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The purpose of this Measles course is to inform nurses about the signs and symptoms, diagnosis, treatment, and public health implications of measles despite its intersection with the anti-vaccination movement.

Introduction   

Measles (Rubeola) is an infectious virus that predominantly affects children. It can affect many systems leading to life-threatening pneumonia or encephalitis. Many healthcare practitioners are inexperienced with the disease as it was rare in the U.S. prior to the current anti-vaccination movement. In this course we will discuss the diagnosis and treatment of measles. We will discuss strategies used to educate families to make an educated vaccination decision.

The History of Measles

Medicine has come a very long way in curing diseases that once wiped out entire populations. Before the vaccine, measles was a serious health concern. Each year, millions of people became infected with measles, and in the United States alone, an average of 495 people died of related complications.

Even beyond the mortality rate, 48,000 people experienced hospitalizations and 1,000 of those developed a significant and lifelong disability every year. One of the most dreaded complications of measles involves the spread to the central nervous system causing subsequent inflammation and risk for brain injury from acute encephalitis (4).

Measles is an acute, viral respiratory illness that is one of the most contagious of all infectious diseases. In fact, 9 out of 10 (90%) susceptible persons with close contact will develop measles. The virus is transmitted by direct contact with infectious droplets or by airborne spread. The measles virus lives for up to two hours on surfaces. The disease is active and contagious in the airspace for two whole hours.

Enter the Measles Vaccine

During a measles outbreak in 1954, physicians collected blood samples from affected students in Boston. They isolated the measles virus from a 13-year-old students blood and created a measles vaccine. In 1963, the live measles vaccine debuted in the United States. Five years later, the modern-day vaccine was introduced.

Measles is usually combined with mumps and rubella as part of the MMR vaccine. It is a very effective vaccine that protects over 97% of recipients (5). By 2000, the Centers for Disease Control and Prevention (CDC) declared measles eliminated. Historically, the development of the measles vaccine changed the scope of public health.

For the first time, prevention proactively saved lives. But now, with the advent of the anti-vaccination campaign, we are at risk for a revival of the diseases that healthcare nearly eliminated.

Signs and Symptoms of Measles

Measles includes the onset of an elevated fever that may be as high as 105 degrees Fahrenheit (4). Other symptoms include:

• Malaise
• Cough
• Noninfectious nonallergic rhinitis (also known as coryza)
• Conjunctivitis
• Koplik’s spots
• Maculopapular rash

Koplik’s spots are unique to measles and highly suggestive of the disease. They occur two to three days before the rash. They are white, clustered lesions on the gums that resemble grains of salt.

The maculopapular rash appears approximately 14 days after exposure and spreads from head to trunk to the extremities. Those with measles are contagious from four days before they showed symptoms until four days after the rash appears. In some cases, immunocompromised patients may not develop a rash. The rash usually disappears within one week (4).

Diagnosis of Measles

A diagnosis is made after evaluation of the signs and symptoms, in particular, a widespread skin rash that appears three to five days after exposure and lasts up to one week. The rash consists of red, itchy bumps. Measles is more likely to occur in unvaccinated children, primarily under five years old.

Once a diagnosis is suspected, measles is verified with laboratory confirmation. The lab tests that are performed are the measles antibodies (IgM) and measles RNA by real-time polymerase chain reaction (RT-PCR). To complete the laboratory tests, the nurse should collect a nasopharyngeal swab and serum sample. The serum sample is for public health implications, and diagnostic testing usually occurs in a specialty lab (4).

Complications of Measles

If measles is not identified and treated, the associated complications can be quite deadly. Possible complications include (4):

• Encephalitis
• Pneumonia
• Ear infection (Otitis media)
• Miscarriage or preterm labor in pregnant women
• Thrombocytopenia
• Blindness
• Severe diarrhea and dehydration

Personal Protective Equipment (PPE)

Because measles is incredibly contagious, it is critical to adhere to all recommendations for isolation and the appropriate personal protective equipment. Patients with measles should be placed on airborne precautions. Airborne precautions are used to prevent the spread of germs through the air (8). Other illnesses with airborne precautions include tuberculosis and chickenpox.

