* - Measles virus infection (rubeola) during pregnancy, tends to be severe, with pneumonitis predominating. Rubeola is associated with spontaneous abortion and premature labor. Neonates born to mothers with active measles virus infection are at risk of developing measles, but no congenital syndrome has been described
GENERAL MEASURES
. Symptomatic therapy (i.e., antipyretics, antitussives, humidification, encourage oral fluids) . Control
. All cases should be placed in respiratory isolation until 4 days after the onset of the exanthem; immunocompromised patients should be isolated for the entire illness
. Notify public health offi cials of suspected cases
. Initiate preventive measures for all exposed susceptible persons or those at high risk for severe infection (i.e., symptomatic HIV infection, children less than 12 months)
. Live measles vaccine can provide protection to susceptible persons if given within 72 hours postexposure
. Immune globulin (Ig) given within 6 days postexposure can prevent or modify measles infection (0.25 mL/kg, maximum dose 15 mL; 0.5 mL/kg for immunocompromised patients)
. Patients with symptomatic HIV infection should receive Ig regardless of prior immunization
. Ig also indicated for susceptible household contacts of measles patient and pregnant women
DRUG(S) OF CHOICE
β’ No proven specific antiviral agent is available
β’ Following the onset of infection, immune globulin has no significant effect on symptoms and duration of illness
β’ Antibiotics reserved for bacterial superinfection
ALTERNATIVE DRUGS
. Vitamin A
. 200,000 IU po per day for 2 days (100,000 IU between 6-12 months) has been shown to decrease the mortality and morbidity of severe measles in areas where vitamin A defi ciency exists and mortality related to measles is . 1%; effi cacy in non-life-threatening infections not established
. Vitamin A currently recommended for the following patients:
- Children 6-24 months hospitalized with complications of measles
- Children over 6 months with immunodefi ciency, malabsorption, moderate to severe malnutrition, ophthalmologic evidence of vitamin A deficiency, or recent immigration from areas with vitamin A deficiency
. Ribavirin
. Virus susceptible in vitro to ribavirin
. Immunosuppressed children with severe measles have been treated with IV or aerosolized ribavirin, but no controlled data and not approved by FDA
PATIENT MONITORING Not required unless complications develop
PREVENTION/AVOIDANCE
. Postexposure prophylaxis
. Vaccine use - protective if given within 72 hours postexposure
. Immune globulin (Ig) - prevents/modifi es illness if given within 6 days postexposure. Dose - usually 0.25 mL/kg IM (for immunocompromised children 0.5 mL/kg IM) not to exceed 15 mL. Indicated for the following
susceptible household contacts: Infants under 1 year, pregnant women, and immunocompromised persons, all HIV infected children and adolescents regardless of prior measles immunization status should if exposed receive IVIG (400 mg/kg) or IG prophylaxis (0.5 mL/kg) unless on monthly IVIG (last dose within the previous 3 weeks)
. Active immunization:
. Live further-attenuated strain vaccine - only currently licensed vaccine available as monovalent vaccine or
in combination with mumps and rubella i.e., measles and rubella (MR); measles, mumps and rubella (MMR)
. Indications:
. Primary vaccination: Two doses of vaccine; 1st MMR at 12-15 months, 2nd dose of MMR SQ at school age (4-6 years). Two dose vaccination schedule mandated by need to compensate for primary vaccine failures and global efforts to eradicate measles. During outbreaks, monovalent measles vaccine may be given to infants > 6 months. These children must be vaccinated with MMR as above. For a comprehensive discussion of the complete use and control of measles outbreaks, the reader is referred to the first listing in References.
. HIV infected children should be vaccinated while asymptomatic and before they develop profound
immunosuppression. One case of a HIV infected young adult with advanced disease who developed measles vaccine virus associated pneumonitis post vaccination. The 2nd dose of vaccine may be given as early as 1 month after the 1st dose.
. Adverse events associated with vaccination (in 5-15% of susceptible vaccinees):
. Fever (7-12 days after)
. Transient rashes (in 5% of vaccinees)
. Convulsions (most likely febrile)
. Children with egg allergy are at low risk for anaphylactic reactions to MMR
. Recent epidemiological evidence has not substantiated any linkage between MMR vaccine and autism
POSSIBLE COMPLICATIONS
. Otitis media (most common)
. Laryngotracheitis
. Bronchopneumonia - viral (Hechts or giant cell pneumonitis) or bacterial in origin
. Encephalitis (incidence 1 per 1000)
. Hemorrhagic lesions (black measles) of skin and bowel
. Thrombocytopenic purpura
. Myocarditis and pericarditis
. Subacute sclerosing panencephalitis - secondary to persistent infection following natural disease; disappearing as a result of mass vaccination
EXPECTED COURSE/PROGNOSIS
Self-limited; prognosis good