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Measles

Resurgence of a once eliminated disease

Perkins, Amanda DNP, RN

doi: 10.1097/01.NME.0000577600.89889.d4
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Currently, we're seeing the highest number of measles cases in the US since it was declared eliminated. Here's what you should know about this preventable, potentially life-threatening respiratory virus.

Currently, we're seeing the highest number of measles cases in the US since it was declared eliminated. Here's what you should know about this preventable, potentially life-threatening respiratory virus.

Amanda Perkins is an Assistant Professor of Nursing at Vermont Tech in Randolph, Vt., and a Nursing made Incredibly Easy! Editorial Board Member.

The author has disclosed no financial relationships related to this article.

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Considered eliminated in the US in 2000, measles has had a resurgence in recent years. Before the development of the live measles vaccine in 1963, there were approximately 549,000 cases of measles and 495 measles-related deaths in the US each year, according to the National Center for Immunization and Respiratory Diseases (NCIRD). Additionally, 48,000 people were hospitalized and 1,000 developed chronic disability as the result of measles. It's believed that there may have been as many as 3 to 4 million people infected annually, but many cases weren't reported.

According to the CDC, as of the end of June 2019 there have been 1,095 measles cases in 28 states, with these numbers expected to rise. Washington and New York have the most and longest-lasting cases. It's important to note that in areas with the highest cases of measles outbreaks, we also see the lowest vaccination rates. If measles isn't controlled, we run the risk of its sustainment in the US.

This article provides an overview of measles, including signs and symptoms, diagnosis, treatment, complications, and prevention, as well as the nurse's role in caring for patients with measles.

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How it's spread

When a disease is classified as eliminated, it means that there have been no endemic cases for at least 12 months in a defined geographic area. This classification doesn't mean that no cases are reported, but rather the number of cases reported is low. Most of the cases of reported measles occur in individuals who aren't vaccinated, highlighting the need for prevention. Additionally, measles is most likely to spread in areas with a high proportion of unvaccinated individuals, whereas we tend to see lower rates of measles in highly vaccinated locations.

In many instances, measles is brought to the US from other countries. In fact, it's believed that the recent measles cases seen in the US started with unvaccinated people who were exposed while traveling and brought the virus back with them.

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Measles is highly contagious, with 9 out of 10 susceptible people exposed developing the infection. Transmission occurs via direct contact with droplets or the airborne route when an infected individual breathes, coughs, sneezes, or talks. Airborne particles can remain in the air for up to 2 hours, increasing the likelihood of infection.

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Signs and symptoms

With the recent uptick in measles cases in the US, nurses need to be able to identify signs and symptoms in patients at risk for measles to facilitate early treatment. The following are common signs and symptoms associated with measles:

  • fever (may be as high as 105° F [40.5° C])
  • malaise
  • cough, coryza (nasal mucous membrane inflammation), conjunctivitis
  • Koplik spots (enanthem, or a rash on the mucous membranes)
  • maculopapular rash (exanthema, or a skin rash).

These signs and symptoms typically develop 7 to 14 days after exposure. White-colored Koplik spots in the mouth often develop within 2 to 3 days (see A closer look at Koplik spots [enanthem]). The maculopapular rash seen with measles usually develops 14 days after exposure and most commonly starts on the head, moving to the trunk and lower extremities in a descending fashion (see A closer look at maculopapular rash [exanthema]). This skin rash appears as flat, red spots; in some cases, small raised bumps develop on the rash and/or sections of the rash may become joined. In many cases, the rash starts to fade after the fever is gone. Patients who are immunocompromised may not develop the rash. Be aware that individuals with measles are contagious for 4 days before and 4 days after the skin rash develops.

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Diagnosis

When caring for a patient with a febrile rash illness, you should suspect measles, especially if the patient has recently traveled internationally. Ask the patient about his or her vaccination status, recent travel, and recent exposure to anyone with measles. If you suspect measles, report the case to the local health department within 24 hours. In addition, follow your facility's specific policies and procedures.

Measles can be diagnosed with lab testing, including, but not limited to, serum levels of measles-specific immunoglobulin (Ig) M antibody and real-time polymerase chain reaction for measles RNA in a respiratory sample. It's recommended that both these tests be completed on any patient with suspected measles. In addition, or in place of a respiratory sample, a urine sample may be collected and used.

If a patient has an active case of measles, he or she should be isolated for at least 4 days after rash development. When in a healthcare setting, these patients should be on airborne precautions, including the use of a single patient room and N95 respirator. Additionally, visitors should be educated about the proper use of personal protective equipment (PPE) and the importance of donning PPE when visiting the patient.

