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Measles

February 15, 2024

This article is about the disease. For other uses, see Measles (disambiguation).
Not to be confused with either rubella or roseola, which are also viral diseases with comparable features.

Measles is a highly contagious, vaccine-preventable infectious disease caused by measles virus.[3][5][11][12] Symptoms usually develop 10–12 days after exposure to an infected person and last 7–10 days.[7][8] Initial symptoms typically include fever, often greater than 40 °C (104 °F), cough, runny nose, and inflamed eyes.[3][4] Small white spots known as Koplik's spots may form inside the mouth two or three days after the start of symptoms.[4] A red, flat rash which usually starts on the face and then spreads to the rest of the body typically begins three to five days after the start of symptoms.[4] Common complications include diarrhea (in 8% of cases), middle ear infection (7%), and pneumonia (6%).[5] These occur in part due to measles-induced immunosuppression.[6] Less commonly seizures, blindness, or inflammation of the brain may occur.[5][7] Other names include morbilli, rubeola, red measles, and English measles.[1][2] Both rubella, also known as German measles, and roseola are different diseases caused by unrelated viruses.[13]

Measles
Other namesMorbilli, rubeola, red measles, English measles[1][2]
A child showing a day-four measles rash
SpecialtyInfectious disease
SymptomsFever, cough, runny nose, inflamed eyes, rash[3][4]
ComplicationsPneumonia, seizures, encephalitis, subacute sclerosing panencephalitis, immunosuppression, hearing loss, blindness[5][6]
Usual onset10–12 days after exposure[7][8]
Duration7–10 days[7][8]
CausesMeasles virus[3]
PreventionMeasles vaccine[7]
TreatmentSupportive care[7]
Frequency20 million per year[3]
Deaths140,000+ (2018)[9][10]

Measles is an airborne disease which spreads easily from one person to the next through the coughs and sneezes of infected people.[7] It may also be spread through direct contact with mouth or nasal secretions.[14] It is extremely contagious: nine out of ten people who are not immune and share living space with an infected person will be infected.[5] Furthermore, measles's reproductive number estimates vary beyond the frequently cited range of 12 to 18.[15] The NIH quote this 2017 paper saying: "[a] review in 2017 identified feasible measles R0 values of 3.7–203.3".[16] People are infectious to others from four days before to four days after the start of the rash.[5] While often regarded as a childhood illness, it can affect people of any age.[17] Most people do not get the disease more than once.[7] Testing for the measles virus in suspected cases is important for public health efforts.[5] Measles is not known to occur in other animals.[14]

Once a person has become infected, no specific treatment is available,[14] although supportive care may improve outcomes.[7] Such care may include oral rehydration solution (slightly sweet and salty fluids), healthy food, and medications to control the fever.[7][8] Antibiotics should be prescribed if secondary bacterial infections such as ear infections or pneumonia occur.[7][14] Vitamin A supplementation is also recommended for children.[14] Among cases reported in the U.S. between 1985 and 1992, death occurred in only 0.2% of cases,[5] but may be up to 10% in people with malnutrition.[7] Most of those who die from the infection are less than five years old.[14]

The measles vaccine is effective at preventing the disease, is exceptionally safe, and is often delivered in combination with other vaccines.[7][18] Vaccination resulted in an 80% decrease in deaths from measles between 2000 and 2017, with about 85% of children worldwide having received their first dose as of 2017.[14] Measles affects about 20 million people a year,[3] primarily in the developing areas of Africa and Asia.[7] It is one of the leading vaccine-preventable disease causes of death.[19][20] In 1980, 2.6 million people died from measles,[7] and in 1990, 545,000 died due to the disease; by 2014, global vaccination programs had reduced the number of deaths from measles to 73,000.[21][22] Despite these trends, rates of disease and deaths increased from 2017 to 2019 due to a decrease in immunization.[23][24][25]

Video summary (script)

Signs and symptoms

 
Maculopapular rash on the abdomen after 3 days of measles infection

Symptoms typically begin 10–14 days after exposure.[26][27] The classic symptoms include a four-day fever (the four Ds) and the three Cs—cough, coryza (head cold, fever, sneezing), and conjunctivitis (red eyes)—along with a maculopapular rash.[28] Fever is common and typically lasts for about one week; the fever seen with measles is often as high as 40 °C (104 °F).[29]

Koplik's spots seen inside the mouth are diagnostic for measles, but are temporary and therefore rarely seen.[28] Koplik spots are small white spots that are commonly seen on the inside of the cheeks opposite the molars.[27] They appear as "grains of salt on a reddish background."[30] Recognizing these spots before a person reaches their maximum infectiousness can help reduce the spread of the disease.[31]

The characteristic measles rash is classically described as a generalized red maculopapular rash that begins several days after the fever starts. It starts on the back of the ears and, after a few hours, spreads to the head and neck before spreading to cover most of the body. The measles rash appears two to four days after the initial symptoms and lasts for up to eight days. The rash is said to "stain", changing color from red to dark brown, before disappearing.[32] Overall, measles usually resolves after about three weeks.[29]

People who have been vaccinated against measles but have incomplete protective immunity may experience a form of modified measles.[33] Modified measles is characterized by a prolonged incubation period, milder, and less characteristic symptoms (sparse and discrete rash of short duration).[33]

Further information: Stimson line
  •  
    A Filipino baby with measles
  •  
    Koplik's spots on the third pre-eruptive day
  •  
    Koplik's spots on the day of measles rash

Complications

Complications of measles are relatively common, ranging from mild ones such as diarrhea to serious ones such as pneumonia (either direct viral pneumonia or secondary bacterial pneumonia), laryngotracheobronchitis (croup) (either direct viral laryngotracheobronchitis or secondary bacterial bronchitis), otitis media,[34] acute brain inflammation,[35] corneal ulceration (leading to corneal scarring),[36] and in about 1 in 600 unvaccinated infants under 15 months while more rarely in older children and adults, subacute sclerosing panencephalitis, which is progressive and eventually lethal.[37]

In addition, measles can suppress the immune system for weeks to months, and this can contribute to bacterial superinfections such as otitis media and bacterial pneumonia.[6][38][39][40][41] Two months after recovery there is a 11–73% decrease in the number of antibodies against other bacteria and viruses.[42]

The death rate in the 1920s was around 30% for measles pneumonia.[43] People who are at high risk for complications are infants and children aged less than 5 years;[17] adults aged over 20 years;[17] pregnant women;[17] people with compromised immune systems, such as from leukemia, HIV infection or innate immunodeficiency;[17][44] and those who are malnourished[17] or have vitamin A deficiency.[17][45] Complications are usually more severe in adults.[46] Between 1987 and 2000, the case fatality rate across the United States was three deaths per 1,000 cases attributable to measles, or 0.3%.[47] In underdeveloped nations with high rates of malnutrition and poor healthcare, fatality rates have been as high as 28%.[47] In immunocompromised persons (e.g., people with AIDS) the fatality rate is approximately 30%.[48]

Even in previously healthy children, measles can cause serious illness requiring hospitalization.[44] One out of every 1,000 measles cases progresses to acute encephalitis, which often results in permanent brain damage.[44] One to three out of every 1,000 children who become infected with measles will die from respiratory and neurological complications.[44]

Cause

 
An electron micrograph of the measles virus

Measles is caused by the measles virus, a single-stranded, negative-sense, enveloped RNA virus of the genus Morbillivirus within the family Paramyxoviridae.[49]

The virus is highly contagious and is spread by coughing and sneezing via close personal contact or direct contact with secretions.[50] Measles is the most contagious virus known.[18] It remains infective for up to two hours in that airspace or nearby surfaces.[26][50] Measles is so contagious that if one person has it, 90% of non-immune people who have close contact with them (e.g., household members) will also become infected.[26][51] Humans are the only natural hosts of the virus, and no other animal reservoirs are known to exist, although mountain gorillas are believed to be susceptible to the disease.[26][52] Risk factors for measles virus infection include immunodeficiency caused by HIV/AIDS,[53] immunosuppression following receipt of an organ or a stem cell transplant,[54] alkylating agents, or corticosteroid therapy, regardless of immunization status;[17] travel to areas where measles commonly occurs or contact with travelers from such an area;[17] and the loss of passive, inherited antibodies before the age of routine immunization.[55]

Pathophysiology

 
Drawing of the measles virus attaching to the lining of the trachea
 
Photomicrograph of a lung tissue specimen, showing the histopathologic changes encountered in a case of measles pneumonia. Included in this view are numerous leukocytes and a multinucleated giant cell. Normal alveolar cytoarchitecture has been obliterated.[56]

