Measles
Measles is a virus that is highly contagious and replicates in the nose, mouth, or throat of infected people. It is transmitted by way of respiratory droplets from sneezing, saliva, or other means of travel (including deposit onto surfaces).
Variable: over 1000 cases 1st half of 2019. This is the most since 1992. For comparison, 2018 had 372 cases.
Infrequent, occurring in outbreaks.
There is a spectrum of severity. About 25% of measles cases require hospital management. Young children and adults are more likely to have complications than school-aged children.
Front-of-Mind
How contagious is measles?
Measles is extremely contagious, with about 90% of exposed, susceptible individuals progressing to infection. The period of contagiousness is on average nine days.
How dangerous is measles?
The severity of a measles infection varies, and is somewhat determined by maturity of an individual’s immune system. Young children under five, adults over 20, pregnant women, and people with compromised immune systems are most vulnerable to complications. The hospitalization rate of measles infections is about one in four. Pneumonia is the most common complication among those hospitalized.
How well does the MMR vaccine work?
If given after 12 months of age, the first dose provides immunity in about 93% of individuals. The majority 90% of those 7% initial nonresponders develop immunity with a second dose. If the vaccines are given on schedule, protection is about 97%.
What’s the typical immunization schedule and why?
The first dose is usually given between 12-15 months of age in America, with the second dose following at ages four-to-six. The second dose can be given as early as 28 days after the first dose.
Until around six months, newborns of vaccinated mothers have maternal antibodies, which can interfere with the desired immune response of the vaccine. For this reason, the first dose is delayed to provoke a more robust immune response in the vaccinated infant. Vaccine success rate is higher at 12 months (close to 95% effective) than at nine months (close to 85%). Ultimately, ideal vaccination timing may be best determined by examining the following factors: local variation in birth rate, seasonality, and access to care.
Given the recent outbreak, are there situations where vaccinations can or should be given sooner?
With a local US outbreak, infants in areas of concern should be vaccinated at six months to confer protection (in addition to the 12-15 month and four-to-six year shots), though that initial dose will not make all of them immune. In some parts of the world, the first shot is given at nine months, which projects an immunity rate of about 85%.
Additional recommendations would be to vaccinate at the beginning of the usual 12-15 month window for older infants and to consider providing the dose usually given at four-to-six years as early as 28 days after the dose usually given at 12-15 months.
What about for international travel?
Non-vaccinated infants aged 6-12 months can get their first dose early, subsequently followed by the normal two dose schedule, for three doses total. This is the same schedule that is recommended for those involved in a local outbreak.
What is “evidence of immunity”?
According to the CDC, preschool-age children and low-risk adults need written documentation that they’ve received one or more doses of a measles-containing vaccine given on or after their first birthday.
School-age children and high-risk adults (college students, healthcare professionals, and international travelers) need laboratory evidence of immunity, laboratory confirmation of measles, or a birthday before 1957.
Is there a way for someone who’s not sure if they’re vaccinated or whether they got both doses to test their antibodies?
Yes, there is a blood test that can validate or invalidate immunity. It’s called a titer or IgG (a type of antibody) level for the virus. We can order this test for you if there is concern about your immunity. Insurance coverage, as with most lab tests, is variable.
Are there any risks with the shot?
There is a small risk (1 in 2500 to 1 in 4000, depending on age) of febrile seizures in children receiving the vaccine. Febrile seizures are something that some children experience in response to high fevers, which do not have negative long-term consequences. There is also a small risk (1 in 40,000) of lowered platelet count in the six weeks post vaccination. MMR vaccines do NOT contribute to development of autism, which sometimes has presenting symptoms near the same age as MMR vaccination.
Are there any typical symptoms/side effects to the shot?
As with most other vaccines, the most common side effects are sore arm (at injection site), rash, fever, and body aches (muscles and joints).
Are there people who should not get it?
Pregnant women, people with a previous life-threatening reaction to MMR vaccine, people with rare immunocompromised conditions, people with a current tuberculosis infection, and people who have received transfused blood or blood products in the past three months shouldn’t get the vaccination, according to the CDC.
Symptoms/Diagnosis
What are typical symptoms of measles?
Most early measles symptoms are also associated with other diseases. However, the sequence in which the symptoms develop helps suggest measles as a possibility. That said, not every person will experience the same pattern.
Initial symptoms are fatigue, loss of appetite and fever (up to 104 F, which may persist for a week or more), followed by a runny nose, cough, and irritated eyes. A finding that is unique to measles, though not always present, is a characteristic rash pattern on the inside of the cheeks dubbed “Koplik spots.”
Two-to-three days later in the infection, a rash develops that begins on the face and spreads down toward the body, arms, and legs. Sometimes, a sore throat is present. Cough and lymph node enlargement may last longer than all other symptoms.
How long do the symptoms last?
The first wave of fever and cold-like symptoms escalates for two-to-three days, after which the rash appears.
The rash, which typically lasts six-to-seven days and is accompanied by spiking fever, resolves in the same pattern it developed—first the face, then the trunk and arms, and lastly the legs and feet.
A cough may persist for a couple weeks, and lymph node enlargement is typical also. The entire course of symptoms is expected to last two-to-three weeks.
What should someone who thinks they’ve been exposed to measles do?
High fever, rash, or exposure to someone with measles are the likely characteristics that distinguish measles from other infections. A doctor’s office should be contacted if there is concern for measles because of those symptoms. A person who has been exposed and is not immune may be able to prevent development if they are given the measles vaccine or in some cases, a medication called immunoglobulin.
When should someone who thinks they may have the measles see a doctor?
Calling a doctor or other medical provider from home should be done before going into a healthcare setting when possible. Obviously, evaluation is needed, but public health protection is critical, so immediate notification of medical staff is important for infection control.
Treatment
How is measles treated?
In most cases, treatment is supportive, meaning we use whatever means needed to help manage symptoms, as opposed to fighting the causative virus. Specific antiviral medications against measles do not exist.
Can other issues come up after recovery?
There are complications that can occur during or immediately after the active infection, such as ear infections, pneumonia, and diarrhea. In addition, there are long term sequelae that are rare, such as reactivation of the virus a decade later, as with subacute sclerosing panencephalitis (SSPE).
Prevention
If someone is vaccinated, can they still pass the disease along?
A vaccinated person, assuming they are not in the 3% of those vaccinated who do NOT achieve immunity, cannot transmit the virus. Their immune system’s antibodies will surround the virus and prevent replication and transmission. For this reason, the vaccinated part of our population provides significant protection to those who are unable to be vaccinated (including infants and those with severe immune conditions).
For a child too young to be vaccinated, what are appropriate precautions for parents to take if there’s been an exposure in their city?
Under six months, exercising precaution in the community is the best strategy. That means avoidance of contact with those known or suspected to be infected with the measles virus. This is a challenge for parents of newborns, understandably, as only so much control is in their hands.
While it isn’t necessary to quarantine their children from the outside world, those parents will need to make some difficult decisions about where they are comfortable taking their babies and on what timeline they want to start the immunization process.
Useful Links
Immunization Action Coalition: (a member of the WHO-led project Vaccine Safety Net (VSN))
Connect with our physicians
Nora Lansen, MD and Andrew Cunningham, MD are both members of the Galileo Clinical Team. Connect with one of our physicians about Measles or any of the many other conditions we treat.