Measles Information for Health Care Professionals
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Measles Information for Health Care Professionals
The United States is currently experiencing a large, multi-state outbreak of measles linked to an amusement park in California. The outbreak started in December 2014 and has spread to more than a dozen other states. Healthcare professionals should consider measles when evaluating patients with febrile rash and ask about a patient's vaccine status, recent travel history, and contact with individuals who have febrile rash illness.
- Clinical Features
- The Virus
- Diagnosis and Laboratory Testing
- People at High Risk for Complications
- Evidence of Immunity
- Vaccine Recommendations Children
- Students at post-high school educational institutions
- Advice for Travelers
- International travelers
- Healthcare personnel
- Additional Resources
Measles is an acute viral respiratory illness. It is characterized by a prodrome of fever (as high as 105°F) and malaise, cough, coryza, and conjunctivitis -the three "C's" -, a pathognomonic enanthema (Koplik spots) followed by a maculopapular rash. The rash usually appears about 14 days after a person is exposed; however, the incubation period ranges from 7 to 21 days. The rash spreads from the head to the trunk to the lower extremities. Patients are considered to be contagious from 4 days before to 4 days after the rash appears. Of note, sometimes immunocompromised patients do not develop the rash.
The Centers for Disease Control and Prevention's (CDC) Dr. Jane Seward describes measles clinical features and what to do if a healthcare provider suspects measles, in this 5-minute video.
Measles is caused by a single-stranded, enveloped RNA virus with 1 serotype. It is classified as a member of the genus Morbillivirus in the Paramyxoviridae family. Humans are the only natural hosts of measles virus.
In the decade before the live measles vaccine was licensed in 1963, an average of 549,000 measles cases and 495 measles deaths were reported annually in the United States. However, it is likely that, on average, 3 to 4 million people were infected with measles annually; most cases were not reported. Of the reported cases, approximately 48,000 people were hospitalized from measles and 1,000 people developed chronic disability from acute encephalitis caused by measles annually.
Measles is one of the most contagious of all infectious diseases; approximately 9 out of 10 susceptible persons with close contact to a measles patient will develop measles. The virus is transmitted by direct contact with infectious droplets or by airborne spread when an infected person breathes, coughs, or sneezes. Measles virus can remain infectious on surfaces and in the air for up to two hours after an infected person leaves an area.
Healthcare practitioners should consider measles in patients presenting with febrile rash illness and clinically compatible measles symptoms, especially if the person recently traveled internationally or was exposed to a person with febrile rash illness. Healthcare providers in Escambia County, Florida should immediately report suspected measles cases to their local health department by calling 850-595-6683 (Monday-Friday 8a.m. to 5p.m. CT) or 850-418-5566 (after hours and on weekends).
Laboratory confirmation is essential for all sporadic measles cases and all outbreaks. Detection of measles-specific IgM antibody and measles RNA are the most common methods for confirming measles infection. Healthcare providers should obtain both a serum sample and a throat (or nasopharyngeal) swab from patients suspected to have measles at first contact with them. Urine samples may also contain virus, and when feasible to do so, collecting both respiratory and urine samples can increase the likelihood of detecting measles virus. For more information, see the CDCâ€™s Measles Lab Tools.
Common complications from measles include otitis media, bronchopneumonia, laryngotracheobronchitis, and diarrhea.
Even in previously healthy children, measles can cause serious illness requiring hospitalization.
- One out of every 1,000 measles cases will develop acute encephalitis, which often results in permanent brain damage.
- One or two out of every 1,000 children who become infected with measles will die from respiratory and neurologic complications.
- Subacute sclerosing panencephalitis (SSPE) is a rare, but fatal degenerative disease of the central nervous system characterized by behavioral and intellectual deterioration and seizures that generally develop 7 to 10 years after measles infection.
People at high risk for severe illness and complications from measles include:
- Infants and children aged <5 years
- Adults aged >20 years
- Pregnant women
- People with compromised immune systems, such as from leukemia and HIV infection
Acceptable presumptive evidence of immunity against measles includes at least one of the following:
- written documentation of adequate vaccination:
- Ã one or more doses of a measles-containing vaccine administered on or after the first birthday for preschool-age children and adults not at high risk,
- Ã two doses of measles-containing vaccine for school-age children and adults at high risk, including college students, healthcare personnel, and international travelers,
- laboratory evidence of immunity,
- laboratory confirmation of measles,
- birth in the United States before 1957.
Healthcare providers should not accept verbal reports of vaccination without written documentation as presumptive evidence of immunity. For additional details about evidence of immunity criteria, see Table 3 at bottom of document in Prevention of Measles, Rubella, Congenital Rubella Syndrome, and Mumps, 2013: Summary Recommendations of the Advisory Committee on Immunization Practices (ACIP).
Measles can be prevented with measles-containing vaccine, which is primarily administered as the combination measles-mumps-rubella (MMR) vaccine. The combination measles-mumps-rubella-varicella (MMRV) vaccine can be used for children aged 12 months through 12 years for protection against measles, mumps, rubella and varicella. Single-antigen measles vaccine is not available.
One dose of MMR vaccine is approximately 93% effective at preventing measles; two doses are approximately 97% effective. Almost everyone who does not respond to the measles component of the first dose of MMR vaccine at age 12 months or older will respond to the second dose. Therefore, the second dose of MMR is administered to address primary vaccine failure 
CDC recommends routine childhood immunization for MMR vaccine starting with the first dose at 12 through 15 months of age, and the second dose at 4 through 6 years of age or at least 28 days following the first dose.
Students at post-high school educational institutions without evidence of measles immunity need two doses of MMR vaccine, with the second dose administered no earlier than 28 days after the first dose.
People who are born during or after 1957 who do not have evidence of immunity against measles should get at least one dose of MMR vaccine.
Outbreaks in countries to which Americans often travel can directly contribute to an increase in measles cases in the United States. In recent years, measles importations have come from frequently visited countries, including, but not limited to, England, France, Germany, India, and the Philippines, where large outbreaks were reported.
Check that your patients 6 months of age or older who will be traveling internationally are protected against measles.
Before travelling internationally,
- Infants 6 through 11 months of age should receive one dose of MMR vaccine;
- Children 12 months of age or older should have documentation of two doses of MMR vaccine (the first dose of MMR vaccine should be administered at age 12 months or older; the second dose no earlier than 28 days after the first dose);
- Teenagers and adults born during or after 1957 without evidence of immunity against measles should have documentation of two doses of MMR vaccine, with the second dose administered no earlier than 28 days after the first dose.
See also, the CDCÃÃÂ¢s webpage for travelers.
Healthcare personnel should have documented evidence of immunity against measles, according to the recommendations of the Advisory Committee on Immunization Practices[48 pages].
For more information, see measles vaccination recommendation.