Measles

Morbilli, 1. infectious disease.

• Highly contagious infectious disease caused by measles viruses
• The measles virus is an RNA virus approximately 140 nm in size, which belongs to the group of paramyxoviruses

• Mostly occurring in winter and spring
• In 1964, the introduction of live measles vaccination led to a significant decrease in incidence
• Most affected are children, adolescents and young adults
• Worldwide 158000 deaths per year
• Europe-wide there is 1 death per 3000 reported cases
• The measles virus has been eliminated in Scandinavia, Australia and in North and South America

• Transmission: droplet infection (speaking, coughing, sneezing)
• The risk of infection is mostly in the catarrhal stage or the early exanthema stage
• Incubation period: 10-14 days
• In the keratinocytes and in the upper dermis, there is the formation of giant cells, the Warthin-Finkeldey cells
as a result of virus replication

• 4 days after incubation period appearance of exanthema

• Catarrhal prodromal stage:
  • Reduced general condition, fever (up to 40°C), pharyngitis, tracheitis, dry cough, rhinitis, conjunctivitis and photophobia
  • After 2-3 days, punctate white mucosal lesions (Koplik's spots) appear enorally in the region of the molars for 48 hours, which cannot be scraped off

• Enanthema: From the 3rd day, there are red spots in the area of the oral mucosa with a simultaneous drop in fever

• Exanthematic stage:
  • Starting retroauricularly, spreading over neck and trunk, morbilliform, erythematous, partly confluent patches finally pass to extremities
  • Simultaneously, the fever begins to rise again, after 3-4 days the body temperature is regressive
  • Foudroyant, sometimes lethal cases occur, especially in adults who have not been vaccinated. These are characterised by somnolence, bloody stools, hyperpyrexia, convulsions and circulatory disorders

• clinic
• BB (leukopenia)
• PCR from body fluids
• When neurological symptoms are present, a neurological consult is essential
• Liquor puncture in case of neurological abnormalities. Note: In acute sclerosing panencephlitis with poor prognosis, very high IgG titres are found in the CSF
• To perform a chest X-ray in case of pulmonary symptoms (streaky drawing)
• IgM antibodies can be detected by ELISA from day 3 of the exanthema stage. If there is a 4-fold increase (2 levels) in the titer after 2 weeks, measles infection can be assumed

• Bronchopneumonia (approx. 4-5%)
• Otitis media (approx. 4-5%)
• Measles croup
• Lupus vulgaris (cutaneous spread of tubercle bacilli)
• Masencephalitis (1:100,000)
• Subacute sclerosing panencephalitis (SSPE)

After a measles infection has already been passed, there is lifelong immunity.

• Bed rest

Antipyretic measures, e.g.:

• Calf compress

• Paracetamol
  • Application:
  • > 12 y. (>40 kg): single dose (ED): 500-1000 mg, max. daily dose (TD): 4 g
  • 9-12 y. (30-40 kg): ED: 500 mg, max. TD: 2 g
  • 6-9 y. (22-30 kg): ED: 250-500 mg, max TD: 750 mg
  • KI: Liver damage, renal insufficiency, acute hepatitis, Meulengracht's disease, pregnancy, lactation

Topical therapy

• Lotio alba

S: Standard vaccinations with general application

I: Indication vaccinations for risk groups with individually (not occupationally) increased risk of exposure, disease or complications as well as for the protection of third parties

B: Vaccinations due to an increased occupational risk, e.g. after risk assessment according to the Occupational Health and Safety Act/Biological Substances Ordinance/Ordinance on Occupational Medical Precautions (ArbMedVV) and/or for the protection of third parties in the context of occupational activities

Robert Koch Institute, Epidemiological Bulletin No. 34. (2015). Rki.de. Retrieved 10 May 2016, from https://www.rki.de/DE/Content/Infekt/EpidBull/Archiv/2015/Ausgaben/34_15.pdf?__blob=publicationFile

* SSPE is a late consequence of a measles infection. Years after the infection, an insidious brain inflammation develops that cannot be cured and is always fatal.

** No death is expected, and to date no death has been reported due to the vaccine; however, the risk cannot be completely ruled out.

Source:Federal Office of Public Health - Measles. (2016). Bag.admin.ch. Retrieved 10 May 2016, from http://www.bag.admin.ch/themen/medizin/00682/00684/01087/index.html?lang=de

• If a measles infection is suspected, a report must be made
• Kindergarten and school ban (unvaccinated children who have had contact with contagious persons must stay at home for max. 3 weeks). In case of suspicion, contact with non-immune persons must be avoided until 5 days after the appearance of the exanthema
• For the first few months, newborns are protected by the mother's antibodies

• MMR vaccination:
  • MMRV vaccination should be given between 11 and 14 months of age. A booster vaccination is recommended 1 ½- 3 months later to detect vaccination failure. For children in childcare facilities, immunisation can be given as early as 9 months of age. The 2nd vaccine should then be given between 12-15 months of age. This is done to immunise the approx. up to 10% vaccination failures (thereafter there are only approx. 5% vaccination failures).
  • The live vaccine can prevent the outbreak in immunocompetent children from 7 months of age onwards - provided it has been used within the first 3 days of exposure
• Passive immunisation:
  • If in immunodeficient patients or children before 7-13 months of age at exposure using
    • Intravenous immunoglobulins i.v. 250-400 mg/kg bw daily for 3-5 days every 3-4 weeks
      • Initial dose: 0.4-0.8 g/kg bw
      • In the course: 0.2 g/kg bw every 3 to 4 weeks
      • Determination of the IgG serum level always immediately before the next infusion!
      • An IgG valley level of at least 5 to 6 g/l should be reached before a new infusion

• indicated and should be given within 6 days of first exposure. In this case, there is no increased risk for the child, but the risk that the existing maternal antibodies neutralise the vaccine. In this case, the second vaccination should be given between the 12th and 15th month of life, as usual
• If a patient was born in 1964 or earlier and has not had measles, vaccination is recommended only in case of exposure
• A contraindication to vaccination is pregnancy. If vaccination is nevertheless given, this is not a reason to terminate the pregnancy
• Possible side effects: Local reaction, pain, swelling, redness. In rare cases, flu-like symptoms, thrombocytopenia and meningitis
• Unlike Dr Wakefield postulated at times, the current data is very clear that there is no link between autism and MMR vaccination
• Costs of MMR vaccination are covered by health insurance (except for the deductible)

• Topical therapy:
  • Drying out shaking concoctions

1. Cutts FT, Henao-Restrepo AM, Olivé JM. Measles elimination: progress and challenges. Vaccine 1999;17:S47-S52.
2. Davidkin I, Valle M, Peltola H, et al. Etiology of Measles‐ and Rubella‐like Illnesses in Measles, Mumps, and Rubella–Vaccinated Children. The Journal of Infectious Diseases 1998;178:1567-70.
3. Velangi, Tidman. Gianotti-Crosti syndrome after measles, mumps and rubella vaccination. British Journal of Dermatology 1998;139:1122-3.
4. Bundesamt für Gesundheit - Masern. (2016). Bag.admin.ch. Retrieved 10 May 2016, from http://www.bag.admin.ch/themen/medizin/00682/00684/01087/index.html?lang=de