Author

Selina SP Chen, MD, MPH Assistant Professor of Pediatrics, Department of Internal Medicine, John A Burns
School of Medicine, University of Hawaii; Internal Medicine and Pediatric Hospitalist, Kapiolani Medical
Center for Women and Children; Internal Medicine Hospitalist, Straub Clinic and Hospital; Electronic Medical
Record Physician Liaison and Trainer

Selina SP Chen, MD, MPH is a member of the following medical societies: American Academy of
Pediatrics, American College of Physicians-American Society of Internal Medicine, Society of Hospital
Medicine

Coauthor(s)

Glenn Fennelly, MD, MPH Director, Division of Infectious Diseases, Lewis M Fraad Department of Pediatrics,
Jacobi Medical Center; Clinical Associate Professor of Pediatrics, Albert Einstein College of Medicine

Glenn Fennelly, MD, MPH is a member of the following medical societies: Pediatric Infectious Diseases
Society

Chief Editor

Russell W Steele, MD Clinical Professor, Tulane University School of Medicine; Staff Physician, Ochsner
Clinic Foundation

Russell W Steele, MD is a member of the following medical societies: American Academy of

Pediatrics, American Association of Immunologists, American Pediatric Society, American Society for
Microbiology, Infectious Diseases Society of America, Louisiana State Medical Society, Pediatric Infectious
Diseases Society, Society for Pediatric Research, Southern Medical Association

Acknowledgements

Melissa Burnett, MD Department of Dermatology, Massachusetts General Hospital

Joseph Domachowske, MD Professor of Pediatrics, Microbiology and Immunology, Department of Pediatrics,

Division of Infectious Diseases, State University of New York Upstate Medical University

Joseph Domachowske, MD is a member of the following medical societies: Alpha Omega Alpha, American
Academy of Pediatrics, American Society for Microbiology, Infectious Diseases Society of America, Pediatric
Infectious Diseases Society, and Phi Beta Kappa

Pamela L Dyne, MD Professor of Clinical Medicine/Emergency Medicine, University of California, Los

Angeles, David Geffen School of Medicine; Attending Physician, Department of Emergency Medicine, Olive
View-UCLA Medical Center

Pamela L Dyne, MD is a member of the following medical societies: American Academy of Emergency
Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Dirk M Elston, MD Director, Ackerman Academy of Dermatopathology, New York

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Heather Kesler DeVore, MD Assistant Professor, Clinical Attending Physician, Department of Emergency
Medicine, Georgetown University Hospital and Washington Hospital Center

Heather Kesler DeVore, MD is a member of the following medical societies: Emergency Medicine Residents
Association and Society for Academic Emergency Medicine
Leonard R Krilov, MD Chief of Pediatric Infectious Diseases and International Adoption, Vice Chair,
Department of Pediatrics, Professor of Pediatrics, Winthrop University Hospital

Leonard R Krilov, MD is a member of the following medical societies: American Academy of

Pediatrics, American Pediatric Society, Infectious Diseases Society of America, Pediatric Infectious Diseases
Society, and Society for Pediatric Research

Paul Krusinski, MD Director of Dermatology, Fletcher Allen Health Care; Professor, Department of Internal
Medicine, University of Vermont College of Medicine

Paul Krusinski, MD is a member of the following medical societies: American Academy of

Dermatology, American College of Physicians, and Society for Investigative Dermatology

Measles, also known as rubeola, is one of the most contagious infectious diseases,
with at least a 90% secondary infection rate in susceptible domestic contacts.
Despite being considered primarily a childhood illness, measles can affect people of
all ages. See the image below.