Once the measles virus gets onto the mucosa, it infects the epithelial cells in the trachea or bronchi.[57][58] Measles virus uses a protein on its surface called hemagglutinin (H protein), to bind to a target receptor on the host cell, which could be CD46, which is expressed on all nucleated human cells, CD150, aka signaling lymphocyte activation molecule or SLAM, which is found on immune cells like B or T cells, and antigen-presenting cells, or nectin-4, a cellular adhesion molecule.[57][59] Once bound, the fusion, or F protein helps the virus fuse with the membrane and ultimately get inside the cell.[57]

As the virus is a single-stranded negative-sense RNA virus, it includes the enzyme RNA-dependent RNA polymerase (RdRp) which is used to transcribe its genome into a positive-sense mRNA strand.[57]

After entering a cell, it is ready to be translated into viral proteins, wrapped in the cell's lipid envelope, and sent out of the cell as a newly made virus.[60] Within days, the measles virus spreads through local tissue and is picked up by dendritic cells and alveolar macrophages, and carried from that local tissue in the lungs to the local lymph nodes.[57][58] From there it continues to spread, eventually getting into the blood and spreading to more lung tissue, as well as other organs like the intestines and the brain.[26][57] Functional impairment of the infected dendritic cells by the measles virus is thought to contribute to measles-induced immunosuppression.[6]

Diagnosis

Typically, clinical diagnosis begins with the onset of fever and malaise about 10 days after exposure to the measles virus, followed by the emergence of cough, coryza, and conjunctivitis that worsen in severity over 4 days of appearing.[61] Observation of Koplik's spots is also diagnostic.[31] Other possible condition that can result in these symptoms include parvovirus, dengue fever, Kawasaki disease, and scarlet fever.[62] Laboratory confirmation is, however, strongly recommended.[63]

Laboratory testing

Laboratory diagnosis of measles can be done with confirmation of positive measles IgM antibodies or detection of measles virus RNA from throat, nasal or urine specimen by using the reverse transcription polymerase chain reaction assay.[62][64] This method is particularly useful to confirm cases when the IgM antibodies results are inconclusive.[62] For people unable to have their blood drawn, saliva can be collected for salivary measles-specific IgA testing.[64] Salivary tests used to diagnose measles involve collecting a saliva sample and testing for the presence of measles antibodies.[65][66] This method is not ideal, as saliva contains many other fluids and proteins which may make it difficult to collect samples and detect measles antibodies.[65][66] Saliva also contains 800 times fewer antibodies than blood samples do, which makes salivary testing additionally difficult. Positive contact with other people known to have measles adds evidence to the diagnosis.[65]

Prevention

Further information: Measles vaccine, MMR vaccine, and MMRV vaccine
 
Rates of measles vaccination worldwide

Mothers who are immune to measles pass antibodies to their children while they are still in the womb, especially if the mother acquired immunity through infection rather than vaccination.[26][55] Such antibodies will usually give newborn infants some immunity against measles, but these antibodies are gradually lost over the course of the first nine months of life.[27][55] Infants under one year of age whose maternal anti-measles antibodies have disappeared become susceptible to infection with the measles virus.[55]

In developed countries, it is recommended that children be immunized against measles at 12 months, generally as part of a three-part MMR vaccine (measles, mumps, and rubella). The vaccine is generally not given before this age because such infants respond inadequately to the vaccine due to an immature immune system.[55] A second dose of the vaccine is usually given to children between the ages of four and five, to increase rates of immunity. Measles vaccines have been given to over a billion people.[18] Vaccination rates have been high enough to make measles relatively uncommon. Adverse reactions to vaccination are rare, with fever and pain at the injection site being the most common. Life-threatening adverse reactions occur in less than one per million vaccinations (<0.0001%).[67]

In developing countries where measles is common, the World Health Organization (WHO) recommends two doses of vaccine be given, at six and nine months of age. The vaccine should be given whether the child is HIV-infected or not.[68] The vaccine is less effective in HIV-infected infants than in the general population, but early treatment with antiretroviral drugs can increase its effectiveness.[69] Measles vaccination programs are often used to deliver other child health interventions as well, such as bed nets to protect against malaria, antiparasite medicine and vitamin A supplements, and so contribute to the reduction of child deaths from other causes.[70]

The Advisory Committee on Immunization Practices (ACIP) recommends that all adult international travelers who do not have positive evidence of previous measles immunity receive two doses of MMR vaccine before traveling, although birth before 1957 is presumptive evidence of immunity.[71] Those born in the United States before 1957 are likely to have been naturally infected with measles virus and generally need not be considered susceptible.[26][72]

There have been false claims of an association between the measles vaccine and autism; this incorrect concern has reduced the rate of vaccination and increased the number of cases of measles where immunization rates became too low to maintain herd immunity.[17] Additionally, there have been false claims that measles infection protects against cancer.[18]

Administration of the MMR vaccine may prevent measles after exposure to the virus (post-exposure prophylaxis).[73] Post-exposure prophylaxis guidelines are specific to jurisdiction and population.[73] Passive immunization against measles by an intramuscular injection of antibodies could be effective up to the seventh day after exposure.[74] Compared to no treatment, the risk of measles infection is reduced by 83%, and the risk of death by measles is reduced by 76%.[74] However, the effectiveness of passive immunization in comparison to active measles vaccine is not clear.[74]

The MMR vaccine is 95% effective for preventing measles after one dose if the vaccine is given to a child who is 12 months or older; if a second dose of the MMR vaccine is given, it will provide immunity in 99% of children.[75]

There is no evidence that the measles vaccine virus can be transmitted to other persons.[76]

Treatment

There is no specific antiviral treatment if measles develops.[50] Instead the medications are generally aimed at treating superinfections, maintaining good hydration with adequate fluids, and pain relief.[50] Some groups, like young children and the severely malnourished, are also given vitamin A, which acts as an immunomodulator that boosts the antibody responses to measles and decreases the risk of serious complications.[50][77][78]

Medications

Treatment is supportive, with ibuprofen or paracetamol (acetaminophen) to reduce fever and pain and, if required, a fast-acting medication to dilate the airways for cough.[79] As for aspirin, some research has suggested a correlation between children who take aspirin and the development of Reye syndrome.[80][81]

The use of vitamin A during treatment is recommended to decrease the risk of blindness;[78] however, it does not prevent or cure the disease.[82] A systematic review of trials into its use found no reduction in overall mortality, but two doses (200,000 IU) of vitamin A was shown to reduce mortality for measles in children younger than two years of age.[77][83] It is unclear if zinc supplementation in children with measles affects outcomes as it has not been sufficiently studied.[84] There are no adequate studies on whether Chinese medicinal herbs are effective.[85]

Prognosis

Most people survive measles, though in some cases, complications may occur. About 1 in 4 individuals will be hospitalized and 1–2 in 1,000 will die. Complications are more likely in children under age 5 and adults over age 20.[86] Pneumonia is the most common fatal complication of measles infection and accounts for 56–86% of measles-related deaths.[87]

Possible consequences of measles virus infection include laryngotracheobronchitis, sensorineural hearing loss,[49] and—in about 1 in 10,000 to 1 in 300,000 cases[88]—panencephalitis, which is usually fatal.[89] Acute measles encephalitis is another serious risk of measles virus infection. It typically occurs two days to one week after the measles rash breaks out and begins with very high fever, severe headache, convulsions and altered mentation. A person with measles encephalitis may become comatose, and death or brain injury may occur.[90]

For people having had measles, it is rare to ever have a symptomatic reinfection.[91]

The measles virus can deplete previously acquired immune memory by killing cells that make antibodies, and thus weakens the immune system, which can cause deaths from other diseases.[40][41][42] Suppression of the immune system by measles lasts about two years and has been epidemiologically implicated in up to 90% of childhood deaths in third world countries, and historically may have caused rather more deaths in the United States, the UK and Denmark than were directly caused by measles.[92] Although the measles vaccine contains an attenuated strain, it does not deplete immune memory.[41]

Epidemiology

Main article: Epidemiology of measles
 
Deaths from measles per million persons in 2012
  no data
  0
  1–8
  9–26
  27–38
  39–73
  74–850
 
Disability-adjusted life year for measles per 100,000 inhabitants in 2004
  no data
  ≤ 10
  10–25
  25–50
  50–75
  75–100
  100–250
  250–500
  500–750
  750–1000
  1000–1500
  1500–2000
  ≥ 2000

