para>Report suspected measles cases to public health authorities. ‚
TREATMENT
GENERAL MEASURES
- Place all patients with measles in respiratory isolation until 4 days after onset of rash; immunocompromised patients should be isolated for duration of illness.
- Supportive therapy (i.e., antipyretics, antitussives, humidification, increased oral fluid consumption)
MEDICATION
- No approved antiviral therapy is available. Immunosuppressed children with severe measles have been treated with IV or aerosolized ribavirin. No controlled trial data exist, and this use is not FDA approved.
- Vitamin A: WHO recommends daily dosages for two consecutive days:
- Children <6 months of age 50,000 IU
- Children 6 to 12 months of age 100,000 IU
- Children >12 months of age 200,000 IU
- Antibiotics
- Reserved for patients with clinical signs of bacterial superinfection (pneumonia, purulent otitis, pharyngitis/tonsillitis) (6)[B]
- A small randomized, double-blinded trial resulted in an 80% (number needed to treat [NNT] = 7) decrease in measles-associated pneumonia with prophylactic antibiotics; consider antibiotic use prophylactically in patients with a high risk of complications (7)[B].
- Outbreak control
- A single case of measles constitutes an outbreak.
- Immunize contacts (individuals exposed or at risk of having been exposed) within 72 hours.
- Monovalent vaccine may be given to infants 6 months to 1 year of age, but two further doses of vaccine after 12 months must be given for adequate immunization.
- Monovalent or combination vaccine may be given to all measles-exposed susceptible individuals age >1 year if not contraindicated.
- Individuals not immunized within 72 hours of exposure should be excluded from school, child care, and health care settings (social quarantine) until 2 weeks after onset of rash in last case of measles.
- Immunoglobulin therapy (passive immunity) may be necessary for the following high-risk individuals exposed to measles for whom vaccine is inappropriate:
- Children age <1 year (infants 6 to 12 months of age may receive MMR vaccine in place of IG if given within 72 hours of exposure)
- Pregnant women
- Individuals with severe immunosuppression
- IM immunoglobulin should be given within 6 days of measles exposure; CDC recommends 0.25 mL/kg to maximum of 15 mL for infants and pregnant women; immunocompromised individuals receive 0.5 mL/kg to a maximum of 15 mL.
INPATIENT CONSIDERATIONS
Outpatient care is appropriate, except where complications develop (e.g., encephalitis, pneumonia). ‚
ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
Signs of complications needing close follow-up include: ‚
- Difficulty breathing or noisy breathing
- Changes in vision
- Changes in behavior, confusion
- Chest or abdominal pain
PATIENT EDUCATION
- Adhere to recommended immunization schedules.
- Avoid exposure, particularly to unimmunized children and adults, pregnant women, and immunocompromised persons, until 4 days after rash onset.
- Avoid contact with potential sources of secondary bacterial pathogens until respiratory symptoms resolve.
- Centers for Disease Control and Prevention. Measles. www.cdc.gov/measles/about/index.html
PROGNOSIS
- Typically self-limited; prognosis good
- High fatality rates may be seen among malnourished or immunocompromised children, particularly in developing countries.
COMPLICATIONS
- Otitis media (5 " “15%)
- The immune response to measles infection paradoxically depresses response to non " “measles-virus antigens, which renders individuals more susceptible to pneumonia and diarrhea.
- Respiratory complications:
- Bronchopneumonia (5 " “10%)
- Accounts for most measles-related deaths
- May be viral or bacterial
- Interstitial pneumonitis (immunocompromised patients)
- Laryngotracheobronchitis ( "measles croup " ť): occurs in younger age group (<2 years)
- GI complications: diarrhea (may lead to dehydration)
- Neurologic complications
- Febrile seizures
- Acute disseminated encephalomyelitis with seizures and neurologic abnormalities (occurs in 1/1,000 cases): presents within 2 weeks of rash, probably an autoimmune response
- Inclusion body encephalitis is rare but fatal in those with defective cellular immunity.
