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Definition
Measles, also known as rubeola, is a highly contagious viral disease. While it can affect people at any age, it is most frequently seen in children (World Health Organization, 2024). Measles remains a major cause of death among young children globally, despite the availability of a safe and effective vaccine. In 2021, there were an estimated 128 000 measles-related deaths globally, mostly among unvaccinated or under vaccinated children below the age of 5 years (World Health Organization, 2024).
There have been recent concerns about the rise in measles cases both globally and in the UK. Since October 2023, there have been a total of 733 laboratory-confirmed measles cases in England (UK Health Security, 2024a). A similar picture has been observed globally, with 2023 seeing a significant rise in incidence in 40 of 53 European countries (European Centre for Disease Prevention and Control, 2024). This increase has largely been attributed to the ongoing decline in vaccine coverage (Misin et al, 2020).
Symptoms
Once infected with the virus, it takes between 7–21 days (usually 10–12 days) for symptoms to develop (Hazell, 2023).
The prodrome phase lasts approximately 2–4 days, during which an infected child would be acutely unwell, with a high temperature (often around 40 degrees), and additional symptoms including:
- runny nose
- conjunctivitis
- diarrhoea (Willacy, 2020)
Over the next 3–4 days, small white spots known as Koplik spots develop in the mouth, followed by a rash, initially on the forehead and neck, spreading to cover the whole body (Willacy, 2020). Koplik spots, present on mucous membranes, are considered unique to measles, occurring 1–2 days before the rash develops (Gastanaduy et al, 2021).
Most children make a full recovery over a 7–10-day period, during which the immune system has made sufficient antibodies to offer lifelong immunity. An infant whose mother has immunity to measles (eg because of previous illness or vaccination) receives antibodies via the placenta, and these antibodies are protective for the first 6–12 months of life (Tesini, 2023). Measles contracted during pregnancy can lead to the baby being born stillborn or prematurely, with a low birth weight or miscarriage (Tesini, 2023).
Severe forms of measles can also occur, especially in individuals with compromised or deficient cellular immunity, such as those being treated for malignant disease, with a trasplant, acquired immunodeficiency syndrome (AIDS), or any form of congenital immunodeficiency (Misin et al, 2020).
Measles can lead to complications involving almost all organs and systems, with incidence affected by the patient’s age and the presence of underlying medical conditions (Misin, 2020). Adults are more likely to develop complications than children, as well as people who are immunocompromised or chronically ill, or children with malnutrition (National Institute for Health and Care Excellence, 2024). Susceptibility to opportunistic infection is increased after recovery, because the measles virus suppresses the body’s immune system (National Institute for Health and Care Excellence, 2024).
Common complications include:
- ear infections: otitis media affects 7–9% of cases
- bronchopneumonia occurs in 1–6% of cases and accounts for 56–86% of deaths
- diarrhoea affects around 8% 0f children and can lead to dehydration (National Institute for Health and Care Excellence, 2024)
Serious complications include:
- encephalitis
- convulsions
- blindness
- subacute sclerosing panencephalitis (National Institute for Health and Care Excellence, 2024)
Aetiology
Transmission of the virus occurs via respiratory droplets expelled by coughing or sneezing. The inhaled virus from the exposed droplets initially infects lymphocytes, dendritic cells and alveolar macrphages in the respiratory tracts, then spreads to the adjacent lymphoid tissue and disseminates throughout the bloodstream (Kondamudi et al, 2023). This results in viremia and leads to subsequent spread to distant organs (Kondamudi et al, 2023).
The virus can transfer itself from dendritic cells and lymphocytes to the epithelial cells of the respiratory tract, and is then shed and expelled as respiratory droplets when coughing and sneezing (Kondamudi et al, 2023). Droplets can spread to surfaces once expelled, and the virus can remain transmissible for up to 2 hours, taking away the need for direct person-to-person contact (Willacy, 2020). Transmission may also occur by small aerosolised droplets that can remain airborne (and thus can be inhaled) for up to 2 hours in closed areas (eg an office examination room) (Tesini, 2023).
Diagnosis
Diagnosis can usually be made after history and clinical examination (National Institute for Health and Care Excellence, 2024). If there is diagnostic uncertainty, a saliva test can be requested to confirm diagnosis (Willacy, 2020).
Measles is a notifiable disease in the UK, so clinicians must report the diagnosis to their local health protection team, who can then arrange testing of close contacts in order to avoid spread of the disease (Willacy, 2020).
Treatment
Measles is usually a self-limiting illness; despite unpleasant symptoms, the condition will usually resolve without intervention over the course of about a week. Any child or adult with symptoms should stay away from school, nursery or work for at least 4 days after the onset of the rash, but it may be sensible to stay at home until fully recovered (Tesini, 2023). Symptoms may be eased by drinking plenty of fluids and taking analgesia to reduce fever, and reduce aches and pains (National Institute for Health and Care Excellence, 2024).
In counties where vitamin A deficiency is common, vitamin A supplements have been shown to help prevent serious complications, although deficiency in the UK is rare (Hazell, 2023). Antibiotics have no affect on measles, and should only be used in the case of an infectious complication. Measles can lead to multiple problems, but the majority are deemed to be caused by disruption of epithelial surfaces and/or immunosuppression (Misin et al, 2020).
Vaccination
The introduction of measles vaccination had a significant impact on measles cases and deaths, achieving a 73% fall in deaths worldwide from 2000–18 (National Institute for Health and Care Excellence, 2024). However, measles can still be fatal, and all deaths in England and Wales since 2000 occurred in individuals who were unvaccinated (National Institute for Health and Care Excellence, 2024).
