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Measles is the archetypal childhood infection - whilst self-limiting in most, it is not a trivial disease with complications in about 10% requiring hospital admission and fatality rates of 1 per 5,000 in the UK (higher rates in other industrialised countries).
Immunisation programmes in the UK and elsewhere had limited many modern clinicians' exposure to the disease. Falls in the uptake of immunisation over the last decade has now increased the susceptible population to such a degree that measles is again endemic here1. There is concern that conditions could permit a large epidemic outbreak in England, with estimates of 30,000 cases in children and young adults affected (or in the worst case scenario, more than 100,000 cases).2,3
Measles is one of the leading causes of death among young children even though a safe and cost-effective vaccine is available.
In 2008, there were 164 000 measles deaths globally - nearly 450 deaths every day or 18 deaths every hour.
More than 95% of measles deaths occur in low-income countries with weak health infrastructures.
Measles vaccination resulted in a 78% drop in measles deaths between 2000 and 2008 worldwide.
In 2008, about 83% of the world's children received one dose of measles vaccine by their first birthday through routine health services - up from 72% in 2000.
Measles is a highly contagious, serious disease caused by a virus.
It remains one of the leading causes of death among young children globally, despite the availability of a safe and effective vaccine. An estimated 164 000 people died from measles in 2008 - mostly children under the age of five. Measles is caused by a virus in the paramyxovirus family. The measles virus normally grows in the cells that line the back of the throat and lungs. Measles is a human disease and is not known to occur in animals.
Targeted vaccination campaigns have had a major impact on reducing measles deaths. From 2000 to 2008 nearly 700 million children aged 9 months to 14 years who live in high risk countries were vaccinated against the disease. Global measles deaths decreased by 78% during this period.
Signs and symptoms
The first sign of measles is usually a high fever, which begins about 10 to 12 days after exposure to the virus, and lasts four to seven days. A runny nose, a cough, red and watery eyes, and small white spots inside the cheeks can develop in the initial stage. After several days, a rash erupts, usually on the face and upper neck. Over about three days, the rash spreads, eventually reaching the hands and feet. The rash lasts for five to six days, and then fades. On average, the rash occurs 14 days after exposure to the virus (within a range of seven to 18 days).
Severe measles is more likely among poorly nourished young children, especially those with insufficient vitamin A, or whose immune systems have been weakened by HIV/AIDS or other diseases.
Most measles-related deaths are caused by complications associated with the disease. Complications are more common in children under the age of five, or adults over the age of 20. The most serious complications include blindness, encephalitis (an infection that causes brain swelling), severe diarrhoea and related dehydration, ear infections, or severe respiratory infections such as pneumonia. As high as 10% of measles cases result in death among populations with high levels of malnutrition and a lack of adequate health care.
People who recover from measles are immune for the rest of their lives.
Who is at risk?
Unvaccinated young children are at highest risk of measles and its complications, including death. Any non-immune person (who has not been vaccinated or previously recovered from the disease) can become infected.
Measles is still common in many developing countries - particularly in parts of Africa and Asia. More than 20 million people are affected by measles each year. The overwhelming majority (more than 95%) of measles deaths occur in countries with low per capita incomes and weak health infrastructures.
Measles outbreaks can be particularly deadly in countries experiencing or recovering from a natural disaster or conflict. Damage to health infrastructure and health services interrupts routine immunization, and overcrowding in residential camps greatly increases the risk of infection.
The highly contagious virus is spread by coughing and sneezing, close personal contact or direct contact with infected nasal or throat secretions.
The virus remains active and contagious in the air or on infected surfaces for up to two hours. It can be transmitted by an infected person from four days prior to the onset of the rash to four days after the rash erupts.
Measles outbreaks can result in epidemics that cause many deaths, especially among young, malnourished children.
In countries where measles has been largely eliminated, cases imported from other countries remain an important source of infection.
Severe complications from measles can be avoided though supportive care that ensures good nutrition, adequate fluid intake and treatment of dehydration with WHO-recommended oral rehydration solution. This solution replaces fluids and other essential elements that are lost through diarrhoea or vomiting. Antibiotics should be prescribed to treat eye and ear infections, and pneumonia.
All children in developing countries diagnosed with measles should receive two doses of vitamin A supplements, given 24 hours apart. This can help prevent eye damage and blindness. Vitamin A supplements have been shown to reduce the number of deaths from measles by 50%.
Routine measles vaccination for children, combined with mass immunization campaigns in countries with high case and death rates, are key public health strategies to reduce global measles deaths. The measles vaccine has been in use for over 40 years. It is safe, effective and inexpensive. It costs less than one US dollar to immunize a child against measles.