See Pediatric Vaccinations: Do You Know the Recommended Schedules?, a Critical

Images slideshow, to help stay current with the latest routine and catch-up
immunization schedules for 16 vaccine-preventable diseases.
Although the elimination of endemic measles transmission in the US in 2000 was
sustained through at least 2011, according to a CDC study, cases continue to be
caused by virus brought into the country by travelers from abroad, with spread
occurring largely among unvaccinated individuals. In 88% of the cases reported
between 2000 and 2011, the virus originated from a country outside the US, and 2
out of every 3 individuals who developed measles were unvaccinated. Moreover, the
director of the CDC noted that, in 2013, US measles cases increased threefold from
the previous median, to 175 cases. [1, 2] Most of these cases were outbreaks in
children whose parents had refused immunization.
This trend of increased incidence continued into 2014. From January 1 to May 23,
2014, 288 confirmed cases were reported to the CDC, a figure that exceeds the
highest reported annual total number of cases (220 cases in 2011) since measles
was declared eliminated in the United States in 2000. Of the 288 cases, 200 (69%)
occurred in unvaccinated individuals and 58 (20%) in persons with unknown
vaccination status. Nearly all of the 2014 cases reported thus far (280 [97%]) were
associated with importations from at least 18 countries. Eighteen states and New
York City reported measles infections during this period, and 15 outbreaks
accounted for 79% of reported cases, including a large ongoing outbreak in Ohio
primarily among unvaccinated Amish persons, with 138 cases reported. [3]
Public health officials confirmed a total of 59 cases of measles in California residents
since the end of December 2014. Of the confirmed cases, 42 have been linked to an
initial exposure in December at Disneyland or Disney California Adventure Park in
Anaheim, California. [4]
A study by Gastañaduy et al found that during the 2014 measles outbreak, the
spread of measles was contained in an undervaccinated Amish community by the
isolation of case patients, quarantine of susceptible individuals, and giving the MMR
vaccine to more than 10,000 people. As a result, the spread of measles was limited
to about 1% in an Amish community of 32,630. [5, 6]
See 11 Travel Diseases to Consider Before and After the Trip, a Critical Images
slideshow, to help identify and manage several infectious travel diseases.
Guidelines on measles from the American Academy of Pediatrics
The American Academy of Pediatrics released updated measles guidelines in
response to the national outbreak of the disease. The new guidelines feature
changes in the evidence required for measles immunity, the use of immune globulin,
vaccination for healthcare personnel, and the management of patients with HIV
infections and other susceptibilities. [7, 8]
Any of the following constitutes evidence of immunity to measles:
See the list below:
 Documentation of age-appropriate vaccination with a live measles virus–
containing vaccine (one dose for preschool-aged children, two doses for
children in kindergarten through 12th grade)
 Laboratory evidence of immunity
 Laboratory confirmation of disease
 Birth before 1957

