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• Volume 13, Issue 2
• Complications of measles: a case series
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• http://orcid.org/0000-0003-3552-4659 Thelma Xerri 1 ,
• Nicola Darmanin 1 ,
• Maria Alessandra Zammit 2 and
• Claudia Fsadni 2
• 1 Department of Medicine , Mater Dei Hospital , Msida , Malta
• 2 Department of Infectious Disease , Mater Dei Hospital , Msida , Malta
• Correspondence to Dr Thelma Xerri; thelmaxerri{at}gmail.com

Measles, which was once thought to be a disappearing viral infection due to effective vaccination, has been re-emerging globally, with increasing cases in adolescents and adults. This has been attributed to anti-vaccination campaigning in the early 21st century, which has resulted in a drop in overall herd immunity. In this case series we report three patients with complications secondary to measles who presented to a hospital in Malta in 2019. Through this series, we discuss the range of possible complications caused by the measles virus, ranging from mild viraemic symptoms to multiorgan involvement which could possibly lead to high-dependency care and may even be fatal. We also highlight recent global statistics which reflect the exponential increase in the incidence of measles, with a special focus on Europe. It is emphasised that vaccine education and compliance with the two-dose measles vaccine should be implemented worldwide.

• vaccination/immunisation
• infectious diseases

https://doi.org/10.1136/bcr-2019-232408

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Measles, a paramyxovirus, is a highly contagious viral respiratory illness characterised by a prodrome of fever along with cough, coryzal symptoms and conjunctivitis. 1 This is followed by a pathognomonic maculopapular rash, starting from the head down to the trunk and lower limbs including the palms and soles. It may also present with Koplik's spots as an enanthema.

Complications from the measles virus have been reported in every organ system. We present three cases with three similar presentations but different complications. With the current global outbreak of measles, we emphasise the importance of an immunisation history in the medical clerking and serology as the diagnostic modality whenever there is a low clinical suspicion for measles. 2 Urgent efforts are needed to ensure global coverage with two-dose measles vaccines through education and strengthening of national immunisation systems.

Case presentations

A 29-year-old Maltese man without a significant past medical history presented with a 4-day history of intermittent fever associated with chills and rigours, nausea and multiple episodes of vomiting. A generalised maculopapular pruritic rash developed on the second day and he was sent to hospital for further investigation. On general examination the patient was haemodynamically stable with a temperature of 38°C. An exanthematous maculopapular rash was evident over the face, trunk and lower limbs including the soles of the feet ( figure 1 ). No Koplik spots were found. On examination there was tenderness in the right upper quadrant of his abdomen.

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Case 1. Macular confluent rash over the soles of the feet.

Investigations

Initial blood investigations showed a lymphocytopenia of 0.35×10 9 /L (range 1.3–3.6×10 9 /L) and liver derangement with a hepatitic picture (GGT 257 U/L with 65 U/L upper limit of normal and ALT 650 U/L with 11 U/L upper limit of normal). Urine and blood cultures were negative and chest x-ray was normal. Abdominal ultrasound imaging was within normal limits. IgM and IgG antibodies using Enzyme Linked Immunosorbent Assay (ELISA) for measles were found to be positive.

A diagnosis of measles complicated with hepatitis was made.

Differential diagnoses

The differential diagnoses included hepatitis, infectious mononucleosis, HIV, cytomegalovirus, syphilis and rubella. All were excluded through negative rapid serological assays.

Treatment, outcome and follow-up

Supportive care was given with intravenous fluids. After 3 weeks the patient recovered without any further sequelae and liver function improved. It was noted that the patient had only taken one dose of the two-dose MMR vaccine in childhood.

An 18-year-old British woman, on holiday in Malta, presented with a 3-day history of a pruritic generalised macular erythematous rash over her trunk ( figure 2 ), face and limbs. She also complained of a prominent dry cough with oxygen desaturation of 89% on room air despite a clear chest, myalgias and right iliac fossa tenderness on palpation, exacerbated by movement. Faint Koplik's spots were evident on examination. The patient had never received the MMR vaccine.

Case 2. Pathognomonic confluent macular rash over the trunk.

A diagnosis of measles was confirmed with positive IgG and IgM antibodies using ELISA. Koplik's spots swabs sent for measles IgM, IgG and PCR were also positive. A plain chest x-ray was normal but a CT of the trunk showed an enhanced fluid-filled appendix confirming appendicitis ( figure 3 ).

Case 2. CT scan of the abdomen showing appendiceal wall inflammation and oedema secondary to appendicitis (marked with a yellow arrow).

A diagnosis of measles appendicitis was made.

Other viral infections with a similar clinical picture such as hepatitis, HIV, syphilis, rubella and infectious mononucleosis were again excluded.

The patient improved with supportive care and broad-spectrum antibiotics and recovered within 2 weeks. Surgical intervention was not required. CT of the thorax excluded possible measles pneumonitis or pneumonia. Respiratory symptoms were attributed to a co-existing viral respiratory tract infection which improved with supportive care.

A 42-year-old man who had been diagnosed with measles by his general practitioner following positive IgM antibody using ELISA for measles presented 1 week later with bilateral blurring of vision. This was associated with eye irritation and a conjunctival discharge. He also complained of compressive, moderate to severe occipital headaches radiating to the front. These were associated with mild phono- and photophobia; there was no associated nausea, vomiting, hallucinations, confusion or aggression.

On examination the patient was afebrile with mild neck stiffness. An ophthalmic review confirmed no papilloedema but he was found to have bilateral pseudodendritic lesions which were treated with dexamethasone eye suspension for 7 days.

A CT of the brain confirmed no structural pathology. A lumbar puncture confirmed viral meningitis and he was diagnosed with meningeal involvement secondary to measles infection.

A similar clinical picture could be seen in other viral infections such as cytomegalovirus infection, which were excluded with PCR testing. A baseline viral screen including hepatitis and HIV were also taken with patient consent.

The patient improved significantly with supportive care over the next 2 weeks, without any neurological sequelae.

Complications from measles have been reported in every organ system as the virus targets epithelial, reticuloendothelial and white blood cells causing immunosuppression. 3 Measles virus infection leads to a decline in CD4 lymphocytes, starting before the onset of the rash and lasting for up to 1 month, resulting in suppression of delayed-type hypersensitivity. 4

According to the Centers for Disease Control and Prevention, approximately 30% of reported measles cases have one or more complications. These occur most commonly in children under 5 years of age and adults above 20 years of age. Currently, there are no reliable available data regarding the incidence of specific complications. 5

Respiratory complications are the most common, presenting with pneumonitis, pneumonia or bacterial suprainfection. The severity depends on how critically ill the patient is, with intensive care being required in some cases. 2

Neurological sequelae range from benign febrile seizures, mostly in children, to viral meningitis, to postinfectious encephalomyelitis (PIE). PIE is more common in adults and presents with sudden onset of new fever, altered mental status, seizures and multifocal neurological signs. Studies have shown that the virus is usually not identified in the central nervous system and symptomatology is secondary to an abnormal immune response that affects myelin basic protein. 6 Unlike PIE, measles antibody is present in cerebrospinal fluid in subacute sclerosing panencephalitis (SSPE), another complication of measles. 7 Both conditions cause neurological deficits, but SSPE causes permanent damage leading to vegetative state.

A nationwide study of severe measles infection in critically ill adult patients requiring intensive care in France showed that measles-associated pneumonitis and, less commonly, post-infectious encephalomyelitis are the the most common complications, worsening morbidity and mortality. 8 Young adults, pregnant women and immunocompromised patients are at a potentially higher risk of such complications.

Gastrointestinal complications include measles-associated diarrhoea with secondary dehydration and cases of appendicitis have also been reported. Characteristic giant cells positive for measles can be seen on immunologic staining of gastric or appendiceal biopsies, which may be present before the emergence of the pathognomonic rash. 9

Conjunctivitis is common in measles and can lead to keratitis, detectable by slit-lamp. In well-nourished immunocompetent patients, these lesions usually heal without any residual damage. 10 However, suprainfection may lead to permanent scarring and blindness. A Cochrane review by Bello et al 11 showed that vitamin A deficiency predisposes to more severe ocular complications and is one of the most common causes of acquired blindness in children in developing countries.

Measles is a vaccine-preventable disease. Despite the availability of a safe and cost-effective vaccine, in 2017 about 110 000 measles deaths were reported globally according to the World Health Organization (WHO), mostly among young children. Large outbreaks with fatalities are currently ongoing in European countries which had previously eliminated or interrupted endemic transmission.

According to the European Centre for Disease Prevention and Control, 12 there have been more than 10 000 cases of measles reported in Europe since the beginning of 2019 up to mid-July, with the highest numbers being in France, Bulgaria, Italy, Poland and Lithuania. This is also reflective of the Maltese Islands which, for a population of half a million, have seen a burst of notified cases of measles with the local Infectious Disease Prevention and Control Unit reporting 29 cases of measles this year to date compared with only one case in 2018 and no cases in the previous 3 years. Almost all cases seen this year have occurred in adults aged 23–45 years.

