Commentary

A Review of Measles

Melissa R. Dardis, RN, BSN, MSN (candidate)1

Abstract

Measles, once a common childhood illness that many older school nurses could recognize without difficulty, needs reviewagain after reemerging from Europe and other continents. A highly contagious disease, which has been referenced since theseventh century, the virus can cause serious illness and death, despite the fact that it is vaccine preventable. School nurses arewise to review the pathogenesis, occurrences, incubation, and communicability as well as methods to diagnose and treatmeasles in order to prevent an outbreak.

Keywords

communicable diseases, immunizations, physical assessment, school nurse education

Measles is one of the most highly contagious diseases ever

known and despite being vaccine preventable continues to

cause serious illness and death. According to the Centers for

Disease Control (CDC, 2011), Western Europe has experi-

enced several thousands of cases of measles this year, and

the disease appears to be reemerging from years past. In the

United States, an average of 70 measles cases per year have

been reported since 2001, but measles continues to cause

outbreaks in Asia, Southeast Asia, the South Pacific, and

Africa (CDC, 2011). Due to the risk of exposure to measles

when travelling, a review of measles might help those who

are unfamiliar with this once common childhood disease.

Origin

Measles can be referenced as early as the seventh century.

The Persian physician Rhazes in the 10th century believed the

acute viral disease to be more dreaded than smallpox

(CDC, 2009). Prior to the availability of vaccine, measles was

considered a universal disease of childhood and greater than

90% of persons became immune by 15 years of age (CDC,2009). Peter Panum, in 1846, realized that after measles was

introduced in a population, fewer cases of measles occurred if

some of the population had already contracted the disease

(Arias, 2010). This then led to the concept of herd immunity.

Pathogenesis

Measles is a paramyxovirus of genus Mobillivirus (CDC,

2009). The diameter of the virus ranges from 100 to 200

nm, with a core of single-stranded RNA and is considered

to be closely related to canine distemper and renderpest

viruses (CDC, 2009). Two membrane envelope proteins

contribute to the pathogenesis. The F (fusion) protein allows

for fusion of the virus with the host cell membranes, viral

penetration, and cell breakdown, while the H (hemaggluti-

nin) protein enables the adsorption of virus into the cells

(CDC, 2009). Measles creates a systemic infection by pri-

marily focusing on the respiratory epithelium of the naso-

pharynx (Figure 2; CDC, 2009). After replicating

successfully in the respiratory epithelium and regional

nodes, the virus undergoes a primary viremia 5 to 7 days

later and then causes an infection in the respiratory tract

and other organs (CDC, 2009).

Signs and Symptoms

A high fever is one of the first signs of measles, which

begins approximately 1012 days after exposure to the virus

and can last for 7 days (World Health Organization [WHO],

2009). Cough, runny nose, red watery eyes, and small white

spots inside the cheeks can develop in the first stage of the

disease, followed by a rash on the face and upper neck

(Figure 1; Lewis & Bear, 2009). The rash progressively

spreads over the trunk and then to the hands and feet, lasts

for 5 to 6 days, and then fades away (Lewis & Bear, 2009).

Complications

According to the CDC (2009) 30% of all reported cases ofmeasles have one or more complications. Measles complica-

tions occur most often in children less than 5 years of age

and in adults of 20 years of age and older (CDC, 2009). The

most serious complications include blindness, encephalitis,

1 Kyrene School District, Tempe, AZ, USA

Corresponding Author:

Melissa R. Dardis 15442 S. 1st Ave, Phoenix, AZ 85045, USA

Email: mrdardis@yahoo.com

The Journal of School Nursing28(1) 9-12 The Author(s) 2012Reprints and permission:sagepub.com/journalsPermissions.navDOI: 10.1177/1059840511429004http://jsn.sagepub.com

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severe diarrhea, seizures, otitis media, and pneumonia (CDC,

2009). Pneumonia associated with measles is the most com-

mon cause of death and accounts for 60% of all deaths (CDC,2009). Pregnant mothers who contract measles have a higher

risk of premature labor, spontaneous abortion, and low birth

weight infants (CDC, 2009).

Occurrences

According to the WHO (2009), more than 20 million people

are impacted by measles annually. The disease is still quite

common and especially frequent in some areas of Africa and

Asia (WHO, 2009). Severe cases of measles occur more

often among poorly nourished children, and especially those

who lack sufficient vitamin A, or whose immune systems

have been weakened by HIV/AIDs or other chronic diseases

(WHO, 2009). Measles is one of the leading causes of death

among children under the age of 5 (WHO, 2009). It has

been reported that there were 164,000 cases of measles that

resulted in death in 2008 (WHO, 2009). This amounts to

almost 450 deaths per day or 18 deaths per hour (WHO,

2009). Those countries that have experienced a natural

disaster or conflict are particularly susceptible (WHO,

2009). As an example, an outbreak of measles occurred

in Haiti as a result of overcrowding in residential camps.

