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Rubeola update for nurses

Heavey, Elizabeth, PhD, RN, CNM; Peterson, Kathleen, PhD, RN, PCPNP-BC

doi: 10.1097/01.NURSE.0000552706.03868.c6

At the State University of New York, Brockport, Elizabeth Heavey is a professor of nursing and the graduate program director, as well as a member of the Nursing2019 editorial board, and Kathleen Peterson is a professor of nursing and department chairperson.

The authors have disclosed no financial relationships related to this article.

COMMONLY KNOWN as measles, rubeola is a highly infectious virus that can result in severe complications, including pneumonia, encephalitis, and death.1 Infection rates are nearly 90% among susceptible populations, such as unvaccinated communities in close contact with contagious individuals.2,3 Globally, 20 million cases of rubeola still occur annually, leading to an estimated 89,780 deaths.1,3

Public health campaigns and vaccination efforts eradicated endemic rubeola in the US as of 2000.4 Despite these elimination efforts, however, outbreaks have occurred from index cases with exposure to the disease outside of the US.3 This article discusses the role of nurses in identifying and caring for infected patients, preventing disease spread, and encouraging vaccination based on CDC guidelines.

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Who is at risk for complications?

Rubeola is a serious concern for all patients, with children younger than 5 years and adults older than age 20 at increased risk for complications.3 Other populations at risk for complications due to infection include pregnant women and immunocompromised individuals.3 About 30% of reported rubeola cases are associated with one or more complications, such as:3,5

  • otitis media (most common)
  • acute disseminated encephalomyelitis
  • encephalitis
  • subacute sclerosing panencephalitis
  • bronchitis, laryngitis, or croup
  • pneumonia
  • preterm labor
  • low birth weight
  • death.
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Signs and symptoms

Rubeola transmission occurs through either direct contact with infectious droplets or inhalation of airborne droplets. According to the CDC, “Measles virus can remain infectious in the air for up to 2 hours after an infected person leaves an area.”3

The incubation period of rubeola is approximately 6 to 21 days from the initial exposure.6 The first signs and symptoms are typically a fever of 101° F (38.3° C) or higher and the appearance of Koplik spots. Koplik spots are 1 to 3 mm whitish, grayish, or bluish elevations with an erythematous base, typically seen on the buccal mucosa opposite the molar teeth. They can also appear on the hard and soft palate, gingival and sometimes labial mucosa, and have been described as “grains of salt on a red background.”6

Cough, coryza, and conjunctivitis, commonly described as “the three C's,” are also present initially.4 This is typically followed by an erythematous, maculopapular rash that begins on the face and spreads cephalocaudally, lasting at least 3 days, although it may not occur in immunosuppressed patients. The rash typically occurs around 14 days after virus exposure.3

Signs and symptoms last approximately 10 days. Patients are contagious for about 4 days before and after the rash appears. After recovery, patients have lifelong immunity.7 For a definitive diagnosis, the virus can be cultured and isolated, serologic testing can be analyzed for immunoglobulin M antibodies, or the associated RNA can be detected via reverse transcription polymerase chain reaction testing.6 Further molecular analyses may be necessary to link cases and determine the pathways of transmission.3

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Rubeola management

Patients with rubeola should be managed in an airborne infection isolation room with airborne precautions in place until 5 days post-rash. An N95 respirator should be used by any healthcare staff in contact with them.3,8 Healthcare personnel without immunity should be reassigned until 21 days after the onset of the last patient's rash.3

Supportive measures are recommended, including comfort measures such as rest, antipyretics, and hydration. Acetaminophen is safe to reduce fever, and ibuprofen can be administered as an alternative but not to infants age 6 months or less.9 Salicylates should not be administered in pediatric patients due to an association with Reye syndrome.9 A humidifier and throat lozenges may also provide some relief. Some patients develop light sensitivity, which can be managed with sunglasses and dimmed lights until the infection resolves.2

In the US, infants and children with severe rubeola, such as those requiring hospitalization, should be administered vitamin A upon diagnosis and again the next day.3 This practice is also generally recommended for pediatric patients with rubeola in areas of the world where children are likely to experience vitamin A deficiency.3,6,10 Because vitamin A is involved in the development of lymph cells and antibodies, adequate levels help to decrease morbidity and mortality associated with rubeola-induced complications and preserve epithelial cell integrity.2,10

Teach patients and families infection control measures to prevent the spread of infection. These include meticulous hand hygiene and practicing respiratory hygiene and cough etiquette.11

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Vaccination prevents disease

More than 80% of rubeola cases occur in unvaccinated populations or those with unknown vaccination status.4 Although rubeola outbreaks can occur even in vaccinated populations, high vaccination rates assist in limiting the number of cases, the duration of symptoms, and the spread of infections.12

The first combination vaccine for measles, mumps, and rubella (MMR) was licensed in 1971.5 From 1971 to 1989, one dose of the MMR vaccine was recommended, but the recommendation was changed following a measles resurgence in 1989. Currently, children should receive two doses of the combination MMR vaccine: the first between ages 12 and 15 months and the second between ages 4 and 6 years (a minimum of 28 days after the initial dose).3,13

