Measles virus: Difference between revisions
From IDWiki
m (Text replacement - "Clinical Presentation" to "Clinical Manifestations") |
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β | * |
+ | *Highly contagious virus that causes a '''triad of cough, coryza, and conjunctivitis''' |
β | == |
+ | ==Background== |
β | === |
+ | ===Microbiology=== |
β | * Enveloped RNA ''Morbillivirus'' in the Paramyxoviridae family |
||
β | ** Family includes parainfluenza, RSV, measles, mumps |
||
β | * Eight structural proteins: F, C, H (haemagglutination), L (large), M (matrix), N (nucleoprotein), P (phosphopolymerase), and V |
||
β | ** N, P, and L complex with RNA |
||
β | ** C and V interact with cellular proteins and regulate replication |
||
β | ** M, H, and F are viral envelope proteins |
||
β | ** H helps with host cell attachment, and F helps with spread between cells |
||
+ | *Enveloped RNA ''Morbillivirus'' in the Paramyxoviridae family |
||
β | === Pathophysiology === |
||
+ | **Family includes parainfluenza, RSV, measles, mumps |
||
β | * Airborne droplets can remain in the air up to 2 hours after a person with measles has coughed |
||
+ | *Eight structural proteins: F, C, H (haemagglutination), L (large), M (matrix), N (nucleoprotein), P (phosphopolymerase), and V |
||
β | ** It is droplet, but just very small droplet |
||
+ | **N, P, and L complex with RNA |
||
β | * Innoculated through respiratory mucosa, enters lymphoid cells via SLAM receptor |
||
+ | **C and V interact with cellular proteins and regulate replication |
||
β | ** SLAM (CDw150) is present on lymphocytes and antigen-presenting cells |
||
+ | **M, H, and F are viral envelope proteins |
||
β | * Spreads to entire respiratory systems, as well as intestines, bladder, skin, and spleen, lymph nodes, liver, conjunctiva, and brain |
||
+ | **H helps with host cell attachment, and F helps with spread between cells |
||
β | * Propagates within T and B lymphocytes and monocytes, but also endothelial, epithelial, and dendritic cells |
||
β | * Host response success causes disappearance of serology and appearance of rash |
||
β | ** Possibly the rash represents a hypersensitivity reaction to the virus mediated by cellular immunity |
||
β | === |
+ | ===Pathophysiology=== |
β | * Infection confers lifelong immunity, though vaccination may not |
||
β | * Worldwide distribution |
||
β | * Prior to vaccination, there were epidemics every 2 to 5 years lasting 3 to 4 months |
||
β | * Vaccine hesitancy is becoming more common |
||
β | ** Parts of Europe |
||
+ | *Airborne droplets can remain in the air up to 2 hours after a person with measles has coughed |
||
β | == Clinical Manifestations == |
||
+ | **It is droplet, but just very small droplet |
||
β | * Incubation period 10-14 days (range up to 21 days), followed by several days of prodrome that includes fever, anorexia, cough, coryza, and conjunctivitis |
||
+ | *Innoculated through respiratory mucosa, enters lymphoid cells via SLAM receptor |
||
β | ** Can be mistaken for common cold or for Kawasaki disease |
||
+ | **SLAM (CDw150) is present on lymphocytes and antigen-presenting cells |
||
β | ** Koplik spots appear at end of prodrome |
||
+ | *Spreads to entire respiratory systems, as well as intestines, bladder, skin, and spleen, lymph nodes, liver, conjunctiva, and brain |
||
β | *** Bluish gray specks on a red base in the oral mucosa ("like grains of sand") |
||
+ | *Propagates within T and B lymphocytes and monocytes, but also endothelial, epithelial, and dendritic cells |
||
β | * Rash follows Koplik spots |
||
+ | *Host response success causes disappearance of serology and appearance of rash |
||
β | ** Spreads from face to body, including palms and soles |
||
+ | **Possibly the rash represents a hypersensitivity reaction to the virus mediated by cellular immunity |
||
β | ** Fevers resolve soon after rash appears |
||