These outbreaks are attributed to declining vaccination levels, mostly due to publicity in the early 2000s related to the conflicting hypothesis that the MMR vaccine can cause autism, despite significant national studies proving otherwise. 13 This has had a global impact with a decrease in herd immunity to measles resulting in its increasing emergence. Thus, global strategies are required to optimise vaccine coverage with a surveillance programme in accordance with WHO recommendations.

Learning points

Measles is a viral illness which can be prevented with appropriate immunisation.

The diagnosis of measles should be suspected in anyone presenting with fever and a maculopapular rash.

Measles infection may be associated with complications affecting different organs.

Global frameworks promoting and implementing two-dose measles vaccination to all ensures an increase in herd immunity worldwide.

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Contributors All authors accept full responsibility for the work and contributed to the writing and correction of the manuscript as well as being involved in the treatment of the patients. TX and ND had the idea for the case series and wrote the article, including a literature search. MAZ and CF made amendments and suggestions contributing to the final article. Images were provided by TX and ND.

Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

Competing interests None declared.

Patient consent for publication Obtained.

Provenance and peer review Not commissioned; externally peer reviewed.

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Open Access

Peer-reviewed

Research Article

Epidemiology of measles cases, vaccine effectiveness, and performance towards measles elimination in The Gambia

Roles Conceptualization, Data curation, Formal analysis, Methodology, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

Affiliation WHO Country Office, Nairobi, Kenya

Roles Conceptualization, Data curation, Methodology, Writing – review & editing

Affiliation Expanded Program on Immunisation, Ministry of Health, Banjul, The Gambia

Roles Conceptualization, Methodology, Writing – review & editing

Affiliation World Bank Country Office, Cape Point, Bakau, The Gambia

Affiliation School of Public Health and Community Medicine, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden

Affiliation Department of Global Public Health, Karolinska Institutet, Solna, Sweden

Roles Conceptualization, Methodology, Writing – original draft, Writing – review & editing

Affiliation WHO Country Office, Juba, South Sudan

• Alieu Sowe, 
• Mbye Njie, 
• Dawda Sowe, 
• Sidat Fofana, 
• Lamin Ceesay, 
• Yaya Camara, 
• Brook Tesfaye, 
• Samba Bah, 
• Alieu K. Bah, 

• Published: October 21, 2021
• https://doi.org/10.1371/journal.pone.0258961
• Reader Comments

Introduction

In 2011, member states of the World Health Organization (WHO) Africa Regional Office (AFRO) resolved to eliminate Measles by 2020. Our study aims to assess The Gambia’s progress towards the set AFRO measles elimination target and highlight surveillance and immunisation gaps to better inform future measles prevention strategies.

Material and methods

A retrospective review of measles surveillance data for the period 2011–2019, was extracted from The Gambia case-based measles surveillance database. WHO—UNICEF national coverage estimates were used for estimating national level MCV coverage. Measles post campaign coverage survey coverage estimates were used to estimate national measles campaign coverage.

One hundred and twenty-five of the 863 reported suspected cases were laboratory confirmed as measles cases. More than half (53.6%) of the confirmed cases have unknown vaccination status, 24% of cases were vaccinated, 52.8% of cases occurred among males, and 72.8% cases were among urban residents. The incidence of measles cases per million population was lowest (0) in 2011–2012 and highest in 2015 and 2016 (31 and 23 respectively). The indicator for surveillance sensitivity was met in all years except in 2016 and 2019. Children aged 5–9 years (Incidence Rate Ratio—IRR = 0.6) and residents of Central River region (IRR = 0.21) had lower measles risk whilst unvaccinated (Adjusted IRR = 5.95) and those with unknown vaccination status (IRR 2.21) had higher measles risk. Vaccine effectiveness was 89.5%.

The Gambia’s quest to attain measles elimination status by 2020 has registered significant success but it is unlikely that all target indicators will be met. Vaccination has been very effective in preventing cases. There is variation in measles risk by health region, and it will be important to take it into account when designing prevention and control strategies. The quality of case investigations should be improved to enhance the quality of surveillance for decision making.

Citation: Sowe A, Njie M, Sowe D, Fofana S, Ceesay L, Camara Y, et al. (2021) Epidemiology of measles cases, vaccine effectiveness, and performance towards measles elimination in The Gambia. PLoS ONE 16(10): e0258961. https://doi.org/10.1371/journal.pone.0258961

Editor: Ali Rostami, Babol University of Medical Science, ISLAMIC REPUBLIC OF IRAN

Received: December 19, 2020; Accepted: October 10, 2021; Published: October 21, 2021

Copyright: © 2021 Sowe et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All relevant data are available in the following repository: 10.6084/m9.figshare.16304982 .

Funding: This research received no funding.

Competing interests: The authors have declared that no competing interests exist.

Measles is a highly infectious vaccine-preventable viral disease that accounted for at least 2 million annual global deaths before the introduction of the measles vaccine in 1963 [ 1 ]. It spreads rapidly and has a basic reproductive number (R0) of approximately 12–18 [ 2 ]. In 2001, the WHO set a goal to reduce global measles mortality and urged member states to fully implement the strategies for measles mortality reduction stated in WHO-UNICEF strategic plan 2001–2005 [ 3 ]. These strategies are: 1) providing the first dose of measles vaccine to successive cohorts of infants; 2) ensuring that all children have a second opportunity for measles vaccination; 3) enhancing measles surveillance with integration of epidemiological and laboratory information and; 4) improving the management of every measles case [ 4 ]. The Global Vaccine Action Plan (GVAP) 2011–2020, building on previous initiatives against measles, ambitiously targeted measles elimination in at least five WHO regions by the end of 2020 [ 5 ]. The “Framework for verifying elimination of measles and rubella” [ 6 ] and the “Guidance for evaluating progress towards elimination of measles and rubella” [ 7 ] provide guidance in measles and rubella elimination. By 2018, global measles deaths decreased to 142,000 from 536,000 in 2000, indicating a reduction of 73% [ 1 ].

In 2011, member states of the WHO Africa Regional Office (AFRO) resolved to eliminate measles by 2020 and made the following targets as indicators of achieving elimination status by countries in the AFRO region: 1) a national measles incidence of less than 1 case per million population; 2) at least 95% measles immunization coverage at national and district levels; 3) at least 95% coverage in all measles supplementary immunisation activities (SIAs); 4) one or more suspected measles cases investigated in at least 80% of districts per year and; 5) a national non-measles febrile rash illness rate (NMFRI) of at least 2 per 100 000 population [ 8 ]. A report published in the Morbidity and Mortality Weekly Report describing global progress towards measles elimination from 2000 to 2018 acknowledged the significant progress made but stressed the need for improving routine immunisation and surveillance amongst others for regional elimination targets to be met [ 9 ]. Country level studies conducted in several countries have also highlighted gaps that need to be addressed to achieve and sustain measles elimination [ 10 – 18 ]. The AFRO region has the highest incidence of measles [ 9 ]. Elimination achievement and sustenance require sufficiently high measles vaccination coverage in the presence of a robust surveillance system in each country.

A strong surveillance system is required to detect and respond to measles outbreaks. The declaration of a measles outbreak could be context specific dependent on incidence. Response strategies to measles outbreaks may include a) putting in place mechanisms to reach vulnerable groups in terms of geographical location, b) identifying weaknesses in immunization and surveillance systems, c) enhancing social mobilization and community participation and, d) understanding the distribution of measles cases over time [ 19 ]. The minimum measles surveillance standards set by AFRO for countries in the region are an important proxy in monitoring performance towards elimination. Country level achievement and sustenance of measles elimination are essential for achieving and maintaining regional level measles elimination. The WHO has established regional verification committees (RVCs) in each of the six WHO regions and recommended that each country establishes a national verification committee (NVC) to annually review performance towards measles elimination through a standardised but adaptable process [ 7 ]. The Gambia is yet to have a NVC. Cognizant of the challenges some countries would have in providing all the evidence needed for verification, the elimination evaluation guiding document gave RVCs leeway to use complementary evidence at their discretion [ 7 ].

