Practice Easily Missed?

Measles in older children and adults

BMJ 2017; 356 doi: https://doi.org/10.1136/bmj.j426 (Published 16 February 2017) Cite this as: BMJ 2017;356:j426
  1. Beatrice Clare Cockbain, foundation year 2 doctor,
  2. Tehmina Bharucha, specialist registrar in combined infection training,
  3. Dianne Irish, consultant virologist,
  4. Michael Jacobs, consultant in infectious diseases
  1. Royal Free Hospital, London
  1. Correspondence to beatricecockbain{at}nhs.net
  • Accepted 12 December 2016

What you need to know

  • Consider measles in patients with fever, flu-like symptoms, and rash, and ask about immunisation and contact with unwell people

  • When a case is suspected, contact local public health authorities and test for measles using immunoglobulin M serology and, if available, reverse transcription polymerase chain reaction

  • Offer opportunistic immunisation for children older than 1 year and adults who are unvaccinated or have only received one dose of the measles, mumps, and rubella vaccine

A 23 year old woman has fever, flu-like symptoms, diarrhoea, and a rash that has spread from her face to her body. She cannot recall being in contact with anyone unwell and has not recently travelled or taken any drugs. She reports missing vaccinations as a child because her parents were concerned about safety. On examination she has a maculopapular blanching rash on her face and chest. Measles was suspected and confirmed with serology that was positive for immunoglobulin M antibodies to the measles virus. Reverse transcription polymerase chain reaction on a throat swab detected measles virus RNA.

What is measles?

Measles is widely perceived as a disease of early childhood, despite almost two thirds of recent cases in the United Kingdom being in those aged 15 and older.1 Patients typically present with fever, cough, coryza, and conjunctivitis, followed two to four days later by a characteristic erythematous maculopapular rash that spreads downwards from the face (figs 1 and 2).2 Patients are infectious from four days before to four days after the onset of rash. Koplik’s spots—whitish lesions on the buccal mucosa—might be seen and are pathognomonic for measles.3

Figure1

Fig 1 Measles rash on face. Patient consent obtained

Figure2

Fig 2 Measles rash on legs. Patient consent obtained

Box 1: How common is measles?

  • More than 134 000 deaths from measles occurred globally in 2015, mostly in under 5s4

  • In 2016, the Americas was the first region declared free of measles5

  • Outbreaks continue to occur in other parts of the world because of poor vaccination coverage, with transmission largely among unvaccinated and incompletely vaccinated individuals

  • Between January and September 2016, 477 cases of measles were confirmed in England, with 65% (302/477) in those aged 15 and older.1 A proportionate increase in measles cases was seen in those aged more than 15: from 31.5% (640/2030 cases) in 2012 to 43% (39/91 cases) in 20156

Why is measles missed?

The reduction in incidence of measles since the introduction of routine vaccination means that clinicians are less likely to recognise clinical features.7 The features are non-specific and can be seen with other infections such as rubella, dengue, and parvovirus B19, as well as with drug reactions.7 For example, a study in London during a period of high measles transmission found that a suggestive prodrome and rash had a positive predictive value for measles of only 19% in primary care, increasing to 50% if Koplik’s spots were present.3

Why does it matter?

Death caused by measles is as high as 10% in some parts of the world.4 Since 1991 there have been 28 confirmed deaths from measles in the UK, 86% (24/28) in those aged 15 or more.8 Most patients recover completely with management of symptoms.9 Deaths occur from complications such as pneumonitis, encephalitis, super-imposed bacterial infections, and, later, subacute sclerosing panencephalitis.2

Measles is highly infectious and spreads by respiratory droplets when an infected person breathes, coughs, or sneezes. Presence in the same room as someone with measles for more than 15 minutes increases the chances of infection.9 10 Early detection and isolation of suspected cases can reduce this risk.

How is measles diagnosed?

Laboratory confirmation is essential to distinguish measles from other febrile illnesses with rash, and to ensure accurate notification of cases and appropriate public health actions.7 9 IgM antibodies can be detected in the serum within a few days of rash onset.7 At first contact with a patient suspected of having measles, obtain a blood sample for IgM enzyme immunoassay (positive predictive value of 98.2% and negative predictive value of 92.0%).11 In addition, where reverse transcription polymerase chain reaction testing is available, obtain a sample of oral fluid and urine, or a throat swab for isolation of measles virus (positive predictive value of 90.9% and negative predictive value of 99.4%).12

How is measles managed?

Most patients can be managed at home with rest, adequate fluid intake, and control of fever with paracetamol.9 Offer admission to patients at a high risk of complications, such as pregnant women and those who are malnourished or immunocompromised.9 10

Advise patients to avoid contact with pregnant women, infants, and those who are unvaccinated. Explain to the patient and carer to report features such as ear infection, breathlessness, uncontrolled or persistent fever, confusion, or convulsions. These may indicate complications such as otitis media, pneumonia, or encephalitis and require urgent admission and possible transfer to a high dependency medical unit.

To reduce nosocomial spread of infection, patients with suspected measles who are admitted to hospital must be nursed in a separate room and by healthcare workers with satisfactory evidence of protection against measles—either two documented doses of measles, mumps, and rubella vaccine or a known positive blood test result for the measles immunoglobulin G antibody.2

In many countries, including the UK, measles is a notifiable disease.2 9 Suspected cases should be notified immediately to local public health authorities, who should undertake contact tracing and offer post-exposure prophylaxis as required. A Cochrane review found an absolute risk reduction of 629 fewer cases per 1000 exposed individuals when human normal immunoglobulin was administered as post-exposure prophylaxis, with a number needed to benefit of 2.13 This immunoglobulin may be offered to non-immune contacts who are pregnant, immunocompromised, or aged less than 1 year. It can be administered up to six days after exposure, but ideally it should be given within three days after exposure.2 9

A full vaccine course comprising two doses is thought to provide lifelong immunity.7 10 Overall uptake of the MMR vaccine in England is around 92.3%, but in London it falls short of 80%.14 Population immunity levels of more than 95% are required to prevent ongoing transmission.2 Offer immunisation to children aged 1 year or older and adults who are unvaccinated or have received one dose of the MMR vaccine only.10 15

How patients were involved in the creation of this article

An adult who was in hospital with measles read an early draft of this article. The patient recommended that we emphasise to clinicians the need to take a full vaccination history in any patient presenting with fever and rash.

Education into practice

Do you routinely ask for immunisation history in patients who present with fever and rash?

Footnotes

  • This is one of a series of occasional articles highlighting conditions that may be more common than many doctors realise or may be missed at first presentation. The series advisers are Anthony Harnden, professor of primary care, Department of Primary Care Health Sciences, University of Oxford, and Kevin Barraclough, School of Social and Community Medicine, University of Bristol. To suggest a topic for this series, please email us at practice{at}bmj.com.

  • We thank Simon Cathcart and Amanda Wright at Public Health England for their early information on the current measles caseload (including age specific data) in London.

  • Contributors: BCC is the guarantor and came up with the idea for the paper and began a first draft, which was revised several times by TB, DI, and MJ.

  • Competing interests: We have read and understood the BMJ policy on declaration of interests and declare the following: none.

  • Provenance and peer review: Commissioned, based on an idea from the author; externally peer reviewed.

  • Patient consent obtained.

References

View Abstract

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