What is the recommended management and treatment for a pediatric patient, under the age of 18, with no known medical history or previous vaccinations, diagnosed with measles?

Management and Treatment of Measles in Unvaccinated Pediatric Patients

For a pediatric patient diagnosed with active measles, immediately isolate the patient for at least 4 days after rash onset, provide supportive care with vitamin A supplementation (200,000 IU for children ≥12 months or 100,000 IU for children <12 months on days 1 and 2), and simultaneously implement aggressive post-exposure prophylaxis for all susceptible household contacts and school contacts. 1, 2

Immediate Isolation and Infection Control

• Isolate the patient immediately for at least 4 days after rash onset, as measles patients are contagious from 4 days before rash through 4 days after rash appearance 1, 2
• Keep the child out of school or daycare during this entire contagious period 1
• All healthcare workers entering the room must wear N95 respirators (not surgical masks), regardless of immunity status 2

Essential Treatment: Vitamin A Supplementation

Vitamin A supplementation is the only evidence-based intervention proven to reduce measles mortality and morbidity and should be administered to all children with clinical measles 2, 3:

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

Supportive Care and Complication Management

• Monitor for common complications including diarrhea, otitis media, bronchopneumonia, and laryngotracheobronchitis 1, 3
• Treat bacterial superinfections with appropriate antibiotics when identified 2, 4
• Provide oral rehydration therapy for diarrhea and maintain nutritional status 2
• Monitor for serious neurological complications (encephalitis occurs in 1 per 1,000 cases) which require intensive supportive care 1, 3

Post-Exposure Prophylaxis for Household and School Contacts

For Susceptible Contacts Who Can Receive Vaccine

MMR vaccine is the preferred post-exposure prophylaxis and must be administered within 72 hours of initial measles exposure to susceptible contacts aged ≥6 months 1, 5:

• Susceptible contacts include anyone without documentation of two doses of measles-containing vaccine after their first birthday or other acceptable evidence of immunity 1
• Vaccinated persons may be readmitted to school immediately 1
• Unvaccinated persons must be excluded from school for 21 days after rash onset in the last case 1

For Infants <6 Months and Other High-Risk Contacts

For household contacts who cannot receive MMR vaccine or were not vaccinated within 72 hours, immune globulin (IG) should be administered within 6 days of exposure 1, 5:

• Standard IG dose for immunocompetent persons: 0.25 mL/kg IM (maximum 15 mL) 1, 5
• High-risk groups requiring IG include: infants <12 months (especially <6 months), pregnant women, and immunocompromised persons 1, 5
• For immunocompromised patients: use 0.5 mL/kg IM (maximum 15 mL), which is double the standard dose 6, 2
• Critical timing: IG is most effective when given within 6 days of exposure; household contacts often exceed the 72-hour window for vaccination before diagnosis 5

Follow-Up Vaccination After IG Administration

• Any person who receives IG must subsequently receive MMR vaccine no earlier than 5-6 months after IG administration, as passively acquired antibodies interfere with vaccine response 5
• For infants vaccinated before 12 months during outbreak control: they must be revaccinated at 12-15 months and again before school entry (4-6 years), as doses given before the first birthday do not count toward the routine series 1

School and Community Outbreak Control

A single confirmed measles case constitutes an urgent public health situation requiring immediate action 1:

• All susceptible students, siblings, and school personnel in affected schools should receive MMR vaccination immediately 1
• Persons without documentation of adequate vaccination (two doses separated by ≥28 days after first birthday) should be vaccinated or excluded from school for 21 days after the last case's rash onset 1
• Revaccination should extend to unaffected schools in the same geographic area that may be at risk for measles transmission 1
• Contact the local or state health department immediately when suspected cases occur, as control activities should not be delayed pending laboratory results 6

Special Populations Requiring Enhanced Management

Immunocompromised Patients

• Immunocompromised patients face severe, prolonged measles illness and require aggressive prophylaxis 2
• Post-exposure IG is mandatory for exposed immunocompromised persons, regardless of previous vaccination status, at 0.5 mL/kg IM (maximum 15 mL) 6, 2
• MMR vaccine is contraindicated during active chemotherapy or immunosuppressive therapy 2

HIV-Infected Children

• MMR vaccine should be administered to asymptomatic HIV-infected children without severe immunosuppression as soon as possible upon reaching their first birthday 6
• Severely immunocompromised HIV-infected patients (CD4+ counts <750 for children <12 months, <500 for ages 1-5 years, <200 for ages ≥6 years) should receive IG if exposed to measles, regardless of vaccination status 6

Common Pitfalls and Caveats

• Do not use surgical masks instead of N95 respirators for healthcare workers caring for measles patients 2
• Do not forget vitamin A supplementation, which is often overlooked but critical for reducing mortality 2
• Do not count any MMR dose given before 12 months toward the routine two-dose series; these children need two additional doses starting at 12-15 months 1
• Do not administer MMR vaccine within 5-6 months of IG administration, as passive antibodies will interfere with vaccine response 5
• Do not delay outbreak control activities pending laboratory confirmation; act immediately on suspected cases 6
• Do not use IG for mass outbreak control; it is reserved for individual high-risk contacts 6