One of the major threats to vaccine utilization may be linked to vaccine hesitancy which is emerging in many developing countries in recent times [ 20 ]. Generally, Gambian women are receptive to vaccination services [ 21 ]. The first dose of the measles vaccine was introduced in the early 1980s whilst the second dose was introduced in 2012 [ 22 ]. In The Gambia and some countries, the first dose of measles vaccine is administered subcutaneously as a 0.5ml dose of antigen given at 9 months of age, and children receive their second dose of measles at 18 months of age. Per WHO—UNICEF national coverage estimates for the first dose of measles containing vaccine (MCV1), The Gambia is one of the best performing countries in the AFRO region [ 22 ]. The country’s national MCV1 coverage has been between 90% and 97% from 2011 to 218 and declined to 85% in 2019. MCV2 coverage was 56% in 2012, the year it was introduced, and 61% in 2019. The country conducted 2 SIA from 2011 to 2019 targeting children 9 months to 14 years. The coverages of those SIAs were 96% and 97% respectively. Despite relatively high coverage, there have been sporadic measles outbreaks over time [ 23 ]. Therefore, identifying and addressing coverage gaps in countries is critical to accelerating and maintaining measles elimination.

When Masresha et al. (2018) included The Gambia in their 2012–2016 assessment of the elimination status of measles in 11 African countries with high routine MCV1 coverage [ 17 ], they concluded that none of the countries assessed were ready for the verification of their measles elimination status [ 17 ]. Wariri et al. (2021) developed a scorecard which they used to track the progress of 15 West African (ECOWAS) countries towards measles control and elimination milestones between 2001 and 2019 [ 24 ]. They found that although 3 countries including The Gambia have made substantial achievements to measles, the ECOWAS block is not track to achieving measles elimination in 2020 [ 24 ]. Since their aim was to mainly assess progress towards measles elimination, Masresha et al. (2018) and Wariri et al. (2021) did not include further analysis such as the epidemiology of cases, risk factors, and vaccine effectiveness, which would also be useful in informing measles control and elimination strategies at country level [ 17 , 24 ]. In addition to that, the occurrence of sporadic measles outbreaks in parts of the country over time, points to immunity gaps and would require further investigation to effectively address such gaps. Identification of MCV vaccination immunity gaps requires a thorough assessment of MCV coverage over time, vaccine effectiveness, cold chain issues, human resource for EPI services, social mobilization, and epidemiological investigation of reported measles cases including measles risk factors amongst others. It is against this background that this study aims to assess The Gambia’s progress towards the set AFRO measles elimination target and highlight surveillance and immunisation performance to better inform future measles elimination strategies.

Materials and methods

The Gambia is West African country with a population of about 2.4 million people. It is bothered to the west by the Atlantic Ocean and to the north, south, and east by Senegal. The country has a human development index of 0.466 [ 25 ]. The Gambia Expanded Program on Immunisation (EPI) was started in 1979 after an outbreak of Yellow Fever. The country has seven health regions which are also considered as reporting districts for immunisation and surveillance purposes. In each of the seven health regions, is a Regional Operations Officer for the national EPI who is responsible for EPI program activities in that region.

Study design and data sources

A retrospective review of measles surveillance data for the period 2011–2019, was extracted from The Gambia case-based measles surveillance database. WHO—UNICEF national coverage estimates were used for estimating national level MCV coverage [ 22 ]. Measles post campaign coverage survey (PCCS) coverage estimates were used to estimate national measles–rubella vaccination campaign conducted in 2016 [ 26 ].

Measles case definitions (outcome variable)

A suspected measles case is defined in The Gambia as any person with fever and generalized maculo-papular rash plus one of the following: cough or coryza (runny nose) or conjunctivitis (red eyes) or any person in whom a clinician suspects measles. A laboratory confirmed measles case is a suspected case of measles that has been confirmed positive by testing in a proficient laboratory, and vaccine-associated illness has been ruled out. All measles cases in the analysis were laboratory confirmed cases.

Selected measles elimination indicators

To track the country’s status towards the elimination goal, we estimated the five core indicators over the study period stated in the AFRO measles elimination resolution. The five indicators and how each was calculated is presented below.

1) National measles incidence rate per million population.

For each of the years in the study period, the total measles cases for the year as per the database were divided by the estimated national population for that year then multiplied by 1,000,000.

2) National measles routine immunization coverage.

National MCV1 and MCV2 coverages over the years were extracted from WHO-UNICEF estimates national vaccination coverages [ 22 ].

3) Measles coverage in SIAs conducted during the study period.

We used the 2011 campaign report and 2016 measles PCCS coverage estimates.

4) Proportion of districts investigating at least 1 measles case per year.

For this indicator, the number of districts which investigated at least one suspected measles case was divided by the total number of districts expected to report suspected measles cases in that year. The results were converted to percentages by multiplying them by 100. There were six reporting districts in 2011–2012 and seven reporting districts 2013–2019 because Western Region 1 and Western Region 2 were one region (Western Region) before 2013.

5) National non-measles febrile rash illness (NMFRI) rate.

This was calculated by taking the total number of discarded (non-measles) cases reported per year and dividing it by the estimated national population in that year then multiplying the result by 100,000 in line with the standard way of calculating the indicator.

Epidemiologic variables (including risk factors)

The epidemiology of cases was described using sex, age, vaccination status, residence type, and health region. All variables were categorized. Sex was categorised as male and female; age was categorised into three–under 5 years, 5–9 years, and 10 years & above. Vaccination status was indicated by vaccinated, unvaccinated, and unknown; residence as urban and rural; and health regions (reporting districts) were listed as Western Region 1, Western region 2, North Bank West, North Bank East, Lower River, Central River, and Upper River. Before 2013, Western Region 1 and Western Region 2 were administered as one reporting district called Western Region.

Vaccine effectiveness

Vaccine effectiveness was calculated using the formula below [ 27 ]. A total of 863 suspected measles cases were reported during the period reviewed. Four hundred and ten (410) of the reported cases have unknown vaccination status and 49 of them were less than 9 months of age. All cases with unknown vaccination status or below 9 months (total 459) were excluded from this analysis. A case was considered vaccinated if he/she received at least one dose of MCV either by card or recall including SIA doses.

VE = Vaccine Effectiveness (in percentage), ARU = Attack Rate in the Unvaccinated, and ARV = Attack Rate in the Vaccinated. The ARU was calculated as the incidence of measles in unvaccinated and ARV was calculated as the measles incidence in the vaccinated.

Approach to analysis

Main analysis..

Selected measles elimination status indicators, epidemiology of cases, and vaccine effectiveness were descriptively analysed using rates or proportions. Risk factors were identified through Poisson regression. The motivation for choosing a Poisson model is to enable the estimation of rate ratios since the outcome is relatively common (>10%). Therefore, a logistic model would tend to overestimate the strengthen of associations when used. Exposure variables with P values ≤ .20 in bivariable analysis were included in the regression models. Two regression models were used. The first one is a crude model in which the outcome variable (in this case measles IgM positivity status indicated as a “1” and a “0” representing a “Yes” and a “No”) was regressed on each of the exposure variables. The second model is a fully adjusted model whereby the outcome variable was regressed on all the exposure variables at once. Incidence rate ratios and their 95% confidence intervals were reported. Data management and analysis were done using Stata 16.1 [ 28 ].

Additional analysis.

Seven observations had missing age. Three of them had measles IgM positive results. All the seven observations were recoded into a category called “missing” and included in the regression models, then it was dropped, and the regressions were repeated. The finding was that dropping them had no major effect on the regression results. And therefore, they were dropped. The possibility of multicollinearity among independent variables was assessed by estimating variance inflation factors (VIFs). As a rule of thumb VIFs below 5 were considered non problematic. The highest VIF was 1.73, suggesting that multicollinearity might not be a problem in the adjusted model. The model goodness of fit P—value for the adjusted model was 1 (good fit should be > 0.05 –the higher the P value, the better the model) indicating that the adjusted model reasonably fits the data well.

Ethical considerations

This study used routine national surveillance data. Therefore, no ethical approval was required. The subset of the data extracted for analysis was fully anonymized before it was accessed for analysis.

Description of measles cases

A total of 863 suspected measles cases were reported across the 9 years analysed. Of these, 125 were confirmed measles cases. As can be seen in Table 1 , most measles cases occurred in 2015 and 2016. By sex, 52.8% of cases were males. Cases tend to vary by age with the frequency of cases decreasing with age e.g., 46.4% among children below 5 years and 18.4% among those aged 10 years and above. Three cases representing 2.4% of the total measles cases had missing age. More than half (53.6%) of the cases have unknown vaccination status and 24% of the total cases were vaccinated. A little less than three quarters (72.8%) of all cases were among urban residents. Most cases were from Western Region 1 (44%) and Western Region 2 (34.4%) followed by Upper River region (11.2%). North Bank West and Central River regions accounted for the lowest frequency of cases—at 0.8% each.