The measles vaccine is often incorporated with rubella and/or mumps vaccines in countries where these illnesses are problems. It is equally effective in the single or combined form.
In 2008, about 83% of the world's children received one dose of measles vaccine by their first birthday through routine health services - up from 72% in 2000. Two doses of the vaccine are recommended to ensure immunity, as about 15% of vaccinated children fail to develop immunity from the first dose.
Global health response
The fourth Millennium Development Goal (MDG 4) aims to reduce the under-five mortality rate by two-thirds between 1990 and 2015. Recognizing the potential of measles vaccination to reduce child mortality, and given that measles vaccination coverage can be considered a marker of access to child health services, routine measles vaccination coverage has been selected as an indicator of progress towards achieving MDG 4.
The Measles Initiative is a collaborative effort of WHO, UNICEF, the American Red Cross, the United States Centers for Disease Control and Prevention, and the United Nations Foundation. The Initiative, together with other public and private partners, plays a key role in advancing the global measles strategy. This strategy includes:
Strong routine immunization for children by their first birthday.
A 'second opportunity' for measles immunization through mass vaccination campaigns, to ensure that all children receive at least one dose.
Effective surveillance in all countries to quickly recognize and respond to measles outbreaks.
Better treatment of measles cases, to include vitamin A supplements, antibiotics if
needed, and supportive care that prevents complications.
Bangladesh Med Res Counc Bull. 2009 Dec;35(3):101-4.
Determining infants' age for measles vaccination based on persistence of protective level of maternal measles antibody.
Shilpi T, Sattar H, Miah MR.
Department of Microbiology and Inmunology, Bangabandhu Sheikh Mujib Medical University, Shahbag, Dhaka, Bangladesh.
The present study was conducted over a period of one year to find the right time for measles vaccination when maternal antibody titer in infants was decayed rendering them susceptible to wild virus infection. Blood samples were collected from the cord of new born (147), 2-5 months (47) and 5 to 7.5 months (24) of age. The mean measles IgG antibody titer detected in cord blood at birth (0 months) was 348.8 mlU/mL which steeply decreased to 155.6 mlU/mL by the age of 2-3 months. After that the fall in antibody becomes relatively slower and decreased to 101.6 mIU/mL by the age of 3-5 months and 38.8 mlU/mL by the age of 5-6 months and to 19.2 mIU/mL between the age of 6 to 7.5 months. The fall in antibody level with the advance of age was statistically significant (p < 0.001 ). Majority of the subjects (97.6%) exhibited protective level of antibody at birth. But only a little above one-quarter (25.5%) of them persisted the protective level between the age of 2-5 months and none had protective level from 5 months onwards
The measles rash appears three to four days after initial symptoms and lasts for up to eight days. The spots usually start behind the ears, spread around the head and neck, then spread to the legs and the rest of the body.
The spots are initially small but quickly get bigger and often join together. Similar-looking rashes may be mistaken for measles, but measles has a range of symptoms, not just a rash.
Most childhood rashes are not measles, but see your GP without delay if:
you suspect it is measles,
temperature increases to above 38°C (100.4°F),
temperature stays high after other symptoms have gone, or
Around 9 to 11 days after you get the measles infection, the following symptoms begin to appear:
cold-like symptoms, such as runny nose, watery eyes, swollen eyelids and sneezing,
red eyes and sensitivity to light,
a mild to severe temperature, which may peak at over 40.6°C (105°F) for several days, then fall but go up again when the rash appears,
tiny greyish-white spots (called Koplik's spots) in the mouth and throat,
tiredness, irritability and general lack of energy,
aches and pains,
dry cough, and
red-brown spotty rash (see below).
The above symptoms generally last for up to 14 days.
Infection and spread
Measles is caused by infection with the rubeola virus. This virus is contained in the millions of tiny droplets that come out of the nose and mouth when someone with measles coughs or sneezes.
You can catch measles by breathing in these droplets or, if the droplets have settled on a surface, by touching the surface and then placing your hands near your nose or mouth. The measles virus can survive on surfaces for a few hours.
Once inside your body, the virus multiplies in the back of your throat and lungs before spreading throughout your body, including your respiratory system and the skin.
Someone with measles is infectious for two to four days before the rash appears and for about five days after it appears.
Currently use live strains attenuated by culture in chick fibroblasts.
In developed world given at 14-16 months after maternal antibody that neutralizes the virus has disappeared.
In developing world WHO recommends vaccination at 9 months when it has been shown to produce a significant reduction in all all-cause mortality greater than would be expected from merely preventing measles.12
In UK given as part of MMR vaccination at around 13 months as seroconversion at this age is better than in younger children. A pre-school booster is required. Note that in developing countries where measles mortality is high, measles vaccine is given between 6 and 9 months but vaccine failure is more common.