The initial dose is approximately 93% effective at preventing rubeola. When both MMR vaccinations are administered as scheduled, they are 97% effective.3 This is a live vaccine and is contraindicated in patients who are immunosuppressed, have already experienced a severe allergic reaction to any of the vaccine components, and those who are pregnant or may be pregnant.14

In 2005, the FDA approved a vaccine combining the MMR and varicella vaccines. The measles-mumps-rubella-varicella (MMRV) vaccine may be administered in two doses as well: the first between ages 12 and 15 months and the second between ages 4 and 6 years (a minimum of 28 days after the initial dose).3,13

Without proof of acceptable immunity or at least one dose of MMR, adults born in 1957 or later with no medical contraindications, including nonpregnant women of childbearing age, should receive at least one dose of the MMR vaccine.15 Additionally, healthcare professionals, college students, and international travelers should receive two doses of the MMR vaccine at least 28 days apart unless they have acceptable evidence of immunity confirmed by serologic testing.3,15

Between 2016 and 2017, national MMR vaccination coverage for kindergarteners approached 95%, but clusters of low-vaccination communities continue to exist, creating susceptible pockets.16 After an outbreak in California in 2015, the state eliminated nonmedical vaccine exemptions for both public and private schools, which increased vaccination rates.16 Several other states, including North Dakota, New York, and Tennessee, have taken programmatic steps to increase vaccination rates.16

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Preventing an outbreak

Rubeola is a reportable illness. All close contacts of an infected patient should be traced to identify and isolate anyone who is potentially infectious (see On alert for outbreaks). Options for measles postexposure prophylaxis for children without evidence of measles immunity vary according to age, time of exposure, and contraindications to the MMR vaccine. Postexposure prophylaxis for susceptible individuals exposed to measles consists of an MMR vaccination within 72 hours of exposure (in the absence of a contraindication).

If MMR is contraindicated or more than 72 hours but less than 6 days have elapsed since exposure, immune globulin may prevent or modify measles infection in nonimmune individuals with increased risk of measles complications (including pregnant women without evidence of immunity and immunocompromised patients).3

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Nurses help protect public health

Rubeola is a communicable disease. Appropriate reporting according to state and federal regulations is critical to ensure outbreaks are contained.12 In the US, nurses can contact their local, state, or territorial health departments for a list of reportable diseases and the appropriate guidelines to follow.

Before the introduction of the MMR vaccine in 1963, rubeola was responsible for substantial mortality and morbidity in the US. Many public health measures have been taken to eradicate the virus, but this has not been achieved globally. Worldwide immunization is key to the elimination of rubeola. Nurses should encourage the appropriate immunization protocols in all populations.

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Rubeola resources

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On alert for outbreaks

It is not uncommon for a rubeola diagnosis to be missed, especially before the appearance of the characteristic rash. Patients may be diagnosed with viral upper respiratory infections and either discharged or admitted without the appropriate isolation precautions, increasing the risk of healthcare-associated infections. In one Arizona outbreak, 79% of the identified cases accessed healthcare while infectious, 91% did not receive a prompt diagnosis, and only 9% were appropriately masked and isolated even after presenting with high fever and a rash.17

Air travel may also contribute to the spread of an infection within a plane, at the point of origin, and at the destination. In 2013, an unvaccinated teen was infected in London and returned to the US, leading to 58 documented cases of rubeola in an orthodox Jewish community in New York.7 Family members who refused or delayed vaccination were pivotal in the spread of the disease, but the insular nature of the population helped to limit exposure to other susceptible individuals in the area.7 In 2015, 68 became ill after exposure to rubeola from a contagious individual visiting a theme park in California.7 By the end of the outbreak,147 documented cases occurred, spanning seven states, Mexico, and Canada.4 In 2017, another outbreak occurred in Minnesota in a Somali-American community.18 Antivaccine groups were instrumental in spreading false information, contributing to a total of 75 cases before the outbreak was contained.18

More than 80% of rubeola cases occur in unvaccinated populations or those with unknown vaccination status.4 Of the US residents who were unvaccinated and infected in 2015, 43% claimed philosophical and/or religious exemptions and 40% were too young to be vaccinated or had contraindications, such as immunosuppression or an allergy to one of the vaccine components.4 Even with high vaccination levels, unvaccinated clusters are fairly common within communities, increasing the likelihood of an outbreak once the virus is introduced into these populations. Those unable to be vaccinated who live in proximity to these communities are a heightened risk for infection.

As of November 3, 2018, 220 cases of measles have occurred in 26 states, nearly double the number of cases reported in 2017.12 This is directly linked to 15 separate outbreaks of measles in 2018 alone.12

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15. National Foundation for Infectious Diseases. Facts about mumps for adults. 2012.
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18. Dyer O. Measles outbreak in Somali American community follows anti-vaccine talks. BMJ. 2017;357:j2378.
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