β | ** Rash is erythematous and maculopapular, and my desquamate as it begins to heal |
||
β | ** Usually lasts 5 days, clearing in the same pattern that it appeared |
||
β | * The rash disappears about 7 to 10 days after late prodromal period, with cough being the last symptom to disappear |
||
β | === |
+ | ===Epidemiology=== |
β | * Respiratory involvement, either as primary infection of with bacterial superinfection |
||
β | ** Otitis media, pneumonia (on CXR, even if uncomplicated) |
||
β | * Acute encephalitis, which can have sequelae |
||
β | ** Blindness, corneal scarring |
||
β | * Hepatitis |
||
β | * Complications are more common in adults who are infected |
||
+ | *Infection confers lifelong immunity, though vaccination may not |
||
β | === Subacute sclerosing panencephalitis (SSPE) === |
||
+ | *Worldwide distribution |
||
β | * Degenerative neurological condition caused by persistent CNS infection despite immune response |
||
+ | *Prior to vaccination, there were epidemics every 2 to 5 years lasting 3 to 4 months |
||
β | * 5-10 years after infection |
||
+ | *Vaccine hesitancy is becoming more common |
||
β | * Higher risk if infection before age 2 years |
||
+ | **Parts of Europe |
||
β | * Inevitably ends in death |
||
+ | ==Clinical Manifestations== |
||
β | === Special Populations === |
||
β | ==== Modified measles ==== |
||
β | * Patients with passive immunity to measles may present with a milder form |
||
β | ** Babies with mom's immunoglobulin, or patients who have received immune globulin |
||
β | * The prodrome, Koplik spots, and rash are often absent, and it is sometimes subclinical |
||
+ | *Incubation period [[Usual incubation period::10 to 14 days]] (range [[Incubation period range::up to 21 days]]), followed by several days of prodrome that includes fever, anorexia, cough, coryza, and conjunctivitis |
||
β | ==== Atypical measles ==== |
||
+ | **Can be mistaken for common cold or for Kawasaki disease |
||
β | * Patients with prior immunization with killed vaccine (no longer on market, since 1960s) may have an atypical presentation |
||
+ | **Koplik spots appear at end of prodrome |
||
β | * Prodrome of fever and pain for 1 to 2 days |
||
+ | ***Bluish gray specks on a red base in the oral mucosa ("like grains of sand") |
||
β | * Rash follows, but moves peripherally to centrally, and have varied form (urticarial, maculopapular, hemorrhagic, vesicular) |
||
+ | *Rash follows Koplik spots |
||
β | ** Can mimic vaicella, RMSF, HSP, drug eruption, or toxic shock syndrome |
||
+ | **Spreads from face to body, including palms and soles |
||
β | * Fever continues, with edema, interstitial pneumonia, hepatitis, and occasionally pleural effusion |
||
+ | **Fevers resolve soon after rash appears |
||
β | * More prolonged course, with very high antibody titres |
||
+ | **Rash is erythematous and maculopapular, and my desquamate as it begins to heal |
||
+ | **Usually lasts 5 days, clearing in the same pattern that it appeared |
||
+ | *The rash disappears about 7 to 10 days after late prodromal period, with cough being the last symptom to disappear |
||
β | === |
+ | ===Complications=== |
β | * Chemotherapy, transplantation, AIDS, and congenital cellular immunodefieciency are all risk factors for severe measles |
||
β | ** Possibly also malnutrition |
||
β | * Can develop giant cell pneumonia, without rash, as well as a chronic encephalitis |
||
β | ** Can detect measles RNA in brain tissue |
||
+ | *Respiratory involvement, either as primary infection of with bacterial superinfection |
||
β | ==== Pregnancy ==== |
||
+ | **[[Otitis media]], [[pneumonia]] (on CXR, even if uncomplicated) |
||
β | * Can be severe |
||
+ | *Acute [[encephalitis]] in 1 in 1000-2000 patients, with new fevers, headaches, seizures, and altered level of consciousness |
||
β | * Can cause spontaneous abortion and premature delivery |
||