Use of immune globulin

See the list below:
 Clinicians can administer immune globulin either intramuscularly or
intravenously within 6 days of exposure to prevent or modify measles response
in people who lack evidence of measles immunity.
 The recommended dose is 0.50 mL/kg administered intramuscularly, with a
maximum volume of 15 mL.
 Groups who are at higher risk for complications from severe measles should
receive intravenous application at a dose of 400 mg/kg.
People with HIV infections
See the list below:
 Measles immunization (in the form of the measles, mumps, and rubella
vaccine) for everyone older than 12 mo who is infected by HIV, except those
 who have evidence of severe immunosuppression. Measles can be fatal in
patients with HIV.
 Immune globulin prophylaxis for HIV-infected children who are exposed to
measles, depending on their immune status and measles vaccine history.
Healthcare personnel
See the list below:
 Immunization programs for healthcare personnel, including students, who may
be in contact with patients with measles.
 Birth before 1957 is not a guarantee of measles immunity; facilities should
consider vaccination of unimmunized healthcare personnel who lack laboratory
evidence of immunity who were born before 1957.
Management of susceptible individuals
See the list below:
 Clinicians can best manage immunodeficient and immunosuppressed patients
exposed to measles if they have previous knowledge of the patients' immune
status.
 Children should receive measles vaccination prior to treatment with biological
response modifiers, such as tumor necrosis factor antagonists.
 Susceptible patients with immunodeficiencies should receive immune globulin
after measles exposure.
 Warning against giving live-virus measles vaccines to immunocompromised
patients with disorders associated with increased severity of viral infections
(except people with HIV who do not have evidence of severe
immunosuppression).
 Recommendation not to give immunization for at least a month after a patient
has finished a high-dose course of corticosteroids, such as prednisone.
Signs and symptoms
Onset of measles ranges from 7-14 days (average, 10-12 days) after exposure to the
virus. The first sign of measles is usually a high fever (often >104 o F [40o C]) that
typically lasts 4-7 days. The prodromal phase is also marked by malaise; anorexia;
and the classic triad of conjunctivitis, cough, and coryza (the “3 Cs”). Other possible
prodromal manifestations include photophobia, periorbital edema, and myalgias.
Enanthem
 Koplik spots—bluish-gray specks or “grains of sand” on a red base—develop
on the buccal mucosa opposite the second molars
 Generally appear 1-2 days before the rash and last 3-5 days
 Pathognomonic for measles, but not always present
Rash
 On average, the rash develops about 14 days after exposure
 Mild pruritus may also occur
 Blanching, erythematous macules and papules begin on the face at the
hairline, on the sides of the neck, and behind the ears
 Within 48 hours, the lesions coalesce into patches and plaques that spread
cephalocaudally to the trunk and extremities, including the palms and soles,
while beginning to regress cephalocaudally, starting from the head and neck
  Lesion density is greatest above the shoulders, where macular lesions may
coalesce
 The eruption may also be petechial or ecchymotic in nature
 Patients appear most ill during the first or second day of the rash
 The exanthem lasts for 5-7 days before fading into coppery-brown
hyperpigmented patches, which then desquamate
 Immunocompromised patients may not develop a rash
Clinical course
 Uncomplicated measles, from late prodrome to resolution of fever and rash,
lasts 7-10 days
 Cough may be the final symptom to appear
Modified measles
 Occurs in individuals who have received serum immunoglobulin after exposure
to the measles virus
 The incubation period may be as long as 21 days
 Similar but milder symptoms and signs may occur
Atypical measles
 Occurs in individuals who were vaccinated with the original killed-virus measles
vaccine between 1963 and 1967 and who have incomplete immunity
 A mild or subclinical prodrome of fever, headache, abdominal pain, and
myalgias precedes a rash that begins on the hands and feet and spreads
centripetally
 The eruption is accentuated in the skin folds and may be macular, vesicular,
petechial, or urticarial
See Clinical Presentation for more detail.
Diagnosis
Although the diagnosis of measles is usually determined from the classic clinical
picture, laboratory identification and confirmation of the diagnosis are necessary for
public health and outbreak control. Laboratory confirmation is achieved by means of
the following:
 Serologic testing for measles-specific IgM or IgG titers
 Isolation of the virus
 Reverse-transcriptase polymerase chain reaction (RT-PCR) evaluation
Measles-specific IgM titers
 Obtain blood on the third day of the rash or on any subsequent day up to 1
month after onset
 The measles serum IgM titer remains positive 30-60 days after the illness in
most individuals but may become undetectable in some subjects at 4 weeks