It is vital to place the patient on isolation precautions as soon as you suspect measles to minimize potential exposure to other staff and patients. Place patients in a negative pressure room and wear a fitted N-95 respirator to enter a room. A surgical mask is not appropriate, so a respirator must be worn.

Treatment of Measles

The treatment of measles is broken into different categories, depending on exposure and symptoms: (4)

-Post-exposure prophylaxis for asymptomatic patients who have been exposed to measles. If they are not properly vaccinated or unsure of their immunization status, they should be treated with an MMR vaccine within 72 hours or immunoglobulin within six days of exposure.

• Patients should receive the immunoglobulin if they are not vaccinated against measles and are unable to be vaccinated with the MMR vaccine in the cases of pregnancy, severe immunosuppression, or age less than one-year-old. They should not receive the MMR vaccine for six to eight months following the immunoglobulin administration.
• Patients should avoid public areas for 72 hours due to the contagious nature of the disease (e.g., hospitals, schools, and daycare).
• Immunoglobulin and the vaccine should never be given together as this process invalidates the vaccine. 

-Treatment after the confirmation of measles is individualized and may range from a vaccination, immunoglobulins, vitamin A, Ribavirin, or supportive care (9).

• Acetaminophen PRN for fever and myalgia (muscle aches or pains)
• Humidifier for cough and sore throat
• Rest and hydration
• Isolation for four days after the rash appears
• Educate patients that symptoms will last two to three weeks
• Vitamin A or Ribavirin may be given 

Measles Spread

Although the COVID-19 pandemic has showcased many polarized views on either the support or opposition of vaccinations, the “anti-vax” or “anti-vaccination” movements were around much before then with measles. 

These groups publicly shared views of wanting to eliminate vaccinations and believed that its benefits do not outweigh the overall risk of receiving them. However, evidence does not prove that the risks of vaccinations are significant, especially when compared to the risks of the diseases. 

Encouraging Vaccination Through Education

The best strategy to reduce the spread of measles is to encourage all patients and family members to receive all recommended vaccinations. One of the most important nursing interventions is education, and this is the perfect opportunity to educate your patients.

In 2014, many families visiting Disneyland left with measles. The state of California later reported 159 cases of measles throughout the next several months. When looking at school data in that same year, only 70 percent of counties had the ideal herd immunity status of 95% vaccinated.

In response to this outbreak, California passed Senate Bill 277 that eliminated all personal beliefs and conditional vaccination exemptions before entering school. The law went into effect in 2016 and only allowed medical exemptions and required that all schools report the vaccination status of enrolled children. Officials in California found that by tightening the vaccine regulations, more children received vaccinations before entering kindergarten (6). In 2016, 97% of school districts met herd immunity guidelines.

When patients are discussing travel plans it is an excellent opportunity to provide Measles education(6). Many patients are unaware that leaving the country puts them at risk for specific vaccine-preventable diseases, particularly when traveling to endemic countries.

It is also important that patients and families understand the concept of herd immunity. This is the indirect defense from infectious disease that happens when the majority of the population is immune to a specific infection. Herd immunity ensures that even when a person is not vaccinated, they receive protection because the people surrounding them are resistant to the disease and are unlikely to transmit it to them or harbor an outbreak. However, for herd immunity to be effective, 19 out of 20 people (95%) of the population must be vaccinated (7). When many people are immune, the chances of infection to the rest of the population are rare because it is unlikely an unvaccinated person will come in contact with an infected person.

There are medical conditions that make the vaccine unsafe to receive. New babies are at risk for many diseases until they are old enough to receive all vaccinations (5). Many people are at risk for infectious diseases because they are unable to receive the MMR vaccine. Other populations who should not be vaccinated include patients who are:

• Pregnant,
• An anaphylactic allergic response to a component in the MMR vaccine,
• Immunosuppressed or compromised,
• Recently received blood products,
• Suffering from active tuberculosis or other severe illness.

Lastly, many people are unaware of the risks of measles because they have never seen it. However, measles could become endemic in the U.S. again if vaccine coverage decreases significantly and herd immunity is lost (4). It is critical to discuss this possibility with your patients so that they are aware of the significant risk of the anti-vaccination movement. Most patients and caregivers are unaware that Measles can result in life-threatening complications, such as pneumonia and encephalitis.

