What are the treatment and prevention options for a patient suspected of having measles?

Management of Suspected Measles

Immediately isolate the patient in an airborne-infection isolation room (negative air-pressure) and implement strict airborne precautions with N95 respirators for all staff, regardless of immunity status, while initiating supportive care and vitamin A supplementation. 1

Immediate Infection Control Measures

Patient Isolation Protocol

• Ask the patient to wear a medical mask immediately upon arrival and place them in an airborne-infection isolation room (negative air-pressure room) as soon as possible 1
• If an airborne-infection isolation room is unavailable, place the patient in a private room with the door closed and ensure they wear a mask 1
• Maintain isolation until at least 4 days after rash onset, as patients are infectious from 4 days before through 4 days after rash onset 1, 2

Healthcare Worker Protection

• All staff entering the room must use N95 respirators or equivalent respiratory protection, regardless of presumptive immunity status, due to the ~1% possibility of vaccine failure 1
• Only staff with presumptive evidence of immunity should enter the room when possible 1
• Healthcare workers who develop measles must be excluded from work until ≥4 days following rash onset 1, 2

Diagnostic Confirmation

Laboratory Testing

• Obtain serum for measles-specific IgM antibody testing during the first clinical encounter using a sensitive and specific assay (e.g., direct-capture IgM EIA method) 1
• If the specimen is collected within 72 hours of rash onset and is negative, obtain a second specimen at least 72 hours after rash onset, as IgM may not be detectable initially 1
• Measles IgM becomes detectable at rash onset, peaks at approximately 10 days, and remains detectable for at least 1 month 1
• Consider viral RNA detection from throat/nasopharyngeal swabs, urine, or oral fluid for additional confirmation 3

Clinical Case Definition

A confirmed case requires either: 1

• Positive serologic test for measles IgM antibody, OR
• Significant rise in measles antibody level by standard serologic assay, OR
• Isolation of measles virus from clinical specimen, OR
• Clinical case definition (generalized rash ≥3 days + temperature ≥38.3°C + cough/coryza/conjunctivitis) with epidemiologic linkage to a confirmed case

Treatment and Supportive Care

Vitamin A Supplementation (Critical Intervention)

Administer vitamin A immediately to reduce mortality and complications: 4

• 200,000 IU orally for patients ≥12 months of age
• 100,000 IU orally for children <12 months
• Give a second dose on day 2 for complicated measles (pneumonia, otitis media, croup, diarrhea with dehydration, or neurological problems) 4
• If eye symptoms of vitamin A deficiency are present (xerosis, Bitot's spots, keratomalacia, corneal ulceration), administer a third dose of 200,000 IU 1-4 weeks after initial doses 4

Supportive Management

• Provide symptomatic treatment including fever management (avoid aspirin in children/adolescents due to Reye syndrome risk) 4
• Monitor for and treat secondary bacterial infections with appropriate antibiotics 3, 5
• Ensure adequate hydration, especially if severe diarrhea is present 3
• No specific antiviral therapy is routinely recommended for uncomplicated measles 3

Special Populations Requiring Aggressive Management

• Pregnant women, immunocompromised patients, and unvaccinated individuals require enhanced monitoring and may need additional interventions 6
• Consider ribavirin for severely immunocompromised patients, though efficacy is not definitively established 6

Post-Exposure Prophylaxis for Contacts

Immediate Contact Evaluation

All contacts must be evaluated immediately for presumptive evidence of measles immunity (documentation of 2 MMR doses, laboratory evidence of immunity, laboratory confirmation of disease, or birth before 1957) 1

Vaccination Strategy

• Administer MMR vaccine within 72 hours of exposure to prevent or modify disease in susceptible contacts 1
• Healthcare workers without evidence of immunity should receive the first dose of MMR vaccine and be excluded from work from day 5-21 following exposure 1
• Those with documentation of 1 vaccine dose may remain at work and should receive the second dose 1

Immune Globulin Administration

For contacts who cannot receive MMR vaccine (immunocompromised, pregnant, infants <12 months): 1

• Administer intramuscular immune globulin 0.25 mL/kg (40 mg IgG/kg) for nonimmunocompromised persons within 6 days of exposure
• Administer 0.5 mL/kg (maximum 15 mL) for immunocompromised patients 4
• Quarantine contacts until 21 days after exposure if they do not receive vaccine or immune globulin 1
• If immune globulin is given, extend observation period to 28 days as it may prolong the incubation period 1

Healthcare Worker Exclusion Criteria

• Workers without evidence of immunity who are not vaccinated after exposure must be removed from all patient contact from day 5 after first exposure through day 21 after last exposure, even if they received immune globulin 1

Monitoring for Complications

Critical 10-Day Window for Encephalitis

Maintain heightened vigilance around day 10 post-infection, as encephalitis characteristically presents at this time with peak occurrence approximately 10 days after initial infection 4

• Monitor for seizures (distinct from simple febrile seizures during acute phase), focal neurological deficits, or progressive neurological deterioration 4
• Encephalitis occurs in approximately 1 per 1,000 measles cases and can cause permanent CNS impairment 4

Other Common Complications

• Monitor for otitis media, laryngotracheobronchitis, pneumonia, stomatitis, and diarrhea, which occur in 10-40% of patients 3, 5
• Assess nutritional status and enroll in feeding programs if indicated, as malnutrition significantly increases complication rates 4

Long-Term Surveillance

Counsel patients about subacute sclerosing panencephalitis (SSPE) risk, which occurs in approximately 4-11 per 100,000 measles-infected individuals, with highest risk in children infected before age 2 years 4

Prevention and Outbreak Control

Vaccination Recommendations

• Routine immunization with 2 doses of MMR vaccine is the cornerstone of prevention: first dose at 12-15 months, second dose at 4-6 years 5
• During outbreaks, serologic screening before vaccination is not recommended due to the need for rapid vaccination 1
• Documented age-appropriate vaccination supersedes subsequent serologic testing results 1

Common Pitfalls to Avoid

• Do not delay isolation while awaiting laboratory confirmation—implement airborne precautions immediately based on clinical suspicion 1
• Do not assume patients are non-infectious before rash appears—transmission occurs 4 days before rash onset 1, 2
• Do not forget vitamin A supplementation, which is often overlooked but critical for reducing mortality 4
• Do not rely on surgical masks alone—N95 respirators are required for airborne precautions 1
• Do not assume vaccinated healthcare workers are completely protected—all staff must use N95 respirators due to ~1% vaccine failure rate 1