Measles is extremely infectious and its continued circulation in a community depends on the generation of susceptible hosts by birth of children. In communities that generate insufficient new hosts the disease will die out. This concept was first recognized in measles by Bartlett in 1957, who referred to the minimum number supporting measles as the critical community size (CCS).[93] Analysis of outbreaks in island communities suggested that the CCS for measles is around 250,000.[94] To achieve herd immunity, more than 95% of the community must be vaccinated due to the ease with which measles is transmitted from person to person.[29]

In 2011, the WHO estimated that 158,000 deaths were caused by measles. This is down from 630,000 deaths in 1990.[95] As of 2018, measles remains a leading cause of vaccine-preventable deaths in the world.[19][96] In developed countries the mortality rate is lower, for example in England and Wales from 2007 to 2017 death occurred between two and three cases out of 10,000.[97] In children one to three cases out of every 1,000 die in the United States (0.1–0.2%).[98] In populations with high levels of malnutrition and a lack of adequate healthcare, mortality can be as high as 10%.[7][99] In cases with complications, the rate may rise to 20–30%.[medical citation needed] In 2012, the number of deaths due to measles was 78% lower than in 2000 due to increased rates of immunization among UN member states.[29]

Reported cases[100]
WHO-Region 1980 1990 2000 2010 2020
African Region 1,240,993 481,204 520,102 199,174 115,369
Region of the Americas 257,790 218,579 1,754 247 9,996
Eastern Mediterranean Region 341,624 59,058 38,592 10,072 6,769
European Region 492,660 185,818 37,421 30,625 10,945
Southeast Asia Region 199,535 224,925 78,558 54,228 9,389
Western Pacific Region 1,319,640 155,490 177,052 49,460 6,605
Worldwide 3,852,242 1,325,074 853,479 343,806 159,073

Even in countries where vaccination has been introduced, rates may remain high. Measles is a leading cause of vaccine-preventable childhood mortality. Worldwide, the fatality rate has been significantly reduced by a vaccination campaign led by partners in the Measles Initiative: the American Red Cross, the United States CDC, the United Nations Foundation, UNICEF and the WHO. Globally, measles fell 60% from an estimated 873,000 deaths in 1999 to 345,000 in 2005.[101] Estimates for 2008 indicate deaths fell further to 164,000 globally, with 77% of the remaining measles deaths in 2008 occurring within the Southeast Asian region.[102] There were 142,300 measles related deaths globally in 2018, of which most cases were reported from African and eastern Mediterranean regions. These estimates were slightly higher than that of 2017, when 124,000 deaths were reported due to measles infection globally.[103]

In 2000, the WHO established the Global Measles and Rubella Laboratory Network (GMRLN) to provide laboratory surveillance for measles, rubella, and congenital rubella syndrome.[104] Data from 2016 to 2018 show that the most frequently detected measles virus genotypes are decreasing, suggesting that increasing global population immunity has decreased the number of chains of transmission.[104]

Cases reported in the first three months of 2019, were 300% higher than in the first three months of 2018, with outbreaks in every region of the world, even in countries with high overall vaccination coverage where it spread among clusters of unvaccinated people.[105] The numbers of reported cases as of mid-November is over 413,000 globally, with an additional 250,000 cases in DRC (as reported through their national system), similar to the increasing trends of infection reported in the earlier months of 2019, compared to 2018.[103] In 2019, the total number of cases worldwide climbed to 869,770. The number of cases reported for 2020 is lower compare to 2019.[106] According to the WHO, the COVID-19 pandemic hindered vaccination campaigns in at least 68 countries, including in countries that were experiencing outbreaks, which caused increased risk of additional cases.[106][107]

Europe

 
Incidence of and deaths due to measles in England and Wales between 1940 and 2017

In England and Wales, though deaths from measles were uncommon, they averaged about 500 per year in the 1940s. Deaths diminished with the improvement of medical care in the 1950s but the incidence of the disease did not retreat until vaccination was introduced in the late 1960s. Wider coverage was achieved in the 1980s with the measles, mumps and rubella, MMR vaccine.[108]

In 2013–14, there were almost 10,000 cases in 30 European countries. Most cases occurred in unvaccinated individuals and over 90% of cases occurred in Germany, Italy, Netherlands, Romania, and United Kingdom.[29] Between October 2014 and March 2015, a measles outbreak in the German capital of Berlin resulted in at least 782 cases.[109] In 2017, numbers continued to increase in Europe to 21,315 cases, with 35 deaths.[110] In preliminary figures for 2018, reported cases in the region increased 3-fold to 82,596 in 47 countries, with 72 deaths; Ukraine had the most cases (53,218), with the highest incidence rates being in Ukraine (1209 cases per million), Serbia (579), Georgia (564) and Albania (500).[111][112] The previous year (2017) saw an estimated measles vaccine coverage of 95% for the first dose and 90% for the second dose in the region, the latter figure being the highest-ever estimated second-dose coverage.[112]

In 2019, the United Kingdom, Albania, the Czech Republic, and Greece lost their measles-free status due to ongoing and prolonged spread of the disease in these countries.[113] In the first 6 months of 2019, 90,000 cases occurred in Europe.[113]

Americas

As a result of widespread vaccination, the disease was declared eliminated from the Americas in 2016.[114] However, there were cases again in 2017,[115] 2018, 2019,[116] and 2020[117] in this region.

United States

See also: Measles resurgence in the United States
 
Measles cases in the U.S. from 1938 to 2019

In the United States, measles affected approximately 3,000 people per million in the 1960s before the vaccine was available. With consistent widespread childhood vaccination, this figure fell to 13 cases per million by the 1980s, and to about 1 case per million by 2000.[118]

In 1991, an outbreak of measles in Philadelphia was centered at the Faith Tabernacle Congregation, a faith healing church that actively discouraged parishioners from vaccinating their children. Over 1400 people were infected with measles and nine children died.[119]

Before immunization in the United States, between three and four million cases occurred each year.[5] The United States was declared free of circulating measles in 2000, with 911 cases from 2001 to 2011. In 2014 the CDC said endemic measles, rubella, and congenital rubella syndrome had not returned to the United States.[120] Occasional measles outbreaks persist, however, because of cases imported from abroad, of which more than half are the result of unvaccinated U.S. residents who are infected abroad and infect others upon return to the United States.[120] The CDC continues to recommend measles vaccination throughout the population to prevent outbreaks like these.[121]

In 2014, an outbreak was initiated in Ohio when two unvaccinated Amish men harboring asymptomatic measles returned to the United States from missionary work in the Philippines.[122] Their return to a community with low vaccination rates led to an outbreak that rose to include a total of 383 cases across nine counties.[122] Of the 383 cases, 340 (89%) occurred in unvaccinated individuals.[122]

From 4 January, to 2 April 2015, there were 159 cases of measles reported to the CDC. Of those 159 cases, 111 (70%) were determined to have come from an earlier exposure in late December 2014. This outbreak was believed to have originated from the Disneyland theme park in California. The Disneyland outbreak was held responsible for the infection of 147 people in seven U.S. states as well as Mexico and Canada, the majority of which were either unvaccinated or had unknown vaccination status.[123] Of the cases 48% were unvaccinated and 38% were unsure of their vaccination status.[124] The initial exposure to the virus was never identified.[125]

In 2015, a U.S. woman in Washington state died of pneumonia, as a result of measles. She was the first fatality in the U.S. from measles since 2003.[126] The woman had been vaccinated for measles and was taking immunosuppressive drugs for another condition. The drugs suppressed the woman's immunity to measles, and the woman became infected with measles; she did not develop a rash, but contracted pneumonia, which caused her death.[127][128]

In June 2017, the Maine Health and Environmental Testing Laboratory confirmed a case of measles in Franklin County. This instance marks the first case of measles in 20 years for the state of Maine.[129] In 2018 one case occurred in Portland, Oregon, with 500 people exposed; 40 of them lacked immunity to the virus and were being monitored by county health officials as of 2 July 2018.[130] There were 273 cases of measles reported throughout the United States in 2018,[131] including an outbreak in Brooklyn with more than 200 reported cases from October 2018 to February 2019. The outbreak was tied with population density of the Orthodox Jewish community, with the initial exposure from an unvaccinated child that caught measles while visiting Israel.[132][133]

