What is the recommended treatment and isolation protocol for measles, including vitamin A dosing for children and pregnant or immunocompromised adults, airborne isolation precautions, supportive care, antibiotic therapy for secondary bacterial infections, and use of ribavirin or intravenous immune globulin for severe complications?

Treatment and Isolation Protocol for Measles

Immediate Isolation and Airborne Precautions

Isolate the patient immediately in a negative-pressure room (or private room with door closed) for at least 4 days after rash onset, as patients remain contagious from 4 days before through 4 days after rash appearance. 1

• All healthcare workers entering the room must wear N95 respirators or equivalent respiratory protection, regardless of their immunity status 1
• Only staff with documented measles immunity should provide direct patient care 1
• Upon arrival, the patient must wear a medical-type mask to reduce droplet dissemination 2
• Exposed healthcare workers without documented immunity must be excluded from work from day 5 through day 21 post-exposure 2

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

All patients with clinical measles must receive vitamin A supplementation on day 1, as this is the only proven intervention to reduce measles mortality. 1, 2

Standard Dosing for Children

• Children ≥12 months and adults: 200,000 IU orally on day 1 1, 2
• Children <12 months (including infants 6-11 months): 100,000 IU orally on day 1 1, 3
• Do not administer if the patient received vitamin A supplementation in the preceding month 2

Two-Dose Regimen for Complicated Measles

Administer a second identical dose on day 2 for any patient with complications including pneumonia, otitis media, croup, diarrhea with dehydration, or neurological problems. 1, 2

• This two-dose regimen reduces overall mortality by 64% (RR 0.36) and pneumonia-specific mortality by 67% (RR 0.33) 2, 4
• In children under 2 years, the mortality reduction is 82% (RR 0.18) 2, 4
• Water-based formulations show 81% mortality reduction compared to 48% with oil-based preparations 4

Extended Protocol for Vitamin A Deficiency Eye Signs

If any eye symptoms of vitamin A deficiency are present (xerosis, Bitot's spots, keratomalacia, or corneal ulceration), administer a third dose of 200,000 IU (or 100,000 IU for infants <12 months) at 1-4 weeks after the initial doses. 1, 2

Critical Pitfall to Avoid

• Do not withhold vitamin A supplementation due to toxicity concerns—the standard protocol is safe, as acute toxicity requires >300,000 IU in adults or >60,000 IU in children within hours/days 1
• Do not delay vitamin A administration waiting for laboratory confirmation; begin treatment based on clinical diagnosis 3

Supportive Care and Complication Management

Treat all complications with standard evidence-based therapies, as there is no specific antiviral therapy for measles. 2

• Secondary bacterial pneumonia/acute lower respiratory infection: Initiate standard antibiotic therapy per local protocols 1, 2
• Otitis media: Provide appropriate antibiotic therapy 1, 2
• Diarrhea: Use oral rehydration therapy promptly 1, 2
• Fever: Administer antipyretics (acetaminophen or ibuprofen) as needed 2
• Nutritional monitoring: Assess nutritional status and enroll in feeding programs if indicated 1, 2

Special Populations: Pregnant and Immunocompromised Patients

Pregnant Women

Pregnant women exposed to measles should receive immune globulin (IG) 0.25 mL/kg (maximum 15 mL) within 6 days of exposure. 1, 2

• Once symptomatic, provide supportive care with vitamin A supplementation (200,000 IU on day 1, repeated on day 2 if complicated) 2
• MMR vaccine is contraindicated during pregnancy for post-exposure prophylaxis 5

Immunocompromised Patients

Immunocompromised patients should receive IG 0.5 mL/kg (maximum 15 mL) within 6 days of exposure, regardless of vaccination status. 1, 2

• Once symptomatic, provide vitamin A supplementation (200,000 IU on day 1, repeated on day 2 if complicated) 2
• For patients receiving regular IGIV therapy, administration of at least 100 mg/kg within 3 weeks before exposure provides adequate protection 5, 2

Ribavirin and IVIG for Severe Complications

• For immunocompromised patients with measles pneumonia and respiratory failure, combination therapy with inhaled ribavirin and intravenous immune globulin may be beneficial 6
• This represents case report evidence and should be considered in life-threatening situations 6

Post-Exposure Prophylaxis for Susceptible Contacts

MMR Vaccine (Preferred for Most Contacts)

Administer MMR vaccine within 72 hours of exposure to susceptible household contacts ≥6 months of age to prevent or modify disease. 5, 2

• Infants vaccinated before 12 months must be revaccinated on or after the first birthday with two doses separated by at least 28 days 5
• Vaccine is contraindicated for pregnant women and immunocompromised patients 5

Immune Globulin for High-Risk Contacts

IG is indicated for susceptible household contacts at increased risk: infants ≤12 months, pregnant women, and immunocompromised persons. 5, 2

• Standard dose: 0.25 mL/kg (maximum 15 mL) within 6 days of exposure 5, 2
• Immunocompromised dose: 0.5 mL/kg (maximum 15 mL) within 6 days of exposure 5, 2
• After IG administration, delay MMR vaccination for 5-6 months to avoid interference from passively acquired antibodies 5
• Do not use IG for outbreak control—it is indicated only for individual post-exposure prophylaxis 2

Monitoring and Follow-Up

• Monitor all exposed contacts for 28 days when immunoglobulin is given, as passive antibodies can prolong the incubation period 2
• Consider routine vitamin A supplementation every 3 months in at-risk populations after completing acute measles treatment 1, 3