Measles is in the news again this year! According to the Centers for Disease Control and Prevention (CDC), during the first 2 months of 2024, there were already 41 reported cases in the United States (US) in 16 different jurisdictions. In comparison, there were a total of 58 cases in 20 jurisdictions in 2023 (CDC, 2024). As nurses, we need to stay well-informed of public health trends and be knowledgeable of how we can protect ourselves and our population from the spread of dangerous communicable diseases. Understanding measles transmission, clinical presentation, prevention strategies, and current trends in the US are essential elements to ensure we can actively protect our patients.
 
Measles is a highly contagious, acute febrile rash illness. Infection is spread by direct contact with infectious droplets or by means of airborne spread when an infected person breaths, coughs, or sneezes in close vicinity to a susceptible individual. The virus can remain infectious in the air for up to two hours, contributing to its high transmissibility. There is a 90% secondary attack rate among immunocompromised and unvaccinated populations (Sanyaolu et al., 2019), meaning if a contagious individual is in a room, 90% of those susceptible in close contact will contract the virus.
 
Measles is vaccine-preventable making it a unique public health threat. The measles vaccine is highly efficacious. Full vaccination in accordance with CDC recommendations will prevent measles in 97% of individuals (McClean et al., 2013). Measles vaccination became available in the 1960s. Prior to it’s wide-spread availability, the US had seasonal outbreaks of measles and immunity was conferred after active infection. Measles has been well controlled in the US and was considered eliminated in 2000 but since that time, there have been sporadic outbreaks, the most significant of which was in New York during 2018-2019.
 
This newsworthy outbreak began on September 30, 2018, when an unvaccinated child acquired measles infection internationally and returned home to their close-knit Orthodox Jewish community in Brooklyn, New York (NY). This patient was linked to 702 cases of measles over the next 9.5 months. There was a total of 375 cases in the US in 2018 which included other internationally imported cases. The second major incident contributing to the 2018-2019 measles outbreak was a foreign visitor to NY state on October 1, 2018. This patient was linked to 412 cases in NY state over a 10.5-month period (Patel et al., 2019). These late 2018 outbreaks partially contributed to a total of 1249 measles cases in 2019, representing the most US cases reported in a single year in the US since 1992. 2019 saw a total of 22 outbreaks in 17 states but cases were reported in 31 states total. Overall, 89% of cases in the 2018-2019 outbreak were in under immunized close-knit communities (Patel et al., 2019).  
 
Let’s fast forward to recent history. Once 2018-2019 was under control, 2020 only saw 13 cases, there were 49 cases in 2021, and 121 cases in 2022 with 85 cases in central Ohio between October and December. Ninety-four percent of the 2022 Ohio cases were in unvaccinated children. As noted above, in the first 2 months of 2024, we have already seen 41 cases!
 
Undervaccination, lack of vaccination, and international travel remain the largest threats to widespread measles in the US. Despite lessons learned in the 2018-2019 outbreak, international travel and vaccination remains at the crux of measles outbreak which is the case in the 2023-2024 reported cases. As cases across the world increase, the risk of international travel bringing disease back to the US is a threat. Measles cases are increasing internationally as well. The CDC and World Health Organization found an 18% increase in measles cases and a 43% increase in measles related deaths worldwide in 2022 compared to 2021. Furthermore, vaccination rates are below the 95% rate necessary for population level protection or herd immunity. The CDC’s Morbidity and Mortality Weekly Report published in January 2023 showed that measles vaccination rates among kindergarteners for the 2021 to 2022 school year was only 93% (Minta et al., 2023). The COVID-19 pandemic has contributed to under vaccination. Between 2020 and 2022, there were 61 million doses of measles vaccine delayed or missed (Minta et al., 2023).
 
While many factors are out of our control as healthcare providers, it is important that we are aware of these trends, able to recognize early signs and symptoms of measles, and cognizant of the necessary steps to take for those with suspected or confirmed measles infection.

Clinical Presentation of Measles (Maaks et al., 2020)

The characteristic clinical syndrome associated with measles infection is an acute febrile, respiratory illness that has three distinct phases.

1. Incubation Period: once an individual is exposed to measles there is a 10-to-14-day asymptomatic period.

2. Prodromal Period: 2-4 days before the onset of rash, typically 4 to 5 days of illness
      Clinical Manifestations:

• Fever: develops during this period and typically lasts the duration of the rash
• “The 3 Cs”: cough, coryza (nasal congestion), and conjunctivitis
• Koplik spots: characteristic small, irregular, bluish white granules on an erythematous base in oral mucosa/buccal mucosa; pathognomonic of measles
• Extreme malaise common

 ​3. Rash Stage: Day 0

• Fever may increase; often up to 105℉
• Rash onset: maculopapular (small raised or flat red bumps, may enlarge and coalesce) start on face, hairline, behind ears and over 24-hour period, spreads downward to neck, trunk, and extremities
  • As legs become more involved, face begins to clear.
  • Expect respiratory symptoms to peak in severity on day 3 of rash.
  • Rash typically begins to fade and may develop a residual desquamating light-colored pigmentation for up to 1 week.
  • Immunocompromised patients may not develop rash.
• Transmissibility: measles infection is considered contagious 4 days before and 4 days after the onset of rash

Diagnosis of Measles

• Diagnostic criteria: fever, rash, one of the 3 C’s
• Laboratory diagnosis:
  • Serum IgM: may be positive 1-2 days after rash, and may remain positive for 6-8 weeks following clinical syndrome
    • risk false positives if low clinical suspicion
  • Oral/nasal swab: real time (rt)- PCR to detect measles RNA
    • higher sensitivity and specificity comparted to serum IgM  
• All confirmed cases must be reported to the state within 24 hours of diagnosis.

