Measles


Measles is a highly contagious acute viral infection, transmitted by the airborne route (inhalation of respiratory droplets spread by infected individuals). The disease mainly affects children under 5 years of age and can be prevented by immunization.
For more information, refer to the guide Management of a measles epidemic MSF.

Clinical features

The average incubation period is 10 days.

Prodromal or catarrhal phase (2 to 4 days)
– High fever (39-40 °C) with cough, coryza (nasal discharge) and/or conjunctivitis (red and watery eyes).
– Koplik’s spots: tiny bluish-white spots on an erythematous base, found on the inside of the cheek. This sign is specific of measles infection, but may be absent at the time of examination. Observation of Koplik's spots is not required for diagnosing measles.

Eruptive phase (4 to 6 days)
– On average 3 days after the onset of symptoms: eruption of erythematous, non- pruritic maculopapules, which blanch with pressure. The rash begins on the forehead then spreads downward to the face, neck, trunk (2nd day), abdomen and lower limbs (3rd and 4th day).
– As the rash progresses, prodromal symptoms subside. In the absence of complications, the fever disappears once the rash reaches the feet.
– The rash fades around the 5th day in the same order that it appeared (from the head to the feet).

The eruptive phase is followed by skin desquamation during 1 to 2 weeks, very pronounced on pigmented skin (the skin develops a striped appearance).

In practice, a patient presenting with fever and erythematous maculopapular rash and at least one of the following signs: cough or coryza or conjunctivitis, is a clinical case of measles.

Complications

Most measles cases experience at least one complication:
– Respiratory and ENT: pneumonia, otitis media, laryngotracheobronchitis
– Ocular: purulent conjunctivitis, keratitis, xerophthalmia (risk of blindness)
– Gastrointestinal: diarrhoea with or without dehydration, benign or severe stomatitis
– Neurological: febrile seizures; rarely, encephalitis
– Acute malnutrition, provoked or aggravated by measles (post-measles period)

Pneumonia and dehydration are the most common immediate causes of death.

Case management

– Admit as inpatient children with at least one major complication:
• Inability to eat/drink/suck, or vomiting
• Altered consciousness or seizures
• Dehydration
• Severe pneumonia (pneumonia with respiratory distress or cyanosis or SpO2 < 90%)
• Acute laryngotracheobronchitis (croup)1
• Corneal lesions (pain, photophobia, erosion or opacity)
• Severe oral lesions that prevent eating
• Acute malnutrition

– Treat as outpatient children with no major complications, no complications or minor complications:
• Pneumonia without severe signs
• Acute otitis media
• Purulent conjunctivitis (no corneal lesions)
• Diarrhoea without dehydration
• Oral candidiasis that does not interfere with eating
If in doubt, keep the child under observation for a few hours.

– Isolation
• Isolation of hospitalised patients
• Measles cases treated as outpatients should be kept at home during this period.

Treatment

Supportive and preventive treatment

– Treat fever: paracetamol (Fever, Chapter 1).
– Make the child drink (high risk of dehydration).
– Give smaller, more frequent meals or breastfeed more frequently (every 2 to 3 hours).
– Clear the nasopharynx (nose-blowing or nasal lavages) to prevent secondary respiratory infection and improve the child’s comfort.
– Clean the eyes with clean water 2 times daily and administer retinol on D1 and D2 (see Chapter 5) to prevent ocular complications.
– In children under 5 years: amoxicillin PO for 5 days as a preventive measure (reduction of respiratory and ocular infections).
– In the event of watery diarrhoea without dehydration: oral rehydration according to WHO Plan A (Appendix 2).
– Insert a nasogastric tube for a few days if oral lesions prevent the child from drinking.

Treatment of complications


Treatment of complications

Severe pneumonia

ceftriaxone IV or IM + cloxacillin IV then change to amoxicillin/ clavulanic acid PO (see Chapter 2)
+ oxygen if cyanosis or SpO2 < 90%
+ salbutamol if expiratory wheezing and sibilant rales on auscultation
In all cases, close monitoring.

Pneumonia without severe signs

amoxicillin PO for 5 days

Croup

Inpatient monitoring (risk of worsening). Keep the child calm. Agitation and crying exacerbate the symptoms.
For severe croup:
dexamthasone IM: 0.6 mg/kg single dose
+ nebulized epinephrine (adrenaline, 1 mg/ml ampoule): 0.5 ml/kg (max. 5 ml)
+ oxygen if cyanosis or SpO2 < 90%
Intensive monitoring until symptoms resolve.

Acute otitis media

See Otitis, Chapter 2.

Dehydration

Per oral route or IV depending on the degree of dehydration.

Oral candidiasis

See Stomatitis, Chapter 3.

Purulent conjunctivitis

See Conjunctivitis, Chapter 5.

Keratitis/ keratoconjunctivitis

tetracycline 1% eye ointment 2 times daily for 7 days
+ retinol PO one dose on D1, D2 and D8 (see Xerophthalmia, Chapter 5)
+ eye protection and pain management (see Pain, Chapter 1).

No topical corticosteroids.

Xerophthalmia

See Xerophthalmia, Chapter 5.

Febrile seizures

See Seizures, Chapter 1.

Prevention

– No chemoprophylaxis for contacts.

– Vaccination:
• The first dose is administered at 9 months of age. In situations where there is high risk of infection (overcrowding, epidemics, malnutrition, infants born to a mother with HIV infection, etc.): administer one dose at 6 months of age (between 6 and 8 months) and one dose at 9 months of age, with an interval of at least 4 weeks between injections.
• Children must receive a second dose before they are 5 years old in order to cover unvaccinated children or children who did not respond to the first dose.



Footnotes
Ref Notes
1

Symptoms (hoarse crying or voice, difficulty breathing, a high-pitched inspiratory wheeze [inspiratory stridor], characteristic "barking" cough) are caused by inflammation and narrowing of the larynx. Croup is considered benign or “moderate” if the stridor occurs when the child is agitated or crying, but disappears when the child is calm. The child should be monitored during this period, however, because his general and respiratory status can deteriorate rapidly. Croup is severe when the stridor persists at rest or is associated with signs of respiratory distress.