- Subacute sclerosing panencephalitis
- Rare degenerative CNS disease resulting from persistent measles infection following natural disease; usually fatal
- Presents 5 to 15 years after infection
- Most often in persons infected before age 2 years
- Ocular complications
- Keratitis
- Can lead to permanent scarring, blindness
- Vitamin A deficiency predisposes to more severe keratitis and its complications.
- Other secondary bacterial infections
- Death: results from complications, mainly pneumonia, rather than the virus itself. CDC statistics show that for every 1,000 children who get measles, 1 or 2 will die.
REFERENCES
11 Lessler ‚ J, Reich ‚ NG, Brookmeyer ‚ R, et al. Incubation periods of acute respiratory viral infections: a systematic review. Lancet Infect Dis. 2009;9(5):291 " “300.22 Orenstein ‚ W, Seib ‚ K. Mounting a good offense against measles. N Engl J Med. 2014;371(18):1661 " “1663.33 Althouse ‚ BM, Bergstrom ‚ TC, Bergstrom ‚ CT. Evolution in health and medicine Sackler colloquium: a public choice framework for controlling transmissible and evolving diseases. Proc Natl Acad Sci U S A. 2010;107(Suppl 1):1696 " “1701.44 Rowhani-Rahbar ‚ A, Fireman ‚ B, Lewis ‚ E, et al. Effect of age on the risk of fever and seizures following immunization with measles-containing vaccines in children. JAMA Pediatr. 2013;167(12):1111 " “1117.55 Demicheli ‚ V, Jefferson ‚ T, Rivetti ‚ A, et al. Vaccines for measles, mumps and rubella in children. Cochrane Database Syst Rev. 2005;(4):CD004407.66 Kabra ‚ SK, Lodha ‚ R. Antibiotics for preventing complications in children with measles. Cochrane Database Syst Rev. 2013;(8):CD001477.77 Garly ‚ ML, Bale ‚ C, Martins ‚ CL, et al. Prophylactic antibiotics to prevent pneumonia and other complications after measles: community based randomised double blind placebo controlled trial in Guinea-Bissau. BMJ. 2006;333(7581):1245.
ADDITIONAL READING
- Mulholland ‚ EK, Griffiths ‚ UK, Biellik ‚ R. Measles in the 21st century. N Engl J Med. 2012;366(19):1755 " “1757.
- Papania ‚ MJ, Wallace ‚ GS, Rota ‚ PA, et al. Elimination of endemic measles, rubella, and congenital rubella syndrome from the western hemisphere: the US experience. JAMA Pediatr. 2014;168(2):148 " “155.
CODES
ICD10
- B05.9 Measles without complication
- B05.2 Measles complicated by pneumonia
- B05.89 Other measles complications
- B05.81 Measles keratitis and keratoconjunctivitis
- B05.3 Measles complicated by otitis media
- B05.4 Measles with intestinal complications
- B05.1 Measles complicated by meningitis
- B05.0 Measles complicated by encephalitis
ICD9
- 055.9 Measles without mention of complication
- 055.1 Postmeasles pneumonia
- 055.79 Measles with other specified complications
- 055.71 Measles keratoconjunctivitis
- 055.8 Measles with unspecified complication
- 055.0 Postmeasles encephalitis
- 055.2 Postmeasles otitis media
SNOMED
- 14189004 Measles (disorder)
- 195900001 measles pneumonia (disorder)
- 38921001 Measles with complication
- 60013002 Measles keratoconjunctivitis (disorder)
- 406592004 Measles of the central nervous system (disorder)
- 111873003 Measles without complication (disorder)
CLINICAL PEARLS
- There is no substantiated link between MMR vaccine and autism.
- Measles is a highly communicable viral disease whose natural transmission has been halted in the United States by mass immunization.
- A single case of measles constitutes an outbreak.
- Suspected measles cases must be reported to state or local health departments to contain outbreak.
- Immunization requires two doses: one at 12 to 15 months of age and one at school age (4 to 6 years of age).
- Presentation includes a prodrome of fever, cough, coryza, and conjunctivitis, followed by a descending maculopapular rash beginning on the face and progressing to the chest and lower body (centrifugal).
- Consider measles in the differential diagnosis of a febrile rash illness (especially in unvaccinated individuals with recent international travel).
- Measles-associated pneumonia is the most common cause of mortality.