Concerns about a possible link between the combined measles, mumps and rubella (MMR) vaccine and autism or inflammatory bowel disease were reported in the late 1990s, which negatively impacted vaccine uptake (Elliman et al, 2007). However, these suspected adverse effects have since been discounted following extensive research (Elliman et al, 2007).
There is significant evidence to support the benefits of single vaccines, as spaced out doses leave the child vulnerable to the other two diseases, increasing risk both to the child and other children (UK Health Security Agency, 2014). Nurses and other healthcare professionals can play a vital role in dispelling myths and increasing uptake of the MMR vaccine (Table 1).
| Table 1. Advice to increase vaccination uptake | |
|
Areas to consider |
Additional information |
|
Individual team member to take lead responsibility |
One nurse can coordinate vaccination effort while being supported by other team members |
|
Staff training |
Ensure all staff are up to date with benefits of vaccinations, eligibility and the current vaccination schedule |
|
Patient information |
Staff should be prepared to answer patient questions. Advice leaflets are available on government websites, such as NHS England and UK Health Security Agency |
|
Medical records |
Ensure medical records are up to date to avoid errors when offering vaccination |
|
New patient registrations |
Offer vaccination to new patients and record their vaccination status (particularly if they have been vaccinated overseas) |
|
Cultural sensitivity |
Offer leaflets in a variety of languages if possible |
| From: Bedford and Elliman, 2024 | |
Measles is at best an unpleasant self-limiting illness, and at worse carries the risk of serious complications and potentially fatal outcomes. The UK Health Security Agency (2024b) stated that unless steps are taken to increase MMR vaccination uptake, they anticipate that further outbreaks of measles will spread to other areas. In addition, with increased travel abroad, the UK Health Security Agency (2024c) has expressed concerns about the growing measles threat in countries with suboptimal vaccination rates, and the risk of unvaccinated travellers bringing measles back to the UK.
Nurses can play a key role in educating and advising patients to get their vaccination before travel and ensure this is done in advance of their trip to give enough time for the vaccination to take effect. The UK Health Security Agency (2022) has published a document with guidance on vaccinating all patients of all ages, unless unsuitable (pregnant women and those who are severely immunocompromised).
Health professionals in all healthcare settings can play a part in educating and encouraging those who are hesitant to get vaccinated. By increasing vaccine uptake and addressing the lack of confidence among communities, it is hoped that future outbreaks and unnecessary deaths can be avoided, and the current rise in measles cases will begin to decline.
NMC proficiencies
Nursing and Midwifery Council: standards of proficiency for registered nurses
Part 1: Procedures for assessing people’s needs for person-centred care
1. Use evidence-based, best practice approaches to take a history, observe, recognise and accurately assess people of all ages
Part 2: Procedures for the planning, provision and management of person-centred nursing care
9. Use evidence-based, best practice approaches for meeting needs for care and support with the prevention and management of infection, accurately assessing the person’s capacity for independence and self-care and initiating appropriate interventions
9.2 use standard precautions protocols
Resources
Bedford H, Elliman D. Measles rates are rising again. BMJ. 2024;384:q259. https://doi.org/10.1136/bmj.q259
Elliman D, Bedford H. MMR: where are we now?. Arch Dis Child. 2007;92(12):1055-1057. https://doi.org/10.1136/adc.2006.103531
European Centre for Disease Prevention and control. Measles on the rise in the EU/EEA: considerations for public health response. 2024. https://www.ecdc.europa.eu/sites/default/files/documents/measles-eu-threat-assessment-brief-february-2024.pdf (accessed 22 May 2024)
Gastanaduy P, Haber P, Rota PA, Patel M. Chapter 13: measles. 2021. https://www.cdc.gov/vaccines/pubs/pinkbook/downloads/meas.pdf (accessed 22 May 2024)
Hazell T. Measles. 2023. https://patient.info/skin-conditions/viral-rashes/measles#nav-1 (accessed 22 May 2024)
Kondamudi NP, Waymack JR. Measles. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2023
Misin A, Antonello RM, Di Bella S, et al. Measles: an overview of a re-emerging disease in children and immunocompromised patients. Microorganisms. 2020;8(2):276. https://doi.org/10.3390/microorganisms8020276
National Institute for Health and Care Excellence. Measles. 2024. https://cks.nice.org.uk/topics/measles/ (accessed 22 May 2024)
Tesini BL. Measles. 2023. https://www.msdmanuals.com/en-gb/professional/pediatrics/common-viral-infections-in-infants-and-children/measles (accessed 22 May 2024)
UK Health Security Agency. Measles mumps and rubella (MMR): use of combined vaccine instead of single vaccine. 2014. https://www.gov.uk/government/publications/mmr-vaccine-dispelling-myths/measles-mumps-rubella-mmr-maintaining-uptake-of-vaccine (accessed 22 May 2024)
UK Health Security Agency. MMR for all: general guide. 2022. https://www.gov.uk/government/publications/mmr-for-all-general-leaflet/mmr-for-all-general-guide (accessed 22 May 2024)
UK Health Security Agency. Latest measles statistics published. 2024a. https://gov.uk/government/news/latest-measles-statistics-published (accessed 22 May 2024)
UK Health Security Agency. Measles outbreak could spread warns UKHSA chief executive. 2024b. https://www.gov.uk/governemtn/news/measles-outbreak-could-spread-warns-ukhsa-chief-executive (accessed 22 May 2024)
UK Health Security Agency. Travellers urged to check on vaccinations to protect against risks. 2024c. https://www.gov.uk/government/news/travellers-urged-check-on-vaccinations-to-protect-against-risks (accessed 22 May 2024)
Willacy H. Measles. 2020. https://patient.info/doctor/measles-pro#nav-2 (accessed 22 May 2024)
World Health Organization. Measles. 2024. https://www.who.int/health-topics/measles#tab=tab1 (accessed 22 May 2024)