Older children and adults thought to be susceptible should receive 1 or 2 doses as required. Ideally the second dose should be given after 3 months but where protection is urgently needed, the second can be given a month following the first.
Currently (2008-9), there is a MMR catch-up programme running in England and Wales to try to limit the risk of an epidemic outbreak. Target groups in order of priority are:2
Those aged 13 months to 18 years who have not received any MMR vaccine.
Partially immunised children aged 3 years 7 months (in September 2008) to 11 years.
Partially immunised children aged 12 to 18 years (school years 8 to 13).
Partially immunised individuals over 18 years leaving school to go to higher education or other further education establishments.
HIV positive individuals should also receive MMR provided they are not too severely immunocompromised.
What is Measles? www.kidshealth.org
Measles, also called rubeola, is a highly contagious respiratory infection that's caused by a virus. It causes a total-body skin rash and flu-like symptoms, including a fever, cough, and runny nose. Though rare in the United States, 20 million cases occur worldwide every year.
Since measles is caused by a virus, there is no specific medical treatment and the virus has to run its course. But a child who is sick should be sure to receive plenty of fluids and rest, and be kept from spreading the infection to others.
Signs and Symptoms
While measles is probably best known for the full-body rash it causes, the first symptoms of the infection are usually a hacking cough, runny nose, high fever, and red eyes. A characteristic marker of measles are Koplik's spots, small red spots with blue-white centers that appear inside the mouth.
The measles rash typically has a red or reddish brown blotchy appearance, and first usually shows up on the forehead, then spreads downward over the face, neck, and body, then down to the arms and feet
Is Measles Contagious?
Measles is highly contagious - 90% of people who haven't been vaccinated for measles will get it if they live in the same household as an infected person. Measles is spread when someone comes in direct contact with infected droplets or when someone with measles sneezes or coughs and spreads virus droplets through the air. A person with measles is contagious from 1 to 2 days before symptoms start until about 4 days after the rash appears.
Measles is very rare in the United States. Due to widespread immunizations, the number of U.S. measles cases has declined in the last 50 years. Before measles vaccination became available in the 1960s, more than 500,000 cases of measles were reported every year. From 2000 to 2007, just an average of 63 cases per year was reported.
However, in 2008 the United States saw an increase in measles cases and outbreaks (more than three or more linked cases), with 131 cases reported between January and July. More than 90% of those infected were not immunized or immunization status was unknown.
The most important thing you can do to protect kids from measles is to have them vaccinated according to the schedule prescribed by your doctor.
Infants are generally protected from measles for 6 months after birth due to immunity passed on from their mothers. Older kids are usually immunized against measles according to state and school health regulations.
For most kids, the measles vaccine is part of the measles-mumps-rubella immunizations (MMR) or measles-mumps-rubella-varicella immunization (MMRV) given at 12 to 15 months of age and again at 4 to 6 years of age.
Measles vaccine is not usually given to infants younger than 12 months old. But if there's a measles outbreak, the vaccine may be given when a child is 6-11 months old, followed by the usual MMR immunization at 12-15 months and 4-6 years.
As with all immunization schedules, there are important exceptions and special circumstances. Your child's doctor should have the most current information regarding recommendations about the measles immunization. Measles vaccine should not be given to pregnant women or to kids with untreated tuberculosis, leukemia or other cancers, or people whose immune systems are suppressed for any reason.
Also, the vaccine shouldn't be given to kids who have a history of severe allergic reaction to gelatin or to the antibiotic neomycin, as they are at risk for serious reactions to the vaccine.
During a measles outbreak, people who have not been immunized (especially those at risk of serious infection, such as pregnant women, infants, or kids with weakened immune systems) can be protected from measles infection with an injection of measles antibodies called immune globulin if it's given within 6 days of exposure. These antibodies can either prevent measles or make symptoms less severe. The measles vaccine also may offer some protection if given within 72 hours of measles exposure.
Measles in short
a very contagious viral disease
symptoms include high fever, rash, cough, a runny nose and red, watery eyes
about 20% of patients experience complications such as ear infections, diarrhoea, pneumonia or encephalitis
unimmunized young children under 5 years of age are at highest risk for complications
a safe and effective vaccine is available
immunity (after vaccination or infection) lasts a lifetime
most deaths occur in poor countries, especially in Africa
worldwide immunization efforts led to a 74% reduction in measles deaths (89% reduction in Africa) between 2000 and 2007
Measles infection in a brain cell nucleus © Mike Kayser, Wellcome Images
Measles in detail
The measles virus belongs to the genus Morbillivirus within the family of Paramyxoviruses. It is a single-stranded RNA virus (ssRNA). The nonsegmented helical RNA is associated with nucleocapsid protein N in form of a nucleocapsid. The lipid-bilayer envelope carries two transmembrane viral proteins named haemagglutinin (HA) and the fusion protein (F). The size of the virions varies, with diameters of most particles ranging from 120 to 350 nm.