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https://doi.org/10.1371/journal.pone.0258961.t001

Selected measles elimination status indicators

Table 2 depicts The Gambia’s performance towards measles elimination during 2011–2019. The proportion of districts investigating at least 1 suspected measles case for which blood specimen was collected was the only indicator that was consistently met from 2011 to 2019. There was one SIA conducted during the period reviewed and national coverage was 97%, 2 percentage points above the minimum target. The incidence of measles cases per million population was lowest (0) in 2011–2012 and highest in 2015 and 2016 (about 31 and 23 respectively). Although MCV1 coverage achieved met the set target in 5 of the 9 years assessed, MCV2 coverage has been below the 95% target since its introduction in 2012 and has a median coverage of 69.5%. The indicator for surveillance sensitivity, the NMFRI rate, was met in all years except in 2016 and 2019.

https://doi.org/10.1371/journal.pone.0258961.t002

Four hundred and four (404) of the 863 reported suspected cases have known vaccination status and were above 9 months of age and therefore eligible for inclusion in this analysis. The attack rates were 66.67% and 6.98% among the unvaccinated and vaccinated respectively leading to vaccine effectiveness rate of 89.5%.

Measles risk factors

Table 3 shows exposure variables and their association with measles during the period studied. Children aged 5–9 years (Adjusted IRR = 0.6) and residents of Central River region (Adjusted IRR = 0.21) had lower risk of contracting measles than their respective reference categories. Upper River and Western Region 2 residents respectively have 2.52- and 1.8-folds higher measles risk than residents of Western Region 1. Those unvaccinated (Adjusted IRR = 5.95) and those with unknown vaccination status (Adjusted IRR 2.21) had much higher measles incidence than those vaccinated.

https://doi.org/10.1371/journal.pone.0258961.t003

The WHO AFRO region, including The Gambia, targeted year 2020 as the year to eliminate measles. The achievement of five key measles elimination indicators is the required for measles elimination to be declared at country level. Each country in the AFRO region must achieve and sustain the targets for the region to be considered to have achieved measles elimination. We tracked measles elimination status in The Gambia over the last 9 years from 2011, by epidemiologically describing laboratory confirmed measles cases, evaluating vaccine effectiveness, and identifying risk factors. Our findings highlight that significant achievements have been registered in The Gambia towards measles elimination including high immunization coverage. Nonetheless, the study also illuminated gaps that require attention to reinforce gains made over the past decades in order to accelerate measles elimination.

Over the nine years evaluated, there is no single year in which all the five indicators recommended by AFRO were met [ 8 ]. The finding that each of the reporting districts was able to report at least 1 case per year during the period reviewed highlights that the country has a sensitive surveillance system which is very positive. Although the incidence of measles cases peaked in 2015 and has remained significantly lower since then, the maintenance of the recommended threshold remains a challenge. Reasons given by national staff for the spike in cases in 2015 include a delay in implementing a planned SIA and low MCV 2 coverage. Most of the cases were recorded among foreigners whose vaccination statuses were mostly either unvaccinated or unknown. The decreasing trend of MCV1 and MCV2 coverage rates in 2019 compounded by the intermittent achievement of the surveillance sensitivity target in half of the years after 2015 creates an environment suggesting that The Gambia may not be able to achieve measles elimination by the targeted year.

With regards to the epidemiology of measles cases, interesting and sometimes expected patterns have been observed. Majority of absolute cases occurred among males but proportions of cases by sex are not statistically different. Studies conducted in Nigeria, Ethiopia, Kenya, South Korea, and Iraq also reported higher frequencies of measles cases among males [ 11 – 13 , 16 , 18 ]. The presence of few confirmed measles cases with missing age and a majority of confirmed cases having unknown vaccination status despite over three quarters (79%) of all measles occurring among children less than ten years points to data quality related issues. Vaccination card retention is over 80% in The Gambia [ 29 – 32 ] suggesting that missingness in variables or having unknown vaccination status could be related to the timeliness of investigations and complete filling of case investigation forms. Kisangau et al.’s (2018) study tracking progress towards measles elimination in Kenya made findings similar to ours in that most measles cases had unknown vaccination status [ 16 ]. Unknown vaccination status of cases negatively affects surveillance data quality and consequently decision making [ 33 ]. Unsurprisingly, individuals with unknown vaccination status and the unvaccinated persons have higher risk for measles infection than the vaccinated, even though study participants with unknown vaccination status appear to have a lower risk than those unvaccinated. It has been shown that measles cases are usually more common among those with unknown or missing vaccination status, after those classified as the unvaccinated [ 34 , 35 ]. This suggests that the group with unknown vaccination status may be heterogeneous with majority of them being the unvaccinated than vaccinated.

Our study has shown variation in measles infection risk by geographic groups. It is quite interesting that urban residence was associated with higher likelihood of measles infection than rural residence but only in the crude model. The association disappeared when the variables were controlled for each other in the adjusted model. Regional, district, county or state variations in the distribution of measles cases is not uncommon [ 11 , 13 , 16 , 18 ]. Higher vaccination coverage is usually associated with lower incidence of measles and it is historically known that vaccination coverage is higher in rural than urban areas in The Gambia [ 36 ]. Western Region 1 and Western Region 2 densely populated and account for over 60% of national population and are more urban than the rest of health regions with Western Region 1 being considered fully urban by surveys. Taking into account that the vast majority of confirmed cases occurred in those two regions, it is reasonable that health region explained (confounded) the association between residence and measles infection in this case.

Our study showed that MCV vaccine effectiveness was very high during the period reviewed (considering an MCV vaccine effectiveness threshold of 85% when given at 9 months [ 19 ]) unlike what was found in Kerela, India, where low vaccine effectiveness was reported [ 37 ]. An earlier study assessing measles mortality and vaccine efficacy in The Gambia by Hull et al. (1983) also reported as high as 89% vaccine efficacy among children vaccinated at 9 months or later [ 38 ]. Generally, measles vaccine effectiveness is improves with number of doses e.g. two doses are more effective in preventing measles than 1 dose. Therefore, SIAs also play an important role in boosting population immunity induced through routine immunization.

Limitations

Since the data collected is over nine years, the children in 5–9 years age cohort is not exactly the same across the 9 years reviewed. Therefore, it is important to keep in mind when interpreting results that children grouped 5–9 years is actually an aggregate of children who were in that age group in each of the years and not necessarily the total number of children aged 5–9 years over the study period. This caveat is worth noting to avoid misinterpreting results by assuming that children born five to nine years before the beginning of the study period (2011) were more vulnerable to measles. Another caveat is that the proportions of cases with missing and unknown vaccination status are calculated among measles IgM positive cases. Therefore, the absolute number of observations with missing age or unknown vaccination status will be higher if they were calculated across all the observations in the database.

Policy and research implications

The findings of this study have presented a clear description of measles elimination status in The Gambia and provided insights that can be used to guide stakeholders to strengthen the planning and implementation of measles prevention strategies. The study has shown that a one size fits all approach will not work well to address in meeting measles elimination status indicators in The Gambia. An integrated and context specific approach is needed among programs and all stakeholders to address the challenges. Not much country focused (The Gambia) research has been done in this area. It is therefore envisaged that this study will trigger interest and more research on vaccine-preventable disease surveillance in The Gambia with a view of providing information that actors can use to accelerate the prevention and control of vaccine preventable diseases. There is a need to investigate the declining trend in MCV coverage. The country needs to establish a national verification committee to monitor measles elimination status annually as recommended in the measles elimination evaluation guiding document [ 7 ].

The Gambia’s quest to attain measles elimination status by 2020 has registered significant success but has a daunting challenge. The country’s performance towards the set elimination status indicators has been fluctuating and it is unlikely that all indicator targets will be met by 2020. There is variation in measles risk. Younger age groups and being resident in more urban areas were positively associated with measles infection. Vaccine effectiveness was shown to be very good. However, there is a need to improve on data quality to improve the quality of evidence that may be generated from surveillance date to guide future action.

Acknowledgments

Declaration: Alieu Sowe, Brook Tesfaye, Yaya Camara, and Alagie Touray work at the World Health Organization (through the STOP Transmission of Polio program) and Alieu K Bah works at the World Bank. Views expressed in this paper should be considered as entirely those of the authors and not necessarily the institutions they work for.

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• 31. The Gambia Bureau of Statistics (GBOS). The Gambia Multiple Indicator Cluster Survey report, 2018. Banjul, The Gambia: Gambia Bureau of Statistics (GBOS); 2019.
• 32. The Gambia Bureau of Statistics, ICF International. The Gambia Demographic and Health Survey 2013. Banjul, The Gambia, and Rockville, Maryland, USA: GBOS and ICF International: 2014.

Measles (Rubeola)

Measles , also known as rubeola, is a highly contagious viral infection that affects millions of people worldwide, particularly children. It is characterized by a distinct red rash, fever , cough , and other flu -like symptoms. Measles can lead to serious complications, especially in young children and individuals with weakened immune systems. The disease spreads through respiratory droplets and can rapidly spread in communities with low vaccination rates.

This article aims to serve as a comprehensive nursing guide to measles, exploring its causes, symptoms, complications, prevention through vaccination, and the significance of public health efforts in controlling outbreaks and protecting vulnerable populations from this preventable infectious disease.

