Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content + Download Section PDF Listen ++ For further information, see CMDT Part 32-02: Major Vaccine-Preventable Viral Infections + Key Features Download Section PDF Listen +++ +++ Essentials of Diagnosis ++ Onset of prodrome 7–18 days after exposure 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 ++ Between January 1 and October 1, 2019, a total of 1249 measles cases and 22 measles outbreaks were reported in 31 states of the United States The WHO previously considered measles eradicated in most countries worldwide including the Americas However, many countries now have ongoing measles outbreaks, including The Democratic Republic of the Congo Ethiopia Georgia Kazakhstan Kyrgyzstan Madagascar Myanmar Philippines Sudan Thailand Ukraine During 2019, measles outbreaks have also occurred in countries with high vaccination coverage, including The United States Israel Thailand Tunisia Many European countries Intentional undervaccination continues to undermine measles elimination programs + Clinical Findings Download Section PDF Listen +++ +++ 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 Download Section PDF Listen +++ ++ 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 Download Section PDF Listen +++ ++ 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 Download Section PDF Listen +++ +++ 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 infection with CD4 counts higher than 200 cells/mcL should receive MMR vaccine but not MMRV vaccine Illness confers permanent immunity ++Table Graphic Jump LocationTable 30–7.Recommended adult immunization schedule—United States, 2020.View Table||Download (.pdf) Table 30–7. Recommended adult immunization schedule—United States, 2020. +++ Prognosis ++ An estimated 21.1 million deaths were prevented between 2000 and 2017 by use of measles vaccination 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 Download Section PDF Listen +++ + +Bianchi FP et al. Long-term immunogenicity of measles vaccine: an Italian retrospective cohort study. J Infect Dis. 2020 Feb 18;221(5):721–8. [PubMed: 31580436] + +Hviid A et al. Measles, mumps, rubella vaccination and autism: a nationwide cohort study. Ann Intern Med. 2019 Apr 16;170(8):513–20. [PubMed: 30831578] + +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] + +Nic Lochlainn LM et al. Immunogenicity, effectiveness, and safety of measles vaccination in infants younger than 9 months: a systematic review and meta-analysis. Lancet Infect Dis. 2019 Nov;19(11):1235–45. [PubMed: 31548079] + +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] + +Patel M et al. National update on measles cases and outbreaks—United States, January 1–October 1, 2019. MMWR Morb Mortal Wkly Rep. 2019 Oct 11;68(40):893–6. [PubMed: 31600181] + +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] + +Thornton J et al. Measles cases in Europe tripled from 2017 to 2018. BMJ 2019;364:l634. [PubMed: 30733215] + +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]