should be reported to public health authorities HIV infection Pregnancy ++ When to Admit ++ Meningitis, encephalitis, or myelitis Severe pneumonia Diarrhea that significantly compromises fluid or electrolyte status + References Print Section ++ + +Awotiwon AA et al. Zinc supplementation for the treatment of measles in children. Cochrane Database Syst Rev. 2017 Jun 20;6:CD011177. [PubMed: 28631310] + +Dabbagh A et al. Progress toward regional measles elimination–worldwide, 2000–2016. MMWR Morb Mortal Wkly Rep. 2017 Oct 27;66(42):1148–53. [PubMed: 29073125] + +Ceccarelli G et al. Sanitary Bureau of the Asylum Seekers Center of Castelnuovo di Porto. Susceptibility to measles in migrant population: implication for policy makers. J Travel Med. 2018 Jan 1;25(1). [PubMed: 29232456] + +Hall V et al. Measles outbreak—Minnesota April–May 2017. MMWR Morb Mortal Wkly Rep. 2017 Jul 14;66(27):713–7. [PubMed: 28704350] + +Jackson BD et al. Available studies fail to provide strong evidence of increased risk of diarrhea mortality due to measles in the period 4–26 weeks after measles rash onset. BMC Public Health. 2017 Nov 7;17(Suppl 4):783. [PubMed: 29143685] + +Lo NC et al. Public health and economic consequences of vaccine hesitancy for measles in the United States. JAMA Pediatr. 2017 Sep 1;171(9):887–92. [PubMed: 28738137] + +Moss WJ. Measles. Lancet. 2017 Dec 2;390(10111):2490–502. [PubMed: 28673424] + +Orenstein WA et al. Measles and Rubella Global Strategic Plan 2012–2020 midterm review report: background and summary. Vaccine. 2018 Jan 11;36(Suppl 1):A35–42. [PubMed: 29307368] + +Ortac Ersoy E et al. Severe measles pneumonia in adults with respiratory failure: role of ribavirin and high-dose vitamin A. Clin Respir J. 2016 Sep;10(5):673–5. [PubMed: 25619709] + +Phadke VK et al. Association between vaccine refusal and vaccine-preventable diseases in the United States: a review of measles and pertussis. JAMA. 2016 Mar 15;315(11):1149–58. Erratum in: JAMA. 2016 May 17;315(19):2125. [PubMed: 26978210] + +Trentini F et al. Measles immunity gaps and the progress towards elimination: a multi-country modelling analysis. Lancet Infect Dis. 2017 Oct;17(10):1089–97. [PubMed: 28807627] + +Walker TY et al. National, regional, state, and selected local area vaccination coverage among adolescents aged 13–17 years—United States, 2016. MMWR Morb Mortal Wkly Rep. 2017 Aug 25;66(33):874–82. [PubMed: 28837546] + +Willame C et al. Pain caused by measles, mumps, and rubella vaccines: a systematic literature review. Vaccine. 2017 Oct 9;35(42):5551–8. [PubMed: 28893478]