What are the management options for a patient with measles, considering various patient populations such as those with weakened immune systems (e.g. Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome (HIV/AIDS)) or unvaccinated individuals?

Management of Measles

Immediate Isolation and Infection Control

All patients with suspected or confirmed measles must be immediately isolated in an airborne infection isolation room for at least 4 days after rash onset, as they remain contagious from 4 days before through 4 days after rash appearance 1.

• Healthcare workers must wear N95 respirators or equivalent respiratory protection when entering the room, regardless of their immunity status 1, 2.
• Only staff with documented evidence of measles immunity should provide direct patient care 1.
• Airborne precautions are critical because measles is one of the most contagious infectious diseases, with transmission occurring through respiratory droplets and airborne spread 3, 4.

Vitamin A Supplementation: The Only Evidence-Based Mortality Reduction Intervention

All children and adults with clinical measles should receive vitamin A supplementation immediately, as this is the only intervention proven to reduce measles-related morbidity and mortality 1, 3.

Standard Dosing:

• Adults and children ≥12 months: 200,000 IU orally 1, 3
• Children <12 months: 100,000 IU orally 1, 3
• Do not administer if vitamin A was given within the previous month 3

Repeat Dosing for Complicated Measles:

• Give a second dose of vitamin A on day 2 for patients with complications including pneumonia, otitis media, croup, diarrhea with dehydration, or neurological problems 1, 3.

Extended Treatment for Eye Symptoms:

If any eye symptoms of vitamin A deficiency are present (xerosis, Bitot's spots, keratomalacia, or corneal ulceration), administer 3, 1:

• 200,000 IU oral vitamin A on day 1
• 200,000 IU oral vitamin A on day 2
• 200,000 IU oral vitamin A 1-4 weeks later
• Children <12 months receive half doses for all three administrations 3

Supportive Care and Complication Management

Treatment is primarily supportive, as no specific antiviral therapy exists for measles 4.

• Monitor nutritional status closely and enroll malnourished patients in feeding programs 1, 3.
• Treat diarrhea with oral rehydration therapy 1, 3.
• Administer antibiotics for bacterial superinfections including acute lower respiratory infection, pneumonia, and otitis media 1, 3, 4.
• Monitor for serious complications affecting multiple organ systems, including laryngotracheobronchitis, stomatitis, and neurological complications such as acute disseminated encephalomyelitis 4.

Special Populations Requiring Enhanced Management

Immunocompromised Patients (Including HIV/AIDS)

Severely immunocompromised patients who are exposed to measles should receive immune globulin (IG) 0.5 mL/kg intramuscularly (maximum 15 mL) regardless of vaccination status 1, 3.

• Severely immunocompromised HIV-infected persons are defined as those with CD4+ counts <200 for persons ≥6 years, <500 for children 1-5 years, or <750 for children <12 months 3.
• Alternatively, CD4+ T-lymphocytes <14% of total lymphocytes for persons ≥13 years or <15% for children <13 years 3.
• For patients receiving regular IGIV (100-400 mg/kg), intramuscular IG may not be needed if exposure occurs within 3 weeks of the last IGIV dose 3.
• Unimmunized HIV-infected persons without severe immunosuppression should receive measles vaccine, as undernutrition and HIV infection are not contraindications to vaccination 3.

Pregnant Women

Pregnant women exposed to measles should receive IG 0.25 mL/kg (maximum 15 mL) within 6 days of exposure 1.

Unvaccinated Individuals

Unvaccinated persons exposed to measles should receive MMR vaccine within 72 hours of exposure, which can prevent or modify disease 5.

• If MMR is contraindicated or the exposure occurred >72 hours ago but <6 days, administer IG 0.25 mL/kg (maximum 15 mL) 3.
• Observe exposed individuals for 21 days after exposure (or 28 days if IG was administered) 5.

Critical Pitfalls to Avoid

Do not use surgical masks instead of N95 respirators - measles requires airborne precautions, not just droplet precautions 1, 2.

Do not forget vitamin A supplementation - this is the only evidence-based intervention to reduce measles mortality and must be given to all patients with clinical measles 1, 3.

Do not delay isolation - patients are contagious before rash appears, and nosocomial transmission can result in large numbers of exposed contacts requiring post-exposure prophylaxis 6, 7.

Do not assume fever, respiratory infection, diarrhea, or undernutrition are contraindications to measles vaccination - these conditions are actually strong indications for vaccination in exposed individuals 3.

Do not discontinue isolation prematurely - maintain full airborne precautions for the complete 4-day period after rash onset 1.