Measles (Rubeola)
Description
Measles is an acute, highly communicable viral disease
with prodromal fever, conjunctivitis, coryza, cough, and Koplik spots
on the buccal mucosa. A characteristic red blotchy rash appears around
the third day of illness, beginning on the face and becoming generalized.
Measles is frequently complicated by middle ear infection or diarrhea.
The disease can be severe, with bronchopneumonia or brain inflammation
leading to death in approximately 2 of every 1,000 cases.
Occurrence
Prior to widespread immunization, measles was common
in childhood, with >90% of infants and children infected by 12
years of age. Since vaccine licensure in 1963, measles elimination
efforts in the United States have resulted in record low numbers
of reported measles cases. Since 1997, there have been <150 measles
cases reported annually. Many of these cases were imported from outside
the United States and occurred among adults; roughly half occurred
in U.S. residents returning from visits to foreign countries. The
risk of exposure to measles in the United States is low. Unvaccinated
older persons may still be susceptible to measles.
Risk for Travelers
The risk of exposure to measles outside the United
States could be high. Measles remains a common disease in many countries
of the world, including some developed countries in Europe and Asia.
Prevention
Vaccine
Measles vaccine contains live, attenuated measles
virus. It is available as a single-antigen preparation or combined
with live, attenuated mumps or rubella vaccines, or both. Combined
measles, mumps, and rubella (MMR) vaccine is recommended whenever
one or more of the individual components are indicated.
Although vaccination against measles, mumps, or
rubella is not a requirement for entry into any country (including
the United States), persons traveling or living abroad should ensure
that they are immune to all three diseases. In general, travelers
can be considered immune to measles if they have documentation of
physician-diagnosed measles, laboratory evidence of measles immunity,
or proof of receipt of two doses of live measles vaccine on or after
their first birthday. Most persons born before 1957 are likely to
have had measles disease and generally need not be considered susceptible.
However, measles or MMR vaccine may be given to these persons if
there is reason to believe they might be susceptible.
The first dose of MMR should be routinely administered
when the infant is 12–15 months of age. A single dose of MMR
vaccine induces antibody formation to all three viruses in at least
95% of susceptibles vaccinated at 12 months of age or older.
A second dose is expected to induce immunity in most vaccinees who
do not respond to the first dose. The second dose should be administered
at 4–6 years of age and should be separated from the first
dose by at least 28 days. See Vaccine
Recommendations for Infants and Children for
a discussion of measles immunization schedule modifications for infants
who will be traveling.
MMR may be administered simultaneously (but in a
different site) with any other live or inactivated vaccine. Inactivated
vaccines and typhoid vaccines may be administered at any time before
or after live measles-containing vaccine. However, if MMR vaccine
and live yellow fever vaccine are not administered simultaneously,
they should be separated by an interval of at least 28
days. (See U.S.
Public Health Service Recommendations for more
details.)
Adverse Reactions
Fever and rash are the most common adverse reactions
following MMR vaccine and are usually attributable to the measles
component. Approximately 5% of vaccinees have fever >39.4° C
(>103° F) or a generalized rash. Fever and rash usually occur
7–12 days after vaccination and last 1–2 days. Transient
lymphadenopathy sometimes occurs after MMR and is attributable to
the rubella component. Parotitis has been reported rarely after MMR
receipt and is attributable to the mumps component of the vaccine.
Joint symptoms (arthralgia or arthritis or both) are reported in
25% or fewer of rubella-susceptible postpubertal
women who receive MMR or other rubella-containing vaccine. Joint
symptoms are usually mild and transient. Allergic reactions have
been reported after MMR vaccine, ranging from mild (urticaria or
wheal and flare at the injection site, generalized rash, and pruritis)
to severe anaphylactic reactions. Severe allergic reactions are estimated
to occur less than once per million doses. Clinically apparent low
platelet counts have been reported at a rate of <1 case per 30,000
doses. Central nervous system conditions, including aseptic meningitis,
encephalitis, and encephalopathy, have been reported after MMR receipt,
but are very uncommon (<1 one case per million doses).
Adverse reactions occur only in susceptible vaccine
recipients and do not appear to be age related. Reactions following
the second dose of MMR (except allergic reactions) occur only among
the small proportion of persons who do not respond to the first dose.
Precautions and Contraindications
Allergy. Persons with severe allergy (i.e.,
hives, swelling of the mouth or throat, difficulty breathing, hypotension,
and shock) to gelatin or neomycin or who have had a severe allergic
reaction to a prior dose of MMR should not be vaccinated with MMR
except with extreme caution.
In the past, persons with a history of anaphylactic
reactions after eating eggs were considered to be at increased risk
of serious reactions after receipt of measles- and mumps-containing
vaccines, which are produced in chick embryo fibroblasts. However,
recent data suggest that anaphylactic reactions to measles- and mumps-containing
vaccines are not associated with hypersensitivity to egg antigens,
but to other components of the vaccines (such as gelatin). The risk
for serious allergic reactions following receipt of these vaccines
by egg-allergic persons is extremely low, and skin testing with vaccine
is not predictive of allergic reaction to vaccination. MMR may be
administered to egg-allergic persons without prior routine skin testing
or the use of special protocols.