+ | **Likely from hypersensitivity to virus in the brain rather than from direct infection |
||
β | * Newborn can be infected; they should get immune globulin at birth |
||
+ | **Sequelae include blindness, corneal scarring |
||
+ | *Chronic encephalitis, also called subacute sclerosing panencephalitis |
||
+ | *[[Hepatitis]] |
||
+ | *Complications are more common in adults who are infected |
||
+ | ===Subacute Sclerosing Panencephalitis (SSPE)=== |
||
β | == Differential Diagnosis == |
||
β | * [[Rubella]] |
||
β | * [[Kawasaki syndrome]] |
||
β | * [[Scarlet fever]] |
||
β | * [[Roseola]] |
||
β | * Infectious [[mononucleosis]] |
||
β | * [[Rickettsia species|Risckettsial infections]] |
||
β | * [[Enterovirus|Enteroviral infections]] |
||
β | * [[Adenovirus|Adenoviral infections]] |
||
+ | *Degenerative neurological condition caused by persistent CNS infection despite immune response |
||
β | == Diagnosis == |
||
+ | *5-10 years after infection |
||
β | * Typically diagnosed clinically; CBC may show leukopenia |
||
+ | *Higher risk if infection before age 2 years |
||
β | * If uncertain of the diagnosis, can use serology or molecular tests to confirm |
||
+ | *Inevitably ends in death |
||
β | ** NP swab PCR within 7 days of rash onset |
||
β | ** Urine PCR within 14 days of rash onset |
||
β | ** ELISA IgG serology, repeated after 1 week; fourfold titre increase is diagnostic |
||
β | *** Or IgM, if available, to diagnose on one sample |
||
β | *** IgM can persist for up to a month |
||
β | ** Viral culture is also possible |
||
β | * For SSPE, can demonstrate high titres in serum and CSF |
||
+ | ===Special Populations=== |
||
β | == Management == |
||
+ | ====Modified Measles==== |
||
β | * Most infectious just before rash; quickly becomes non-infectious after end of prodrome |
||
β | * Supportive care |
||
β | * Vitamin A can be given, especially if the child is deficien |
||
β | ** In children >1 year, vitamin A 200,000 IU daily for 2 days |
||
β | ** If 6-12 months old, use 100,000 IU for 2 days |
||
β | ** Less than 6 months, use 50,000 IU |
||
β | ** If deficient, give another dose at 2 to 4 weeks |
||
β | * Ribavirin unhelpful but sometimes given |
||
+ | *Patients with passive immunity to measles may present with a milder form |
||
β | == Prevention == |
||
+ | **Babies with mom's immunoglobulin, or patients who have received immune globulin |
||
β | === Infection control === |
||
+ | *The prodrome, Koplik spots, and rash are often absent, and it is sometimes subclinical |
||
β | * Infectious period is 5 days prior to until 4 days after onset of rash |
||
β | * Need to do contact tracing, including people up to two hours after any room they were in |
||
β | * All contacts should be quarantined at home regardless of symptoms |
||
+ | ====Atypical Measles==== |
||
β | === Post-exposure prophylaxis (PEP) === |
||
β | * Indications for passive immunization with immune globulin |
||
β | ** High risk for severe or fatal measles and are susceptible |
||
β | ** Includes children with malignancy, cell-mediated immunodeficiency (including AIDS), and possibly babies <1 year |
||
β | ** Must be given within 6 days of exposure |
||
β | ** Infants <1 year: IMIg 0.25 mL/kg once |
||
β | ** Other children: IMIg 0.5 mL/kg once (maximum of 15 mL) |
||
β | * Immunization for post-exposure prophylaxis can be done in other, immunocompetent patients |
||
β | ** Can shorten the time to rash, suggesting a shorter period of infectiousness |
||
+ | *Patients with prior immunization with killed vaccine (no longer on market, since 1960s) may have an atypical presentation |
||
β | === Vaccination === |
||
+ | *Prodrome of fever and pain for 1 to 2 days |
||
β | * Live vaccine given in MMR at 12-15 months, with a booster later in childhood |
||
+ | *Rash follows, but moves peripherally to centrally, and have varied form (urticarial, maculopapular, hemorrhagic, vesicular) |
||
