Measles 2014

Resurgence of Measles in the U.S.

Natalie Boyd, PharmD & Jennifer Seltzer, PharmD

September 2014

The U.S. is currently experiencing the highest number of measles cases observed since 1994, with nearly 600 people infected this year alone.^1,2 Although many cases are mild to moderate in severity, measles can lead to serious complications and deaths, particularly for those in developing countries. Prior to use of the live measles vaccine, which became available in 1963, an estimated 3-4 million cases occurred annually in the U.S., mostly in children.^3-6 Successful implementation of vaccination programs led to elimination of measles in the U.S.in 2000.^7,8 However, outbreaks still occur through importation of measles cases from endemic areas.^9-11

Measles infection, also referred to as rubeola, is a highly contagious, acute respiratory viral illness characterized by fever, cough, coryza, and maculopapular rash.^{1, 2}. Measles is caused by a single-stranded RNA virus belonging to the genus Morbillivirus of the family Paramyxoviridae.¹² Approximately 7-10 days after a person is exposed, symptoms typically begin with mild to moderate fever, cough, coryza, conjunctivitis (the three “C”s), and appearance of tiny white spots inside the mouth, known as Koplik’s spots.^{1, 2, 13} A maculopapular rash follows 3-5 days after onset of initial symptoms, starting on the face and spreading downward to neck, trunk, arms, legs, and feet. Patients are considered infectious four days before and after appearance of the rash. Some people also experience diarrhea, vomiting, abdominal pain, pharyngitis, lymphadenopathy, and general malaise.

Complications may develop in approximately 30% of measles cases, with higher rates observed in those < 5 years of age as well as those > 20 years of age.^13-16 Pneumonia accounts for approximately 60% of deaths in infants with measles.¹⁷ Otitis media, which can lead to permanent hearing loss, is present in roughly 10% of cases. Encephalitis develops in approximately one in every 1000 infected persons, and often results in permanent neurologic sequelae. One to two deaths occur for every 1000 reported cases.¹⁸ The mortality rate in underdeveloped countries is substantially higher, particularly in children, with approximately 330 deaths occurring every day.⁷

Transmission and spread: a global impact

Regarded as one of the most contagious infectious diseases, measles is transmitted through direct contact with droplets from the nose, mouth, or throat of infected individuals.^19-22 Certain populations remain vulnerable to measles infection, including: i) individuals who refuse vaccination, ii) pregnant women, iii) immunocompromised patients, and iv) children aged < 1 year.^{6, 11} Approximately 90% of people lacking measles immunity who have close contact with a measles case will become infected. Transmission is easily prevented through administration of measles vaccine, given as part of the measles-mumps-rubella (MMR) combination vaccine. However, despite the known benefits and protective effects of the measles vaccine, some individuals/communities remain skeptical.²³ A perceived causal link between vaccinations and development of autism, autoimmune diseases, neurotoxicities, and/or other chronic conditions has given rise to increased vaccine hesitancy.^24,25 Multiple studies have either refuted or failed to demonstrate an association with any of these conditions.^26,27

Global initiatives are currently underway to improve vaccination coverage in other parts of the world where measles is poorly controlled.²⁸ Unvaccinated travelers returning from abroad are frequent sources of imported cases and subsequent outbreaks. From 2001 to 2011, 911 measles cases were reported in the U.S., representing an annual median incidence of 61 cases.²⁹ This year alone, measles cases have already reached a staggering 593 cases. Examples of several notable outbreaks in recent years are discussed in Table 1.

Table 1. Notable Outbreaks during Years of Higher Measles Incidence 1, 2,9,11, 29-33

* Total reported Jan 1st through Aug 15th, 2014

Treatment

No specific treatment exists for measles, but patients are generally managed with supportive care (e.g. hydration, antipyretics) and monitored for development of complications. Antimicrobials may be required for treatment of bacterial superinfections but are not recommended as prevention. Vitamin A deficiency is a known risk factor for severe measles and supplementation is therefore recommended by the World Health Organization.^{34, 35}

Early recognition is critical for implementing adequate infection control measures and reducing transmission. The Centers for Disease Control and Prevention recommends that health-care providers consider measles in the differential diagnosis when evaluating patients with a febrile rash. Furthermore, these patients should also be questioned about recent international travel abroad as well as vaccine status. Routine immunization and post-exposure prophylaxis measures are outlined in Table 2.

Table 2. Measles Vaccination Schedule and Post-exposure Prophylaxis^{a 13, 36}

^acontraindicated for use in pregnant women and immunocompromised patients (except patients with human immunodeficiency virus with CD4 counts > 200 cells/μL)
^bMMR doses always separated by at least 28 days
^cAdolescents and adults who have not had measles or have not received vaccine should get 2 doses, separated by 28 days
^dExposed individuals who are without evidence of measles immunity

References:

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