Podcast #147 - 10 Things to Remember About Measles

With the recent surge of measles cases, it is important to understand the facts with measles.  In this post we cover a recent paper that reminds us some of the key details.

​We will break this down into 10 sections for easier discussion.  Check this recent review article published in the Emergency Medicine Journal.

1. Presentation

• Cases can occur year round but it is most common in the spring and summer with the peak being in March.
• Unvaccinated populations, travelers to an endemic area (including Africa especially in Nigeria, in China, the Philippines, and the Middle East including Yemen), or immunocompromised patients are most at risk.
• The incubation period is 6-21 days with a median of about 2 weeks.
• Fever starts first, up to 40°C (104°F) by day 5.
• Conjunctivitis, cough, coryza (copious nasal drainage) is the next stage.
• Koplik spots on the buccal mucosa, usually opposite of the molars, start appearing approximately 48 hours prior to the rash but these spots may be anywhere on the oropharyngeal mucosa, such as the soft palate. 
• The last part is the rash which starts on the face, especially along the hairline behind the ears, spreading across the face, down the neck, onto the trunk but spares palms and soles.
• Rash is morbilliform in appearance which blanches initially and later does not blanch.
• This rash usually resolves within a week.
• Lab tests for the initial diagnosis are not necessary but may show eosinophilia or elevated transaminases.
• Images below are from the CDC.

2. Complications

• Complications are very frequent and occur in 30%.
• Diarrhea  is the most common occurring in 8%.
• Global immunosuppression and secondary bacterial infections are common (such as otitis media and pneumonia) and are commonly staphylococcal, streptococcal, or H. influenzae infections.
  • This can be devastating being present in 7% of patients infected  and the need to assess as well as treat such bacterial infections is essential.
  • Pneumonia is the most common cause of death and this infection occurs in 6% of patients.
• Encephalitis occurs in 1/1000 (0.1%) and can quickly become lethal.  
• Acute demyelinating encephalomyelitis (ADEM) occurs in 1/1000, with 10-20% mortality rate.
• Rarely, delayed onset subacute sclerosing panencephalitis occurs (rates seem to be more prevalent than initially thought) which is a progressive neurological decline that is universally fatal.

3. Pregnancy

• Although pregnancy is not a risk factor for developing measles, it has serious complications in pregnancy.
• There is a severe risk of maternal and fetal complications including intrauterine death.

4. Contagiousness

• Measles is very contagious and spreads via airborne particles up to two hours after an infected patient has left the room, with a 90% attack rate.
• This 90% attack rate means that if you are susceptible and exposed there is a 90% chance you will get measles.
• It can spread 2 days before incubation to 4 days after the rash has appeared.

5. Isolation

• Given how contagious this disease is as described above, isolation is key.
• Patients should be placed in isolation using airborne precautions. 
• An N-95 mask, gown, and gloves are needed.

6. Confirmation

• Clinical diagnosis is primary, but later testing is beneficial.
• Test by RNA/IgM in saliva after the rash appears.
• Blood samples are also a feasible option.

7. Vitamin A

• Vitamin A has proven to be animportant part of treatment.
• Deficiency and lack of Vitamin A supplementation has demonstrated increased mortality in children with measles.

8. Vaccination

• Vaccination is key to prevention and avoiding spread.
• A single dose is 90% effective and two doses is almost 100% effective.
• Follow the CDC guidelines for vaccinating children and adults.

9. Autism

• THERE IS NO LEGITIMATE LINK TO AUTISM!
• Andrew Wakefield is a fraud.

10. Public Health 

• Given how contagious it is and the many complications it is a concern for public health.
• It is necessary to report measles to public health officials.

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