β | * Don't vaccinate for 5-6 months after receiving immune globulin |
||
+ | **Can mimic [[varicella]], [[RMSF]], [[HSP]], [[drug eruption]], or [[toxic shock syndrome]] |
||
β | * No adverse effects of revaccination |
||
+ | *Fever continues, with edema, interstitial pneumonia, hepatitis, and occasionally pleural effusion |
||
β | * Rates need to be >95% to prevent imported cases from causing outbreaks |
||
+ | *More prolonged course, with very high antibody titres |
||
β | * Rates less than 80% allow endemic transmission with cyclical outbreaks every 3-5 years |
||
β | * Vaccination is contraindicated in AIDS, other cell-mediated immunodeficiency, and in pregnancy |
||
β | ** Wait 3 months after chemotherapy |
||
β | ** Don't use MMRV, since no safety data are available |
||
β | * Can be associated with anaphylaxis in patients with true egg allergy |
||
β | ==== |
+ | ====Immunocompromised==== |
+ | |||
β | * Improper storage >4ΒΊ C |
||
+ | *Chemotherapy, transplantation, AIDS, and congenital cellular immunodefieciency are all risk factors for severe measles |
||
β | * Failure to use proper diluent for lyophilized vaccine |
||
+ | **Possibly also malnutrition |
||
β | * Exposure to light or heat |
||
+ | *Can develop giant cell pneumonia, without rash, as well as a chronic encephalitis |
||
β | * Vaccination in the presence of passive antibody |
||
+ | **Can detect measles RNA in brain tissue |
||
+ | |||
+ | ====Pregnancy==== |
||
+ | |||
+ | *Can be severe |
||
+ | *Can cause spontaneous abortion and premature delivery |
||
+ | *Newborn can be infected; they should get immune globulin at birth |
||
+ | |||
+ | ==Differential Diagnosis== |
||
+ | |||
+ | *[[Rubella]] |
||
+ | *[[Kawasaki syndrome]] |
||
+ | *[[Scarlet fever]] |
||
+ | *[[Roseolavirus|Roseola]] |
||
+ | *[[Infectious mononucleosis]] |
||
+ | *[[Rickettsioses]] |
||
+ | *[[Enterovirus|Enteroviral infections]] |
||
+ | *[[Adenovirus|Adenoviral infections]] |
||
+ | |||
+ | ==Diagnosis== |
||
+ | |||
+ | *Typically diagnosed clinically; CBC may show leukopenia |
||
+ | *If uncertain of the diagnosis, can use serology or molecular tests to confirm |
||
+ | **NP swab PCR within 7 days of rash onset |
||
+ | **Urine PCR within 14 days of rash onset |
||
+ | **ELISA IgG serology, repeated after 1 week; fourfold titre increase is diagnostic |
||
+ | ***Or IgM, if available, to diagnose on one sample |
||
+ | ***IgM can persist for up to a month |
||
+ | **Viral culture is also possible |
||
+ | *For SSPE, can demonstrate high titres in serum and CSF |
||
+ | |||
+ | ==Management== |
||
+ | |||
+ | *Most infectious just before rash; quickly becomes non-infectious after end of prodrome |
||
+ | *Supportive care |
||
+ | *Vitamin A can be given, especially if the child is deficien |
||
+ | **In children >1 year, vitamin A 200,000 IU daily for 2 days |
||
+ | **If 6-12 months old, use 100,000 IU for 2 days |
||
+ | **Less than 6 months, use 50,000 IU |
||
+ | **If deficient, give another dose at 2 to 4 weeks |
||
+ | *Ribavirin unhelpful but sometimes given |
||
+ | |||
+ | ==Prevention== |
||
+ | ===Infection Control=== |
||
+ | |||
+ | *Infectious period is 5 days prior to until 4 days after onset of rash |
||
+ | *Need to do contact tracing, including people up to two hours after any room they were in |
||
+ | *All contacts should be quarantined at home regardless of symptoms |
||
+ | **Susceptible contacts should be placed in airborne precautions from 5 days after first exposure to 21 days after last exposure |
||
+ | |||
+ | ===Post-Exposure Prophylaxis (PEP)=== |
||
+ | |||
+ | *Use either MMR vaccine or immune globulin in susceptible people |
||
+ | *'''Immunization''' |
||
+ | **Should be offered to all susceptible, immunocompetent people age 6 months and older |
||
+ | **Give within 72 hours of exposure |
||
+ | **Can shorten the time to rash, suggesting a shorter period of infectiousness |
