Measles is a highly contagious disease, caused by a virus belonging to the paramyxovirus family. Although predominantly a disease of childhood, measles can affect people of any age. The illness can be unpleasant, and although usually self-limiting, complications can occur, and fatality rates remain high in developing countries (Perry and Halsey, 2004). The introduction of the measles vaccine in 1968, followed by the measles mumps and rubella (MMR) vaccination in 1988 reduced the number of cases considerably to a point that in 2017 the World Health Organization (WHO) declared that the UK had eliminated measles completely (Public Health England, 2019). However, these statistics have not been maintained and the UK is no longer considered to be ‘measles free’ by WHO. Concerns among the general public about the safety of the MMR vaccine led to a fall in the uptake of immunisation, and in 2018, there was a marked increase in the number of people diagnosed, with 991 confirmed cases in England and Wales, compared with 284 cases in 2017 (Public Health England, 2019). Practice nurses have a vital role to play in promoting uptake of immunisations. This article gives practice nurses an overview of this disease and aims to offer guidance on improving the situation in the future.
Pathophysiology
The disease is most likely to occur in late winter or spring. Spread occurs via respiratory droplets, which can remain active and contagious, either airborne or on surfaces, for up to 2 hours (Chen, 2019). Once the virus has entered the body, replication occurs in the bronchial epithelial cells and also in the trachea. After 2-4 days, measles virus infects local lymphatic tissues, possibly carried by pulmonary macrophages (Chen, 2019). An uncontrolled proliferation then begins and the virus is then able to spread to various organs of the body, prior to the onset of the rash.
Clinical features
Measles has an estimated incubation period of about 10 days, with a further 2–4 days of prodromal symptoms (this is the period relating to the time between the initial symptoms of malaise fever, feeling unwell) and the outbreak of the characteristic skin rash. Approximately 60–-70 % of patients develop Koplik's spots 2–3 days before the rash appears, small red spots on the buccal mucosa (Knott, 2015). These are considered to be characteristic of measles infection. Fever increases during the prodromal phase to reach a peak of around 39°C at about the time the rash appears, and then gradually decreases (National Institute for Health and Care Excellence (NICE), 2018). The rash first appears behind the ears and on the face, and then spreads to the trunk and limbs over the course of a few days (usually 3–4). The rash fades after it has been present on an area for about 5 days, with the total duration of up to 1 week (NICE 2018), and by this time the person has started to recover and should be feeling a lot better.
Treatment and management
Measles is a notifiable disease and requires GPs to report any cases of the illness to the local Health Protection Team. They are also able to offer advice and guidance on the management of measles cases in patients who are at greater risk of a more serious illness and complications, such as pregnant women, babies or any patient who is immunocompromised. No specific treatment is recommended for measles and the condition is self-limiting and should resolve without further intervention.
Table 1 shows recommended advice to patients.
Table 1. Recommended guidance for patients with measles
| Advice | Additional information |
|---|---|
| Analgesia |
|
| Avoid school or work |
|
| Contact |
|
Complications
Complications, although rare, do occur and can range in severity and are more commonly seen where factors such as co-existent immunodeficiency, malnutrition, vitamin A deficiency, pregnancy and high exposure levels due to overcrowding exist (Knott, 2015). Common complications will be discussed below, rarer ones are shownin Table 2.
