Measles (Rubeola)

Picture of measles rash; SOURCE: CDC/Dr. Heinz F. Eichenwald

Facts You Should Know About Measles

1. Measles is an extremely contagious viral disease that causes a high fever, generalized rash, runny nose, cough, red eyes without discharge, and can have severe complications, including death.
2. Anyone who has a fever and a rash should seek medical attention.
3. Though there is no specific measles treatment or cure, there are home remedies that can help alleviate symptoms and signs.

Measles is vaccine-preventable illness best known for causing a high fever (often up to 104 F), a characteristic rash, cough, runny nose (coryza), and redness of the eyes without discharge (conjunctivitis). Measles may occur in any nonimmune person -- both children and adults. Vaccination has significantly reduced the number of cases in the United States, although at the time of this article, a nationwide outbreak has been predominantly due to an increased number of individuals refusing vaccination.

There are two types of measles, each caused by a different virus. Although both produce a rash and fever, they are different diseases. When most people use the term measles, they are referring to the first condition below.

• The rubeola virus causes "red measles," also known as "hard measles" or just "measles." Although most people recover without problems, rubeola can lead to ear infections, pneumonia, or inflammation of the brain (encephalitis).
• The rubella virus causes "German measles," also known as "3-day measles." This is usually a milder disease than red measles. However, this virus can cause profound birth defects if an infected pregnant woman passes the virus to her unborn child.

Rubeola ("red measles" or "hard measles")

Symptoms and signs appear about 8 to 12 days after the rubeola virus infects a person. This time between exposure to the measles virus and the development of initial symptoms is the incubation period. Symptoms and signs occur in two phases.

• The early phase begins with these symptoms:
  • Fever (up to 104 F)
  • A run-down or lethargic feeling
  • Cough
  • Red watery eyes without discharge (conjunctivitis)
  • Runny nose (coryza)
  • Loss of appetite
• The red measles rash develops 2 to 4 days after the onset of the initial symptoms and signs.
  • The rash usually starts on the face, spreading to the trunk and then to the arms and legs.
  • The rash is initially small red bumps that may blend into each other as more appear. From a distance, the rash often looks uniformly red. The rash lasts for 5 to 7 days.
  • People with measles may develop small grayish spots on the inside of the cheek called "Koplik spots." Koplik spots are about the size of a grain of sand with the gray spots having a red collarette. They are not painful.
  • The skin rash is usually not itchy or painful, but as it clears up, the skin may shed (this looks like skin that is peeling after a sunburn).
  • Patients with measles look and feel miserable. Common (10%) complications include ear infections and diarrhea. Approximately 1 in 20 people with measles develop pneumonia. This complication is especially serious in infants and is responsible for most deaths in this age group. Inflammation of the brain (encephalitis) occurs about once in every thousand cases of measles and is a serious complication that can be fatal. Overall, approximately 1 in 1,000 people who develop measles will die from a complication of the disease. Young unvaccinated infants and those with compromised immune systems are most vulnerable.
  • Red measles is particularly severe in people with weakened immune systems, including people who are malnourished, receiving chemotherapy, or have HIV.
  • A rare and always fatal delayed complication of measles is SSPE (subacute sclerosing panencephalitis). This condition will develop 7-10 years after experiencing measles and is most frequent in people who developed measles at less than 2 years of age.
  • Measles contracted during pregnancy can be associated with prematurity and low birth weight in the newborn.

Rubella ("German measles")

German measles causes milder symptoms than red measles. The incubation period between getting the virus and getting sick is 16-18 days.

• Initially, some people experience fatigue, low-grade fever, headache, or red eyes several days before the rash appears. These symptoms and signs are more common in adults than in children.
• Swollen, tender lymph nodes may occur in the back of the neck.
• The rash is light red to pink. It starts as individual spots that may merge over time. The rash usually starts on the face and moves down to the trunk.
• The rash does not usually itch, but as it clears up, the skin may shed. Individuals are most contagious a few days before the rash develops to seven days after it first appeared.
• Adolescents and adults who get rubella may get painful joints for days to weeks after the infection. This typically affects the hands, wrists, and knees.
• Symptoms and signs may be so mild that people do not notice them, especially in children. Studies have shown that approximately 25%-50% of infected people do not have any symptoms or signs. Most symptoms resolve in a few days, but swollen lymph nodes may persist for a few weeks.
• The most feared complication of rubella is "congenital rubella," which occurs when an infected pregnant woman passes the virus to her unborn child. Among other problems and birth defects, affected infants may have cataracts, heart defects, hearing impairment, and learning disabilities. The risk of transmission is highest early in pregnancy. The virus may also cause miscarriage or stillbirth.

Both the rubeola and rubella viruses spread through the respiratory route. This means they infect susceptible individuals exposed to an infected person who is coughing and sneezing. The rash is not contagious. The rubeola virus is one of the most contagious viruses known to man. As a result, it can spread rapidly in a susceptible population.

If people are immune to the virus (either through vaccination or by having had measles in the past), they cannot get the disease caused by that virus. For example, someone who had rubeola as a child would not be able to get the disease again. Remember that rubella and rubeola are different viruses. An infection with or vaccination against one of these viruses does not protect against infection with the other.

Infected people carry the virus in their respiratory tract before they get sick, so they can spread the disease without being aware of it. This is because there is an 8- to 12-day incubation period. The incubation period is the time between exposure to the measles virus and the onset of first symptoms.