||
+ | *'''Immunoglobulin''' can provide short-term protection to certain susceptible, immunocompromised people |
||
+ | **Given to people with high risk for severe or fatal measles and are susceptible: |
||
+ | ***Susceptible pregnant women |
||
+ | ***Susceptible immunocompromised people |
||
+ | ****Regardless of prior vaccination, should also be considered in advanced [[HIV]] |
||
+ | ****Regardless of prior vaccination, should also be consider in all patients with [[hematopoietic stem cell transplantation]] until they have been revaccinated post-transplant with confirmed adequate antibody titres |
||
+ | ***Susceptible infants <6 months of age |
||
+ | ***Susceptible immunocompetent infants from 6 to 11 months of age who present after 72 hours |
||
+ | **Give within 6 days of exposure |
||
+ | |||
+ | {| class="wikitable" |
||
+ | ! rowspan="2" |Population |
||
+ | ! colspan="2" |Time since measles exposure |
||
+ | |- |
||
+ | !β€72 hours |
||
+ | !73 hours to 6 days |
||
+ | |- |
||
+ | |Susceptible infants <6 months old |
||
+ | | colspan="2" |IMIg 0.5 mL/kg |
||
+ | |- |
||
+ | |Susceptible immunocompetent infants 6-12 months old |
||
+ | |MMR |
||
+ | |IMIg 0.5 mL/kg |
||
+ | |- |
||
+ | |Susceptible immunocompetent people β₯12 months old |
||
+ | | colspan="2" |MMR |
||
+ | |- |
||
+ | |Susceptible pregnant people |
||
+ | | colspan="2" |IVIg 400 mg/kg (preferred) or IMIg 0.5 mL/kg |
||
+ | |- |
||
+ | |Immunocompromised individuals |
||
+ | | colspan="2" |IVIg 400 mg/kg (preferred) or IMIg 0.5 mL/kg |
||
+ | |- |
||
+ | |People with confirmed immunity |
||
+ | | colspan="2" |None |
||
+ | |} |
||
+ | |||
+ | ===Vaccination=== |
||
+ | |||
+ | *Live vaccine (given in MMR or MMRV) at 12-15 months, with a booster later in childhood between 18 months and school entry |
||
+ | **Wait at least 5-6 months after receiving immunoglobulin |
||
+ | **Wait at least 4 weeks from a dose given before 12 months for post-exposure prophylaxis |
||
+ | *No adverse effects of revaccination |
||
+ | *Rates need to be >95% to prevent imported cases from causing outbreaks |
||
+ | *Rates less than 80% allow endemic transmission with cyclical outbreaks every 3-5 years |
||
+ | *Vaccination is contraindicated in advanced [[HIV]], other cell-mediated immunodeficiency, and in [[pregnancy]] |
||
+ | **Wait 3 months after chemotherapy |
||
+ | **Don't use MMRV, since no safety data are available |
||
+ | *Can be associated with anaphylaxis in patients with true egg allergy |
||
+ | |||
+ | ====Vaccine Failure==== |
||
+ | |||
+ | *Improper storage >4ΒΊ C |
||
+ | *Failure to use proper diluent for lyophilized vaccine |
||
+ | *Exposure to light or heat |
||
+ | *Vaccination in the presence of passive antibody |
||
+ | |||
+ | ====Catch-Up==== |
||
+ | |||
+ | *2 doses of MMR at least 4 weeks apart |
||
+ | |||
+ | ==Further Reading== |
||
+ | |||
+ | *[https://www.canada.ca/en/public-health/services/publications/healthy-living/canadian-immunization-guide-part-4-active-vaccines/page-12-measles-vaccine.html#pep Measles vaccine: Canadian Immunization Guide]. Public Health Agency of Canada. |
||
[[Category:Paramyxoviridae]] |
[[Category:Paramyxoviridae]] |
Latest revision as of 18:37, 27 September 2023
- Highly contagious virus that causes a triad of cough, coryza, and conjunctivitis
Background
Microbiology
- Enveloped RNA Morbillivirus in the Paramyxoviridae family
- Family includes parainfluenza, RSV, measles, mumps
- Eight structural proteins: F, C, H (haemagglutination), L (large), M (matrix), N (nucleoprotein), P (phosphopolymerase), and V
- N, P, and L complex with RNA
- C and V interact with cellular proteins and regulate replication
- M, H, and F are viral envelope proteins
- H helps with host cell attachment, and F helps with spread between cells
Pathophysiology
- Airborne droplets can remain in the air up to 2 hours after a person with measles has coughed