The virus is easily destroyed by light, high temperatures, UV radiation or disinfectants. Outside its host it can survive for up to 2 hours. Infected humans are the only reservoir of the virus.
Measles is one of the most contagious diseases known. The virus resides within the nose and throat of infected persons and is easily spread by coughing, sneezing or by close contact. The contagion index reaches nearly 100%, meaning that nearly every unimmunized person coming in close contact with a patient will also become infected with measles.
The virus enters the body through the upper respiratory tract or the conjunctiva. It then spreads to the lymph nodes, where the first viraemia starts. During the second viraemia the virus spreads to the skin, kidney and bladder.
After an incubation period of about 10 to 12 days during which the infected person is symptom-free, first signs of the infection show. These may include fever, malaise, sneezing, rhinitis, cough and conjunctivitis. White Koplik's spots appear on the oral mucosa. After a couple of days, the typical rash appears, starting behind the ears and on the forehead and eventually spreading over the whole body to finally reach the hands and feet of the patient. The rash typically last for 5 to 6 days and then fades. Measles patient are contagious from approximately 4 days prior to 4 days after the onset of the rash.
Measles is commonly a mild or moderately severe illness. However, approximately 20% of infected people experience one or more complications, mainly children under 5 years of age or adults above 20 years of age. Undernourished or vitamin A-deficient children have the highest risk of severe complications. Measles deaths are not caused by the virus itself but by the complications.
The transient suppression of immunity accompanying measles infection enables secondary bacterial infections - the most common complications of measles - to take hold. Ear infections are reported in 5-15% of measles cases, and 1 out of 20 children with measles gets pneumonia, the most common cause of death associated with measles.
Diarrhoea can lead to dehydration and thus severely threaten the life of infected persons, especially young and poorly nourished children.
Acute measles encephalitis
Around 1 child in 1000 develops acute measles encephalitis, an inflammation of the brain that can lead to convulsions and can have severe consequences, such as deafness or mental retardation. The mortality rate of measles encephalitis is around 15%.
Subacute sclerosing panencephalitis (SSP)
This fatal complication occurs in 1-10 patients in 100,000 and usually starts 6 to 8 years after the initial measles infection. First signs are intellectual deterioration or psychological disturbances, and other neurological symptoms, e.g. convulsions or aphasia, follow. The disease progresses slowly with a highly variable course. Some 75% of patients go blind during the course of infection. The illness lasts 1 to 3 years and inevitably leads to death.
Measles in pregnancy
An infection during pregnancy often results in spontaneous abortion or premature birth. Some surviving infants develop only mild disease, while others show severe symptoms and complications, often pneumonia.
Measles is a self-limiting disease, and there is no treatment for the virus infection itself. However, complications can be avoided, for example through nutritional support. Antibiotic treatment might be indicated in cases of bacterial superinfection (pneumonia or otitis media). According to World Health Organization (WHO) recommendations, children in developing countries should receive vitamin A supplements to prevent eye damage and blindness.
A safe, effective and inexpensive vaccine is available. The measles vaccine is a live, attenuated vaccine often combined with the rubella and/or mumps vaccine (MR or MMR). Immunization coverage rates vary considerably by region. Countries with high rates have very low measles incidence, and cases that do occur are often imported. In general, illness is rare in most industrialized countries. However, suboptimal vaccination rates - even in developed countries - still support the circulation of the virus.
Incidence and mortality
Between 2000 and 2007, the number of measles-related deaths worldwide fell by 74%, from an estimated 750,000 to 197,000, according to the latest WHO data. In Africa, the death rate fell by 89%, and the Eastern Mediterranean region (including Afghanistan, Pakistan, Somalia and Sudan) has cut measles deaths by a remarkable 90%, thereby achieving "the United Nations goal to reduce measles death by 90% by 2010 3 years early," the WHO reports
Clinical and Vaccine Immunology, April 2006, p. 437-443, Vol. 13, No. 4
Copyright © 2006, American Society for Microbiology. All Rights Reserved.
Immune Containment and Consequences of Measles Virus Infection in Healthy and Immunocompromised Individuals
Sallie R. Permar,1 Diane E. Griffin,2 and Norman L. Letvin1*
Division of Viral Pathogenesis, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts 02115,1 W. Harry Feinstone Department of Molecular Microbiology and Immunology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland 212052