Measles

Last Updated: 2019-08-27

Author(s): Anzengruber, Navarini

Morbilli, first infectious disease.

  • Highly contagious infectious disease caused by measles viruses.
  • The measles virus is an approximately 140 nm RNA virus which belongs to the group of paramyxoviruses.
  • Especially occurring in winter and spring.
  • 1964 saw the introduction of live measles vaccination, which led to a significant decline in incidence.
  • Children, adolescents and young adults are particularly affected.
  • Worldwide 1580,000 deaths per year.
  • Throughout Europe, there are 1 death per 3,000 reported illnesses.
  • The measles virus has been eliminated in Scandinavia, Australia and North and South America.
  • Transmission: droplet infection (speaking, coughing, sneezing).
  • The risk of infection usually exists in the catarrhal stage or in the early exanthema stage.
  • Incubation period: 10-14 days.
  • In the keratinocytes and in the upper dermis giant cells, the Warthin-Finkeldey cells, are formed as a result of virus replication.
  • 4 days after incubation period occurrence of an exanthema.

 

  • Catarrhal prodromal stage:
  • Reduced general condition, fever (up to 40°C), pharyngitis, tracheitis, dry cough, rhinitis, conjunctivitis and photophobia.
  • After 2-3 days for 48 hours enoral pointlike, white mucous membrane changes (Koplik spots), which are not scratchable, occur in the area of the molar teeth.

 

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

 

  • Exanthematic stage
  • Starting retroauricularly, spreading over neck and trunk, morbilliform, erythematous, partially confluent spots finally pass to the extremities.
  • At the same time the fever starts to rise again, after 3-4 days the body temperature regresses.
  • Especially in adults who are not vaccinated, there are foudroyant, sometimes lethal cases. These are characterized by somnolence, bloody stools, hyperpyrexia, cramps and circulatory disorders.
  • Clinic.
  • Blood Count (Leukopenia).
  • PCR from body fluids.
  • In case of neurological symptoms, a neurological consil is essential.
  • CSF puncture for neurological abnormalities. Note: In acute sclerosing panencephlitis with infaust prognosis, very high IgG titres are found in the cerebrospinal fluid.
  • Thoracic x-ray in case of pulmonary symptoms (striped drawing).
  • ELISA can be used to detect IgM antibodies from day 3 of the exanthema stage. In case of a 4-fold increase (2 steps) of the titre after 2 weeks, a measles infection can be assumed.
  • Bronchopneumonia (approx. 4-5%)
  • Otitis media (approx. 4-5%)
  • Measles croup
  • Lupus vulgaris (cutaneous scattering of tubercle bacteria)
  • Measles encephalitis (1:100,000)
  • Subacute sclerosing panencephalitis (SSPE)

After a measles infection has already occurred, a lifelong immunity exists.

  • bed rest

 

Antipyretic measures, e.g:

  • Calf compress
  • paracetamol
  • Anw:
  • > 12 years (>40 kg): Single dose (ED): 500-1000 mg, max. daily dose (TD): 4 g.
  • 9-12 years (30-40 kg): ED: 500 mg, max. TD: 2 g.
  • 6-9 years (22-30 kg): ED: 250-500 mg, max. TD: 750 mg.
  • CI: liver damage, renal insufficiency, acute hepatitis, Meulengracht disease, pregnancy, lactation.

 

Topical therapy

  • Lotio alba

Vaccination against

 Category Indication Application notes
Measles S

Persons born after 1970 ≥ 18 years old with unclear vaccination status, without vaccination or with only one vaccination in childhood

Single vaccination with an MMR vaccine
  I

When admission is imminent or when visiting a community institution (e.g. day care centre):

Infants aged 9 months and over

Double vaccination with one MMR/V-*vaccine

If the first vaccination takes place at the age of 9 - 10 months, the 2nd MMR/V vaccination should already be given at the beginning of the 2nd year of life.
  I

Born after 1970 from the age of 9 months with unclear vaccination status, without vaccination or with only one vaccination in childhood

 

exceptionally 6 - 8-month-old infants after individual risk-benefit analysis (off-label use)

Single MMR(V)-**vaccination

If necessary, complete in accordance with the recommendations applicable to the age group.