There are several ongoing outbreaks of measles in Europe

at the present time (CDC, 2009). Populations being

affected are younger than 20 years of age and account for

76% of the cases; 91% of the cases are persons who areunvaccinated (CDC, 2009).

Incubation and Communicability

The incubation period for measles from the time of exposure

to the time of symptoms averages 10 days, but may be 718

days from onset of fever and 14 days post rash, rarely as long

as 1921 days (Heymann, 2009). The period of communic-

ability is considered to be 1 day prior to symptoms until 4

days after the rash appears (Heymann, 2009). Communic-

ability, therefore, should be considered possible at least 7

days beyond the start of the first symptoms (Lewis & Bear,

2009). The virus is highly contagious and is spread by

coughing and sneezing, close person contact, or via direct

contact with infected nasal or throat secretions (American

Academy of Pediatrics [AAP], 2003). The measles virus can

remain activated and contagious in the air or on the surfaces

for approximately 2 hr (WHO, 2009). The only natural host

is human (AAP, 2003).

Outbreak Control Measures

Any child or adult displaying symptoms of measles should

be isolated, excluded, and referred to a health care provider

for diagnosis (Lewis & Bear, 2009). Infants and preschool

age children are especially vulnerable (CDC, 2009). School,

county, and state guidelines should be followed to notify par-

ents or caregivers of any infected case and those of students

not adequately immunized (Lewis & Bear, 2009). Local

health department regulations should be followed for report-

ing and for readmittance to school (Lewis & Bear, 2009). All

students should be observed for potential new cases, and a list

of students who lack measles vaccination should be created

(Lewis & Bear, 2009). Students should not be allowed to

return to school a minimum of 4 days after rash onset and

should check with the health care provider for clearance

before returning to school (Lewis & Bear, 2009). Proper hand

washing technique should also be reviewed with all school

personnel and students (Lewis & Bear, 2009).

Diagnostic Methods

According to the CDC (2009), isolation is not recommended

as a routine method to diagnose measles. Virus isolates,

Figure 1. Face of boy with measles on third day of rash.Content Provider: Centers for Disease Control

Figure 2 Kopliks spots on palate.Content provider: CDC/Dr. Heinz F. Eichenwald

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however, are very important for molecular epidemiologic

surveillance and can help determine the geographic origin

of the virus and any viral strains that may be circulating in

the United States (CDC, 2009). Infection with the measles

virus can be confirmed via a positive serologic test for

measles immunoglobulin M (IgM) antibody, a marked

increase in measles IgG antibody concentration coupled

with acute and convalescent serum specimens via standard

serologic assay or by isolating the measles virus from speci-

mens of urine, blood, or nasopharyngeal secretions (AAP,

2003). The easiest way to diagnose the disease is by testing

for IgM antibody on a single serum specimen when first

encountering a person suspected of being infected with

measles (AAP, 2003). According to the AAP (2003),

measles IgM assay sensitivity can vary and may be dimin-

ished during the first 72 hr after rash onset (AAP, 2003).

If the test is negative for measles IgM and the patient dis-

plays a generalized rash that lasts more than 72 hr, the

measles IgM test should be repeated (AAP, 2003). Measles

IgM can be detected for at least 1 month after the rash

appears (AAP, 2003). Persons who are seronegative for

measles IgM, but have a fever and rash, should be tested for

rubella using the same viral samples (AAP, 2003).

Treatment Recommendations

No antiviral therapy specifically for measles is available at

the current time. According to the AAP (2003) the virus

shows in vitro susceptibility to Ribaviran which has been

given intravenously along with aerosol to treat severely

affected children and those who are immunocompromised.

Ribaviran is not licensed by the U.S. Food and Drug Admin-

istration (USFDA) for treatment of measles (AAP, 2003).

Vitamin A is recommended to be administered to chil-

dren diagnosed with the disease in communities where vita-

min A deficiency exists or where the measles case fatality

rate is 1% or more (AAP, 2003). Two doses of vitamin A sup-plements given 24 hours apart are recommended and can help

prevent eye damage and blindness (WHO, 2009).

Supportive care, adequate nutrition, and fluid intake can

also prevent complications from measles (WHO, 2009).

An oral rehydration solution can replace fluids and other

essential elements that are lost through diarrhea or vomit-

ing. Antibiotics should only be prescribed when eye and

ear infections occur and or when pneumonia is present

(WHO, 2009).