- It is droplet, but just very small droplet
- Innoculated through respiratory mucosa, enters lymphoid cells via SLAM receptor
- SLAM (CDw150) is present on lymphocytes and antigen-presenting cells
- Spreads to entire respiratory systems, as well as intestines, bladder, skin, and spleen, lymph nodes, liver, conjunctiva, and brain
- Propagates within T and B lymphocytes and monocytes, but also endothelial, epithelial, and dendritic cells
- Host response success causes disappearance of serology and appearance of rash
- Possibly the rash represents a hypersensitivity reaction to the virus mediated by cellular immunity
Epidemiology
- Infection confers lifelong immunity, though vaccination may not
- Worldwide distribution
- Prior to vaccination, there were epidemics every 2 to 5 years lasting 3 to 4 months
- Vaccine hesitancy is becoming more common
- Parts of Europe
Clinical Manifestations
- Incubation period 10 to 14 days (range up to 21 days), followed by several days of prodrome that includes fever, anorexia, cough, coryza, and conjunctivitis
- Can be mistaken for common cold or for Kawasaki disease
- Koplik spots appear at end of prodrome
- Bluish gray specks on a red base in the oral mucosa ("like grains of sand")
- Rash follows Koplik spots
- Spreads from face to body, including palms and soles
- Fevers resolve soon after rash appears
- Rash is erythematous and maculopapular, and my desquamate as it begins to heal
- Usually lasts 5 days, clearing in the same pattern that it appeared
- The rash disappears about 7 to 10 days after late prodromal period, with cough being the last symptom to disappear
Complications
- Respiratory involvement, either as primary infection of with bacterial superinfection
- Otitis media, pneumonia (on CXR, even if uncomplicated)
- Acute encephalitis in 1 in 1000-2000 patients, with new fevers, headaches, seizures, and altered level of consciousness
- Likely from hypersensitivity to virus in the brain rather than from direct infection
- Sequelae include blindness, corneal scarring
- Chronic encephalitis, also called subacute sclerosing panencephalitis
- Hepatitis
- Complications are more common in adults who are infected
Subacute Sclerosing Panencephalitis (SSPE)
- Degenerative neurological condition caused by persistent CNS infection despite immune response
- 5-10 years after infection
- Higher risk if infection before age 2 years
- Inevitably ends in death
Special Populations
Modified Measles
- Patients with passive immunity to measles may present with a milder form
- Babies with mom's immunoglobulin, or patients who have received immune globulin
- The prodrome, Koplik spots, and rash are often absent, and it is sometimes subclinical
Atypical Measles
- Patients with prior immunization with killed vaccine (no longer on market, since 1960s) may have an atypical presentation
- Prodrome of fever and pain for 1 to 2 days
- Rash follows, but moves peripherally to centrally, and have varied form (urticarial, maculopapular, hemorrhagic, vesicular)
- Can mimic varicella, RMSF, HSP, drug eruption, or toxic shock syndrome
- Fever continues, with edema, interstitial pneumonia, hepatitis, and occasionally pleural effusion
- More prolonged course, with very high antibody titres
Immunocompromised
- Chemotherapy, transplantation, AIDS, and congenital cellular immunodefieciency are all risk factors for severe measles
- Possibly also malnutrition
- Can develop giant cell pneumonia, without rash, as well as a chronic encephalitis
- Can detect measles RNA in brain tissue
Pregnancy
- Can be severe
- Can cause spontaneous abortion and premature delivery
- Newborn can be infected; they should get immune globulin at birth
Differential Diagnosis
- Rubella
- Kawasaki syndrome
- Scarlet fever
- Roseola
- Infectious mononucleosis
- Rickettsioses
- Enteroviral infections
- Adenoviral infections
Diagnosis