- Respiratory: Measles infects the respiratory tracts of nearly all affected persons and pneumonia is the most common severe complication of measles (Perry and Halsey, 2004), and is reported to be the most common cause of death in infants in the USA (Tesini, 2019), similarly bronchopneumonia occurs in up to 5% of cases, in the UK, producing serious respiratory difficulties and it accounts for 56–86% of deaths (Knott, 2015)
- Laryngotracheobronchitis (Croup): A viral infection characterised by a harsh barking cough, and although usually self-limiting, secondary bacterial infection can lead to pneumonia and tracheitis (Knott, 2015)
- Ear infections: Otitis media causing earache is common in children with measles under five, decreasing in occurrence with increasing age (Perry and Halsey, 2004)
- Febrile convulsions: These may occur when the fever is at its highest. They are usually not associated with any long-term effects
- Gastro-intestinal: Diarrhoea and vomiting, if severe, can lead to dehydration. In developing countries gastro-intestinal complications can be more severe and may be associated with prolonged diarrhoea, weight loss and oral ulcers
- Immunodeficiency: Measles infection causes lymphopenia (low lymphocyte count) and there is often a delayed recovery in adults and infants once the disease has resolved. Even after lymphocyte counts have normalised, immunodeficiency persists for many weeks and this is thought to be a major contributor to the high all-cause mortality following acute measles worldwide (Knott, 2015)
- Eye infections: Conjunctivitis occurs in most people with measles, and inflammation of the cornea (keratitis) is common (Perry and Halsey, 2004)
- Vitamin A deficiency and blindness: Vitamin A deficiency (VAD) has been recognised as a public-health issue in developing countries, exacerbated by poor nutritional status and poor living conditions and sanitation (Akhtar et al, 2013). Vitamin A deficiency raises the risk of death and blindness in those who develop measles. The deficiency manifests itself as xerophthalmia (corneal ulceration and scarring and is an important cause of blindness worldwide (Knott, 2015) worldwide.
Small red sports known as Koplik's will appear 2–3 days before the outbreak of the characteristic skin rash
Table 2. Less common and rarer complications
| Less common complication | Additional information |
|---|---|
| Encephalitis |
|
| Meningitis |
|
| Hepatitis |
|
| Strabismus |
|
| Rare complication | Additional information |
Serious eye disorders:
|
|
| Sub-acute sclerosing panencephalitis |
|
| Acute thrombocytopenic purpura |
|
Pregnancy
Measles, in common with several other infectious diseases, can be more severe in pregnancy. Although not thought to cause congenital malformations, the disease may be associated with several possible complications, and can increase thenlikelihood of:
- Premature birth
- Low birth weight babies
- Miscarriage
- Post exposure prophylaxis
- MMR vaccine may be effective if given within 72 hours of exposure to those over the age of 6 months or age.
- In babies below the age of 12 months response to the MMR vaccination is often suboptimal and it is therefore recommended that a further two doses of vaccine are administered at the recommended ages
- Both children and adults who have been exposed to measles vaccine and who are immunocompromised should be considered for vaccination with human normal immunoglobulin (HNIG)
- The majority of pregnant women will have had measles in childhood, however they have not (and are antibody negative) they can also be considered for vaccination with HNIG.
Prevention
The best prevention is vaccination and with initiatives worldwide, measles vaccine has prevented an estimated 20.4 million deaths from 2000-2016 and reduced worldwide deaths by 75% (Centres for Disease Control and Prevention (CDC), 2017). The current NHS schedule for MMR vaccination advises that babies receive their first dose at one year of age, followed by a second dose at 3 years and four months (NHS, 2019). University students who have not previously been vaccinated can also request immunisation as there have been instances of measles and mumps outbreaks at university campuses.
Practice nurse involvement
The NHS has recently highlighted the need to increase efforts to Improve uptake rates and practice nurses will be at the forefront of this. Educating and encouraging parents Is vital to dispel myths and correct misguided information surrounding the MMR vaccine. Later evening surgeries and weekend opening Is hoped to Improve access for working parents.
Prognosis
Disease severity varies widely and can range from being relatively mild through to more severe, with more unpleasant cases likely to occur in the very young or in adults, and in those who are immunocompromised or malnourished. Although death rates have improved with vitamin A therapy and antibiotics should the affected person develop a bacterial complication. Deaths from measles in developing countries remain 10–100-fold higher than in developed countries (Perry and Halsey, 2004). In England, statistic from Public Health England reported on death in a child over the age of 15 (Public health England, 2019). For those who make a fully recovery, they will develop sustained levels of neutralising antibody and life-long protective immunity (Griffin, 2016).
Conclusion
Although for the majority of those affected, measles is a mild self-limiting illness, there are cases which are more serious, and although rare, deaths do still occur. Vaccination clearly the key to reducing the incidence of this preventable disease and widespread education of the public is needed to improve uptake rates.
Many people will be unaware of some of the more serious consequences of this illness and practice nurses have an important role to play in advising and educating parents, and in raising awareness of the potentially devastating effects of this disease. In addition, they can also play an important part encouraging the uptake of this important immunisation. It is intended that this article has given practice nurses an insight into this disease and will give them greater confidence when advising parents and other family members.