Measles

FAQs for Health Care Providers

Measles (Rubeola) Risk, Diagnosis, and Treatment in Afghan Evacuees

Have there been confirmed cases in the Afghan evacuees? Yes

There is a current outbreak in Afghan evacuees both in certain US camps and at “lilypad” locations outside the U.S.--in 3rd countries waiting for US resettlement.

Epidemiology (related to Afghan evacuees)

Measles occurs worldwide and remains a leading cause of childhood mortality. In 2020, there were a total of >26,000 measles cases reported In the Eastern Mediterranean Region with 766 reported in Afghanistan, primarily among children < 10 years of age and from 20 of 34 provinces. Afghanistan ranks seventh in the world for measles cases. Vaccine rates have been declining since 2014, with routine doses for infants well under 90%, and more recently have likely dropped further recently due to the COVID-19 pandemic. Measles outbreaks in refugee camps and other congregate settings lead to high morbidity and mortality (as high as 34%).

When should I consider measles?

Clinical Presentation

Think of measles in any child with cough, coryza and conjunctivitis especially in the appropriate setting (such as with the current Afghan evacuee situation).

The prodromal period is characterized by the triad of cough, coryza and conjunctivitis (3-c’s). Koplik spots are found in the oropharynx (picture below and here), appearing as glistening sand against with underlying erythema, typically on the buccal surface over the second molar. If seen Koplik spots are pathognomonic of measles there are typically not seen at the time of presentation.

A maculopapular rash (also below) appears day 3-5 (usually one day after Koplik spots appear) and is usually accompanied by a high fever, begins on the head and spreads to the trunk and extremities. It is typically present, however it may be altered, very subtle or absent in undernourished, immunocompromised or young infants with partial immunity due to maternal antibody and may be more difficult to visualize on darker skin. The rash usually appears ~14 days after initial exposure.

Measles case definitions can be found here. Acute measles should be expected in anyone with the following constellation:

• Generalized, maculopapular rash lasting ≥3 days; and

• Temperature ≥101°F or 38.3°C; and

• Cough, coryza, or conjunctivitis.

On taking a history and doing a physical examination for a child suspected of having measles focus on the clinical features of measles plus potential complications such as otitis media, pneumonia, diarrhea, and keratoconjunctivitis. Assessment of nutrition, specifically vitamin A deficiency and HIV infection, will identify children at higher risk for death. Children < 5 years, pregnant women, undernourished and immunocompromised persons are at greatest risk.

Is measles contagious? Yes, extremely.

Measles R₀ (average number of secondary cases per index case) is >14 compared to COVID-19 estimated <3, and with a single exposure up to 90% of susceptible people can be infected. Measles virus can live for up to two hours in an airspace after an infected person leaves an area. The infectious period is four days before through four days after the rash appearance.

Are there special infectious disease precautions for someone with measles?

• All healthcare providers (HCP) working with Afghan refugees must themselves meet immunity standards.

• A suspected measles case must be immediately isolated

• Standard and Airborne Precautions must be exercised and maintained for 4 days before, and 4 days following the rash in all immunocompetent patients.

If a suspect case is identified in the outpatient setting, a mask should be immediately placed on the patient. The HCPs must wear appropriate airborne respiratory protection (e.g. N95, respirator). The patient should be escorted to a separate area, preferably a private room (with negative pressure).

How do I diagnose measles?

Laboratory confirmation is essential for all suspected measles cases. All suspect cases should have the following collected:

• Blood (serum) (measles-specific antibody testing)

• A throat or nasopharyngeal swab (RNA testing by RT-PCR[1] )

• A urine (RNA testing by RT-PCR)

What is the treatment for measles?

Supportive care

1. Prevent and treat dehydration and nutritional deficiencies

2. Treat otitis media and pneumonia with antibiotics IF secondary bacterial infection is suspected

3. Treat all children with vitamin A as outlined here:

Vitamin A should be administered immediately on diagnosis and repeated the next day. The recommended age-specific daily doses are:

• 50,000 IU for infants younger than 6 months of age

• 100,000 IU for infants 6–11 months of age

• 200,000 IU for children 12 months of age and older

A third age-specific dose is recommended 2 through 6 weeks later if signs and symptoms of vitamin A deficiency.

What else should I know about measles?

• Measles must be reported immediately in the military camps

• Measles is a reportable disease in all states

• High risk individuals with exposure to a measles case must be offered post-exposure prophylaxis (CDC). Guidance also available in the AAP table below.

• Afghan refugees who are being resettled through the military bases are receiving MMR vaccination

Resources and References

1. Centers for Disease Control and Prevention: Overview

2. Centers for Disease Control and Prevention general measles FAQs.

3. World Health Organization: Overview

4. UpToDate: Clinical manifestations, diagnosis, treatment, and prevention

5. American Academy of Pediatrics Red Book, 2021.

6. Moss, William J. Measles. The Lancet. 2017. v390, pg 2490-2501.

Contributors

Olaf Morkeberg

Cindy Howard MD

Beth Theilen MD

William Stauffer MD

Jen Beckman

Risha Moskalewicz, MD