Measles - Clinical Refresher, February 2024

Given the increasing incidence of measles outbreaks in Europe and the United Kingdom, these slides represent a clinical refresher on this condition for medical professionals in Ireland.



Slides for educational purposes only, and should not replace clinical judgement. No monetary gain was made for this work. Image sources credited in references. Information presented based on interpretation of published material.

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1. Measles Dr. Robert Ferris

2. Measles Also known as English measles, rubeola or morbilli Causes by measles virus UK declared free of measles in 2016, bus cases rapidly climbing as of January 2024 Mainly due to incomplete vaccine coverage Alert issued by ICGP 26/01/2024 MMR uptake <90% nationwide over last 7 consecutive quarters As low as 77.3% in one region Represents a risk to large numbers of children, vulnerable adults, as well as general practice and paediatric services First confirmed case in Ireland in 2024 was in an adult, who subsequently died

3. Transmission Airborne/droplet Also contact with droplets on surfaces Infectious window typically 10-12 days between exposure and symptom onset May vary from 7 to 21 days in rare cases Virulence: 1 infected person can affect approx. 18 other contacts (COVID-19 is 1-1.5 others) Typically progresses to the “Three Cs”: Cough Coryza Conjunctivitis with further symptoms following

4. Transmission Risks Very elderly Very young Immunocompromised Low socio-economic backgrounds Close-quartered living Young people aged mid-late 20s (M>F)

5. Disease Stages, per NCBI (2023) Incubation: largely asymptomatic. Typically 10-12 days, may be longer. Prodromal: onset of fever, coryza, respiratory sx ., general malaise. Koplik spots on oral mucosa are typical. 4-6 days. Eruptive: appearance of maculopapular rash, typically beginning on the head and progressing downward. 3-4 days. Convalescent: fever and malaise begin to lift 2-3 days following rash, which itself starts to fade after 3-4 days from appearance

6. Management Treatment is primarily supportive. Patients should be isolated, where possible, and managed with appropriate hydration and analgaesics /antipyretics. Good safety netting is important, especially for parents of young children, to enable early recognition of signs of complications. Measles is a notifiable disease in Ireland.

7. Complications (in addition to the aforementioned) Common: Acute OM Bronchopneumonia GI upset Febrile convulsions Uncommon: Meningitis Encephalitis Immunosuppression

8. Consider onward referral in The Very Unwell Child Immunocompromised patients Very young/premature Very elderly Unvaccinated (if very unwell) Sx . of concern for IC involvement Atypical presentation

9. Prevention Per ICGP Clinical Notification 09/02/2024, individuals may be considered immune if: They have received to MMR vaccines, both given after the person’s first birthday, at least four weeks apart They were born before 1978 (this cohort almost certainly have had prior measles infection)

10. Prevention MMR (Measles, Mumps, Rubella) is among the most effective vaccinations. Two doses are recommended for best protection. Childhood schedule in Ireland is at 12 months and again at Junior Infants (4-5 years old). Older children who have missed doses should receive catch-up vaccination as soon as possible. There is no upper-age limit for vaccination with MMR. First dose offers approx. 95% protection. Second dose offers close to 99% protection and lifelong coverage in most people.

11. Who Should Not Receive MMR? Confirmed vaccine allergy Personal or strong family hx . of immunocompromise Bleeding disorder Active TB Recent (≤3/12) recipient of blood products Acute illness Other live vaccine (including prior MMR) in past 4/52 <1 year old Pregnant

12. Measles Exposure in Pregnancy No evidence of congenital defects from measles during pregnancy Higher risk of both maternal and foetal mortality in unvaccinated patients HPSC recommends use of human normal immunoglobulin (HNIG) in susceptible (e.g. unvaccinated, serological evidence of lack of immunity, ethnic/disadvantaged background) woman who have been subject to significant exposure All such women should be referred promptly to a local High-Risk Antenatal Clinic

13. Thank you. Any questions? References: ‘Measles Clinical Alert’, ICGP January 2024, accessed at https://www.icgp.ie/go/about/news/C1061A16-C75D-4629-B66D2C93A364EDF5.html on 31/01/2024 ‘Measles’, Red Whale January 2024, accessed at https://www.gp-update.co.uk/SM4/Mutable/Uploads/pdf_file/GP_Child_Health_Measles_January2024.pdf on 31/01/2024 ‘Measles (morbilli)’, DermNet October 2020, accessed at https://dermnetnz.org/topics/measles on 31/01/2024 ‘Measles’, World Health Organisation (WHO) August 2023, accessed at https://www.who.int/news-room/fact-sheets/detail/measles#:~:text=Measles%20infects%20the%20respiratory%20tract,body%20fight%20off%20the%20virus on 31/01/2024 ‘National measles guidelines’ UK Health Security Agency, February 2024 ‘Measles’, GP Notebook, February 2024, accessed at https://gpnotebook.com/pages/infectious-disease/measles on 07/02/2024 ‘Clinical Notification Measles’ ICGP update 9 th February 2024

14. References (contd.): Coughs and Sneezes Spread Diseases’ poster (c. 1918), attributed to the U.S. Public Health Service ‘Rubeola (Measles)’, National Centre for Biotechnology Information (NCBI) 2023, accessed at https://www.ncbi.nlm.nih.gov/books/NBK557716/#:~:text=The%20clinical%20picture%20of%20measles,cough%2C%20conjunctivitis%2C%20and%20coryza on 07/02/2024 ‘Measles’, Health Protection Surveillance Centre (HSPC) January 2024, accessed at https://www.hpsc.ie/a-z/vaccinepreventable/measles/factsheet/measlesfrequentlyaskedquestions/ on 07/02/2024 ‘Measles’, Health Services Executive (HSE) April 2021, accessed at https://www2.hse.ie/conditions/measles/ on 07/02/2024 ‘Measles’, NHS Inform February 2024, accessed at https://www.nhsinform.scot/illnesses-and-conditions/infections-and-poisoning/measles/ on 07/02/2024 ‘Adult with confirmed case of measles dies, HSE says’, RTE News February 2023, accessed at https://www.rte.ie/news/ireland/2024/0207/1431067-measles-death/ on 12/02/2024 ‘Measles exposure during pregnancy – guidance document’, HSPC July 2018, accessed at https://www.hpsc.ie/a-z/vaccinepreventable/measles/guidance/20180719_measles%20exposure%20during%20pregnancy%20v1.1.pdf on 12/02/2024