• BC PICNet Quick Reference Guide

• Key Clinical Signs for Suspicion of Measles
• • Fever: Early and high: 38.3 °C or greater
  • Three Cs: Cough, Coryza, and Conjunctivitis
  • Rash: Generalized maculopapular rash of any duration

• Triage and Immediate Isolation: On suspicion of measles, triage should prioritize immediate isolation to prevent transmission of this highly contagious virus.

• PPE for Healthcare Providers: Use appropriate protective gear before examination.

• Complications in close to 10%:
  • Otitis Media – leading to hearing loss
  • Pneumonia – leading cause of measles associated mortality
  • Croup
  • Less commonly:
    • Keratoconjunctivitis leading to blindness especially Vitamin A deficient
    • Acute encephalitis (1/1,000 cases)

• Risk of complications:
  • Infants and > 20 years
  • Pregnant
  • Immunocompromised
  • Unvaccinated
  • Poor nutritional status (especially Vitamin A deficient)

Measles is a highly contagious viral infection caused by the Measles Morbillivirus. Transmission rate is as high as 90% in susceptible exposed individuals.

• Measles, a preventable infectious disease, has seen a resurgence in recent years due to reduced rates of vaccination and transmission from travelers arriving from endemic areas.
• Measles should be suspected in any unvaccinated individual from an area with circulating measles presenting with fever, cough, conjunctivitis, diarrhea, and/or rash.
• Testing – nasopharyngeal or throat swab for NAT/PCR testing recommended with confirmatory testing by serum anti-measles IgM/IgG Ab. BCCDC still recommends IgM but others do not.
• Supportive management is indicated as there is no specific antiviral treatment.
• Vitamin A deficiency increases risk of measles complications due to compromised epithelial barriers and impaired immune response, and supplementation reduces this risk.
• Outpatient management is appropriate unless there are risk factors for severe infection:
  • children < 12 months
  • age > 20 years
  • unvaccinated (need at least 2 doses MMR/MMRV if born after 1970).
  • immunocompromised
  • pregnancy

• Severe complications include:
  • Pneumonia – 2-5% measles develop pneumonia – leading cause of measles associated mortality
  • Acute encephalitis – 1/1,000 cases
• Other complications:
  • Otitis media – can lead to hearing loss – not rare
  • Laryngotracheobronchitis (croup) – not rare
  • Keratoconjunctivitis – can lead to blindness (especially in Vitamin A deficient)
  • Hepatitis
  • Seizures
  • Thrombocytopenic purpura
  • Miscarriage, Preterm
• Subacute Sclerosing Panencephalitis (SSPE) – fatal degenerative disease 2 – 10 years following infection due to reactivation of measles virus or inappropriate immune response

Diagnosis is largely clinical, with measles infection divided into 4 stages: incubation, prodrome, exanthem and recovery.

• The incubation period is 6 to 21 days.
• The prodrome period involves the development of fever, tachycardia, malaise, and anorexia, followed by conjunctivitis, cough, and coryza.
• 2-3 days after start of the prodrome and 48 hours prior to the development of the exanthem, patients may develop an enanthem (mucosal rash) Koplik spots, 1-3 mm white/gray spots with an erythematous base seen on the oral mucosa. These spots slough off as the exanthem begins to appear.
• 2-5 days after start of the prodrome, the exanthem (skin rash) appears. The erythematous morbilliform rash starts on the face and spreads caudally, often sparing the palms and soles. The rash is initially blanching. Accompanying symptoms include lymphadenopathy, pharyngitis, fever, and/or diarrhea.

Differential diagnosis includes common respiratory viruses – RSV, adenovirus. Notably coxsackievirus and other enteroviruses that cause hand foot and mouth disease can also present as maculopapular rash with mucosal involvement

Measles images (Accessed from DermNet NZ)

Bloodwork may show leukopenia and thrombocytopenia and chest X-ray may reveal interstitial pneumonitis.

• Test all patients with possible exposure (i.e. all those in affected area or with travel there within incubation period or with known contact) presenting with febrile rash illness and other compatible symptoms – cough, coryza, conjunctivitis – especially in those lacking immunity
• Specimens for testing: nasopharyngeal swab, urine and blood serology for IgM/IgG.
• Highest sensitivity if tested within 7 days after rash onset.
• Nucleic acid testing (NAT or PCR) – nasopharyngeal swab < 7 days
• Urine testing sensitive up to 14 days after rash onset.
• Serologic testing for acute measles – IgM and IgG – most useful in suspect cases who did not have samples collected for NAT shortly after rash onset. IgM positive in 80% by day 3, IgG develop 7 days and peak 2-3 weeks.

