A recent study projects that small decreases in the MMR vaccine could lead to large increases in measles outbreaks.1 The study is a response to the 18 states which allow for non-medical or philosophical belief exemptions to vaccinations. The study cites that as a nation, the United States is “near the threshold of 90 to 95 percent vaccine coverage needed to prevent measles outbreaks” in several regions. It has used statistical analysis and logarithmic projections to reach a conclusion that a 5 percent drop in the number of children 2 to 11 receiving vaccination against measles will result in triple the number of annual cases for this age group – the measles vaccine is given as part of the MMR vaccine which includes measles, mumps and rubella.
In 2016, there were 70 cases of measles; a 3 x increase would be 210 cases annually. In regions where there is less vaccination, or a drop further than 5 percent, perhaps more cases will be seen. For physicians too young to have ever seen measles first hand (because remember, this used to a ubiquitous illness of childhood – the first of the 5 common illnesses of childhood: measles, scarlet fever, rubella, dukes’ disease, fifth disease (erythema infectiosum, roseola).
Recognizing Measles
Measles is a very contagious illness, which includes four phases: Incubation, prodrome, exanthem and recovery.
Incubation
Incubation period lasts for 6-21 days after susceptible person has come into contact with the virus. The period of infectiousness is presumed to be roughly 5 days before the onset of rash, to four days after rash resolution. Infected individuals are generally asymptomatic during the incubation period.
Prodrome
Prodrome can last as long as 8 days, but normally only 2-4 days. Symptoms of the prodrome include: fever, malaise, and anorexia; conjunctivitis, coryza and cough usually follow. The prodromal symptoms can sometimes intensify a few days before the exanthem.
Enanthem – 48 hours before onset of exanthem, patients may experience enanthem of the buccal mucosa (Koplik’s spots). These will typically present as 1-3 mm whitish, grayish, or bluish elevations with an erythematous base.
Exanthem
The exanthem of measles presents as an erythematous, maculopapular rash, which does blanch. It classically starts on the face and spreads downward to include the neck, trunk and extremities. The palms and soles are NOT usually involved. Fever, respiratory symptoms, and conjunctivitis are also common at this time.
The rash is self-limiting and resolves in 2-3 days. After 3-4 days the rash typically darkens to a brownish color (in patients with light skin). In the most severely affected areas, the rash will desquamate.
Recovery
Cough may persist for a couple weeks after resolution of the measles rash. And a fever beyond the third of fourth day of the rash may be suggestive of a complication.
References
- Lo NC, Hotez PJ. Public Health and Economic Consequences of Vaccine Hesitancy for Measles in the United States. JAMA Pediatr. 2017
- Perry RT, Halsey NA. The clinical significance of measles: a review. J Infect Dis. 2004;189 Suppl 1:S4-16.
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Node Smith, associate editor for NDNR, is a fifth year naturopathic medical student at NUNM, where he has been instrumental in maintaining a firm connection to the philosophy and heritage of naturopathic medicine amongst the next generation of docs. He helped found the first multi-generational experiential retreat, which brings elders, alumni, and students together for a weekend campout where naturopathic medicine and medical philosophy are experienced in nature. Three years ago he helped found the non-profit, Association for Naturopathic ReVitalization (ANR), for which he serves as the board chairman. ANR has a mission to inspire health practitioners to embody the naturopathic principles through experiential education. Node also has a firm belief that the next era of naturopathic medicine will see a resurgence of in-patient facilities which use fasting, earthing, hydrotherapy and homeopathy to bring people back from chronic diseases of modern living; he is involved in numerous conversations and projects to bring about this vision.
