Overview/Definition
Definition:
• Measles is highly contagious viral infection caused by measles virus (family Paramyxoviridae) characterized by fever, cough, conjunctivitis, and pathognomonic Koplik spots followed by maculopapular rash
Despite effective vaccination, global resurgence occurred in 2018-2019 with declining vaccination coverage and vaccine hesitancy.
Epidemiology:
• India reported 58,179 measles cases in 2019, significant increase from previous years
Resurgence attributed to suboptimal vaccination coverage (85-90%), vaccine hesitancy, and migration patterns
Case fatality rate 1-3% in children, higher in malnourished and immunocompromised
Endemic in many states with seasonal peaks during winter-spring.
Age Distribution:
• Infants (<9 months): Protected by maternal antibodies, vaccination not routinely recommended
Children (9 months-15 years): Primary target group for vaccination and outbreaks
Adolescents (15-18 years): Susceptible if inadequately vaccinated, important for herd immunity
Adults: Secondary cases from infected children.
Clinical Significance:
• Critical topic for DNB Pediatrics and NEET SS examinations focusing on outbreak management, vaccination strategies, and complication prevention
Understanding measles elimination goals, catch-up vaccination programs, and public health response essential
Knowledge of modified measles in partially immune individuals important.
Age-Specific Considerations
Newborn:
• Neonates (0-8 months): Usually protected by maternal antibodies if mother immune
Maternal antibody wanes by 6-9 months depending on maternal antibody levels
Vaccination not recommended <9 months except during outbreaks (6-8 months)
Severe disease possible in infants born to non-immune mothers.
Infant:
• Infants (9-24 months): MR vaccine at 9-12 months, MMR at 16-24 months as per UIP schedule
Higher risk for severe disease and complications
Vitamin A supplementation crucial for complication prevention
Outbreak settings may require vaccination at 6-8 months with revaccination later.
Child:
• Children (2-15 years): Most common age group affected during outbreaks
Two-dose MMR schedule provides 95-98% immunity
Catch-up vaccination important for incompletely vaccinated children
School-based surveillance and vaccination programs effective for outbreak control.
Adolescent:
• Adolescents (15-18 years): Often missed in routine vaccination programs
Higher risk for complications including pneumonia, encephalitis
Important reservoir for transmission to vulnerable populations
College outbreaks common requiring mass vaccination campaigns.
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Clinical Presentation
Symptoms:
• Prodromal phase (2-4 days): High fever (39-40°C), malaise, anorexia, conjunctivitis with photophobia
Respiratory symptoms: Harsh barking cough, coryza, hoarse voice
Koplik spots: Pathognomonic bluish-white spots on buccal mucosa appearing 1-2 days before rash.
Physical Signs:
• Exanthem phase: Erythematous maculopapular rash appearing on face, spreading centrifugally to trunk and extremities over 3-4 days
Rash becomes confluent, gives characteristic measles appearance
Lymphadenopathy: Generalized, especially posterior cervical and occipital
Conjunctival injection and photophobia prominent.
Severity Assessment:
• Uncomplicated measles: Typical presentation with fever, rash, respiratory symptoms resolving in 7-10 days
Complicated measles: Secondary bacterial infections (pneumonia, otitis media), encephalitis, severe diarrhea
Modified measles: Atypical presentation in partially immune individuals.
Differential Diagnosis:
• Rubella: Milder symptoms, posterior cervical lymphadenopathy, no Koplik spots
Roseola infantum: Younger age, rash appears after fever subsides
Drug rash: History of medication use, no systemic symptoms
Kawasaki disease: Prolonged fever, specific diagnostic criteria.
Diagnostic Approach
History Taking:
• Vaccination history: Number of MMR doses received, timing of last dose
Contact history: Exposure to measles cases in preceding 7-21 days
Travel history to measles-endemic areas
Household and school contacts assessment
Previous measles illness history.
Investigations:
• Measles IgM antibody: Positive 3 days to 4 weeks after rash onset
RT-PCR: Throat swab or urine sample for viral RNA detection
Measles IgG: Paired sera showing four-fold rise in convalescent sample
Viral culture: Throat swab, urine, or blood for virus isolation (rarely done).
Normal Values:
• Measles IgM: Negative in immune individuals
Measles IgG: >200 mIU/ml indicates immunity, <150 mIU/ml suggests susceptibility
RT-PCR: Negative in non-infected individuals
White blood cell count: Often low during acute phase (leucopenia common).
Interpretation:
• IgM positive: Recent measles infection (appears day 3-4 of rash)
IgG seroconversion: Four-fold rise confirms recent infection
RT-PCR: Most sensitive in early illness, useful for outbreak investigation
Clinical diagnosis sufficient during confirmed outbreaks with typical presentation.
Management/Treatment
Acute Management:
• Supportive care: Adequate hydration, fever management with paracetamol, rest in darkened room for photophobia
Vitamin A supplementation: 200,000 IU for children >12 months, 100,000 IU for 6-12 months, reduces complications and mortality
Isolation precautions for 4 days after rash onset.
Chronic Management:
• Complication management: Antibiotic therapy for secondary bacterial infections (pneumonia, otitis media)
Respiratory support for severe pneumonia
Anticonvulsants for febrile seizures
Nutritional rehabilitation post-illness
Ophthalmological assessment for vitamin A deficiency complications.