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Treatment

The treatment for measles is supportive and focused on managing the patient's symptoms. In addition, any complications that develop must be treated accordingly. It's important to provide quiet activities for the patient with measles, especially pediatric patients who may have more difficulty spending extended time in the hospital environment. Remember that patients who are on airborne precautions may need additional emotional support because they can feel isolated and alone.

For severe measles cases in children, treatment with vitamin A may be necessary because a deficiency of this vitamin has been associated with delayed recovery and measles-related complications. Administer vitamin A immediately after diagnosis and again the next day. According to the NCIRD, the following vitamin A doses are used for children: younger than age 6 months, 50,000 IU; 6 to 11 months old, 100,000 IU; and older than age 12 months, 200,000 IU. If a patient has signs of vitamin A deficiency, a third dose may be administered approximately 4 to 6 weeks later. It may be beneficial for nurses to encourage patients to consume foods that are high in vitamin A, such as sweet potatoes, spinach, carrots, cantaloupe, and pumpkin.

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Complications

A variety of complications can develop in the patient with measles, including encephalopathy, otitis media, bronchopneumonia, laryngotracheobronchitis, and diarrhea. The individuals with the highest likelihood of complications are children younger than age 5 and adults older than age 20. Measles can increase the risk of miscarriage.

According to the NCIRD, 1 in 1,000 measles cases will lead to acute encephalitis, a severe complication that can cause permanent neurologic damage. Fifteen percent of children who develop acute encephalitis as the result of measles will die. Additionally, 1 to 2 in 1,000 children with measles will die as the result of respiratory or neurologic complications.

A rare complication of measles is subacute sclerosing panencephalitis (SSPE), a fatal degenerative disease of the central nervous system. SSPE is caused by a mutated measles virus that causes an incurable form of dementia. Signs and symptoms include behavioral changes, intellectual deterioration, and seizures. Interestingly, this disease develops 7 to 10 years after infection with measles.

Another complication that may develop is acute disseminated encephalomyelitis (ADEM), in which the brain develops an allergic reaction to the measles virus. The signs and symptoms of ADEM are an apparent recovery followed by fever, confusion, headaches, and a stiff neck. This disorder is seen in approximately 1 in 1,000 measles cases and can lead to epilepsy, brain damage, developmental delay, and death.

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Prevention

Encouraging vaccination against measles will help prevent its spread. Vaccination against measles is included in the combination measles-mumps-rubella (MMR) vaccine. To review, vaccines are suspensions of organisms that have either been weakened or inactivated. The vaccine stimulates the immune system to form antibodies against a specific pathogen. The MMR vaccine is relatively fragile; it must be stored in the freezer at 58° F to 5° F (–50° C to –15° C). Additionally, it must be used within 30 minutes of reconstitution.

The MMR vaccine is used in children older than age 12 months. One dose is typically 93% effective and two doses, 97% effective. For children, two doses are routinely administered, with the first dose being given at ages 12 to 15 months and the second administered at ages 4 to 6. Post high-school students at educational institutions who have no evidence of immunity should receive two doses, at least 28 days apart. Adults born in 1957 or after who have no evidence of immunity should receive at least one dose. International travelers between the ages of 6 and 11 months should receive one dose of the vaccine; those older than age 12 months should receive two doses. Lastly, healthcare workers should have evidence of immunity.

In areas where there's a measles outbreak, children who are younger than 6 months old may be vaccinated. If this occurs, the child will still need to follow the normal vaccination schedule and receive an additional vaccination at ages 12 to 15 months and ages 4 to 6.

In some cases, certain patients may need to avoid vaccination. Patients should consult with a healthcare provider before receiving the vaccine if they:

  • are pregnant (In addition, patients shouldn't get pregnant for at least 4 weeks after being vaccinated.)
  • have a history of a life-threatening reaction to the vaccine
  • are allergic to any of the vaccine components
  • have a disease of the immune system
  • are taking steroids or other drugs that affect the immune system
  • have cancer
  • have a low platelet count/bleeding disorder
  • received another vaccine within 4 weeks
  • received a recent transfusion.
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Patient exposure

If a patient is exposed to a person with measles and he or she has no evidence of immunity, postexposure prophylaxis should be initiated, which includes receiving the MMR vaccine within 72 hours or Ig within 6 days. The vaccine and Ig shouldn't be administered at the same time because this will make the vaccine ineffective.