Pregnancy. Pregnant women should not receive
MMR vaccine. Pregnancy should be avoided for 1 month after receipt
of monovalent measles vaccine and MMR or other rubella-containing
vaccines. Close contact with pregnant women is not a contraindication
to MMR vaccination.
Breast-feeding is not a contraindication to MMR
vaccination of either a woman or an infant. MMR vaccination has no
effect on antibiotics or antimalarial drugs, and the drugs do not
reduce the immunogenicity of MMR. Women taking these products should
be vaccinated as usual.
Immunosuppression. Replication of vaccine
viruses can be prolonged in persons who are immunosuppressed or immunodeficient
for any reason (e.g., who have congenital immunodeficiency, HIV infection,
leukemia, lymphoma, or generalized malignancy, or who are receiving
therapy with alkylating agents, antimetabolites, radiation, or large
doses of corticosteroids). Evidence based on case reports has linked
infection with measles vaccine virus to subsequent death in six severely
immunosuppressed persons. For this reason, persons who are severely
immunosuppressed for any reason should not be given MMR vaccine.
Healthy, susceptible close contacts of severely immunosuppressed
persons may be vaccinated.
In general, persons receiving large daily doses
of corticosteroids (>2 mg per kg per day or >20 mg per day
of prednisone) for 14 days or moreshould not receive MMR vaccine
because of concern about vaccine safety. MMR and its component vaccines
should be avoided for at least 1 month after cessation of high-dose
therapy. Persons receiving low-dose or short-course (<14 days)
therapy; alternate-day treatment; maintenance physiologic doses;
or topical, aerosol, intra-articular, bursal, or tendon injections
may be vaccinated. Although persons receiving high doses of systemic
corticosteroids daily or on alternate days during an interval of <14
days generally can receive MMR or its component vaccines immediately
after cessation of treatment, some experts prefer waiting until 2
weeks after completion of therapy. Persons receiving cancer chemotherapy
or radiation who have not received these treatments for at least
3 months may receive MMR or its component vaccines.
Measles disease can be severe in persons with HIV
infection. Available data indicate that vaccination with MMR has
not been associated with severe or unusual adverse events in HIV-infected
persons without evidence of severe immunosuppression, although antibody
responses have been variable. MMR vaccine is recommended for all
asymptomatic HIV-infected persons and should be considered for symptomatic
persons who are not severely immunosuppressed. Asymptomatic HIV-infected
infants, children, and adolescents do not need to be evaluated and
tested for HIV infection before MMR or other measles-containing vaccines
are administered. A theoretical risk of an increase (probably transient)
in HIV viral load after MMR vaccination exists because such an effect
has been observed with other vaccines. The clinical significance
of such an increase is not known.
MMR and other measles-containing vaccines are not
recommended for HIV-infected persons with evidence of severe immunosuppression
(e.g., a very low CD4+ T-lymphocyte count), primarily because of
the report of a case of measles pneumonitis in a measles vaccine
recipient who had an advanced case of AIDS. Refer to the Advisory
Committee on Immunization Practices (ACIP) statement on MMR [1] for
additional details on vaccination of persons with symptomatic HIV
infection.
Acute Illness. Vaccination of travelers with
moderate or severe acute illness should be postponed until their
condition has improved. Minor illnesses, such as upper respiratory
infections with or without low-grade fever, do not preclude vaccination.
Immune Globulin or Other Antibody-Containing
Blood Products. MMR or its component vaccines should be administered at
least 14 days before the administration of antibody-containing
blood products, such as IG. Because passively acquired antibodies
might interfere with the response to the vaccine, MMR should be
delayed after administration of blood products. The length of delay
varies from 3 to 11 months, depending on the type of blood product
received. (See U.S.
Public Health Service Recommendations for
more details.)
Tuberculosis. Tuberculosis can be exacerbated
by measles disease. There is no evidence, however, that live measles
virus vaccine has such an effect. Purified protein derivative (PPD)
tuberculin testing is not a prerequisite for vaccination with MMR
or other measles-containing vaccine. PPD testing has no effect on
the response to MMR vaccination. However, measles vaccine (and possibly
mumps, rubella, and varicella vaccines) can suppress the response
to PPD in a person infected with Mycobacterium tuberculosis.
To minimize the risk of a false-negative interpretation, PPD testing
should be delayed for 4–6 weeks after MMR vaccination. If PPD
testing is needed, it should be done prior to MMR vaccination. In
addition, the PPD may be applied at the same time as MMR is administered,
because the mild immunosuppressive effect of the vaccine will not
occur for several days after vaccination.
— Mark
Papania
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