Lifestyle Modifications:
• Isolation at home for 4 days after rash onset to prevent transmission
Adequate nutrition and hydration during illness
Avoid aspirin due to Reye syndrome risk
Eye protection from bright light during conjunctival involvement
Gradual return to normal activities post-recovery.
Follow Up:
• Daily monitoring during acute phase for complications
Weekly follow-up for 2-3 weeks post-illness
Growth monitoring especially in malnourished children
Hearing assessment if otitis media occurred
Vaccination status review and catch-up if needed.
Age-Specific Dosing
Medications:
• Vitamin A supplementation: Children >12 months: 200,000 IU orally on days 1 and 2, repeat at 4 weeks if deficiency signs
Infants 6-12 months: 100,000 IU orally on days 1 and 2
Infants <6 months: 50,000 IU orally
Paracetamol: 10-15 mg/kg every 6 hours for fever.
Formulations:
• Vitamin A: Capsules 200,000 IU, 100,000 IU, liquid formulation 50,000 IU/ml
Paracetamol: Suspension 120 mg/5 ml, 250 mg/5 ml, tablets, dispersible tablets
MMR vaccine: Live attenuated vaccine, 0.5 ml subcutaneous injection.
Safety Considerations:
• Vitamin A toxicity rare with recommended doses but monitor for hypervitaminosis signs
Avoid aspirin in children due to Reye syndrome risk
MMR vaccine contraindicated in immunocompromised children, pregnancy, severe illness
Live vaccine interaction considerations.
Monitoring:
• Clinical improvement: Fever resolution, appetite return, activity increase
Complication monitoring: Respiratory distress, altered consciousness, secondary bacterial infections
Nutritional status assessment especially in malnourished children
Hearing and vision assessment post-recovery.
Prevention & Follow-up
Prevention Strategies:
• Routine immunization: MR vaccine at 9-12 months, MMR at 16-24 months
Catch-up vaccination for incompletely vaccinated children
Outbreak response: Ring vaccination around cases, mass vaccination campaigns
Herd immunity threshold 95% to prevent outbreaks.
Vaccination Considerations:
• MMR vaccine schedule: First dose 12-15 months, second dose 4-6 years
Catch-up: Two doses separated by minimum 4 weeks
Outbreak settings: Vaccination from 6 months with revaccination at appropriate age
Post-exposure prophylaxis within 72 hours of exposure.
Follow Up Schedule:
• Post-vaccination: No routine follow-up needed unless adverse events
Outbreak investigation: Contact tracing, secondary case surveillance for 21 days
Community surveillance: Enhanced surveillance during outbreaks
Annual vaccination coverage assessment.
Monitoring Parameters:
• Vaccination coverage monitoring at community level
Outbreak surveillance: Case-based surveillance with laboratory confirmation
Adverse events following immunization (AEFI) monitoring
Population immunity assessment through serosurveys.
Complications
Acute Complications:
• Secondary bacterial infections: Pneumonia (most common cause of death), otitis media, sinusitis requiring antibiotic therapy
Laryngotracheobronchitis (croup): Respiratory compromise requiring close monitoring
Febrile seizures: Usually brief and self-limiting
Encephalitis: Rare but serious, 1:1000 cases.
Chronic Complications:
• Subacute sclerosing panencephalitis (SSPE): Rare chronic degenerative CNS disease, 7-10 years after measles
Vitamin A deficiency complications: Blindness, keratomalacia
Secondary immunosuppression: Increased susceptibility to other infections for weeks to months.
Warning Signs:
• Respiratory distress indicating pneumonia or croup
Altered consciousness, seizures suggesting encephalitis
High fever persisting >5 days after rash onset
Signs of dehydration: Decreased urine output, dry mucous membranes
Secondary bacterial infection signs.
Emergency Referral:
• Immediate referral for respiratory distress, altered consciousness, signs of encephalitis
ICU consultation for severe pneumonia, respiratory failure
Ophthalmology referral for eye complications
Neurology consultation for seizures, encephalitis
Intensive monitoring for high-risk groups.
Parent Education Points
Counseling Points:
• Measles is serious but preventable disease through vaccination
Two doses of MMR vaccine provide lifelong immunity in 95-98% children
Importance of completing vaccination schedule and catch-up vaccination
Understanding of outbreak risks and community protection through herd immunity.
Home Care:
• Isolation for 4 days after rash onset to prevent transmission to others
Adequate fluid intake to prevent dehydration
Dim lighting to reduce discomfort from photophobia
Paracetamol for fever, avoid aspirin
Nutritious diet as tolerated, vitamin A supplementation important.
Medication Administration:
• Vitamin A capsules can be opened and contents given with food if child cannot swallow
Paracetamol dosing based on weight, not age
Complete vitamin A course as prescribed
Monitor for side effects and report if concerned
Store medications safely away from children.
When To Seek Help:
• Immediate medical attention for difficulty breathing, persistent high fever >5 days
Altered consciousness, seizures, severe headache
Signs of dehydration: No urination for >8 hours, dry mouth, lethargy
Eye problems: Pain, discharge, vision changes
Any worsening symptoms or parental concerns.