A resurgence of measles occurred during 2019, which has been generally tied to parents choosing not to have their children vaccinated as most of the reported cases have occurred in people 19 years old or younger.[134][135][136][137][138] Cases were first reported in Washington state in January, with an outbreak of at least 58 confirmed cases most within Clark County, which has a higher rate of vaccination exemptions compared to the rest of the state; nearly one in four kindergartners in Clark did not receive vaccinations, according to state data.[132] This led Washington state governor Jay Inslee to declare a state of emergency, and the state's congress to introduce legislation to disallow vaccination exemption for personal or philosophical reasons.[139] In April 2019, New York Mayor Bill de Blasio declared a public health emergency because of "a huge spike" in cases of measles where there were 285 cases centred on the Orthodox Jewish areas of Brooklyn in 2018, while there were only two cases in 2017. There were 168 more in neighboring Rockland County.[140] Other outbreaks have included Santa Cruz County and Butte County in California, and the states of New Jersey and Michigan.[138] As of April 2019, there have been 695 cases of measles reported in 22 states.[116] This is the highest number of measles cases since it was declared eradicated in 2000.[116] From 1 January, to 31 December 2019, 1,282 individual cases of measles were confirmed in 31 states.[117] This is the greatest number of cases reported in the U.S. since 1992.[117] Of the 1,282 cases, 128 of the people who got measles were hospitalized, and 61 reported having complications, including pneumonia and encephalitis.[117]

Following the end of the 2019 outbreak, reported cases have fallen to pre-outbreak levels: 13 cases in 2020, 49 cases in 2021, and 121 cases in 2022.[141]

Brazil

The spread of measles had been interrupted in Brazil in 2016, with the last-known case twelve months earlier.[142] This last case was in the state of Ceará.[143]

Brazil won a measles elimination certificate by the Pan American Health Organization in 2016, but the Ministry of Health has proclaimed that the country has struggled to keep this certificate, since two outbreaks had already been identified in 2018, one in the state of Amazonas and another one in Roraima, in addition to cases in other states (Rio de Janeiro, Rio Grande do Sul, Pará, São Paulo and Rondônia), totaling 1,053 confirmed cases until 1 August 2018.[144][145] In these outbreaks, and in most other cases, the contagion was related to the importation of the virus, especially from Venezuela.[144] This was confirmed by the genotype of the virus (D8) that was identified, which is the same that circulates in Venezuela.[145]

Southeast Asia

In the Vietnamese measles epidemic in spring of 2014, an estimated 8,500 measles cases were reported as of 19 April, with 114 fatalities;[146] as of 30 May, 21,639 suspected measles cases had been reported, with 142 measles-related fatalities.[147] In the Naga Self-Administered Zone in a remote northern region of Myanmar, at least 40 children died during a measles outbreak in August 2016 that was probably caused by lack of vaccination in an area of poor health infrastructure.[148][149] Following the 2019 Philippines measles outbreak, 23,563 measles cases have been reported in the country with 338 fatalities.[150] A measles outbreak also happened among the Malaysian Orang Asli sub-group of Batek people in the state of Kelantan from May 2019, causing the deaths of 15 from the tribe.[151][152]

South Pacific

A measles outbreak in New Zealand has 2193 confirmed cases and two deaths. A measles outbreak in Tonga has 612 cases of measles.

Samoa

A measles outbreak in Samoa in late 2019 has over 5,700 cases of measles and 83 deaths, out of a Samoan population of 200,000. Over three percent of the population were infected, and a state of emergency was declared from 17 November to 7 December. A vaccination campaign brought the measles vaccination rate from 31 to 34% in 2018 to an estimated 94% of the eligible population in December 2019.[153]

Africa

The Democratic Republic of the Congo and Madagascar have reported the highest numbers of cases in 2019. However, cases have decreased in Madagascar as a result of nationwide emergency measles vaccine campaigns. As of August 2019 outbreaks were occurring in Angola, Cameroon, Chad, Nigeria, South Sudan and Sudan.[154]

Madagascar

An outbreak of measles in 2018 has resulted in well beyond 115,000 cases and over 1,200 deaths.[155]

Democratic Republic of Congo

An outbreak of measles with nearly 5,000 deaths and 250,000 infections occurred in 2019, after the disease spread to all the provinces in the country.[156] Most deaths were among children under five years of age.[157] The World Health Organization (WHO) has reported this as the world's largest and fastest-moving epidemic.[158]

History

 
16th-century Aztec drawing of someone with measles

Measles is of zoonotic origin, having evolved from rinderpest, which infects cattle.[159] A precursor of the measles began causing infections in humans as early as the 4th century BC[160][161] or as late as after 500 AD.[159] The Antonine Plague of 165–180 AD has been speculated to have been measles, but the actual cause of this plague is unknown and smallpox is a more likely cause.[162] The first systematic description of measles, and its distinction from smallpox and chickenpox, is credited to the Persian physician Muhammad ibn Zakariya al-Razi (860–932), who published The Book of Smallpox and Measles.[163] At the time of Razi's book, it is believed that outbreaks were still limited and that the virus was not fully adapted to humans. Sometime between 1100 and 1200 AD, the measles virus fully diverged from rinderpest, becoming a distinct virus that infects humans.[159] This agrees with the observation that measles requires a susceptible population of over 500,000 to sustain an epidemic, a situation that occurred in historic times following the growth of medieval European cities.[94]

 
Maurice Hilleman's measles vaccine is estimated to prevent one million deaths per year.[164]

Measles is an endemic disease, meaning it has been continually present in a community and many people develop resistance. In populations not exposed to measles, exposure to the new disease can be devastating. In 1529, a measles outbreak in Cuba killed two-thirds of those indigenous people who had previously survived smallpox. Two years later, measles was responsible for the deaths of half the population of Honduras, and it has ravaged Mexico, Central America, and the Inca civilization.[165]

Between roughly 1855 and 2005, measles is estimated to have killed about 200 million people worldwide.[166]

The 1846 measles outbreak in the Faroe Islands was unusual for being well studied.[167] Measles had not been seen on the islands for 60 years, so almost no residents had any acquired immunity.[167] Three-quarters of the residents got sick, and more than 100 (1–2%) died from it before the epidemic burned itself out.[167] Peter Ludvig Panum observed the outbreak and determined that measles was spread through direct contact of contagious people with people who had never had measles.[167]

Measles killed 20 percent of Hawaii's population in the 1850s.[168] In 1875, measles killed over 40,000 Fijians, approximately one-third of the population.[169] In the 19th century, the disease killed more than half of the Great Andamanese population.[170][better source needed] Seven to eight million children are thought to have died from measles each year before the vaccine was introduced.[29]

In 1914, a statistician for the Prudential Insurance Company estimated from a survey of 22 countries that 1% of all deaths in the temperate zone were caused by measles. He observed also that 1–6% of cases of measles ended fatally, the difference depending on age (0–3 being the worst), social conditions (e.g. overcrowded tenements) and pre-existing health conditions.[171]

In 1954, the virus causing the disease was isolated from a 13-year-old boy from the United States, David Edmonston, and adapted and propagated on chick embryo tissue culture.[172] The World Health Organization recognizes eight clades, named A, B, C, D, E, F, G, and H. Twenty-three strains of the measles virus have been identified and designated within these clades.[173] While at Merck, Maurice Hilleman developed the first successful vaccine.[174] Licensed vaccines to prevent the disease became available in 1963.[175] An improved measles vaccine became available in 1968.[176] Measles as an endemic disease was eliminated from the United States in 2000, but continues to be reintroduced by international travelers.[177] In 2019 there were at least 1,241 cases of measles in the United States distributed across 31 states, with over three quarters in New York.[178]

Society and culture

German anti-vaccination campaigner and HIV/AIDS denialist[179] Stefan Lanka posed a challenge on his website in 2011, offering a sum of €100,000 for anyone who could scientifically prove that measles is caused by a virus and determine the diameter of the virus.[180] He posited that the illness is psychosomatic and that the measles virus does not exist. When provided with overwhelming scientific evidence from various medical studies by German physician David Bardens, Lanka did not accept the findings, forcing Bardens to appeal in court. The initial legal case ended with the ruling that Lanka was to pay the prize.[109][181] However, on appeal, Lanka was ultimately not required to pay the award because the submitted evidence did not meet his exact requirements.[182] The case received wide international coverage that prompted many to comment on it, including neurologist, well-known skeptic and science-based medicine advocate Steven Novella, who called Lanka "a crank".[183]

