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Infectious Diseases

Measles

An acute, highly communicable viral infection caused by the measles virus, characterized by fever, cough, coryza, conjunctivitis, Koplik's spots, followed by a generalized maculopapular rash. A notifiable disease.

Also known as: Rubeola

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Referral and warning signs

When to refer

Refer to Hospital (HC4/H) if: Signs of complications (pneumonia, dehydration, croup, encephalitis, seizures, corneal ulceration). Severe malnutrition. Immunocompromised child. Infant <6 months.

Red flags

  • Difficulty breathing / Respiratory distress / Chest indrawing.
  • Altered consciousness / Lethargy / Seizures.
  • Signs of severe dehydration.
  • Corneal clouding or ulceration.
  • Inability to drink or feed.
  • Persistent vomiting.
  • Bleeding.

Signs and symptoms

  • Incubation period: 10-14 days.
  • Prodromal (Catarrhal) Stage (2-4 days):
  • - High fever.
  • - The '3 Cs': Cough (often barking), Coryza (runny nose), Conjunctivitis (red, watery eyes, photophobia).
  • - Koplik's Spots: Pathognomonic sign. Small white/bluish-white spots on an erythematous base on the buccal mucosa (opposite molars). Appear 1-2 days before rash, fade quickly.
  • - Malaise, anorexia.
  • Eruptive (Rash) Stage:
  • - Maculopapular rash (red, blotchy, slightly raised spots that may coalesce).
  • - Typically starts behind ears and on hairline -> spreads downwards to face, trunk, and limbs over 2-3 days.
  • - Rash often accompanied by peak fever.
  • - Rash fades in order of appearance after 3-7 days, may leave brownish discoloration and fine desquamation (peeling).
  • Other symptoms: Diarrhoea, vomiting, lymphadenopathy.

Risk factors

  • Lack of immunization (MMR/Measles vaccine).
  • Infancy (especially after maternal antibodies wane ~6-9 months, before first vaccine dose).
  • Immunocompromised individuals (HIV, malnutrition) - risk of severe disease.
  • Vitamin A deficiency.
  • Crowded living conditions.
  • Travel to endemic areas.

Diagnosis

Clinical assessment

Diagnosis usually clinical, based on characteristic prodrome (fever + 3 Cs), presence of Koplik's spots (if seen), followed by typical descending maculopapular rash.

Differential diagnosis

  • Rubella (German Measles) (milder prodrome, rash spreads faster, postauricular/suboccipital nodes).
  • Roseola Infantum (Exanthem Subitum) (high fever first, rash appears as fever breaks).
  • Scarlet Fever (sandpaper rash, strawberry tongue, Pastia's lines).
  • Kawasaki Disease (prolonged fever, conjunctivitis, rash, lymphadenopathy, changes in extremities, coronary aneurysms).
  • Drug eruptions.
  • Other viral exanthems (Enterovirus, Adenovirus).
  • Dengue Fever (rash variable).

Investigations

  • Clinical diagnosis usually sufficient, especially during outbreaks.
  • Serology: Detection of Measles-specific IgM antibodies in serum (confirms acute infection, appears few days after rash onset). IgG for immunity status.
  • RT-PCR: Detection of measles virus RNA from throat swab, nasopharyngeal aspirate, or urine (useful early in illness or for outbreak confirmation).

Diagnostic criteria

Clinical case definition (fever + maculopapular rash + at least one of Cough/Coryza/Conjunctivitis) +/- Laboratory confirmation (IgM/PCR).

Management

Non-pharmacological management

  • Supportive Care:
  • - Maintain hydration (oral fluids, IV if needed).
  • - Nutritional support (encourage feeding, manage malnutrition).
  • - Rest.
  • - Tepid sponging for high fever.
  • - Eye care: Clean eyes gently. Tetracycline eye ointment 1% BID for 5 days (as per UCG) if conjunctivitis severe or secondary infection suspected.
  • Isolation: Prevent spread (highly contagious via respiratory droplets). Isolate for 4 days after rash onset.

Pharmacological treatment

  • Vitamin A Supplementation: Crucial. Reduces morbidity (pneumonia, diarrhoea, blindness) and mortality. Give to ALL children diagnosed with measles.
  • - Dosing (WHO/UCG Protocol): Give 2 doses 24 hours apart.
  • - Age <6 months: 50,000 IU PO daily x 2 doses.
  • - Age 6-11 months: 100,000 IU PO daily x 2 doses.
  • - Age ≥12 months: 200,000 IU PO daily x 2 doses.
  • - Give a third dose 2-4 weeks later (Day 14 per UCG) if signs of Vitamin A deficiency present (xerophthalmia).
  • Antipyretics: Paracetamol for fever/discomfort. (LOC: HC2)
  • Antibiotics: ONLY for treating secondary bacterial complications (e.g., pneumonia, otitis media, diarrhoea with suspected bacterial cause). NOT for uncomplicated measles. Choice depends on complication (e.g., Amoxicillin for pneumonia/otitis).
  • Antivirals (Ribavirin): Investigational, may be considered in severe cases in immunocompromised (specialist use).

Monitoring

Monitor for complications, especially respiratory distress (pneumonia), dehydration (diarrhoea/vomiting), neurological signs (encephalitis), eye signs (keratitis), and nutritional status.

Complications

  • Diarrhoea (common).
  • Otitis Media (common).
  • Pneumonia (most common cause of death - viral or secondary bacterial).
  • Laryngotracheobronchitis (Croup).
  • Keratoconjunctivitis / Corneal ulceration / Blindness (esp. if Vit A deficient).
  • Encephalitis (Acute post-infectious).
  • Subacute Sclerosing Panencephalitis (SSPE) (rare, fatal degenerative CNS disease years later).
  • Thrombocytopenia.
  • Myocarditis.
  • Exacerbation of Tuberculosis.
  • Severe Acute Malnutrition (SAM).
  • Noma (Cancrum oris).

Prevention

  • Vaccination: Highly effective Measles-containing vaccine (MCV - typically MMR or MR) given as part of routine childhood immunization schedule (e.g., at 9 months and 15-18 months). Supplementary Immunization Activities (SIAs)/Campaigns crucial.
  • Post-Exposure Prophylaxis (PEP):
  • - Vaccine: If given within 72 hours of exposure to susceptible individuals.
  • - Immunoglobulin (IG): For susceptible high-risk contacts (infants <6-12m, pregnant women, immunocompromised) given within 6 days of exposure.
  • Isolation of cases.
  • Vitamin A supplementation in endemic areas.

Patient education

  • Explanation of measles as contagious viral illness.
  • Importance of supportive care (fluids, nutrition).
  • Role of Vitamin A.
  • Antibiotics only needed for complications.
  • Isolation to prevent spread.
  • Recognizing danger signs requiring immediate return.
  • Importance of completing routine vaccinations for prevention.

Uganda-specific notes

Measles outbreaks still occur despite vaccination efforts, often affecting unvaccinated or malnourished children. Pneumonia and diarrhoea are major causes of mortality. Vitamin A administration is a critical intervention. Case-based surveillance and reporting essential.

References

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 2, Section 2.3.3

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 17 (IMCI)

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 18 (Immunization)

For learning and professional reference. Use current local guidance and clinical judgement.

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