Measles Makes a Comeback

Measles Makes a Comeback Virulent disease spreads across the U.S.
By Cheryl England

FROM JANUARY 1 to April 26 of this year, 704 individual cases of measles have been confirmed in 22 states including Illinois, according to the Centers for Disease Prevention and Control (CDC). And the disease is spreading. The week ending April 26 showed an increase of 78 cases from the previous week. The cumulative total of cases is already the greatest number of cases reported in the United States since 1994 and since measles was declared eliminated in 2000.

The spread of measles is linked mainly to unvaccinated people—especially when there are geographic pockets of unvaccinated people--and travelers who bring measles back from other countries such as Israel, Ukraine, and the Philippines, where large measles outbreaks are occurring. In addition, measles is especially contagious—the virus spreads to others through coughing and sneezing. The measles virus can live for up to two hours in a person’s hair or in an airspace where the infected person coughed or sneezed.

About the Measles
Measles is characterized by a prodrome of fever (as high as 105°F) and malaise, cough, coryza, and conjunctivitis, a pathognomonic enanthema (Koplik spots) followed by a maculopapular rash. The rash usually appears about 14 days after a person is exposed. The rash spreads from the head to the trunk to the lower extremities. Patients are considered to be contagious from 4 days before to 4 days after the rash appears. Of note, sometimes immunocompromised patients do not develop the rash.

According to the World Health Organization (WHO), global measles deaths have decreased by 84% worldwide in recent years—from 550,100 deaths in 2000 to 89,780 in 2016—but it is still common in many developing countries, particularly in parts of Africa and Asia. The overwhelming majority (more than 95%) of measles deaths occur in countries with low per capita incomes and weak health infrastructures. 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. The most serious complications include blindness, encephalitis, severe diarrhea and related dehydration, and severe respiratory infections such as pneumonia.

In 2000, measles was declared eliminated from the U.S. Elimination is defined as the absence of endemic measles virus transmission in a defined geographic area, such as a region or country, for 12 months or longer in the presence of a
well-performing surveillance system. However measles cases and outbreaks still occur every year in the U.S. because measles is still commonly transmitted in many parts of the world.

Vaccination is Key
The best way to prevent the spread of measles is to make sure your patients and their children have been vaccinated. Reaching all children with two doses of the measles vaccine, either alone, or in a measles-rubella (MR), measles-mumps-rubella (MMR), or measles-mumps-rubella-varicella (MMRV) combination, should be the standard for all national immunization programs, according to WHO. Multiple studies have shown that there is no connection between the MMR vaccine and autism.

Most of the recent measles cases have occurred in children, but adults may need to get another dose of the vaccine, according to the CDC. Adults born before 1957, when the vaccine was introduced, are assumed to have immunity from the disease. But adults born between 1957 and 1989 may have received only one, potentially weaker, dose or no doses.

When the vaccine first came out, there were two versions. One was much less effective than the other. That, combined with the fact that most older adults don’t have access to their childhood medical records, makes the immunity status of some adults unclear. Giving children two doses of the more effective version became standard in 1989. One dose of the current iteration of the vaccination provides 93% immunity, according to CDC, and a second shot raises the level to 97%. Fully vaccinated people are less likely to spread the disease to other people, including people who can’t get vaccinated because they are too young or have contraindications, such as weakened immune systems.

What Physicians Can Do
According to the CDC, healthcare providers should consider measles in patients presenting with febrile rash illness and clinically compatible measles symptoms, especially if the person recently traveled internationally or was exposed to a person with febrile rash illness. Healthcare providers should report suspected measles cases to their local health department within 24 hours.

Laboratory confirmation is essential for all measles cases. Healthcare providers should obtain both a serum sample and a throat swab (or nasopharyngeal swab) from patients suspected to have measles. Urine samples may also contain virus, and when feasible to do so, collecting both respiratory and urine samples can increase the likelihood of detecting measles virus.