As outbreaks easily occur in under-vaccinated populations, the disease is seen as a test of sufficient vaccination within a population.[184] Measles outbreaks have been on the rise in the United States, especially in communities with lower rates of vaccination.[117] A different vaccine distribution within a single territory by age or social class may define different general perceptions of vaccination efficacy.[185] It is often introduced to a region by travelers from other countries and it typically spreads to those who have not received the measles vaccination.[117]

Alternative names

Other names include morbilli, rubeola, red measles, and English measles.[1][2]

Research

In May 2015, the journal Science published a report in which researchers found that the measles infection can leave a population at increased risk for mortality from other diseases for two to three years.[92] Results from additional studies that show the measles virus can kill cells that make antibodies were published in November 2019.[41]

A specific drug treatment for measles, ERDRP-0519, has shown[when?] promising results in animal studies, but has not yet[when?] been tested in humans.[186][187]

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February 15, 2024
measles, this, article, about, disease, other, uses, disambiguation, confused, with, either, rubella, roseola, which, also, viral, diseases, with, comparable, features, highly, contagious, vaccine, preventable, infectious, disease, caused, measles, virus, symp. This article is about the disease For other uses see Measles disambiguation Not to be confused with either rubella or roseola which are also viral diseases with comparable features Measles is a highly contagious vaccine preventable infectious disease caused by measles virus 3 5 11 12 Symptoms usually develop 10 12 days after exposure to an infected person and last 7 10 days 7 8 Initial symptoms typically include fever often greater than 40 C 104 F cough runny nose and inflamed eyes 3 4 Small white spots known as Koplik s spots may form inside the mouth two or three days after the start of symptoms 4 A red flat rash which usually starts on the face and then spreads to the rest of the body typically begins three to five days after the start of symptoms 4 Common complications include diarrhea in 8 of cases middle ear infection 7 and pneumonia 6 5 These occur in part due to measles induced immunosuppression 6 Less commonly seizures blindness or inflammation of the brain may occur 5 7 Other names include morbilli rubeola red measles and English measles 1 2 Both rubella also known as German measles and roseola are different diseases caused by unrelated viruses 13 MeaslesOther namesMorbilli rubeola red measles English measles 1 2 A child showing a day four measles rashSpecialtyInfectious diseaseSymptomsFever cough runny nose inflamed eyes rash 3 4 ComplicationsPneumonia seizures encephalitis subacute sclerosing panencephalitis immunosuppression hearing loss blindness 5 6 Usual onset10 12 days after exposure 7 8 Duration7 10 days 7 8 CausesMeasles virus 3 PreventionMeasles vaccine 7 TreatmentSupportive care 7 Frequency20 million per year 3 Deaths140 000 2018 9 10 Measles is an airborne disease which spreads easily from one person to the next through the coughs and sneezes of infected people 7 It may also be spread through direct contact with mouth or nasal secretions 14 It is extremely contagious nine out of ten people who are not immune and share living space with an infected person will be infected 5 Furthermore measles s reproductive number estimates vary beyond the frequently cited range of 12 to 18 15 The NIH quote this 2017 paper saying a review in 2017 identified feasible measles R0 values of 3 7 203 3 16 People are infectious to others from four days before to four days after the start of the rash 5 While often regarded as a childhood illness it can affect people of any age 17 Most people do not get the disease more than once 7 Testing for the measles virus in suspected cases is important for public health efforts 5 Measles is not known to occur in other animals 14 Once a person has become infected no specific treatment is available 14 although supportive care may improve outcomes 7 Such care may include oral rehydration solution slightly sweet and salty fluids healthy food and medications to control the fever 7 8 Antibiotics should be prescribed if secondary bacterial infections such as ear infections or pneumonia occur 7 14 Vitamin A supplementation is also recommended for children 14 Among cases reported in the U S between 1985 and 1992 death occurred in only 0 2 of cases 5 but may be up to 10 in people with malnutrition 7 Most of those who die from the infection are less than five years old 14 The measles vaccine is effective at preventing the disease is exceptionally safe and is often delivered in combination with other vaccines 7 18 Vaccination resulted in an 80 decrease in deaths from measles between 2000 and 2017 with about 85 of children worldwide having received their first dose as of 2017 14 Measles affects about 20 million people a year 3 primarily in the developing areas of Africa and Asia 7 It is one of the leading vaccine preventable disease causes of death 19 20 In 1980 2 6 million people died from measles 7 and in 1990 545 000 died due to the disease by 2014 global vaccination programs had reduced the number of deaths from measles to 73 000 21 22 Despite these trends rates of disease and deaths increased from 2017 to 2019 due to a decrease in immunization 23 24 25 source source source track Video summary script Contents 1 Signs and symptoms 1 1 Complications 2 Cause 3 Pathophysiology 4 Diagnosis 4 1 Laboratory testing 5 Prevention 6 Treatment 6 1 Medications 7 Prognosis 8 Epidemiology 8 1 Europe 8 2 Americas 8 2 1 United States 8 2 2 Brazil 8 3 Southeast Asia 8 4 South Pacific 8 4 1 Samoa 8 5 Africa 8 5 1 Madagascar 8 5 2 Democratic Republic of Congo 9 History 10 Society and culture 10 1 Alternative names 11 Research 12 References 13 External linksSigns and symptoms nbsp Maculopapular rash on the abdomen after 3 days of measles infectionSymptoms typically begin 10 14 days after exposure 26 27 The classic symptoms include a four day fever the four Ds and the three Cs cough coryza head cold fever sneezing and conjunctivitis red eyes along with a maculopapular rash 28 Fever is common and typically lasts for about one week the fever seen with measles is often as high as 40 C 104 F 29 Koplik s spots seen inside the mouth are diagnostic for measles but are temporary and therefore rarely seen 28 Koplik spots are small white spots that are commonly seen on the inside of the cheeks opposite the molars 27 They appear as grains of salt on a reddish background 30 Recognizing these spots before a person reaches their maximum infectiousness can help reduce the spread of the disease 31 The characteristic measles rash is classically described as a generalized red maculopapular rash that begins several days after the fever starts It starts on the back of the ears and after a few hours spreads to the head and neck before spreading to cover most of the body The measles rash appears two to four days after the initial symptoms and lasts for up to eight days The rash is said to stain changing color from red to dark brown before disappearing 32 Overall measles usually resolves after about three weeks 29 People who have been vaccinated against measles but have incomplete protective immunity may experience a form of modified measles 33 Modified measles is characterized by a prolonged incubation period milder and less characteristic symptoms sparse and discrete rash of short duration 33 Further information Stimson line nbsp A Filipino baby with measles nbsp Koplik s spots on the third pre eruptive day nbsp Koplik s spots on the day of measles rashComplications Complications of measles are relatively common ranging from mild ones such as diarrhea to serious ones such as pneumonia either direct viral pneumonia or secondary bacterial pneumonia laryngotracheobronchitis croup either direct viral laryngotracheobronchitis or secondary bacterial bronchitis otitis media 34 acute brain inflammation 35 corneal ulceration leading to corneal scarring 36 and in about 1 in 600 unvaccinated infants under 15 months while more rarely in older children and adults subacute sclerosing panencephalitis which is progressive and eventually lethal 37 In addition measles can suppress the immune system for weeks to months and this can contribute to bacterial superinfections such as otitis media and bacterial pneumonia 6 38 39 40 41 Two months after recovery there is a 11 73 decrease in the number of antibodies against other bacteria and viruses 42 The death rate in the 1920s was around 30 for measles pneumonia 43 People who are at high risk for complications are infants and children aged less than 5 years 17 adults aged over 20 years 17 pregnant women 17 people with compromised immune systems such as from leukemia HIV infection or innate immunodeficiency 17 44 and those who are malnourished 17 or have vitamin A deficiency 17 45 Complications are usually more severe in adults 46 Between 1987 and 2000 the case fatality rate across the United States was three deaths per 1 000 cases attributable to measles or 0 3 47 In underdeveloped nations with high rates of malnutrition and poor healthcare fatality rates have been as high as 28 47 In immunocompromised persons e g people with AIDS the fatality rate is approximately 30 48 Even in previously healthy children measles can cause serious illness requiring hospitalization 44 One out of every 1 000 measles cases progresses to acute encephalitis which often results in permanent brain damage 44 One to three out of every 1 000 children who become infected with measles will die from respiratory and neurological complications 44 Cause nbsp An electron micrograph of the measles virusMeasles is caused by the measles virus a single stranded negative sense enveloped RNA virus of the genus Morbillivirus within the family Paramyxoviridae 49 The virus is highly contagious and is spread by coughing and sneezing via close personal contact or direct contact with secretions 50 Measles is the most contagious virus known 18 It remains infective for up to two hours in that airspace or