Measles Management in 2019

Measles was discussed in the PedEM Morsels in 2011 and again in 2015. Sadly, measles is even more important today for us to review. While we refresh our memories about what measles may look like and can cause, let us also know what we need to do when we suspect there is a measles case in our ED. Let’s digest a Morsel about Measles Management:

Measles in 2019

  • Measles is known for the 3 C’s (just like every other virus!):
    • Cough
    • Coryza
    • Conjunctivitis
  • Distinguishing features may include:
    • Higher fevers and malaise.
    • Papular rash that starts at the hairline and then spreads down to trunk and extremities and can include the palms and soles.
    • Koplik Spots are pathognomonic (but occur after 3 C’s and resolve when rash develops)! [Kobaidze, 2017]
  • Vaccination is SAFE and effective at preventing Measles! [CDC.gov; Halsey, 2001]
    • Measles is one of THE MOST CONTAGIOUS infectious diseases.
      • Often those who are unvaccinated/under-vaccinated, cluster geographically, further increasing risk! [Lieu, 2015]
      • In the US, vaccine refusal is associated with increased risk for measles among the unvaccinated and the vaccinated patients. [Phadke, 2016]
    • MMR vaccination is 93% effective after 1 dose and 97% effective after 2nd dose.
    • MMR is scheduled to be given at 12-15 months and then again at 4-6 years of age.

Measles: Complications

  • Measles is typically a self-limited disease, but can develop complications. [Kobaidze, 2017]
    • Some will require hospitalization.
    • High risk for complications: < 5 years, > 20 years, pregnant, and immunocompromised patients.
    • EVERY ORGAN SYSTEM CAN BE INVOLVED!
  • Severe Complications (rare, but can even occur in previously healthy patients): [Kobaidze, 2017]

Measles Management

  • Think about it!
    • Fever + Rash should evoke measles on our DDx.
    • Look for the distinguishing features.
    • Ask about specific vaccination status!
    • Inquire about travel or exposure to others with similar fever & rash.
  • Test for it! [Kobaidze, 2017]
    • Measles-specific IgM antibody in serum
    • Measles RNA detection via RT-PCR from throat/nasopharyngeal swab
    • Refer to the CDC for guidance!
  • Isolate it!
    • Cases should be isolated until 4 days AFTER they develop the rash.
    • Airborne precautions are required in the healthcare setting.
  • Treat symptoms![Kobaidze, 2017]
    • Supportive care (fever and hydration management) will be the main therapies.
    • Direct other specific therapies toward complications if present.
  • Give Vitamin A for severe / hospitalized cases.
    • < 6 months – 50,000 IU
    • 6-11 months – 100,000 IU
    • >11 months – 200,000 IU
  • Antiviral therapy (Ribavirin) has been investigated in high risk populations, but is not universally recommended at this time. [Kobaidze, 2017; Moulik, 2013]
  • Post-Exposure Prophlyaxis [CDC.gov; Kobaidze, 2017]
    • Post-exposure prophylaxis should be offered to those who are exposed to measles and cannot prove immunity to it.
    • MMR vaccine can be given within 72 hours of exposure.
      • MMR can be given to infants 6 – 11 months in these situations.
    • Immunoglobulin can also be given up to 6 days of exposure.
      • High risk individuals should be given immunoglobulin.
      • Can be given IM (0.5 mL/kg, max = 15 mL) or IV (400 mg/kg, if >30 kg, use IM).
    • MMR and Immunoglobulin should not be given at the same time.

Moral of the Morsel

  • Open those old text books people! Measles is still around (sadly)!
  • Fever + Rash? Think about Measles.
  • Ask about specific vaccination status and risk factors!
  • Collect the specimens! Serum and Throat Swabs are helpful to not just this patient, but all of the other humans that come in contact with her/him.

References

Kobaidze K1, Wallace G2. Forgotten but Not Gone: Update on Measles Infection for Hospitalists. J Hosp Med. 2017 Jun;12(6):472-476. PMID: 28574541. [PubMed] [Read by QxMD]
Phadke VK1, Bednarczyk RA2, Salmon DA3, Omer SB4. Association Between Vaccine Refusal and Vaccine-Preventable Diseases in the United States: A Review of Measles and Pertussis. JAMA. 2016 Mar 15;315(11):1149-58. PMID: 26978210. [PubMed] [Read by QxMD]
Bednarczyk RA, Orenstein WA, Omer SB. Estimating the Number of Measles-Susceptible Children and Adolescents in the United States Using Data From the National Immunization Survey-Teen (NIS-Teen). Am J Epidemiol. 2016 Jul 15;184(2):148-56. PMID: 27338281. [PubMed] [Read by QxMD]
Li J1, Zhao Y, Liu Z, Zhang T, Liu C, Liu X. Clinical report of serious complications associated with measles pneumonia in children hospitalized at Shengjing hospital, China. J Infect Dev Ctries. 2015 Oct 29;9(10):1139-46. PMID: 26517490. [PubMed] [Read by QxMD]
Lieu TA1, Ray GT2, Klein NP3, Chung C4, Kulldorff M5. Geographic clusters in underimmunization and vaccine refusal. Pediatrics. 2015 Feb;135(2):280-9. PMID: 25601971. [PubMed] [Read by QxMD]
Casasoprana A1, Honorat R, Grouteau E, Marchou B, Claudet I. A comparison of adult and pediatric measles patients admitted to emergency departments during the 2008-2011 outbreak in the Midi-Pyrénées region of France. Jpn J Infect Dis. 2014;67(2):71-7. PMID: 24647247. [PubMed] [Read by QxMD]
Orenstein W1, Seib K. Mounting a good offense against measles. N Engl J Med. 2014 Oct 30;371(18):1661-3. PMID: 25354100. [PubMed] [Read by QxMD]
Roy Moulik N1, Kumar A, Jain A, Jain P. Measles outbreak in a pediatric oncology unit and the role of ribavirin in prevention of complications and containment of the outbreak. Pediatr Blood Cancer. 2013 Oct;60(10):E122-4. PMID: 23629813. [PubMed] [Read by QxMD]
Moss WJ1, Griffin DE. Measles. Lancet. 2012 Jan 14;379(9811):153-64. PMID: 21855993. [PubMed] [Read by QxMD]
Halsey NA, Hyman SL; Conference Writing Panel. Measles-mumps-rubella vaccine and autistic spectrum disorder: report from the New Challenges in Childhood Immunizations Conference convened in Oak Brook, Illinois, June 12-13, 2000. Pediatrics. 2001 May;107(5):E84. PMID: 11331734. [PubMed] [Read by QxMD]

Sean M. Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renown educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

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