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

Year

Total # of Cases

Location/Setting

Source(s) of Outbreak

2014

593*

  • Ohio: 377 cases
  • Multiple outbreaks, particularly Amish communities
Unvaccinated travelers, primarily to and from the Philippines
  • California: 61 cases
  • Multiple areas/counties affected
13 imported cases, 8 of these visited the Philippines

2013

187

  • Brooklyn, NY: 58 cases
  • Jewish Orthodox communities
17 yr old male, unvaccinated, returning from UK
  • Newark, Texas: 27 cases
  • Megachurch community
Adult male, unknown measles vaccination status

2011

222

  • Hennepin County, MN: 21 cases
  • Homeless shelters, healthcare facility
30 month old, unvaccinated from Kenya; initially misdiagnosed w/ otitis media and bronchiolitis

2008

140

  • San Diego: 12 cases
  • School
7 year old boy, unvaccinated, returning from Switzerland
  • Pima County, AZ: 14 cases
  • Healthcare facility
Unvaccinated traveler from Switzerland

* 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 Prophylaxisa 13, 36

Routine MMR Vaccination

MMR dose

Recommended Age

1st dose

  • 12 to 15 months
  • Persons born on or after 1957 without evidence of immunity

2nd dose

  • 4 to 6 years (before school entry)

or

  • Minimum of 28 days from 1st doseb
MMR Vaccination for International Travelers

MMR dose

Recommended Age

1st dose

  • 6 to 11 months

2nd dose

  • 12 months or olderb
  • Adults born on or after 1957 without evidence of immunityc
Post-Exposure Prophylaxisd

MMR Vaccine

  • May provide protection only if given within 72 hours of measles exposure

Immunoglobulin

  • May decrease disease severity and risk for complications if given within 6 daysof exposure
  • Indicated in severely compromised, infants < 12 months of age, and pregnant women without measles immunity

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:

  1. Centers for Disease Control and Prevention. Measles cases and outbreaks. Available at: http://www.cdc.gov/measles/cases-outbreaks.html. Accessed Aug 15, 2014.
  2. Centers for Disease Control. Notifiable diseases and mortality tables. MMWR Morb Mortal Wkly Rep. 2014;63(32):ND 438-ND 451.
  3. American Academy of Pediatrics. Measles. In: Pickering LK, Baker CJ, Kimberlin DW, Long SS, editors. 2012 Red book: report of the committee on infectious diseases. 29th edition. Elk Grove Village, IL: American Academy of Pediatrics; 2012:489–99.
  4. Strebel P, Papania MJ, Dayan GH, Halsey NA. Measles vaccine. In: Plotkin SA, Orenstein WA, Offit PA, editors. Vaccines. 6th edition. Philadelphia: WB Saunders; 2013:352–87.
  5. Simons E, Ferrari M, Fricks J, et al. Assessment of the 2010 global measles mortality reduction goal: results from a model of surveillance data. Lancet. 2012;379:2173–8.
  6. World Health Organization. Measles fact sheet No.286. Available at: http://www.who.int/mediacentre/factsheets/fs286/en/. Accessed Aug 15, 2014.
  7. Katz SL, Hinman AR. Summary and conclusions: Measles elimination meeting, 16–17 March 2000. J Infect Dis. 2004;189:S43–7.
  8. Orenstein WA, Papania MJ, Wharton ME. Measles elimination in the United States. J Infect Dis. 2004;189(Suppl 1):S1–3.
  9. Centers for Disease Control and Prevention. Summary of notifiable diseases—United States, 2011. MMWR Morb Mortal Wkly Rep. 2013;60(53):1-117.
  10. Fiebelkorn AP, Redd SB, Gallagher K, et al. Measles in the United States during the post-elimination era. J Infect Dis. 2010;202:1520-8.
  11. Gastañaduy PA, Redd SB, Fiebelkorn AP, et al. Measles – United States, January 1-May23, 2014. MMWR Morb Mortal Wkly Rep. 2014;63(22):496-9.
  12. Griffin DE, Lin WH, Pan CH. Measles virus, immune control, and persistence. FEMS Microbiol Rev. 2012;36(3):649-62.
  13. Centers for Disease Control and Prevention. Measles for healthcare professionals. Available at: http://www.cdc.gov/measles/hcp/index.html. Accessed Aug 15, 2014.
  14. Sabella C. Measles: not just a childhood rash. Cleve Clin J Med. 2010;77:207-13.
  15. Miller DL. Frequency of complications of measles, 1963. Report on a national inquiry by the Public Health Laboratory Service in collaboration with the Society of Medical Officers of Health. Br Med J. 1964;2:75–8.
  16. Perry RT, Halsey NA. The clinical significance of measles: a review. J Infect Dis. 2004;189(Suppl 1):S4-S16.
  17. Barkin RM. Measles mortality. Analysis of the primary cause of death. Am J Dis Child. 1975;129:307-309.
  18. Gindler J, Tinker S, Markowitz L, et al. Acute measles mortality in the United States, 1987–2002. J Infect Dis. 2004;189(Suppl 1):S69–S77.
  19. Ruckle G, Rogers KD. Studies with measles virus: II. Isolation of virus and immunologic studies in persons who have had the natural disease. J Immunol. 1957;78:341-55.
  20. Bloch AB, Orenstein W, Ewing WM, et al. Measles outbreak in a pediatric practice: airborne transmission in an office setting. Pediatrics. 1985;75:767-83.
  21. Remington PL, Hall W, Davis IH, et al. Airborne transmission of measles in a physician’s office. JAMA. 1985;253:1574-7.
  22. Ehresmann KR, Hedberg CW, Grimm MB, et al. An outbreak of measles at an international sporting event with airborne transmission in a domed stadium. J Infect Dis. 1995;171:679-83.
  23. Gust DA, Darling N, Kennedy A, Schwartz B. Parents with doubts about vaccines: which vaccines and reasons why. Pediatrics. 2008;122(4):718-25.
  24. Bloom BR, Marcuse E, Mnookin S. Addressing vaccine hesitancy. Science. 2014;344(6182):339.
  25. Larson HJ, Caitlin J, Eckersberger E, Smith DM, Paterson P. Understanding vaccine hesitancy around vaccines and vaccination from a global perspective: a systematic review of published literature, 2007-2012. Vaccine. 2014;32(19):2150-9.
  26. Centers for Disease Control and Prevention. Vaccine safety: measles, mumps, and rubella (MMR) vaccine. Available at: http://www.cdc.gov/vaccinesafety/Vaccines/MMR/. Accessed Aug 23, 2014.
  27. Taylor LE, Swerdfeger AL, Eslick GD. Vaccines are not associated with autism: An evidence-based meta-analysis of case-control and cohort studies. Vaccine. 2014;32:3623-29.
  28. Measles and Rubella Initiative. A global partnership to stop measles and rubella. Available at: http://www.measlesrubellainitiative.org/. Accessed Aug 23, 2014.
  29. Papania MJ, Wallace GS, Rota PA, et al. Elimination of Endemic Measles, Rubella, and Congenital Rubella Syndrome From the Western Hemisphere The US Experience. JAMA Pediatr. 2014;168(2);148-55.
  30. Ohio Department of Health: Measles Outbreak 2014. Available at: http://www.odh.ohio.gov/features/odhfeatures/Measles%202014.aspx. Accessed Aug 15, 2014.
  31. Texas Department of State Health Services: Infectious Disease Control – Measles. Available at: http://www.dshs.state.tx.us/idcu/disease/measles/. Accessed Aug 15, 2014.
  32. Kuehm, BM. Public health officials mark 50th year of measles vaccine: concern remains about outbreaks in pockets of unvaccinated. JAMA.  2014;311:345-6.
  33. National Public Radio. Texas megachurch of center of measles outbreak. September 1st, 2013. Available at http://www.npr.org/2013/09/01/217746942/texas-megachurch-at-center-of-measles-outbreak.  Accessed Aug 23, 2014.
  34. Frieden TR, Sowell AL, Henning K, et al. Vitamin A levels and severity of measles. Am J Dis Child. 1992;146:82-6.
  35. Hussey GD, Klein M. A randomized, controlled trial of vitamin A in children with severe measles. N Engl J Med. 1990;323:160-4.
  36. Centers for Disease Control and Prevention. Prevention of measles, rubella, congenital rubella syndrome, and mumps, 2013: Summary recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2013;62(RR04):1–34.