If the first vaccination takes place at the age of 9 - 10 months, the 2nd MMR/V* vaccination should already be given at the beginning of the 2nd year of life.

For first vaccination at the age of 6 - 8 months, a 2nd and 3rd MMR/V* vaccination should be given at the age of 11 - 14 and 15 - 23 months.

* MMR/V = MMRV or MMR in co-administration with VZV vaccine

** MMR(V) = MMR with or without co-administration of VZV vaccine
  B

Health services or care for immunodeficient or immunocompromised persons or persons working in community institutions: after 1970 Gebo-rene with unclear vaccination status, without vaccination or with only one vaccination in childhood.

Single vaccination with an MMR vaccine

S: Standard vaccinations with general use

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

B: Vaccinations due to an increased occupational risk, e.g. after risk assessment in accordance with the Occupational Health and Safety Act/Biostuffs Ordinance/Ordinance on Occupational Health and Safety (ArbMedVV) and/or for the protection of third parties within the scope of the occupational activity

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

 

Adverse side effects after MMR vaccination per 1 million vaccinated persons

Complications of measles per 1 million measles sufferers
Immunodeficiency Very rare All patients

Ear infection

 0 70000-90000
Pneumonia 0 10000-60000
Hospitalisation 20-50 10000-25000
Febrile convulsions 30-300 5000-7000
Brain inflammation 0.6-1.6 200-2000
Platelet count 30 330

Subacute sclerosing

Panencephalitis (SSPE)*

 0 1-10

Allergic shock reaction

(anaphylaxis)

 1-10 0
Autism 0 0

Deaths

 < 1** 300 bis 1000

Expenses

 1 million vaccinations cost 140 million francs.

1 million patients cost between 3.6 and 5 billion Swiss francs.

* The SSPE is a late consequence of a measles infection. Years after the infection, a creeping inflammation of the brain develops, which cannot be cured and is always fatal.

** No death is expected and no death due to the vaccine is known to date, but 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=en

  • If measles infection is suspected, a report must be made.
  • Kindergarten and school ban (non-vaccinated children who have had contact with infectious persons must stay at home for a maximum of 3 weeks). If suspected, contact with non-immune persons must be avoided until 5 days after the occurrence of the exanthema.
  • Newborns are protected by their mother's antibodies for the first few months.

 

  • MMR vaccination:
  • MMRV vaccination should be given between the age of 11 and 14 months. A booster vaccination is recommended 1 ½- 3 months later to detect vaccination failures. Children in childcare facilities can be immunized at the age of 9 months. The 2nd vaccine should then be administered between the 12th and 15th month of life. This is done to immunize the up to 10% vaccination failure (after that it is only about 5% vaccination failure).
  • The live vaccine can prevent the outbreak in immunocompetent children from the 7th month of life - provided that it was used within the first 3 days after exposure.
  • Passive immunisation:
  • If in immunodeficient patients or children before the 7th -13th month of life with exposure by means of

 

  • Intravenous immunoglobulins (Privigen®) 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
  • During 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 achieved before the next infusion.

 

  • and should be administered within 6 days of initial exposure. In this case there is no increased risk for the child, but the danger that the existing maternal antibodies neutralize the vaccine. The second vaccination in this case as usual between the 12th and 15th month of life.
  • If a patient was born in 1964 or earlier and is not suffering from measles, vaccination is recommended only in case of exposure.
  • Pregnancy is a contraindication against vaccination. However, if vaccination is given, this is not a reason for abortion.
  • Possible side effects: Local reaction, pain, swelling, redness. In rare cases flu-like symptoms, thrombocytopenia and meningitis.
  • Contrary to what Dr. Wakefield postulated at times, the current data is very clear that there is no connection between autism and MMR vaccination.
  • Costs of MMR vaccination: 55-70 Swiss francs per vaccination dose, which is covered by health insurance (except for the deductible).
  •  
  • Topical therapy
  • Drying shaking mixes.
  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