Table of Contents

What is measles , pathophysiology, statistics and incidences, clinical manifestations, assessment and diagnostic findings, pharmacologic therapy, nursing assessment, nursing diagnosis, nursing care planning and goals, nursing interventions, documentation guidelines.

Measles is an acute viral respiratory illness.

• Measles , also known as rubeola, is one of the most contagious infectious diseases, with at least a 90% secondary infection rate in susceptible domestic contacts.
• Despite being considered primarily a childhood illness, measles can affect people of all ages.
• Measles is marked by prodromal fever, cough , coryza, conjunctivitis, and pathognomonic enanthem (ie, Koplik spots), followed by an erythematous maculopapular rash on the third to the seventh day.
• Infection confers lifelong immunity.

In temperate areas, the peak incidence of infection occurs during late winter and spring.

• Infection is transmitted via respiratory droplets, which can remain active and contagious, either airborne or on surfaces, for up to 2 hours.
• Initial infection and viral replication occur locally in tracheal and bronchial epithelial cells.
• After 2-4 days, the measles virus infects local lymphatic tissues, perhaps carried by pulmonary macrophages .
• Following the amplification of the measles virus in regional lymph nodes, a predominantly cell-associated viremia disseminates the virus to various organs prior to the appearance of a rash.
• Measles virus infection causes generalized immunosuppression marked by decreases in delayed-type hypersensitivity, interleukin (IL)-12 production, and antigen-specific lymphoproliferative responses that persist for weeks to months after the acute infection.

The practice of administering 2 doses of live-attenuated measles vaccine to children to prevent school outbreaks of measles was implemented when the vaccine was first licensed in 1963.

• The immunization program resulted in a decrease of more than 99% in reported incidence.
• From 1989 to 1991, a major resurgence occurred, affecting primarily unvaccinated preschoolers; this measles resurgence resulted in 55,000 cases and 130 deaths and prompted the recommendation that the second dose of measles vaccine be given to preschoolers in a mass vaccination campaign that led to the effective elimination in the United States of endemic transmission of the measles virus.
• By 1997-1999, the incidence of measles had been reduced to a historic low (< 0.5 cases per million persons).
• From 1997 to 2004, the reported incidence was as low as 37-116 cases per year.
• From 2000 through 2007, an average of 63 cases were reported annually to the US Centers for Disease Control and Prevention (CDC).
• In 2004, 34 cases were reported; after that all-time low, however, the annual incidence began to increase, with most cases linked either directly or indirectly to international travel.
• In 2005, 66 cases of measles were reported to the CDC. Of these, 34 were linked to a single outbreak in Indiana associated with the return of an unvaccinated 17-year-old American traveling in Romania.
• In 2006, a total of 49 confirmed cases were reported in the United States.
• From January to June 2008, 131 cases of measles were reported to the CDC.
• At least 47% of the 131 measles infections were in school-aged children whose parents chose not to have them vaccinated.
• In the period from January 1 to May 20, 2011, a total of 118 cases were reported to the CDC; this represents the highest reported number of measles cases for the same period since 1996.
• Of the 118 cases, 105 (89%) were associated with importation; the source of the remaining 13 cases could not be ascertained.
• In all, 105 (89%) of the 118 patients were unvaccinated; 24 (20%) were persons 12 months to 19 years of age whose parents claimed a religious or personal exemption.
• Approximately half of the 118 cases—58, or 49%—were accounted for by 9 outbreaks.
• The largest of these outbreaks involved 21 persons in Minnesota, in a setting where parental concerns about the safety of measles, mumps, and rubella (MMR) vaccine caused many children to go unvaccinated.
• As a result of this outbreak, many persons were exposed, and at least 7 infants too young to receive MMR vaccine were infected.
• From January 1 to May 23, 2014, 288 confirmed cases were reported to the CDC, a figure that exceeds the highest reported annual total number of cases (220 cases in 2011) since measles was declared eliminated in the United States in 2000.
• In developing countries, measles affects 30 million children a year and causes 1 million deaths.
• Measles causes 15,000-60,000 cases of blindness per year.
• In 1998, the cases of measles per 100,000 total population reported to the WHO was 1.6 in the Americas, 8.2 in Europe, 11.1 in the Eastern Mediterranean region, 4.2 in South East Asia, 5.0 in the Western Pacific region, and 61.7 in Africa.
• In 2006, only 187 confirmed cases were reported in the Western Hemisphere (mainly in Venezuela, Mexico, and the United States).
• Between 2000 and 2008, the number of worldwide measles cases reported to the WHO and the United Nations Children’s Fund (UNICEF) declined by 67% (from 852,937 to 278,358).
• Of the 66 cases of measles reported in the United States in 2005, 7 (10.6%) involved infants, 4 (6.1%) involved children aged 1-4 years, 33 (50%) involved persons aged 5-19 years, 7 (10.6%) involved adults aged 20-34 years, and 15 (22.7%) involved adults older than 35 years.
• Among the 118 US patients reported to have measles between January 1 and May 20, 2011, ages ranged from 3 months to 68 years.

The cause of measles is the measles virus , a single-stranded, negative-sense enveloped RNA virus of the genus Morbillivirus within the family Paramyxoviridae.

• Host. Humans are the natural hosts of the virus; no animal reservoirs are known to exist.
• Mode of transmission. This highly contagious virus is spread by coughing and sneezing via close personal contact or direct contact with secretions.
• Immunodeficiency. Children with immunodeficiency due to HIV or AIDS , leukemia , alkylating agents , or corticosteroid therapy, regardless of immunization status, are likely to contract measles.
• Environment. Travel to areas where measles is endemic or contact with travelers to endemic areas could cause measles.
• Absence of antibodies. Infants who lose passive antibody before the age of routine immunization easily contracts measles.

The incubation period from exposure to onset of measles symptoms ranges from 7 to 14 days (average, 10-12 days).

• High fever. The first sign of measles is usually a high fever (often >104 o F [40 o C]) that typically lasts 4-7 days.
• Prodromal phase symptoms. This prodromal phase is marked by malaise, fever, anorexia , and the classic triad of conjunctivitis, cough, and coryza (the “3 Cs”).
• Exanthem. The characteristic exanthem generally appears 2-4 days after the onset of the prodrome and lasts 3-5 days; the exanthem usually appears 1-2 days after the appearance of Koplik spots; mild pruritus may be associated, on average, the rash develops about 14 days after exposure, starting on the face and upper neck (see the image below) and spreading to the extremities.
• Koplik’s spots. Small spots (Koplik spots) can be seen inside the cheeks during this early stage.

Although the diagnosis of measles is usually determined from the classic clinical picture, laboratory identification and confirmation of the diagnosis are necessary for the purposes of public health and outbreak control.

• Antibody assays. The measles virus sandwich-capture IgM antibody assay, offered through many local health departments and through the CDC, is the quickest method of confirming acute measles; laboratories can confirm measles by demonstrating more than a 4-fold rise in IgG antibodies between acute and convalescent sera, although relying solely on rising IgG titers for the diagnosis delays treatment considerably.
• Viral culture. Throat swabs and nasal swabs can be sent on a viral transport medium or a viral culturette swab to isolate the measles virus; urine specimens can be sent in a sterile container for viral culture.
• Reverse-transcription polymerase chain reaction (PCR). Reverse-transcription polymerase chain reaction (PCR) evaluation is highly sensitive to visualizing measles virus RNA in blood , throat, nasopharyngeal, or urine specimens and, where available, can be used to rapidly confirm the diagnosis of measles.
• Chest radiography . If bacterial pneumonia is suspected, perform chest radiography; the frequent occurrence of measles pneumonia , even in uncomplicated cases, limits the predictive value of chest radiography for bacterial bronchopneumonia .

Medical Management

Treatment of measles is essentially supportive care.

• Hydration . Maintenance of good hydration and replacement of fluids lost through diarrhea or emesis is a primary concern.
• Vitamin A supplementation. Vitamin A supplementation, especially in children and patients with clinical signs of vitamin A deficiency, should be considered.
• Hospitalization. Hospitalization may be indicated for the treatment of measles complications (eg, bacterial superinfection, pneumonia , dehydration , croup ).
• Antibiotic therapy. Secondary infections (eg, otitis media or bacterial pneumonia) should be treated with antibiotics ; patients with severe complicating infections (eg, encephalomyelitis) should be admitted for observation and antibiotics, as appropriate to their clinical condition.
• Post Exposure prophylaxis. Prevention or modification of measles in exposed susceptible individuals involves the administration of the measles virus vaccine or human immunoglobulin (Ig).

Medications used in the treatment or prevention of measles include vitamin A, antivirals (eg, ribavirin ), measles virus vaccine, and human immunoglobulin (Ig).