Epidemiological Considerations

According to the CDC (2009), the number and makeup of

outbreak of measles has varied since the 1980s. Before

1989, most of the outbreaks occurred among middle, high

school, and college student populations. It was discovered

that 95% of persons infected at the time of the outbreaks hadreceived one previous dose of measles vaccine. In 1989, a

second dose of measles vaccine was recommended for

school-age children. Currently all states in the United States

require two doses of measles vaccine for children. It is now

rare to have a measles outbreak in school settings in the

United States (CDC, 2009). It is believed that the increase

in the number of cases in 2008 was a direct result of more

measles transmission after the virus was imported. The

majority of imported cases have occurred among unvacci-

nated school-age children; many of whom were home-

schooled (CDC, 2009).

An international imported measles case is considered to

be imported if the source originated outside the country, rash

onset occurs within 21 days after entry into the country, and

illness is not found to be linked to local transmission (CDC,

2009). An indigenous case of measles is any case that is not

imported; however there are subclasses of indigenous cases

(CDC, 2009). Measles continues to be designated as a noti-

fiable infectious disease at the national level since it is

highly contagious and can lead to serious complications and

death (CDC, 2009).

Recommendations for Prevention

Measles vaccination is the primary public health strategy

to reduce global measles deaths (CDC, 2009). According

to the CDC (2009), the measles vaccine has been available

for over 40 years. The vaccine has proven to be safe, effec-

tive, and inexpensive; costing less than 1 U.S. dollar per

child. Due to the fact that approximately 15% of the vac-cinated children fail to develop passive immunity from one

dose of measles vaccine, two doses are recommended to

ensure immunity (CDC, 2009). Measles exposure does not

contraindicate immunization to the disease (AAP, 2003).

Live-virus measles vaccine, if given within 72 hr of expo-

sure to measles, often provides protection in many cases

(AAP, 2003).

Ig may be given to prevent or lessen the effects of

measles in susceptible persons within 6 days of exposure

(AAP, 2003). Ig is recommended for susceptible household

contacts of patients with measles, especially for those who

are less than 1 year of age, pregnant women, and immuno-

compromised individuals when the risk of complications is

greater (AAP, 2003).

The Measles Initiative is a joint effort of WHO, United

Nations International Childrens Emergency Fund (UNI-

CEF), the American Red Cross, the CDC, and the United

Nations Foundation (CDC, 2009). The collaborative efforts

of these agencies, along with private and public affiliates,

play a major role in promoting a global measles strategy

(CDC, 2009). The strategy includes:

1. routine immunization for children at 1 year of age;

2. mass vaccination campaigns to ensure that all children

get at least one dose of measles;

Dardis 11

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3. ongoing surveillance in all countries to quickly perceive

and respond to outbreaks of measles; and

4. improved treatment of cases with measles, to include

vitamin A administration and antibiotics when indi-

cated, and supportive care that reduces complications

(CDC, 2009)

Conclusion

It is important for school nurses to be able to recognize

measles when it occurs. Websites such as the CDC, WHO

as well as local health departments can provide additional

information about measles and show visual images

of measles rash to help distinguish it from other rash-

type illnesses. It is clear that the disease remains highly

contagious and can occur within a community almost

overnight. By reviewing the origin of the disease, the

pathogenesis, occurrences, incubation, and communic-

ability as well as methods to diagnose measles and treat-

ment options, school nurses can be proactive in

preventing an outbreak. Measles remains a leading cause

of death among children even though it is a vaccine-

preventable disease. Perhaps with responses, such as the

measles initiative, more children will become vaccinated

against measles and the disease will no longer be as infec-

tious as it presently is.

Declaration of Conflicting Interests

The author declared no potential conflicts of interest with respect to

the research, authorship, and/or publication of this article.

Funding

The author received no financial support for the research,

authorship, and/or publication of this article.

References

American Academy of Pediatrics. (2003). Red book: 2003 report

of the committee on infectious diseases (26th ed.). Elk Grove

Village, Ill: American Academy of Pediatrics.

Arias, K. M. (2010). Outbreak, prevention, and control in health

care settings (2nd ed.). Sudbury, MA: Jones and Bartlett

Publishers.

Centers for Disease Control. (2009). Epidemiology and prevention

of vaccine-preventable diseases (11th ed.). Washington, DC:

Public Health Foundation.

Centers for Disease Control. (2011, June 21). 2011 update on

measles for air travelers. Retrieved from http://wwwnc.cdc.

gov/travel/page/measles-for-air-travelers.htm

Heymann, D. L. (2008). Control of communicable diseases

manual (19th ed.). Washington, DC: American Public Health

Association.

Lewis, K. D., & Bear, B. J. (2009).Manual of school health (3rd ed.).

St. Louis, MO: Saunders Elsevier.

World Health Organization. (2009). Measles fact sheet. Retrieved

from http://www.who.int/mediacentre/factsheets/fs286/en/

Bio

Melissa R. Dardis, RN, BSN, MSN (candidate), is a district nurse

at Kyrene School District, Tempe, AZ, USA.

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