Health Professionals

Travel Health Information Sheets

Measles

Introduction

Epidemiology

Risk for travellers

Transmission

Signs and symptoms

Treatment

Prevention

Vaccine information

References

Links

Introduction

 

Measles is a highly contagious infection caused by a virus of the paramyxovirus family. Measles remains a leading cause of death amongst young children globally, despite the availability of an effective vaccine. In 2011, an estimated 158,000 people died from measles worldwide, approximately 430 deaths everyday [1]. In some developing countries, case-fatality rates for measles among young children can reach 5–6% [2].

 

Epidemiology

Global epidemiology

In countries where vaccine coverage is low, measles is a leading cause of death and morbidity.

 

Globally measles deaths have decreased by from 535,300 deaths in 2000 to 139,300 in 2010. However, measles is still common in many developing countries, particularly in parts of Africa and Asia; more than 95% of measles deaths occur in countries with low per capita incomes and poor health infrastructures [3]. The main reason for this is the difficulty that affected countries have in delivering at least one dose of measles vaccine to each child.

In England and Wales, statutory notification of measles began in 1940.  Before the introduction of measles vaccination in 1968, notifications of the illness varied from 160,000 to 800,000 cases annually [4]. Although measles vaccine was introduced in 1968, vaccine coverage remained low until the late 1980s and measles remained a major cause of morbidity and mortality in England and Wales.

In 1988 measles, mumps, and rubella (MMR) vaccine was introduced in England and Wales and vaccine coverage exceeded 90%. As a consequence, measles notifications fell. Despite this fall, cases continued to occur in older, unimmunised children who had not been exposed to measles at an early age and therefore, a catch-up vaccination campaign was implemented in 1994 and a two-dose MMR schedule in 1996 [5]. Due to an increase in measles reported in England and Wales in 2012, an MMR vaccination catch up campaign targeting unvaccinated and partially vaccinated 10-16 year-olds was implemented in 2013 in the UK [6].

A total of 8,326 measles cases were reported throughout the European Union countries from December 2011 to the end of November 2012. The France, Italy, Romania, Spain and UK, accounted for 87% of the cases in Europe [7].

Measles in England and Wales associated with overseas travel

In 2012, there were 2,030 confirmed cases reported in England and Wales, the highest since 1994; of these, 58 were thought to have acquired their measles infection either through recent travel abroad or through close contact with a case returning from abroad [8]. Travel history for measles is under reported; where travel has been recorded, cases reported recent travel to: Afghanistan, Antigua and Barbuda, Bangladesh, China, Czech Republic, France, Germany, India, Ireland, Italy,  Japan, Netherlands, Pakistan Romania, Russia, Somalia, Spain and Uganda. Data for Northern Ireland and Scotland are available elsewhere [9, 10].

Risk for overseas travellers

All previously unvaccinated and non-immune travellers are at risk from measles when visiting countries where measles continues to occur.  Travellers should be offered vaccination as part of their pre-travel health consultation. See Vaccine Information section for indications for the use of vaccine.

Transmission

Measles is one of the most contagious infectious diseases; it is transmitted via respiratory droplets. Individuals are infectious from when the first symptoms appear until four days after the appearance of rash.

 

Signs and symptoms

Following an incubation period ranging from eight to 12 days, measles begins with a two to four day prodrome characterised by fever, malaise, coryza (runny nose), conjunctivitis and cough. Koplik’s spots, small papular white lesions, usually appear one day before the onset of rash on the buccal mucosa in line with the molars.

The hallmark of measles is a rash. A red maculopapular rash first appears on the face and spreads down to the trunk and extremities. The rash begins to fade after three to four days. In uncomplicated cases clinical recovery begins soon after the appearance of the rash.

The rate of complications of measles varies by age, and is increased by malnutrition, vitamin A deficiency, and immune deficiency.  The risk of mortality as a result of measles complications is highest among children aged less than five years and adults aged over 20 years [11]. The most common complications are otitis media (7-9%), diarrhoea (8%), pneumonia (1-6%), and convulsions (0.5%) [5].

Recovery from measles results in life-long immunity. However, those who have recovered from measles should still receive a two dose schedule of MMR vaccine if protection against mumps or rubella is required. There are no known safety concerns about giving MMR vaccine to immune persons [6].

 

Treatment

Uncomplicated measles in immune competent persons is usually a self limiting illness. Secondary infections may require treatment with antibiotics.

Prevention

Vaccination should be offered to all previously unvaccinated individuals who are travelling abroad provided there are no contraindications to the vaccine. Persons born before 1970 are likely to have acquired natural immunity, but there is no upper age limit to vaccination and MMR vaccine can be offered if they are not immune and at risk of exposure.

Measles is a notifiable disease in the United Kingdom (UK) and cases should be reported to the appropriate local health protection team. The necessary public health action including contact tracing and vaccination can then be implemented.

 

Vaccine information

Availability

There are two MMR vaccines available in the UK, MMRVaxPRO™ (Sanofi Pasteur MSD) and Priorix™. The Summary of Product Characteristics (SmPC) should be consulted prior to the administration of any vaccine [12, 13].

Indications for use of vaccine

Measles vaccine is available as a combined product with mumps and rubella, and forms part of the UK vaccination schedule. The aim of the programme is to ensure that all susceptible persons receive two doses of measles, mumps, and rubella (MMR) vaccine.  The second dose of vaccine aims to prevent an accumulation of susceptible individuals that could be sufficient to re-establish measles transmission.