Treatment of Measles

• Supportive management
  • Antipyretics, rest, hydration, air humidification
• Post-exposure prophylaxis to confer protection or reduce disease severity.
  • In vaccine eligible individuals, administer measles vaccine within 72 hours; 1^st line for infants between 6 and 12 months.
  • Consider immunoglobulin in vaccine ineligible patients (infants younger than 12 months, pregnant women, immunocompromised individuals).
• Vitamin A, once daily for 2 days
  • Under 6 months – 50,000 IUs
  • 6 to 11 months – 100,000 IUs
  • 12 months or older – 200,000 IUs
• Treat secondary bacterial infections
• Isolation – 4 days after rash onset, longer for certain immunological conditions
• Utilize standard and airborne isolation precautions in the healthcare settings.

Complications of Measles

• 90% of suspectable household contacts will develop illness. 
• Bacterial superinfection and viral complications manifested as diarrhea, acute otitis media, laryngitis, mastoiditis, pneumonia
• Encephalitis
• Subacute sclerosing panencephalitis

Prevention of Measles

• Measles, mumps, rubella (MMR) vaccine (McClean et al., 2013)
  • Dose # 1 between 12 to 15 months
  • Dose #2 between 4 and 6 years of age (at least 28 days after 1^st dose)

Our responsibility as nurses is to recognize suspected measles, isolate those with suspected or confirmed infection to prevent the spread of disease, be aware of high-risk travel, and promote immunization in the communities in which we work. Measles is preventable; keeping our patients well informed and having non-judgmental conversations about vaccine hesitancies can improve vaccination rates and reduce the impact of measles in the US.
 

References: 
 
CDC (2024, March 4). Measles cases and outbreaks. National Center for Immunization and Respiratory Disease, Division of Viral Illness. https://www.cdc.gov/measles/cases-outbreaks.html
 
Maaks, D.L. G., Starr, N., & Gaylord, N. (2020). Burns' Pediatric Primary Care (7th ed.). Elsevier Health Sciences (US). https://pageburstls.elsevier.com/books/9780323581967
 
McLean, H. Q., Fiebelkorn, A. P., Temte, J. L., Wallace, G. S., & Centers for Disease Control and Prevention (2013). Prevention of measles, rubella, congenital rubella syndrome, and mumps, 2013: summary recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR, Recommendations and reports: Morbidity and mortality weekly report. Recommendations and reports, 62(RR-04), 1–34.
 
Minta, A. A., Ferrari, M., Antoni, S., Portnoy, A., Sbarra, A., Lambert, B., Hatcher, C., Hsu, C. H., Ho, L. L., Steulet, C., Gacic-Dobo, M., Rota, P. A., Mulders, M. N., Bose, A. S., Caro, W. P., O'Connor, P., & Crowcroft, N. S. (2023). Progress toward measles elimination - Worldwide, 2000-2022. MMWR, Morbidity and mortality weekly report, 72(46), 1262–1268. https://doi.org/10.15585/mmwr.mm7246a3
 
Patel, M., Lee, A. D., Clemmons, N. S., Redd, S. B., Poser, S., Blog, D., Zucker, J. R., Leung, J., Link-Gelles, R., Pham, H., Arciuolo, R. J., Rausch-Phung, E., Bankamp, B., Rota, P. A., Weinbaum, C. M., & Gastañaduy, P. A. (2019). National update on measles cases and outbreaks - United States, January 1-October 1, 2019. MMWR. Morbidity and mortality weekly report, 68(40), 893–896. https://doi.org/10.15585/mmwr.mm6840e2
 
Porter, A. & Goldfarb, J. (2019). Measles: A dangerous vaccine-preventable disease returns. Cleveland Clinical Journal of Medicine 86(6), 393-398. https://doi.org/10.3949/ccjm.86a.19065    
 
Sanyaolu, A., Okorie, C., Marinkovic, A., Ayodele, O., Abbasi, A. F., Prakash, S., Gosse, J., Younis, S., Mangat, J., & Chan, H. (2019). Measles outbreak in unvaccinated and partially vaccinated children and adults in the United States and Canada (2018-2019): A Narrative review of cases. Inquiry: a journal of medical care organization, provision and financing, 56, 46958019894098. https://doi.org/10.1177/0046958019894098
 
Strebel, P. M., & Orenstein, W. A. (2019). Measles. The New England journal of medicine, 381(4), 349–357. https://doi.org/10.1056/NEJMcp1905181
 
Suran M. (2024). Measles Cases Are Spreading in the US-Here's What to Know. JAMA, 10.1001/jama.2024.1949. Advance online publication. https://doi.org/10.1001/jama.2024.1949

 

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CE ARTICLE	PRACTICE SPECIALTY	POCKET CARD
Measles: Moving Toward Eradication	Infection Control/ID	Isolation Precautions