• Vitamin A. Vitamin A treatment for children with measles in developing countries has been associated with a marked reduction in morbidity and mortality; thus, two doses of vitamin A given 24 hours apart are recommended; a third age-specific dose should be given 2 to 4 weeks later to children with clinical signs and symptoms of vitamin A deficiency.
• Antivirals. Measles virus is susceptible to ribavirin in vitro; although ribavirin (either IV or aerosolized) has been used to treat severely affected and immunocompromised adults with acute measles or SSPE (IV plus intrathecal high-dose interferon alfa), no controlled trials have been conducted; ribavirin is not approved by the US Food and Drug Administration (FDA) for this indication, and such use should be considered experimental.
• Vaccines. The live MMR vaccine is used to induce active immunity against viruses that cause measles, mumps, and rubella.
• Immunoglobulins. Human Ig prevents or modifies measles in susceptible individuals if administered within 6 days of exposure.

Nursing Management

The nurse caring for the child should be aware of the proper procedure to be done and how to handle the patient.

Assessment of the patient with measles includes:

• Physical exam. Assess the child for symptoms that may indicate the presence of measles.
• Knowledge of the disease. Assess the patient’s or significant other ‘s knowledge regarding the disease.
• Hygienic practices. Assess the family’s hygienic practices to prevent the spread of the disease.

Based on the assessment data, the major nursing diagnoses are:

• Impaired social interaction related to isolation from friends.
• Risk for impaired skin integrity related to raking pruritus.
• High risk of infection related to the host and infectious agents.
• Acute pain related to skin lesions and irritated mucous membranes.

The major goals for a child with measles are:

• Skin will stay clean, dry, and intact.
• Mucous membranes will stay moist, discomfort will stay within the defined tolerable range by the patient.
• Patient will understand the purpose of isolation , cooperate, and be free of distress.

Interventions for a child with measles are:

• Isolation. Patients will need to be on isolation precautions to decrease transmission within the community; emphasize the need for immediate isolation when early catarrhal symptoms appear.
• Skin care. Measles causes extreme pruritus; nursing interventions include keeping the patient’s nails short, encouraging long pants and sleeves to prevent scratching, keeping skin moist with healthcare provider-recommended lotions, and avoiding sunlight and heat.
• Eye care. Treat conjunctivitis with warm saline when removing eye secretions and encourage the patient not to rub eyes; protect the eyes from the glare of strong light.
• Hydration. Encourage oral hydration; medical literature encourages the use of oral rehydration solution.
• Temperature control. Antipyretics should be administered to the patient as ordered for a temperature greater than 100.4 Fahrenheit unless directed else wise by a healthcare provider; be sure to remind parents not to administer aspirin due to the risk of Reye’s syndrome.

Evaluation of a child with measles should include:

• Skin became clean, dry, and intact.
• Mucous membranes stayed moist, discomfort will stay within defined tolerable range by the patient.
• Patient understood the purpose of isolation, was cooperative, and was free of distress.

Documentation for a patient with measles includes:

• Individual findings include factors affecting, interactions, the nature of social exchanges, and specifics of individual behavior.
• Cultural and religious beliefs, and expectations.
• Plan of care.
• Teaching plan.
• Responses to interventions, teaching, and actions performed.
• Attainment or progress toward the desired outcome.
• Long-term needs.

3 thoughts on “Measles (Rubeola)”

Please add as more points as possible on nursing interventions, I am a student nurse, these guide me

Thanks for the feedback! I’ll definitely take note of that. You can go check the nursing care plans for more interventions.

I am a student nurse this guide me

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Measles Outbreak in the Post-elimination Era: Case Study

Given the ongoing risks of importation and reintroduction of the measles and rubella viruses faced by the countries of the Region, the Pan American Health Organization (PAHO) and the World Health Organization (WHO) are seeking to reinforce the knowledge, attitudes, and practices of health workers as one of the key strategies to protect the hard-earned elimination gains. As such, PAHO and WHO are offering this training to their Member States, which is based on the true events of a measles outbreak that has been adapted and developed for educational purposes.

Didactic Strategies Didactic resources and virtual platform tools are used to boost the learning experience from a practical perspective via interactive activities that allow users to advance through successive modules.

Purpose of the Course This course seeks to strengthen the national and subnational capabilities for the organization and implementation of a rapid response to a measles outbreak in the post-elimination era, in order to interrupt the circulation of the virus as fast as possible. The goal is to transfer updated knowledge to health workers and thus support the efforts led by countries to maintain their progress in virus elimination. The on-line availability of this training facilitates and expands access to this new updated knowledge for the new cohorts of health workers seeking training on a fast and timely response to measles or rubella outbreaks.

Learning Objectives

Main Objective

• Strengthen the capabilities of health teams at the national and subnational levels to provide a rapid response to imported cases of measles and rubella. 

Specific Objectives

• Identify and apply procedures and methods for the timely notification and epidemiological field investigation of measles or rubella outbreaks.
• Identify and apply response measures to measles or rubella outbreaks.
• Interpret laboratory test results to confirm cases of measles or rubella.
• Understand and implement the criteria to verify the interruption of measles or rubella outbreaks.

Intended Audience Health workers from the national, subnational and local levels involved in the rapid response to measles outbreaks from the following technical areas: immunization, epidemiology and laboratory; Clinical and laboratory staff conducting immunization and epidemiological surveillance activities regarding measles and rubella.

Length of the Course This course is open and available at the Virtual Campus for Public Health (VCPH). Since this is a self-paced e-learning program, users can choose when to take each module and how much time to dedicate. The estimated time to complete all the modules and the final assessment is about 10 hours.

Capabilities Developed in the Course This course provides opportunities to develop capabilities related to the management and shared use of information and documents on immunization, and the implementation of a rigorous, collaborative, and adaptable perspective for decision-making in different areas in order to reach the coverage goals of immunization programs.

Course Structure

• Course Introduction Video
• Madero Outbreak Introduction Video
• Section 1: Clinical manifestations and differential diagnosis of measles compared to arboviral diseases
• Section 2: Detection and notification of cases
• Section 3: Epidemiological investigation of cases and contact tracing
• Section 4: Laboratory investigation
• Section 5: Virus spread and response measures
• Section 6: Criteria to verify outbreak interruption
• Interactive Scenario 1: Simona, the backpacker
• Interactive Scenario 2: Sergio Carranza Hospital

Measles outbreak at Chicago shelter occurred mostly in unvaccinated, case study shows

CDC / Molly Kurnit

A  study published yesterday in Morbidity and Mortality Weekly Report  ( MMWR )details a measles outbreak that sickened 57 people at a Chicago migrant shelter this year and how  a prompt and coordinated mass-vaccination campaign helped contain it.

Measles is a highly contagious respiratory virus that can cause severe complications, hospitalization, and death. In 2000, the United States declared measles eradicated, but cases still occur because of ongoing global spread and undervaccination, noted the Centers for Disease Control and Prevention (CDC)-led study team. "Receipt of 1 and 2 doses of measles vaccine is 93% and 97% effective, respectively, in preventing measles."

Since August 2022, they said, about 41,000 migrants have arrived in Chicago from the southern US border, 88% of them from Venezuela, which has seen a decline—from 96% in 2017 to 68% in 2021—in routine childhood vaccinations, including the measles vaccine.

First reported case was in 1-year-old boy

On February 22, 2024, about 12,000 people were staying in 27 temporary migrant shelters run by the city of Chicago. On that date, the largest of them—the affected shelter, called "shelter A" in the report—was housing roughly 2,100 people, with 500 or more staying in some rooms. In addition to congregate sleeping areas, the migrants shared a dining area and bathrooms.

Given the congregate nature of the setting, high transmissibility of measles, and low measles vaccination coverage among shelter residents, measles virus had the potential to spread rapidly among approximately 2,100 presumed exposed shelter residents.

The first case of the outbreak was identified in a 1-year-old boy living at the shelter. He developed a rash on February 26 and was hospitalized the next day for suspected measles. 

The boy had arrived in the United States more than 5 months earlier and had received one dose of measles, mumps, and rubella (MMR) vaccine 5 weeks before symptom onset; he had not traveled recently or had a known exposure to measles. The Chicago Department of Public Health (CDPH) confirmed the infection on March 7.

"Given the congregate nature of the setting, high transmissibility of measles, and low measles vaccination coverage among shelter residents, measles virus had the potential to spread rapidly among approximately 2,100 presumed exposed shelter residents," the researchers wrote.

CDPH worked with state and local health departments, health care facilities, city agencies, and shelters on outbreak investigation and response. On March 8, CDPH began case-finding efforts and launched a mass-vaccination campaign at the shelter, vaccinating 882 residents and verifying previous vaccination for 784 over 3 days. 

"These activities resulted in 93% measles vaccination coverage (defined as receipt of ≥1 recorded measles vaccine dose) by March 11," the authors said. "By May 13, a total of 57 confirmed measles cases associated with residing in or having contact with persons from shelter A had been reported."