Children under ten years of age

MMR vaccine should be offered to infants shortly after their first birthday, usually at 13 months of age.

A second dose of MMR is normally given before school entry, but can be given routinely at any time from three months after the first dose. Allowing three months between doses is likely to maximise the response rate, particularly in young children under the age of 18 months where maternal antibodies may reduce the response to vaccination. If the child is under the age of 18 months of age and second dose is given within three months of first, the routine pre-school dose should also be given to ensure full protection

Children ten years and older, and adults

MMR vaccine can be given at any age, and a travel health consultation is an opportunity to ensure that individuals have received two doses of the MMR vaccine given at least one month apart.

Adults born in the UK before 1970

These adults are likely to have developed immunity following natural infection. Vaccination would not normally be given, unless they are considered to be non-immune and at risk of infection.

Overseas travellers

All travellers should ensure that they are fully immunised according to the UK schedule. MMR vaccine can be considered for infants from six months age if they are visiting a measles endemic area; if MMR is given before the first birthday, two further doses should be given at the recommended times (between 12 and 13 months of age and at three years four months to five years of age) [5].

Interrupted courses

There is no evidence that an interrupted course of MMR vaccine needs to be restarted regardless of the interval between the two doses.

Contraindications

MMR vaccine should not be given to:

Precautions

MMR vaccine should be used with caution in the following individuals and specialist advice sought as appropriate prior to vaccinating. Further guidance can be found in the Department of Health’s Immunisation against infectious disease (‘The Green Book’).

  • Individuals with a history of idiopathic thromocytopaenic purpura (ITP) following previous MMR vaccine.
  • HIV positive individuals
  • Deteriorating neurological conditions including poorly controlled epilepsy

Adverse events

For detailed information on adverse events associated with each vaccine see the summary of product characteristics [12, 13]. Adverse events (except allergic reactions) following MMR vaccine are due to replication of the vaccine viruses. They are seen in individuals who are not immune to one or more of the viruses in the vaccine. Events due to the measles component occur six to 11 days after vaccination and to the mumps or rubella components two to three weeks following vaccination, but can occur up to six weeks later.

Undesirable adverse events include:

  • Common: malaise, fever, and/or rash.
  • Rare: febrile seizures, Idiopathic thrombocytopaenic purpura, arthralgias, or arthritis.

References

1. World Health Organization. Measles fact Sheet No. 286. February 2013. [Accessed 30 August 2013]. Available at: http://www.who.int/mediacentre/factsheets/fs286/en/index.html

2. Wolf son LJ, Grais RF, Liquor FJ, et al. Estimates of measles case fatality ratios: a comprehensive review of community-based studies. International Journal of Epidemiology, 2009, 38:192–205.

3. World Health Organization. Measles. Immunization, Vaccines and Biologicals. [Accessed 30 August 2013]. Available at: http://www.who.int/immunization/topics/measles/en/index.html

4. Health Protection Agency. All laboratory confirmed cases of measles, mumps and rubella England and Wales, 1996 – 2012. [Accessed 30 August 2013]. Available at http://www.hpa.org.uk/web/HPAweb&HPAwebStandard/HPAweb

_C/1195733833790

5. Salisbury D, Ramsay M, Noakes K. [eds.] Immunisation against infectious disease. 2006. Chapter 21 Measles.

6. Department of Health, London. [Accessed 30 August 2013]. Available at:  https://www.gov.uk/government/publications/measles-the-green-book-chapter-21

7. European Centres for Disease Prevention and Control (ECDC). Surveillance Report: Measles and Rubella Monitoring May 2013. [Accessed 30 August, 2013]. Available at: http://ecdc.europa.eu/en/publications/Publications/measles-rubella-monitoring-may-2013.pdf

8. ECDC Surveillance report. Measles and Rubella monitoring. January 2013. [Accessed 30 August 2013]. Available at: http://ecdc.europa.eu/en/publications/Publications/measles-rubella-monitoring-jan-2013.pdf

9. Public Health England. Measles epidemiological data. Respiratory and vaccine preventable diseases [Accessed 30 August 2013]. Available at: http://www.hpa.org.uk/Topics/InfectiousDiseases/Infections

AZ/TravelHealth/EpidemiologicalData/RespiratoryAndVaccine

PreventableInfections/travMeasles/

10. Health Protection Scotland. Measles. http://www.hps.scot.nhs.uk/immvax/measles.aspx

11. Strebel PM, Papania MJ, Dayan GH, Halsey NA. Measles vaccine In. Plotkin SA and Orenstein WA, Offit P (eds) (2008) Vaccines, 6th edition. Philadelphia: WB Saunders Company, Chapter 18.

12. Sanofi Pasteur MSD. Summary of Product Characteristics for MMRVAXPRO. Updated 27 March 2013. [Accessed 30 August 2013]. Available at: http://www.medicines.org.uk/emc/medicine/20968/SPC/MMRV

AXPRO/

13. GlaxoSmithKline. Summary of Product Characteristics for Priorix. Updated 14 August 2013. [Accessed 30 August 2013]. Available at: http://www.medicines.org.uk/emc/medicine/2054/SPC/Priorix/


Links

ECDC: European Monthly Measles Monitoring

NaTHNaC Outbreak Surveillance Database

Public Health England: Measles

World Health Organization: Measles

WHO: Position paper on Measles

Updated August 2013

Printable Version