The following groups are considered high-risk and should be given Ig if they're exposed to measles: infants younger than age 12 months, patients who are pregnant with no evidence of immunity, and anyone who has a compromised immune system. When administering Ig to high-risk patients, children younger than age 12 months should receive an IM dose of 0.5 mL/kg for a maximum dose of 15 mL; all others should receive an I.V. dose of 400 mg/kg. According to the Chicago Department of Public Health, the dosing for IM Ig is 40 mg/kg for a patient who isn't compromised and 80 mg/kg for the immunocompromised patient.

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Education first

Nurses are often the first contact for patients entering a healthcare facility. For this reason, it's important to be able to accurately identify possible cases of measles so that patients can be diagnosed and treated early. At this time, there's a lot of misinformation about the effectiveness and safety of vaccines, leading to the resurgence of diseases once thought to be eliminated such as measles. Ensure that your patients are properly educated about the safety and efficacy of vaccination against measles. Through education and outreach, we can have a dramatic effect on the elimination of this disease once again.

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cheat sheet

Signs and symptoms

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  • Fever
  • Malaise
  • Cough, coryza, conjunctivitis
  • Koplik spots
  • Maculopapular rash
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key points

Nursing assessment

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Priority assessments for the patient at risk for, or suspected of having, measles include the attainment of vital signs and a thorough head-to-toe exam. The main vital signs change in the patient with measles is an elevated temperature, although other vital signs changes may be observed in patients who develop measles-associated complications. For example, the patient who develops a respiratory complication may present with tachycardia. When completing the head-to-toe assessment, you typically won't observe mental status changes, unless a complication such as encephalitis has developed. An assessment of the integumentary system will reveal white-colored lesions in the patient's mouth and a maculopapular rash that starts at the patient's head and moves in a downward fashion. The cardiovascular assessment will typically be within normal limits. A pulmonary assessment will lead to the identification of a cough and, in some instances, adventitious lung sounds, especially if a respiratory infection develops. Lastly, an abdominal assessment may reveal hyperactive bowel sounds and diarrhea.

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on the web

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CDC:www.cdc.gov/measles/index.html

NCIRD:www.cdc.gov/ncird

World Health Organization:www.who.int/immunization/diseases/measles/en

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did you know?

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Why measles? Why now? We're seeing a resurgence of measles because of a decline in vaccinations. This is alarming because measles can be prevented, and vaccination is highly effective and safe. It's believed that decreased rates of vaccinations are due to the anti-vaccination movement and misinformation, such as the belief that vaccination will lead to autism. Although this has been proven to be untrue, many people believe that vaccinations cause autism and avoid vaccinating themselves and their children. As nurses, we need to focus on vaccination efforts through increased outreach, especially in areas with low vaccination rates.

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REFERENCES

Centers for Disease Control and Prevention. Measles cases and outbreaks. 2019. http://www.cdc.gov/measles/cases-outbreaks.html.
    Centers for Disease Control and Prevention. Measles isn't just a little rash: an introduction to measles. 2019. http://www.cdc.gov/measles/downloads/IntroToMeaslesSlideSet.pdf.
      Centers for Disease Control and Prevention. Measles (rubeola): for healthcare professionals. 2018. http://www.cdc.gov/measles/hcp/index.html.
        Gonzales R. CDC reports largest U.S. measles outbreak since year 2000. National Public Radio. 2019. http://www.npr.org/2019/04/24/716953746/cdc-reports-largest-u-s-measles-outbreak-since-year-2000.
          Leifer G. Introduction to Maternity and Pediatric Nursing. 8th ed. St. Louis, MO: Elsevier; 2018.
            Leventhal J. A quiet rise in unvaccinated children could put the US at risk of outbreaks. PBS News Hour. 2018. http://www.pbs.org/newshour/health/u-s-at-risk-of-outbreaks.
              National Institutes of Health. Decline in measles vaccination is causing a preventable global resurgence of the disease. 2019. http://www.nih.gov/news-events/news-releases/decline-measles-vaccination-causing-preventable-global-resurgence-disease.
                Ross J. Measles: the forgotten killer. Harvard Medical School. 2019. http://www.health.harvard.edu/blog/measles-the-forgotten-killer-2019052316683.
                  Seward J. Suspect measles and act fast. Medscape. 2014. http://www.medscape.com/viewarticle/828508.
                    World Health Organization. Measles vaccines: WHO position paper. 2009. https://apps.who.int/iris/handle/10665/241405.
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