As of May 13, CDPH had held roughly 130 mass vaccination events at 25 Chicago migrant shelters and administered about 9,500 MMR vaccine doses, prioritizing the shelters that had previously received residents from shelter A and those housing pregnant women and young children. "This strategy included additional vaccination events at shelter A beginning on March 25, with a focused second-dose vaccination campaign during April 8–10," the researchers said.

Index infection likely acquired locally

Most infections (72%) occurred in unvaccinated residents, and 28% were diagnosed in those who had received at least one measles vaccine dose at least 21 days before the first known measles exposure.

The risk for transmission within and outside of shelters can be mitigated by maintaining high MMR vaccination coverage among both established and newly arrived residents.

Fifty-two of the 57 infected people were shelter residents, while three were staff workers, and two were community members. The median patient age was 3 years. Two cases occurred among people who had lived at the affected shelter but had resettled or transferred to less-crowded shelters with private sleeping areas after March 7; no secondary cases were identified at those shelters. 

Fifty-one people (89%) were hospitalized for isolation and/or measles complications, but no deaths were reported. The last known exposure at the affected shelter was April 5. As of May 13, the same measles genotype D8 sequences had been identified from 52 case specimens; the remaining 5 isolates couldn't be sequenced.

" Although persons in the community affected by this outbreak had recently arrived in the United States, the index patient’s arrival in Chicago months before illness onset suggests that the disease was acquired locally," the authors concluded. "The risk for transmission within and outside of shelters can be mitigated by maintaining high MMR vaccination coverage among both established and newly arrived residents."

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• Continuing Education Activity

Measles, also known as rubeola, is a preventable, highly contagious, acute febrile viral illness. It remains an important cause of global mortality and morbidity, particularly in the regions of Africa and Southeast Asia. It accounts for about 100,000 deaths annually despite the availability of an effective vaccine. Public health officials declared the elimination of measles from the U.S. in 2000, marking the absence of continuous disease transmission for one year and from the region of the Americas in 2016. However, outbreaks continue to occur through imported disease and transmission among unvaccinated groups of children in the community. According to the Center for Disease Control (CDC), there were 372 cases in 2018 and 764 cases through May of 2019. This activity provides an overview of measles prevention, transmission, and diagnosis and highlights the role of the interprofessional team in helping their patients prevent this disease.

• Describe the pathophysiology of measles.
• Describe the epidemiology of measles.
• Summarize the role of vaccination in the prevention of measles.
• Describe the importance of communication between the interprofessional care teams and patients to improve vaccination rates and thereby limit morbidity and mortality associated with measles.
• Introduction

Measles, also known as rubeola, is a preventable, highly contagious, acute febrile viral illness. It remains an important cause of global mortality and morbidity, particularly in the regions of Africa and Southeast Asia. [1] [2] It accounts for about 100,000 deaths annually despite the availability of an effective vaccine. Public health officials declared the elimination of measles from the U.S. in 2000, marking the absence of continuous disease transmission for one year and from the region of the Americas in 2016. However, outbreaks continue to occur through imported disease and transmission among unvaccinated groups of children in the community. Measles is a reportable disease in most nations, including the United States. [3]

The causative organism is the measles virus, a member of the  Paramyxoviridae  family and  Morbillivirus  genus. It is an enveloped, single-stranded, nonsegmented, negative-sense RNA virus. The genome encodes six structural proteins and two non-structural proteins, V and C. The structural proteins are nucleoprotein, phosphoprotein, matrix, fusion, haemagglutinin (HA), and large protein. The HA protein is responsible for virus attachment to the host cell. [4]

• Epidemiology

The epidemiology of measles is variable across the globe and is related to immunization levels achieved in a particular region. Before implementing widespread vaccination programs, measles accounted for an estimated 2.6 million deaths. Despite vaccination in the present era, The World Health Organization (WHO) reported that approximately 134,200 deaths (15 deaths/hour) occurred in 2015 due to measles.  According to the CDC, there were 372 cases in 2018 and 764 cases through May of 2019.  Measles is a reportable disease in most nations, including the United States.

The measles virus has no animal reservoir and occurs only in humans. The virus is highly contagious, with each case capable of causing 14 to 18 secondary cases among susceptible populations. Measles is transmitted from person to person by respiratory droplets, small particle aerosols, and close contact. The incubation period is 10 to 14 days, although longer periods have been reported. Unvaccinated young children and pregnant women are at high risk for contracting measles, and measles most commonly affects young children. More recently, there has been a shift to older children and adolescents due to increasing levels of immunization coverage and alterations in the levels of population immunity at different ages. Young infants born to mothers with acquired immunity are protected from measles due to passive antibody transfer, but as these antibodies wane, they become susceptible. Infectiousness of a case is maximal in the four days before and four days after the rash develops, which coincides with peak levels of viremia and the features of cough, conjunctivitis, and coryza. [5] [6] [7] [8]

• Pathophysiology

The inhaled virus from the exposed droplets initially infects the respiratory tract’s lymphocytes, dendritic cells, and alveolar macrophages. It then spreads to the adjacent lymphoid tissue and disseminates throughout the bloodstream resulting in viremia and spreading to distant organs. The virus residing in the dendritic cells and lymphocytes transfers itself to the epithelial cells of the respiratory tract, which are shed and expelled as respiratory droplets during coughing and sneezing, infecting others and perpetuating the cycle. The initial inflammation leads to symptoms of coryza, conjunctivitis, and cough. The appearance of fever coincides with the development of viremia. The skin rash occurs after dissemination and is due to perivascular and lymphocytic infiltrates.

During the prodromal phase, the measles virus depresses host immunity by suppressing interferon production through its nonstructural proteins, V and C. The increasing viral replication then triggers both humoral and cellular immunological responses. The initial humoral response consists of IgM antibody production, which is detectable 3 to 4 days after the rash appears and can persist for 6 to 8 weeks. Subsequently, IgG antibodies are produced, primarily against the viral nucleoprotein. Cellular immune responses are essential for recovery, as demonstrated by elevated Th1-dependent plasma interferon-gamma levels during the acute phase and subsequent elevation of Th2-dependent interleukin 4, interleukin 10, and interleukin 13 levels. [9]

Lymph node biopsy will show the characteristic Warthin-Finkeldey giant cells (fused lymphocytes) in a background of paracortical hyperplasia. [10]

The measles virus is known to induce immunosuppression that can last for weeks to months, even years. This causes increased susceptibility to secondary bacterial and other infections. While the mechanisms causing this phenomenon are unclear, it is hypothesized that measles infection induces the proliferation of measles-specific lymphocytes that replace the previously established memory cells causing "immune amnesia." This results in enhanced susceptibility of the host to secondary infections, leading to most of the morbidity and mortality associated with measles. The neutralizing IgG antibodies against hemagglutinin are responsible for lifelong immunity as they block host cell receptors from binding to the virus.

• History and Physical

The WHO clinical case definition of measles is "any person with fever, generalized maculopapular rash, cough, coryza, or conjunctivitis." Measles is an acute febrile exanthema that is characterized by the three “Cs”: cough, coryza, and conjunctivitis. Koplik spots, small white papules on the buccal mucosa, are pathognomonic for measles and appear a day or two before the rash, although they are not always seen. The fever precedes the rash. The rash appears first on the face and spreads caudally to become generalized. Uncomplicated measles typically resolves a week after the rash onset. [11]

The diagnosis of measles hinges on a high clinical suspicion, especially when evaluating children with febrile illness and a maculopapular rash. A complete blood count may show leukopenia, particularly lymphopenia, and thrombocytopenia. Electrolyte abnormalities may be detected in children with poor intake or diarrhea. Identification of measles-virus-specific IgM antibodies in serum or plasma confirms the diagnosis, although it may be a false negative in up to 25% of cases when done early (less than 3 days of rash onset.) These antibodies usually peak within 1 to 3 weeks after the onset of a rash and become undetectable by 4 to 8 weeks. The gold standard test is the plaque reduction neutralization assay which has the highest sensitivity. Measle virus can be cultured from nasopharyngeal secretions, but this is labor intensive and not practical. [12]

In current clinical practice, polymerase chain reaction detection of viral ribonucleic acid from throat, nasal, nasopharyngeal, and urine samples is most often performed, with sensitivity approaching 100%.  

• Treatment / Management

There is no specific antiviral therapy for measles; treatment is primarily supportive. Control of fever, prevention, and correction of dehydration, and infection control measures including appropriate isolation form the mainstay of therapy. [13]

The WHO recommends the administration of daily doses of vitamin A for 2 days and more days for malnourished children. Measles complications should be identified early and appropriate therapy initiated. [14]

• Differential Diagnosis
• Drug infections
• Erythema infectiosum
• Kawasaki disease
• Parvovirus B19 infection
• Pediatric enteroviral infections
• Pediatric rubella
• Pediatric sepsis
• Pediatric toxic shock syndrome
• Scarlet fever

While many will recover from measles with no complications, there is a risk of a poor prognosis.  The more common complications due to infection with measles include otitis media and diarrhea.  The otitis may lead to hearing loss.  Those more likely to have severe complications include infants and children under the age of five years, adults over the age of twenty, pregnant women, and those who are immunocompromised.  Encephalitis may occur in 1 out of every 1000 infected children, and 1-2 of all infected children will die of neurologic or respiratory complications from measles.