nearby surfaces 26 50 Measles is so contagious that if one person has it 90 of non immune people who have close contact with them e g household members will also become infected 26 51 Humans are the only natural hosts of the virus and no other animal reservoirs are known to exist although mountain gorillas are believed to be susceptible to the disease 26 52 Risk factors for measles virus infection include immunodeficiency caused by HIV AIDS 53 immunosuppression following receipt of an organ or a stem cell transplant 54 alkylating agents or corticosteroid therapy regardless of immunization status 17 travel to areas where measles commonly occurs or contact with travelers from such an area 17 and the loss of passive inherited antibodies before the age of routine immunization 55 Pathophysiology nbsp Drawing of the measles virus attaching to the lining of the trachea nbsp Photomicrograph of a lung tissue specimen showing the histopathologic changes encountered in a case of measles pneumonia Included in this view are numerous leukocytes and a multinucleated giant cell Normal alveolar cytoarchitecture has been obliterated 56 Once the measles virus gets onto the mucosa it infects the epithelial cells in the trachea or bronchi 57 58 Measles virus uses a protein on its surface called hemagglutinin H protein to bind to a target receptor on the host cell which could be CD46 which is expressed on all nucleated human cells CD150 aka signaling lymphocyte activation molecule or SLAM which is found on immune cells like B or T cells and antigen presenting cells or nectin 4 a cellular adhesion molecule 57 59 Once bound the fusion or F protein helps the virus fuse with the membrane and ultimately get inside the cell 57 As the virus is a single stranded negative sense RNA virus it includes the enzyme RNA dependent RNA polymerase RdRp which is used to transcribe its genome into a positive sense mRNA strand 57 After entering a cell it is ready to be translated into viral proteins wrapped in the cell s lipid envelope and sent out of the cell as a newly made virus 60 Within days the measles virus spreads through local tissue and is picked up by dendritic cells and alveolar macrophages and carried from that local tissue in the lungs to the local lymph nodes 57 58 From there it continues to spread eventually getting into the blood and spreading to more lung tissue as well as other organs like the intestines and the brain 26 57 Functional impairment of the infected dendritic cells by the measles virus is thought to contribute to measles induced immunosuppression 6 DiagnosisTypically clinical diagnosis begins with the onset of fever and malaise about 10 days after exposure to the measles virus followed by the emergence of cough coryza and conjunctivitis that worsen in severity over 4 days of appearing 61 Observation of Koplik s spots is also diagnostic 31 Other possible condition that can result in these symptoms include parvovirus dengue fever Kawasaki disease and scarlet fever 62 Laboratory confirmation is however strongly recommended 63 Laboratory testing Laboratory diagnosis of measles can be done with confirmation of positive measles IgM antibodies or detection of measles virus RNA from throat nasal or urine specimen by using the reverse transcription polymerase chain reaction assay 62 64 This method is particularly useful to confirm cases when the IgM antibodies results are inconclusive 62 For people unable to have their blood drawn saliva can be collected for salivary measles specific IgA testing 64 Salivary tests used to diagnose measles involve collecting a saliva sample and testing for the presence of measles antibodies 65 66 This method is not ideal as saliva contains many other fluids and proteins which may make it difficult to collect samples and detect measles antibodies 65 66 Saliva also contains 800 times fewer antibodies than blood samples do which makes salivary testing additionally difficult Positive contact with other people known to have measles adds evidence to the diagnosis 65 PreventionFurther information Measles vaccine MMR vaccine and MMRV vaccine nbsp Rates of measles vaccination worldwideMothers who are immune to measles pass antibodies to their children while they are still in the womb especially if the mother acquired immunity through infection rather than vaccination 26 55 Such antibodies will usually give newborn infants some immunity against measles but these antibodies are gradually lost over the course of the first nine months of life 27 55 Infants under one year of age whose maternal anti measles antibodies have disappeared become susceptible to infection with the measles virus 55 In developed countries it is recommended that children be immunized against measles at 12 months generally as part of a three part MMR vaccine measles mumps and rubella The vaccine is generally not given before this age because such infants respond inadequately to the vaccine due to an immature immune system 55 A second dose of the vaccine is usually given to children between the ages of four and five to increase rates of immunity Measles vaccines have been given to over a billion people 18 Vaccination rates have been high enough to make measles relatively uncommon Adverse reactions to vaccination are rare with fever and pain at the injection site being the most common Life threatening adverse reactions occur in less than one per million vaccinations lt 0 0001 67 In developing countries where measles is common the World Health Organization WHO recommends two doses of vaccine be given at six and nine months of age The vaccine should be given whether the child is HIV infected or not 68 The vaccine is less effective in HIV infected infants than in the general population but early treatment with antiretroviral drugs can increase its effectiveness 69 Measles vaccination programs are often used to deliver other child health interventions as well such as bed nets to protect against malaria antiparasite medicine and vitamin A supplements and so contribute to the reduction of child deaths from other causes 70 The Advisory Committee on Immunization Practices ACIP recommends that all adult international travelers who do not have positive evidence of previous measles immunity receive two doses of MMR vaccine before traveling although birth before 1957 is presumptive evidence of immunity 71 Those born in the United States before 1957 are likely to have been naturally infected with measles virus and generally need not be considered susceptible 26 72 There have been false claims of an association between the measles vaccine and autism this incorrect concern has reduced the rate of vaccination and increased the number of cases of measles where immunization rates became too low to maintain herd immunity 17 Additionally there have been false claims that measles infection protects against cancer 18 Administration of the MMR vaccine may prevent measles after exposure to the virus post exposure prophylaxis 73 Post exposure prophylaxis guidelines are specific to jurisdiction and population 73 Passive immunization against measles by an intramuscular injection of antibodies could be effective up to the seventh day after exposure 74 Compared to no treatment the risk of measles infection is reduced by 83 and the risk of death by measles is reduced by 76 74 However the effectiveness of passive immunization in comparison to active measles vaccine is not clear 74 The MMR vaccine is 95 effective for preventing measles after one dose if the vaccine is given to a child who is 12 months or older if a second dose of the MMR vaccine is given it will provide immunity in 99 of children 75 There is no evidence that the measles vaccine virus can be transmitted to other persons 76 TreatmentThere is no specific antiviral treatment if measles develops 50 Instead the medications are generally aimed at treating superinfections maintaining good hydration with adequate fluids and pain relief 50 Some groups like young children and the severely malnourished are also given vitamin A which acts as an immunomodulator that boosts the antibody responses to measles and decreases the risk of serious complications 50 77 78 Medications Treatment is supportive with ibuprofen or paracetamol acetaminophen to reduce fever and pain and if required a fast acting medication to dilate the airways for cough 79 As for aspirin some research has suggested a correlation between children who take aspirin and the development of Reye syndrome 80 81 The use of vitamin A during treatment is recommended to decrease the risk of blindness 78 however it does not prevent or cure the disease 82 A systematic review of trials into its use found no reduction in overall mortality but two doses 200 000 IU of vitamin A was shown to reduce mortality for measles in children younger than two years of age 77 83 It is unclear if zinc supplementation in children with measles affects outcomes as it has not been sufficiently studied 84 There are no adequate studies on whether Chinese medicinal herbs are effective 85 PrognosisMost people survive measles though in some cases complications may occur About 1 in 4 individuals will be hospitalized and 1 2 in 1 000 will die Complications are more likely in children under age 5 and adults over age 20 86 Pneumonia is the most common fatal complication of measles infection and accounts for 56 86 of measles related deaths 87 Possible consequences of measles virus infection include laryngotracheobronchitis sensorineural hearing loss 49 and in about 1 in 10 000 to 1 in 300 000 cases 88 panencephalitis which is usually fatal 89 Acute measles encephalitis is another serious risk of measles virus infection It typically occurs two days to one week after the measles rash breaks out and begins with very high fever severe headache convulsions and altered mentation A person with measles encephalitis may become comatose and death or brain injury may occur 90 For people having had measles it is rare to ever have a symptomatic reinfection 91 The measles virus can deplete previously acquired immune memory by killing cells that make antibodies and thus weakens the immune system which can cause deaths from other diseases 40 41 42 Suppression of the immune system by measles lasts about two years and has been epidemiologically implicated in up to 90 of