Forgotten but not gone: Update on measles infection for hospitalists
Measles (rubeola) continues to be endemic and epidemic in many regions of the world. Measles is primarily a disease of childhood, but it can also affect adult populations, and therefore it is important that both adult and pediatric hospitalist physicians be able to recognize it. Although the disease is rarely encountered in the United States, measles infection can spread rapidly across vulnerable populations. In addition, infected adults can develop complications that may require hospitalization for treatment. This review summarizes the typical clinical course and complications of measles infection, along with recommendations for diagnosis and management for both adult and pediatric hospitalists. Journal of Hospital Medicine 2017;12:472-476. © 2017 Society of Hospital Medicine
© 2017 Society of Hospital Medicine
MANAGEMENT
General Principles
Uncomplicated measles treatment is supportive and includes oral fluids and antipyretics.7,22 Severe bacterial infections, encephalitis, or dehydration may require hospitalization, and in these cases infectious disease consultation is recommended. Patients with pneumonia, purulent otitis media, or tonsillitis should be treated with antibiotics.35 Observational data suggest antibiotics may reduce the occurrence of bacterial infection in children, but there are no usage guidelines.35 Vitamin A supplementation has been associated with a 50% decrease in morbidity and mortality and with blindness prevention.22 This supplementation should be considered in severe measles cases (all hospitalized patients), especially for children, regardless of country of residence, and for adult patients who exhibit clinical signs of vitamin A deficiency.22,24
Antiviral Treatment
No specific treatment is available.36 Ribavirin demonstrates in vitro activity against the virus, but the Food and Drug Administration has not approved the drug for treatment of measles. Ribavirin has been used for cases of severe measles, and for patients with SSPE along with intrathecal interferon alpha. This antiviral treatment is considered experimental.37
All patients hospitalized with measles infection should be cautioned about the potential downstream complications of the disease and should follow up with their primary care physician for surveillance after discharge.38
If measles symptoms develop, patients should self-quarantine and contact their primary care physician or public health department as soon as possible. Regardless of immune status, family members and other exposed persons should be educated about the measles symptoms that may occur during the 21 days after exposure.38
Both suspected and confirmed cases of measles should be reported immediately to local public health authorities.
Infection Control and Prophylaxis
Current guidelines recommend 2 doses of measles-containing vaccine to all adults at higher risk for contracting measles: international travelers, healthcare personnel, and high school and college students. Infants 6 or 11 months old should receive 1 MMR dose before international travel.1,38
Strict airborne isolation—use of N95 respirator or respirator with similar effectiveness in preventing airborne transmission—is mandatory from 3 to 5 days before rash onset to 4 days after rash onset (immunocompetent patients) or for the duration of the disease (immunocompromised patients).38
Healthcare workers should have documented presumptive evidence of immunity to measles.39 Healthcare providers without evidence of immunity should be excused from work from day 5 to day 21 of exposure, even if they have received postexposure vaccine or intramuscular immunoglobulin. They should be offered the first MMR dose within 72 hours of measles exposure to prevent or modify the disease. Susceptible family members or visitors should not be allowed in the patient’s room.1
Postexposure Prophylaxis
Standard MMR vaccination within 72 hours after exposure may protect against disease in people without a contraindication to measles vaccine. The public health department usually identifies these individuals and provides postexposure prophylaxis recommendations.38,39
People with HIV, patients receiving immunosuppressive therapy, and pregnant women and infants who have been exposed to measles and who are at risk for developing morbid disease can be treated with immunoglobulin (IG). If administered within 6 days of exposure, IG can prevent or modify disease in people who are unvaccinated or severely immunocompromised (ie, not immune). The recommended dose of IG administered intramuscularly is 0.5 mL/kg of body weight (maximum, 15 mL), and the recommended dose of IG given intravenously is 400 mg/kg. Anyone heavier than 30 kg would require intravenous IG to achieve adequate antibody levels.
Physicians should not vaccinate pregnant women, patients with severe immunosuppression from disease or therapy, patients with moderate or severe illness, and people with a history of severe allergic reaction to the vaccine.1,40 The measles vaccine should be deferred for 6 months after IG administration.36 More details are available in the recommendations made by the Advisory Committee on Immunization Practices.1
CONCLUSION
Although rare in the United States, measles remains a common and potentially devastating infection among patients who have not been vaccinated. Diagnosis requires clinical suspicion, engagement of public health authorities, and judicious use of laboratory testing. Hospitalists may encounter infectious and neurologic complications of measles long after the initial infection and should be aware of these associations.
Disclosure
Nothing to report.