Parent Education and Shared Decision Making

While many healthcare professionals have strong opinions regarding vaccination, using shared decision-making to further parental understanding of vaccinations is critical. It can be upsetting for parents to see their infant or child receive multiple injections. By opening the discussion of the risks and benefits, the nurse provides parents with essential information regarding vaccination. It is crucial that nurses have an open discussion and acknowledge the concerns of patients and families.

Despite multiple immunizations in each visit until their second birthday, the CDC states that a healthy child’s immune system will not become overwhelmed by the vaccinations. There is a slight risk for side effects with immunizations up to severe allergy, disease, and death, but most are mild, like redness and swelling at the injection site (3). However, vaccine-preventable diseases can be fatal, and the benefits of the vaccine far outweigh the risks. The risks of becoming ill with measles are far worse than the risks associated with the vaccination (3). These are important points to make families aware of.

The U.S. FDA ensures the safety, effectiveness, and availability of vaccines. Current vaccinations have each been evaluated by scientists and continually monitor for other side effects after FDA licensure. Any complications or adverse effects are tracked by the Vaccine Adverse Event Reporting System (VAERS). If the CDC and FDA find a link between a particular immunization and a specific side effect, they will weigh the benefits against the risks and update the safety information on the Vaccine Information Sheets (VIS) (3).

The Anti-Vaccination Movement and Public Health Implications

In 2018, there was a measles outbreak in Washington that was considered a public health crisis. In the first few months of 2019, more than 100 vaccine-related bills were introduced in 30 states across the country.

Some states have proposed to eliminate vaccine exemptions or tighten the laws surrounding mandatory vaccination to attend school, while other state regulations recommend exemption expansions.

The Food and Drug Administration (FDA) commissioner Scott Gottlieb controversially made a public statement warning state legislators that they must replace lax laws. Mr. Gottlieb notified states that if they do not tighten vaccine exemptions than the federal government would take action (2).

Recent News

The MMR vaccine is very effective against measles. Receiving two doses of MMR is 97% effective, while just one dose is still 93% effective (5). However, measles is an extremely contagious disease that can spread quickly in an unvaccinated population . In 2013, an unvaccinated teenager returned to New York from the U.K. Over the next three months, measles spread throughout Brooklyn. At the conclusion, 58 people across the city became infected with measles. Not a single person who became ill with measles had documentation of being vaccinated (6).

The “anti-vax” movement goes beyond lay people. In the fall of 2018, a Texas nurse posting on social media about a toddler with measles in the PICU. The nurse shared to an anti-vaccination group that measles was much worse than she expected. “I think it’s easy for us nonvaxxers to make assumptions, but some of us have never and will never see one of these diseases. (1)”

She stated that despite the severity of the disease in the toddler, she wanted to purposely transmit measles from the child to her unvaccinated child at home. While she possessed nursing knowledge, she did not understand epidemiology. She felt that natural immunity would be safer than vaccination. Despite seeing measles for the first time and knowing how ill the child was, she did not change her vaccination stance and acknowledged she never would.

Her beliefs did not affect her employment, but her behavior did. She was fired from the children’s hospital for sharing private health information after families made hospital administrators aware (1). Thus, it is essential to obtain your data from evidence-based resources like the CDC instead of peers.

The moral of this story is that no amount of evidence can convince hardline anti-vaccinations proponents. It is our job to provide information, education, and promote shared decision making. Ultimately it is the parent or patient’s right (in most states) to refuse vaccines.

Summary

Nurses are busy working to assess, evaluate, educate, and empower their patients. Administering vaccines piles another task on a nurse’s overburdened list, but it is our job to ensure each patient receives appropriate education on vaccinations. Assessing vaccination status should be a priority for each and every admission and intake. It is critical to evaluate each patient’s vaccination status to ensure that all vaccines have been administered per the wishes of the parents and/or patients.

For further information about immunizations specific to healthcare providers, please visit: www.cdc.gov/vaccines/hcp

If you need more information about measles, see: www.cdc.gov/measles

To report an adverse reaction to a specific vaccination, visit: vaers.hhs.gov

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