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: [email protected]
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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