- Typically diagnosed clinically; CBC may show leukopenia
- If uncertain of the diagnosis, can use serology or molecular tests to confirm
- NP swab PCR within 7 days of rash onset
- Urine PCR within 14 days of rash onset
- ELISA IgG serology, repeated after 1 week; fourfold titre increase is diagnostic
- Or IgM, if available, to diagnose on one sample
- IgM can persist for up to a month
- Viral culture is also possible
- For SSPE, can demonstrate high titres in serum and CSF
Management
- Most infectious just before rash; quickly becomes non-infectious after end of prodrome
- Supportive care
- Vitamin A can be given, especially if the child is deficien
- In children >1 year, vitamin A 200,000 IU daily for 2 days
- If 6-12 months old, use 100,000 IU for 2 days
- Less than 6 months, use 50,000 IU
- If deficient, give another dose at 2 to 4 weeks
- Ribavirin unhelpful but sometimes given
Prevention
Infection Control
- Infectious period is 5 days prior to until 4 days after onset of rash
- Need to do contact tracing, including people up to two hours after any room they were in
- All contacts should be quarantined at home regardless of symptoms
- Susceptible contacts should be placed in airborne precautions from 5 days after first exposure to 21 days after last exposure
Post-Exposure Prophylaxis (PEP)
- Use either MMR vaccine or immune globulin in susceptible people
- Immunization
- Should be offered to all susceptible, immunocompetent people age 6 months and older
- Give within 72 hours of exposure
- Can shorten the time to rash, suggesting a shorter period of infectiousness
- Immunoglobulin can provide short-term protection to certain susceptible, immunocompromised people
- Given to people with high risk for severe or fatal measles and are susceptible:
- Susceptible pregnant women
- Susceptible immunocompromised people
- Regardless of prior vaccination, should also be considered in advanced HIV
- Regardless of prior vaccination, should also be consider in all patients with hematopoietic stem cell transplantation until they have been revaccinated post-transplant with confirmed adequate antibody titres
- Susceptible infants <6 months of age
- Susceptible immunocompetent infants from 6 to 11 months of age who present after 72 hours
- Give within 6 days of exposure
- Given to people with high risk for severe or fatal measles and are susceptible:
Population | Time since measles exposure | |
---|---|---|
β€72 hours | 73 hours to 6 days | |
Susceptible infants <6 months old | IMIg 0.5 mL/kg | |
Susceptible immunocompetent infants 6-12 months old | MMR | IMIg 0.5 mL/kg |
Susceptible immunocompetent people β₯12 months old | MMR | |
Susceptible pregnant people | IVIg 400 mg/kg (preferred) or IMIg 0.5 mL/kg | |
Immunocompromised individuals | IVIg 400 mg/kg (preferred) or IMIg 0.5 mL/kg | |
People with confirmed immunity | None |
Vaccination
- Live vaccine (given in MMR or MMRV) at 12-15 months, with a booster later in childhood between 18 months and school entry
- Wait at least 5-6 months after receiving immunoglobulin
- Wait at least 4 weeks from a dose given before 12 months for post-exposure prophylaxis
- No adverse effects of revaccination
- Rates need to be >95% to prevent imported cases from causing outbreaks
- Rates less than 80% allow endemic transmission with cyclical outbreaks every 3-5 years
- Vaccination is contraindicated in advanced HIV, other cell-mediated immunodeficiency, and in pregnancy
- Wait 3 months after chemotherapy
- Don't use MMRV, since no safety data are available
- Can be associated with anaphylaxis in patients with true egg allergy
Vaccine Failure
- Improper storage >4ΒΊ C
- Failure to use proper diluent for lyophilized vaccine
- Exposure to light or heat
- Vaccination in the presence of passive antibody
Catch-Up
- 2 doses of MMR at least 4 weeks apart
Further Reading
- Measles vaccine: Canadian Immunization Guide. Public Health Agency of Canada.