after rash onset
 False-positive results can occur in patients with rheumatologic diseases,
parvovirus B19 infection, or infectious mononucleosis
Measles-specific IgG titers
 More than a 4-fold rise in IgG antibodies between acute and convalescent sera
confirms measles
 Acute specimens should be drawn on the seventh day after rash onset
 Convalescent specimens should be drawn 10-14 days after that drawn for
acute serum
 The acute and convalescent sera should be tested simultaneously as paired
sera
Viral culture
 Throat swabs and nasal swabs can be sent on viral transport medium or a viral
culturette swab
 Urine specimens can be sent in a sterile container
 Viral genotyping in a reference laboratory may determine whether an isolate is
endemic or imported
 In immunocompromised patients, isolation of the virus or identification of
measles antigen by immunofluorescence may be the only feasible method of
confirming the diagnosis
Polymerase chain reaction
 RT-PCR, if available, can rapidly confirm the diagnosis of measles [9]
 Blood, throat, nasopharyngeal, or urine specimens can be used
 Samples should be collected at the first contact with a suspected case of
measles
Case reporting
Immediately reporting any suspected case of measles to a local or state health
department is imperative. The US CDC clinical case definition for reporting purposes
requires only the following:
 Generalized rash lasting 3 days or longer
 Temperature of 101.0°F (38.3°C) or higher
 Cough, coryza, or conjunctivitis
For reporting purposes for the CDC, cases are classified as follows:
 Suspected: Any febrile illness accompanied by rash
 Probable: A case that meets the clinical case definition, has noncontributory or
no serologic or virologic testing, and is not epidemiologically linked to a
confirmed case
 Confirmed: A case that is laboratory confirmed or that meets the clinical case
definition and is epidemiologically linked to a confirmed case; a laboratory-
confirmed case need not meet the clinical case definition
See Workup for more detail.
Management
Treatment of measles is essentially supportive care, as follows:
 Maintenance of good hydration and replacement of fluids lost through diarrhea
or emesis
 IV rehydration may be necessary if dehydration is severe
 Vitamin A supplementation should be considered
Postexposure prophylaxis should be considered in unvaccinated contacts; timely
tracing of contacts should be a priority. Patients should receive regular follow-up
care with a primary care physician for surveillance of complications arising from the
infection.
Vitamin A supplementation
The World Health Organization recommends vitamin A supplementation for all
children diagnosed with measles, regardless of their country of residence, based on
their age, [10] as follows:
 Infants younger than 6 months: 50,000 IU/day PO for 2 doses
 Age 6-11 months: 100,000 IU/day PO for 2 doses
 Older than 1 year: 200,000 IU/day PO for 2 doses
 Children with clinical signs of vitamin A deficiency: The first 2 doses as
appropriate for age, then a third age-specific dose given 2-4 weeks later
Approach Considerations
Although the diagnosis of measles is usually determined from the classic
clinical picture (see Clinical), laboratory identification and confirmation of
the diagnosis are necessary for the purposes of public health and outbreak
control. Laboratory confirmation is achieved by means of serologic testing
for immunoglobulin G (IgG) and M (IgM) antibodies, isolation of the virus,
and reverse-transcriptase polymerase chain reaction (RT-PCR) evaluation.
A complete blood cell count (CBC) may reveal leukopenia with a relative
lymphocytosis and thrombocytopenia. Liver function test (LFT) results may
reveal elevated transaminase levels in patients with measles hepatitis.
Consult public health or infectious disease specialists for recommendations
and guidelines for diagnostic confirmation of cases and prophylaxis of
susceptible contacts.
Case reporting
Because the transmission of indigenous measles has been interrupted in
the United States and all recent US epidemics have been linked to
imported cases, immediately reporting any suspected case of measles to a
local or state health department is imperative, as is obtaining serum for IgM
antibody testing as soon as possible (ie, on or after the third day of rash).
The US Centers for Disease Control and Prevention (CDC) clinical case
definition for reporting purposes requires only the following:
 Generalized rash lasting 3 days or longer
 Temperature of 101.0°F (38.3°C) or higher
 Cough, coryza, or conjunctivitis
Further, for reporting purposes for the CDC, cases are classified as follows:
 Suspected - Any febrile illness accompanied by rash
 Probable - A case that meets the clinical case definition, has
noncontributory or no serologic or virologic testing, and is not
epidemiologically linked to a confirmed case
 Confirmed - A case that is laboratory confirmed or that meets the
clinical case definition and is epidemiologically linked to a confirmed
case; a laboratory-confirmed case need not meet the clinical case
definition