childhood deaths in third world countries and historically may have caused rather more deaths in the United States the UK and Denmark than were directly caused by measles 92 Although the measles vaccine contains an attenuated strain it does not deplete immune memory 41 EpidemiologyMain article Epidemiology of measles nbsp Deaths from measles per million persons in 2012 no data 0 1 8 9 26 27 38 39 73 74 850 nbsp Disability adjusted life year for measles per 100 000 inhabitants in 2004 no data 10 10 25 25 50 50 75 75 100 100 250 250 500 500 750 750 1000 1000 1500 1500 2000 2000Measles is extremely infectious and its continued circulation in a community depends on the generation of susceptible hosts by birth of children In communities that generate insufficient new hosts the disease will die out This concept was first recognized in measles by Bartlett in 1957 who referred to the minimum number supporting measles as the critical community size CCS 93 Analysis of outbreaks in island communities suggested that the CCS for measles is around 250 000 94 To achieve herd immunity more than 95 of the community must be vaccinated due to the ease with which measles is transmitted from person to person 29 In 2011 the WHO estimated that 158 000 deaths were caused by measles This is down from 630 000 deaths in 1990 95 As of 2018 measles remains a leading cause of vaccine preventable deaths in the world 19 96 In developed countries the mortality rate is lower for example in England and Wales from 2007 to 2017 death occurred between two and three cases out of 10 000 97 In children one to three cases out of every 1 000 die in the United States 0 1 0 2 98 In populations with high levels of malnutrition and a lack of adequate healthcare mortality can be as high as 10 7 99 In cases with complications the rate may rise to 20 30 medical citation needed In 2012 the number of deaths due to measles was 78 lower than in 2000 due to increased rates of immunization among UN member states 29 Reported cases 100 WHO Region 1980 1990 2000 2010 2020African Region 1 240 993 481 204 520 102 199 174 115 369Region of the Americas 257 790 218 579 1 754 247 9 996Eastern Mediterranean Region 341 624 59 058 38 592 10 072 6 769European Region 492 660 185 818 37 421 30 625 10 945Southeast Asia Region 199 535 224 925 78 558 54 228 9 389Western Pacific Region 1 319 640 155 490 177 052 49 460 6 605Worldwide 3 852 242 1 325 074 853 479 343 806 159 073Even in countries where vaccination has been introduced rates may remain high Measles is a leading cause of vaccine preventable childhood mortality Worldwide the fatality rate has been significantly reduced by a vaccination campaign led by partners in the Measles Initiative the American Red Cross the United States CDC the United Nations Foundation UNICEF and the WHO Globally measles fell 60 from an estimated 873 000 deaths in 1999 to 345 000 in 2005 101 Estimates for 2008 indicate deaths fell further to 164 000 globally with 77 of the remaining measles deaths in 2008 occurring within the Southeast Asian region 102 There were 142 300 measles related deaths globally in 2018 of which most cases were reported from African and eastern Mediterranean regions These estimates were slightly higher than that of 2017 when 124 000 deaths were reported due to measles infection globally 103 In 2000 the WHO established the Global Measles and Rubella Laboratory Network GMRLN to provide laboratory surveillance for measles rubella and congenital rubella syndrome 104 Data from 2016 to 2018 show that the most frequently detected measles virus genotypes are decreasing suggesting that increasing global population immunity has decreased the number of chains of transmission 104 Cases reported in the first three months of 2019 were 300 higher than in the first three months of 2018 with outbreaks in every region of the world even in countries with high overall vaccination coverage where it spread among clusters of unvaccinated people 105 The numbers of reported cases as of mid November is over 413 000 globally with an additional 250 000 cases in DRC as reported through their national system similar to the increasing trends of infection reported in the earlier months of 2019 compared to 2018 103 In 2019 the total number of cases worldwide climbed to 869 770 The number of cases reported for 2020 is lower compare to 2019 106 According to the WHO the COVID 19 pandemic hindered vaccination campaigns in at least 68 countries including in countries that were experiencing outbreaks which caused increased risk of additional cases 106 107 Europe nbsp Incidence of and deaths due to measles in England and Wales between 1940 and 2017In England and Wales though deaths from measles were uncommon they averaged about 500 per year in the 1940s Deaths diminished with the improvement of medical care in the 1950s but the incidence of the disease did not retreat until vaccination was introduced in the late 1960s Wider coverage was achieved in the 1980s with the measles mumps and rubella MMR vaccine 108 In 2013 14 there were almost 10 000 cases in 30 European countries Most cases occurred in unvaccinated individuals and over 90 of cases occurred in Germany Italy Netherlands Romania and United Kingdom 29 Between October 2014 and March 2015 a measles outbreak in the German capital of Berlin resulted in at least 782 cases 109 In 2017 numbers continued to increase in Europe to 21 315 cases with 35 deaths 110 In preliminary figures for 2018 reported cases in the region increased 3 fold to 82 596 in 47 countries with 72 deaths Ukraine had the most cases 53 218 with the highest incidence rates being in Ukraine 1209 cases per million Serbia 579 Georgia 564 and Albania 500 111 112 The previous year 2017 saw an estimated measles vaccine coverage of 95 for the first dose and 90 for the second dose in the region the latter figure being the highest ever estimated second dose coverage 112 In 2019 the United Kingdom Albania the Czech Republic and Greece lost their measles free status due to ongoing and prolonged spread of the disease in these countries 113 In the first 6 months of 2019 90 000 cases occurred in Europe 113 Americas As a result of widespread vaccination the disease was declared eliminated from the Americas in 2016 114 However there were cases again in 2017 115 2018 2019 116 and 2020 117 in this region United States See also Measles resurgence in the United States nbsp Measles cases in the U S from 1938 to 2019In the United States measles affected approximately 3 000 people per million in the 1960s before the vaccine was available With consistent widespread childhood vaccination this figure fell to 13 cases per million by the 1980s and to about 1 case per million by 2000 118 In 1991 an outbreak of measles in Philadelphia was centered at the Faith Tabernacle Congregation a faith healing church that actively discouraged parishioners from vaccinating their children Over 1400 people were infected with measles and nine children died 119 Before immunization in the United States between three and four million cases occurred each year 5 The United States was declared free of circulating measles in 2000 with 911 cases from 2001 to 2011 In 2014 the CDC said endemic measles rubella and congenital rubella syndrome had not returned to the United States 120 Occasional measles outbreaks persist however because of cases imported from abroad of which more than half are the result of unvaccinated U S residents who are infected abroad and infect others upon return to the United States 120 The CDC continues to recommend measles vaccination throughout the population to prevent outbreaks like these 121 In 2014 an outbreak was initiated in Ohio when two unvaccinated Amish men harboring asymptomatic measles returned to the United States from missionary work in the Philippines 122 Their return to a community with low vaccination rates led to an outbreak that rose to include a total of 383 cases across nine counties 122 Of the 383 cases 340 89 occurred in unvaccinated individuals 122 From 4 January to 2 April 2015 there were 159 cases of measles reported to the CDC Of those 159 cases 111 70 were determined to have come from an earlier exposure in late December 2014 This outbreak was believed to have originated from the Disneyland theme park in California The Disneyland outbreak was held responsible for the infection of 147 people in seven U S states as well as Mexico and Canada the majority of which were either unvaccinated or had unknown vaccination status 123 Of the cases 48 were unvaccinated and 38 were unsure of their vaccination status 124 The initial exposure to the virus was never identified 125 In 2015 a U S woman in Washington state died of pneumonia as a result of measles She was the first fatality in the U S from measles since 2003 126 The woman had been vaccinated for measles and was taking immunosuppressive drugs for another condition The drugs suppressed the woman s immunity to measles and the woman became infected with measles she did not develop a rash but contracted pneumonia which caused her death 127 128 In June 2017 the Maine Health and Environmental Testing Laboratory confirmed a case of measles in Franklin County This instance marks the first case of measles in 20 years for the state of Maine 129 In 2018 one case occurred in Portland Oregon with 500 people exposed 40 of them lacked immunity to the virus and were being monitored by county health officials as of 2 July 2018 130 There were 273 cases of measles reported throughout the United States in 2018 131 including an outbreak in Brooklyn with more than 200 reported cases from October 2018 to February 2019 The outbreak was tied with population density of the Orthodox Jewish community with the initial exposure from an unvaccinated child that caught measles while visiting Israel 132 133 A resurgence of measles occurred during 2019 which has been generally tied to parents choosing not to have their children vaccinated as most of the reported cases have occurred in people 19 years old or younger 134 135 136 137 138 Cases were first reported in Washington state in January with an outbreak of at least 58 confirmed cases most within Clark County which has a higher rate of vaccination exemptions compared to the rest of the state nearly one in four kindergartners in Clark did