A patient suspected of having measles should be placed under airborne precautions as measles can remain airborne for up to 2 hours.  Also use droplet precaution if diagnosis unclear or possible bacterial infection (airborne, droplet and contact)

Report cases to the BCCDC.

Treatment is largely supportive with fluids, antipyretics, and treatment of complications or bacterial superinfections as appropriate.

For children, 2 doses of vitamin A may be beneficial in acute or severe cases. A third dose can be given 4-6 weeks later if there are clinical signs/symptoms of vitamin A deficiency.  Do not give if the family has given at home due to risk of Vitamin A toxicity. (Some families have heard of / believed the social media trends about vitamin A preventing measles.) Not recommend for routine measles – only if the child is malnourished or is being hospitalized.

https://shop.healthcarebc.ca/phsa/BCWH_2/Pharmacy,%20Therapeutics%20and%20Nutrition/C-05-07-63104.pdf

• <6 months old dose: 50,000 IU.
• 6-11 months old dose: 100,000 IU.
• ≥ 12 months old dose: 200,000 IU.

Clinical improvement occurs about 48 hours following the emergence of ex-anthem. After 3-4 days, the skin eruption darkens, then fades.

• There may be a persistent cough up to 2 weeks after measles.

All unvaccinated patients unless pregnant or severely immunocompromised should be encouraged to receive two doses of the MMR vaccine at least 4 weeks apart. Unvaccinated patients exposed to a known case of measles may receive the MMR vaccine or IVIG as post-exposure prophylaxis.

• Patients should be educated on the safety of the MMR vaccine, addressing common myths around vaccine hesitancy.
• MMR is an attenuated live virus vaccine that causes a relatively benign infection in the body with minimal symptoms prior to being eliminated by the immune system.
• Common side effects are a mild truncal rash and mild fever lasting 2-3 days approximately 1-2 weeks post-injection. There may also be temporary joint pain/stiffness in older individuals who are not rubella immune.
• Extremely rare side effects include febrile seizures (4/10,000), thrombocytopenia (ITP – 1/40,000), neck/cheek swelling, and anaphylaxis.
• There is no evidence that the MMR vaccine causes Autism Spectrum Disorder (ASD); the time frame when ASD features begin to manifest coincides with the recommended childhood vaccine schedule.
• Unvaccinated patients exposed to measles may receive their first dose of the MMR vaccine within 3days for Post Exposure Prophylaxis (PEP). Between 3-6 days, consideration of IVIG (400 mg/kg) for PEP. Avoid administering both IVIG and the MMR vaccine simultaneously, as IVIG reduces the immunogenicity of MMR. Physicians should also be aware that IVIG administration delays the subsequent administration of MMRV by at least 8 months.

1. Measles (bccdc.ca)

   
   

2. Effects of ribavirin on measles.
   Pal, G., J Indian Med Assoc. 2011;109(9):666.

   -Read by QxMD

   
   

3. Vitamin A for treating measles in children. Cochrane Database of Systematic Reviews. Huiming Y, Chaomin W, Meng M.  2005, (4):CD001479.
   -PubMed

   
   

4. Measles vaccines: WHO position paper. Measles and Vitamin A. 
   World Health Organization. (Accessed on December 07, 2021).
   -WHO

   
   

5. An Update and Review of Measles for Emergency Physicians. Alves Graber, E.M., Andrade, F.J., Bost, W., Gibbs, M.A., 2020. The Journal of Emergency Medicine 58, 610–615.. 
   -PubMed

   
   

6. Vaccines for measles, mumps, rubella, and varicella in children.
   Di Pietrantonj C, Rivetti A, Marchione P, Debalini MG, Demicheli V.  Cochrane Database of Systematic Reviews 2021, Issue 11. Art. No.: CD004407.
   -Cochranelibrary

   
   

7. BCCH ID rReview of Vitamin A use. https://shop.healthcarebc.ca/phsa/BCWH_2/Pharmacy,%20Therapeutics%20and%20Nutrition/C-05-07-63104.pdf

   
   

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   All You Need to Know About Measles: All You Need to Know About Measles

   • Rebel EM – REBEL EM – Emergency Medicine Blog

   An Update and Review of Measles for Emergency Physicians

   Alves E. March 2020 – The Journal of Emergency Medicine.

   Images are courtesy of – DermNet NZ