Both rubella and rubeola have become so uncommon that those affected normally go to their doctor with a rash and the other associated findings noted above. In general, both children and adults who have a fever and a rash should contact their physician. Doctors should evaluate people who encounter an infected person to see if they need special measures to keep them from developing measles. Normally, measles is not a disease that requires emergency care or hospitalization.

• Depending on the symptoms, the doctor may diagnose measles based on the patient's history and physical exam alone.
• In questionable cases, the doctor can perform specialized blood tests to help with the diagnosis, but these tests usually are unnecessary.
• Blood tests can also determine if a person is immune to measles.

There is no specific antiviral treatment or cure for measles. Children should stay at home and out of school until cleared to return by their health care professional. Health researchers have noticed that some children in underdeveloped countries or those throughout the globe who develop a severe case of measles have low vitamin A blood levels and seem to have a reduction of their symptoms if given vitamin A supplementation. Current guidelines are that all patients with rubeola should start a 2-day course of vitamin A at the time of diagnosis.

Although there is no cure for measles, there are steps that can make the disease tolerable. These include the following:

• Get plenty of rest.
• Sponge baths with lukewarm water may reduce discomfort due to fever.
• Drink plenty of fluids to help avoid dehydration.
• A humidifier or vaporizer may ease the cough and nasal congestion.
• Pain relievers and fever reducers such as acetaminophen (Tylenol and other brands) and ibuprofen (Advil, Motrin, and other brands) can help with symptoms when used according to directions. Remember never to give aspirin to children or teenagers because it may cause a disease known as Reye syndrome. Reye syndrome is a rare and often fatal disease affecting the brain and liver.

Although complications are rare, one should contact a physician if symptoms worsen or do not resolve, or if there is confusion or change in the level of consciousness. Shortness of breath, a cough that produces sputum, and/or chest pain may be symptoms of pneumonia. Doctors must report all cases of rubeola and rubella to the local public health department. This allows close monitoring, which is necessary to track new cases and enables the U.S. Centers for Disease Control and Prevention (CDC) to have up-to-date statistics for both local regions and the entire United States.

Because of widespread vaccination of children, both kinds of measles occur much less often than in the past. However, recently there have been a number of well-publicized outbreaks in communities around the United States. One of the most common scenarios would be the introduction of the measles virus from an overseas traveler during the incubation (and thus asymptomatic) period. Nonimmune people (for example, nonimmunized individuals) contract the disease and in turn expose other susceptible individuals. Studies regarding measles document that once generalized measles immunity falls below 90% of the population, herd immunity collapses, and an epidemic may develop. Herd immunity occurs when the large majority of the population is able to protect a much smaller and more vulnerable population.

The CDC documents that from the years 2000 to 2015 worldwide cases of measles declined from 37.7 million to 9.7 million. Worldwide deaths declined from 9.7 million to 134,000 individuals. This remarkable reduction was due to an aggressive program to provide vaccination for all nonimmune individuals. Such a similar measles immunization program allowed the CDC to announce in 2000 that measles had been eliminated in the United States. Unfortunately, due to a vocal anti-vaccination program, a resurgence of new cases of measles is currently under way. Newest data indicate that from Jan. 1, 2019, to Aug. 15, 2019, U.S. health officials documented 1,203 cases in 30 states. Due to the number of unvaccinated individuals, health officials do not anticipate a slowdown in the surge in cases in the near future. Regions in the United States which are experiencing a resurgence of measles include New York City (primarily among religiously conservative Jews), Pennsylvania (Amish region), southern Washington state, and Southern California (with a large anti-vaccine population).

• The most effective way to prevent measles is through immunization.
  • Children in the United States routinely receive the measles-mumps-rubella (MMR) vaccine according to a published immunization schedule. This vaccine protects against both red measles and German measles. Vaccination is required for entry into school.
  • Doctors usually give children their first dose of the measles immunization at 12-15 months of age. They commonly give a separate vaccination against chickenpox (varicella) at the same time.
  • Doctors give a second MMR immunization when the child is 4 to 6 years old, along with a second vaccination against varicella. The varicella vaccine may be combined with the MMR vaccination at this time. The combination MMR and varicella vaccine is called MMRV.
  • Although most children tolerate the MMR vaccination well, a few may develop a side effect of a low-grade (101 F) fever and even a rash from 5 to 12 days after the immunization. Adults who get the vaccine may notice short-term aching in their joints.
  • The MMR vaccine is about 95% effective in preventing measles of either type. That means that a small number of people who get the vaccine may still be able to get measles.
  • Many recent studies indicate that those with egg allergies may now get the MMR vaccine.
  • Rarely, the measles vaccine can cause a measles-like illness. This is most common in people with weak immune systems, such as those with advanced HIV or those on chemotherapy. These patients should balance the risk of vaccination carefully against the risk of getting measles.
  • Women who may become pregnant should have a blood test to be sure they are immune to rubella ("German measles"). If not immune to rubella, they should be immunized after delivery of their infant. There are no reports of fetal complications should a non-rubella-immune woman inadvertently receive an immunization against rubella.
• Both types of measles are still common in areas that do not offer immunization and in unimmunized people.
• As with all other contagious illnesses, covering the mouth when coughing or sneezing and good hand-washing practices will help prevent the spread of the diseases.
• A special immunization -- immune globulin -- may be necessary for certain high-risk people after a measles exposure. These include children younger than 1 year, children with weakened immune systems, and pregnant women. If exposed to measles, contact your physician to determine if you need immune globulin.

• Measles of either type usually clears up on its own in 7 to 10 days. Once a person has had a case of the measles, they are typically immune for life.
• As discussed above, complications are rare but may be serious. This is the reason why health care professionals recommend vaccination.