Page 139 - JSOM Summer 2020

blindness in the developing world, especially in those who are Classic maculopapular rash of measles on the face of an
vitamin A deficient. Malnourished children with measles are ill-appearing adult patient
also at higher risk of developing noma (or cancrum oris), a Source: CDC, Public Health Image Library.
rapidly progressive gangrenous infection of the mouth and https://phil.cdc.gov/Details.aspx?pid=22149
face. Most deaths due to measles are caused by pneumonia,
diarrhea or neurological complications in young children,
severely malnourished or immunocompromised individuals,
and pregnant women. A rare sequela of measles is subacute
sclerosing panencephalitis, which is a degenerative condition
occurring a decade or more after initial infection and causing
significant behavioral change and seizures.

Diagnosis

Medical providers should consider measles as the cause of
illness if the patient has a generalized, maculopapular rash that
lasts at least 3 days and a temperature of at least 101° F in the
setting of cough, runny nose and conjunctivitis. Confirmation
4
of measles requires laboratory testing or known contact with
someone with laboratory-confirmed measles. Laboratory
confirmation includes a positive measles PCR, elevated measles
IgM antibody, seroconversion of measles IgG antibody (four- Signs of measles in an infant with runny nose and a red,
fold increase on titers at least 10 days apart), or isolation of confluent maculopapular rash
measles virus on culture. If confirmation is unavailable for Source: CDC, Public Health Image Library, 1976.
a patient who meets the clinical criteria for measles without https://phil.cdc.gov/Details.aspx?pid=17639
an alternative explanation for their symptoms, then they
should be managed as if they have measles. Alternative
diagnoses that should be considered include Kawasaki disease,
dengue, roseola, rubella, erythema infectiosum, and group A
streptococcal and meningococcal infections.

Management
Treatment of measles consists of supportive care measures
including management of fever and secondary infections, hy-
dration and respiratory support if needed. For children with
measles, daily supplementation with vitamin A is recom-
mended for 2 days (50,000 IU for less than 6 months, 100,000
IU for 6 to 11 months, and 200,000 IU for greater than 12
months) with a third dose 2 to 4 weeks later if they have clini-
cal vitamin A deficiency. Two doses of vitamin A given to pa-
3
tients less than 2 years old have been shown to reduce overall
deaths from measles and deaths from secondary pneumonia.
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Patients should be isolated using airborne precautions until
4 days following onset of the rash. Additionally the measles
vaccine should be administered to all exposed contacts who
are over 6 months old and who have not been fully immu-
nized within 72 hours of exposure. If development of noma
is suspected then the patient should be started on antibiotics,
receive wound care, and have careful management of fluid and
nutrition status.
vaccine series or in the 5% of individuals with waning immu-
nity and could become infected with measles. It is therefore
Importance in a Deployed Setting
highly important that appropriate precautions are taken if
Service members may be deployed to regions with endemic measles is suspected. It is crucial that all military medical pro-
measles or other settings with an elevated risk of measles viders are able to recognize the signs and symptoms of measles
outbreak, such as camps for displaced peoples or natural di- to prevent the spread of this highly infectious and deadly acute
saster response efforts. Additionally, medical providers may viral illness.
be caring for military health system beneficiaries who are un-
der-immunized due to age, missing vaccine doses, or vaccine Disclaimer
refusal. All service members should have received the two-dose The views expressed in this publication are those of the au-
measles vaccine series and should be protected from measles. thors and do not reflect the official policy or position of the
There is the chance that a service member is among the 1% Department of the Army, Department of Defense, or the
of vaccinated individuals who did not respond to the measles United States Government.

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