• Complications

Complications of measles occur most commonly in young infants, pregnant women, and malnourished or immunocompromised children. The most common complication is pneumonia which can be due to the measles virus itself (Hecht giant cell pneumonia) or a secondary bacterial infection. Other complications include croup, otitis media, and diarrhea from secondary infections. Pregnant women with measles are at increased risk for maternal death, spontaneous abortion, intrauterine fetal death, and low birth-weight infants. Measles keratoconjunctivitis occurs mostly in children with vitamin A deficiency and can lead to blindness. Central nervous system complications include acute disseminated encephalomyelitis (ADEM), measles inclusion body encephalitis (MIBE), and subacute sclerosing panencephalitis (SSPE). [15] ADEM is an autoimmune demyelinating disease that occurs within days to weeks. [16]  MIBE is thought to be a progressive brain infection in patients with impaired cellular immunity occurring within months of the initial infection. SSPE is a progressive neurological disease that presents 5 to 10 years after the acute illness and is thought to be caused by an abnormal host response to the production of mutated virions. [17] It occurs mostly among children that developed measles before 2 years of age and manifest with seizures and progressive loss of cognitive and motor function.

• Pearls and Other Issues

Measles is a preventable disease due to the availability of a safe, inexpensive, and effective vaccine. The vaccine is a live attenuated measles strain that is used either as a single component or as a combination vaccine (MMR, MMR-V). The WHO recommends two doses of measles vaccination beginning at age 9 to 12 months and 15 to 18 months in countries where incidence and mortality are still high in the first year of life. In the United States and other developed countries, the first vaccine is given at 12 to 15 months and the second at 4 to 5 years. The WHOs Global Vaccine Action Plan has targeted measles and rubella for elimination in five WHO Regions by 2020. To eliminate measles, vaccination rates of the population must be in the 93% to 95% range.

A widely discredited and withdrawn Lancet article in 1998 created considerable misinformation, purporting a link between the MMR vaccine and autism that led to declining immunization rates, particularly in the United Kingdom and the United States. Many subsequent studies have debunked this myth.

• Enhancing Healthcare Team Outcomes

Measles is a preventable infection, and hence all healthcare workers, including nurses and pharmacists should educate patients on the importance of vaccination. Patients should be informed that the adverse effects of the measles vaccination are rare and minor; without vaccination, there is a high risk of transmitting the infection to others and inducing serious neurological complications.

• Review Questions
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• Comment on this article.

Measles Infection DermNet New Zealand

This patient presented on the third pre-eruptive day with “Koplik spots” indicative of the beginning onset of measles. In the prodromal or beginning stages, one of the signs of the onset of measles is the eruption of “Koplik spots” (more...)

Exanthem subitum (meaning sudden rash), also referred to as roseola infantum (or rose rash of infants), sixth disease (as the sixth rash-causing childhood disease) and (confusingly) baby measles, or three day fever, is a benign disease of children, generally (more...)

This child shows a classic day-4 rash with measles Contributed by Centers for Disease Control and Prevention (Public Domain)

Paramyxovirus Virion Under Transmission Electron Microscope. The image displays the viral nucleocapsid of a paramyxovirus virion as visualized under a transmission electron microscope. F Murphy, MD; Public Health Image Library, Public Domain, (more...)

Disclosure: Noah Kondamudi declares no relevant financial relationships with ineligible companies.

Disclosure: James Waymack declares no relevant financial relationships with ineligible companies.

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• Cite this Page Kondamudi NP, Waymack JR. Measles. [Updated 2023 Aug 12]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

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Local disparities may prevent national vaccination efforts for rubella

When public health officials make policies about when and how vaccination programs are implemented, they must weigh the benefits and risks of how infectious diseases spread throughout the country. However, these analyses are often based on national-level data and, in some countries, may overlook nuances at the local level.

A new analysis by an international team, including Penn State researchers, revealed that the resulting recommendations may keep some countries from realizing the benefits of vaccination and globally eradicating diseases, such as rubella -- a contagious viral infection that causes mild symptoms in children. The team examined data from Nigeria, one of 19 countries that hasn't yet introduced rubella vaccination, as a case study. Their findings were published in the journal Vaccine.

"It's this interesting challenge where rubella is a mild disease if you get it as a kid, but it's high risk if you get it as an adult," said senior author Matthew Ferrari, professor of biology and director of the Center for Infectious Disease Dynamics at the Huck Institutes of Life Sciences at Penn State. "All of the policy surrounding rubella vaccination has been guided by that risk in adults, which has been holding back the benefit of rubella vaccination in some countries."

The primary concern among adults is the potential risk for congenital rubella syndrome (CRS), a serious health condition that can occur if a pregnant person contracts the virus. When an infectious disease like rubella is common, people are more likely to contract it earlier in life. And because the rubella virus is immunizing, those who are infected as children won't have pregnancies at risk of CRS when they are older.

Vaccination, on the other hand, reduces the amount of circulating virus, meaning individuals who were not vaccinated as children are less likely to be infected with rubella by adolescence or adulthood, Ferrari explained. As a result, even as the total number of rubella cases goes down with vaccination, the number of rubella infections in people of reproductive age -- who were neither infected nor vaccinated as children -- increases, putting those pregnancies at risk of CRS. Because of this complex dynamic, the World Health Organization (WHO) recommends that countries demonstrate that they can achieve a coverage level of 80% or greater, through either routine immunization or supplemental campaigns, before introducing rubella vaccination. The conventional wisdom has been that when vaccination coverage is above this threshold, the reduced risk of CRS due to less rubella virus offsets the paradoxical increase in CRS risk because infections tend to happen later in life, Ferrari explained.

The research team, working in partnership with the U.S. Centers of Disease Control and Prevention and the Nigeria Centre for Disease Control and Prevention, studied the epidemiology of rubella in Nigeria. Rubella is a comparatively rare disease, so it's difficult to quantify the potential harm and risk of CRS. These assessments are further complicated by the fact that Nigeria, Ferrari said, is a country with disparate ranges of wealth, vaccination coverage, health care access and birth rates, all of which play a role in infection and CRS risk.

To gain a better understanding of the factors at play, the team analyzed data from a nationally representative serosurvey, which detects the presence of antibodies in blood. The data allowed the researchers to see how many people, particularly women of reproductive age, had rubella antibodies, how many were potentially at risk of rubella infection and where the infection risk was greatest geographically. They identified regional differences in transmission between the northern versus southern part of the country, finding that transmission in the north was two-times higher compared to the south. They were also able to estimate the number of pregnancies affected by rubella infection today.

"We grounded the current infection risk and potential pregnancies at risk in strong empirical data and real-world phenomena," Ferrari said. "Parts of the country can already vaccinate more than 80% of kids, based on their current rate of measles vaccination, but low vaccination coverage in the north is a barrier to introduction across the whole country under the current recommendation."

What's more, the concern about increased CRS cases may not be as bad as conventionally believed, Ferrari noted. The team's new estimates of transmission rates show that the 80% threshold is conservative and that introducing a rubella vaccination program in Nigeria today could reduce the number of CRS cases by thousands in the first five years. "Some states could see CRS risk increase by hundreds of cases," he said, "but that increased risk would not come to fruition until 10 years down the road" -- providing a decade for public health officials to implement policies and programs to prevent this possibility.

"Strengthening and improving routine immunization programs and advancing them everywhere in the world is a benefit to everyone in the world. The more we do this, the elimination of rubella as a virus on this planet is entirely feasible," Ferrari said.

• Mumps, Measles, Rubella
• Infectious Diseases
• Diseases and Conditions
• Public Health
• Disaster Plan
• Travel and Recreation
• STEM Education
• Public health
• MMR vaccine
• Epidemiology
• Vaccination

Story Source:

Materials provided by Penn State . Original written by Christine Yu. Note: Content may be edited for style and length.

Journal Reference :

• Taishi Nakase, Tenley Brownwright, Oyeladun Okunromade, Abiodun Egwuenu, Oladipo Ogunbode, Bola Lawal, Kayode Akanbi, Gavin Grant, Orji O. Bassey, Melissa M. Coughlin, Bettina Bankamp, Ifedayo Adetifa, C. Jessica E. Metcalf, Matthew Ferrari. The impact of sub-national heterogeneities in demography and epidemiology on the introduction of rubella vaccination programs in Nigeria . Vaccine , 2024; DOI: 10.1016/j.vaccine.2024.05.030

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