not receive vaccinations according to state data 132 This led Washington state governor Jay Inslee to declare a state of emergency and the state s congress to introduce legislation to disallow vaccination exemption for personal or philosophical reasons 139 In April 2019 New York Mayor Bill de Blasio declared a public health emergency because of a huge spike in cases of measles where there were 285 cases centred on the Orthodox Jewish areas of Brooklyn in 2018 while there were only two cases in 2017 There were 168 more in neighboring Rockland County 140 Other outbreaks have included Santa Cruz County and Butte County in California and the states of New Jersey and Michigan 138 As of April 2019 update there have been 695 cases of measles reported in 22 states 116 This is the highest number of measles cases since it was declared eradicated in 2000 116 From 1 January to 31 December 2019 1 282 individual cases of measles were confirmed in 31 states 117 This is the greatest number of cases reported in the U S since 1992 117 Of the 1 282 cases 128 of the people who got measles were hospitalized and 61 reported having complications including pneumonia and encephalitis 117 Following the end of the 2019 outbreak reported cases have fallen to pre outbreak levels 13 cases in 2020 49 cases in 2021 and 121 cases in 2022 141 Brazil The spread of measles had been interrupted in Brazil in 2016 with the last known case twelve months earlier 142 This last case was in the state of Ceara 143 Brazil won a measles elimination certificate by the Pan American Health Organization in 2016 but the Ministry of Health has proclaimed that the country has struggled to keep this certificate since two outbreaks had already been identified in 2018 one in the state of Amazonas and another one in Roraima in addition to cases in other states Rio de Janeiro Rio Grande do Sul Para Sao Paulo and Rondonia totaling 1 053 confirmed cases until 1 August 2018 144 145 In these outbreaks and in most other cases the contagion was related to the importation of the virus especially from Venezuela 144 This was confirmed by the genotype of the virus D8 that was identified which is the same that circulates in Venezuela 145 Southeast Asia In the Vietnamese measles epidemic in spring of 2014 an estimated 8 500 measles cases were reported as of 19 April with 114 fatalities 146 as of 30 May 21 639 suspected measles cases had been reported with 142 measles related fatalities 147 In the Naga Self Administered Zone in a remote northern region of Myanmar at least 40 children died during a measles outbreak in August 2016 that was probably caused by lack of vaccination in an area of poor health infrastructure 148 149 Following the 2019 Philippines measles outbreak 23 563 measles cases have been reported in the country with 338 fatalities 150 A measles outbreak also happened among the Malaysian Orang Asli sub group of Batek people in the state of Kelantan from May 2019 causing the deaths of 15 from the tribe 151 152 South Pacific A measles outbreak in New Zealand has 2193 confirmed cases and two deaths A measles outbreak in Tonga has 612 cases of measles Samoa A measles outbreak in Samoa in late 2019 has over 5 700 cases of measles and 83 deaths out of a Samoan population of 200 000 Over three percent of the population were infected and a state of emergency was declared from 17 November to 7 December A vaccination campaign brought the measles vaccination rate from 31 to 34 in 2018 to an estimated 94 of the eligible population in December 2019 153 Africa The Democratic Republic of the Congo and Madagascar have reported the highest numbers of cases in 2019 However cases have decreased in Madagascar as a result of nationwide emergency measles vaccine campaigns As of August 2019 outbreaks were occurring in Angola Cameroon Chad Nigeria South Sudan and Sudan 154 Madagascar An outbreak of measles in 2018 has resulted in well beyond 115 000 cases and over 1 200 deaths 155 Democratic Republic of Congo An outbreak of measles with nearly 5 000 deaths and 250 000 infections occurred in 2019 after the disease spread to all the provinces in the country 156 Most deaths were among children under five years of age 157 The World Health Organization WHO has reported this as the world s largest and fastest moving epidemic 158 History nbsp 16th century Aztec drawing of someone with measlesMeasles is of zoonotic origin having evolved from rinderpest which infects cattle 159 A precursor of the measles began causing infections in humans as early as the 4th century BC 160 161 or as late as after 500 AD 159 The Antonine Plague of 165 180 AD has been speculated to have been measles but the actual cause of this plague is unknown and smallpox is a more likely cause 162 The first systematic description of measles and its distinction from smallpox and chickenpox is credited to the Persian physician Muhammad ibn Zakariya al Razi 860 932 who published The Book of Smallpox and Measles 163 At the time of Razi s book it is believed that outbreaks were still limited and that the virus was not fully adapted to humans Sometime between 1100 and 1200 AD the measles virus fully diverged from rinderpest becoming a distinct virus that infects humans 159 This agrees with the observation that measles requires a susceptible population of over 500 000 to sustain an epidemic a situation that occurred in historic times following the growth of medieval European cities 94 nbsp Maurice Hilleman s measles vaccine is estimated to prevent one million deaths per year 164 Measles is an endemic disease meaning it has been continually present in a community and many people develop resistance In populations not exposed to measles exposure to the new disease can be devastating In 1529 a measles outbreak in Cuba killed two thirds of those indigenous people who had previously survived smallpox Two years later measles was responsible for the deaths of half the population of Honduras and it has ravaged Mexico Central America and the Inca civilization 165 Between roughly 1855 and 2005 measles is estimated to have killed about 200 million people worldwide 166 The 1846 measles outbreak in the Faroe Islands was unusual for being well studied 167 Measles had not been seen on the islands for 60 years so almost no residents had any acquired immunity 167 Three quarters of the residents got sick and more than 100 1 2 died from it before the epidemic burned itself out 167 Peter Ludvig Panum observed the outbreak and determined that measles was spread through direct contact of contagious people with people who had never had measles 167 Measles killed 20 percent of Hawaii s population in the 1850s 168 In 1875 measles killed over 40 000 Fijians approximately one third of the population 169 In the 19th century the disease killed more than half of the Great Andamanese population 170 better source needed Seven to eight million children are thought to have died from measles each year before the vaccine was introduced 29 In 1914 a statistician for the Prudential Insurance Company estimated from a survey of 22 countries that 1 of all deaths in the temperate zone were caused by measles He observed also that 1 6 of cases of measles ended fatally the difference depending on age 0 3 being the worst social conditions e g overcrowded tenements and pre existing health conditions 171 In 1954 the virus causing the disease was isolated from a 13 year old boy from the United States David Edmonston and adapted and propagated on chick embryo tissue culture 172 The World Health Organization recognizes eight clades named A B C D E F G and H Twenty three strains of the measles virus have been identified and designated within these clades 173 While at Merck Maurice Hilleman developed the first successful vaccine 174 Licensed vaccines to prevent the disease became available in 1963 175 An improved measles vaccine became available in 1968 176 Measles as an endemic disease was eliminated from the United States in 2000 but continues to be reintroduced by international travelers 177 In 2019 there were at least 1 241 cases of measles in the United States distributed across 31 states with over three quarters in New York 178 Society and cultureGerman anti vaccination campaigner and HIV AIDS denialist 179 Stefan Lanka posed a challenge on his website in 2011 offering a sum of 100 000 for anyone who could scientifically prove that measles is caused by a virus and determine the diameter of the virus 180 He posited that the illness is psychosomatic and that the measles virus does not exist When provided with overwhelming scientific evidence from various medical studies by German physician David Bardens Lanka did not accept the findings forcing Bardens to appeal in court The initial legal case ended with the ruling that Lanka was to pay the prize 109 181 However on appeal Lanka was ultimately not required to pay the award because the submitted evidence did not meet his exact requirements 182 The case received wide international coverage that prompted many to comment on it including neurologist well known skeptic and science based medicine advocate Steven Novella who called Lanka a crank 183 As outbreaks easily occur in under vaccinated populations the disease is seen as a test of sufficient vaccination within a population 184 Measles outbreaks have been on the rise in the United States especially in communities with lower rates of vaccination 117 A different vaccine distribution within a single territory by age or social class may define different general perceptions of vaccination efficacy 185 It is often introduced to a region by travelers from other countries and it typically spreads to those who have not received the measles vaccination 117 Alternative names Other names include morbilli rubeola red measles and English measles 1 2 ResearchIn May 2015 the journal Science published a report in which researchers found that the measles infection can leave a population at increased risk for mortality from other diseases for two to three years 92 Results from additional studies that show the measles virus can kill cells that make antibodies were published in November 2019 41 A specific drug treatment for measles ERDRP 0519 has shown when promising results in animal studies but has not yet when 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