One Nurse At A Time modules are intended to help nurses understand disease processes that are uncommon in our work practices at home. They are intended to be practical guides and not exhaustive dissertations. Education is a dynamic, ongoing process. We value your input and comments on the content of this module. Please feel free to write to OneNurseAtATime@gmail.com.
Those of us who were children before 1970 remember getting Measles when we were kids. Fever, sponge baths, worried mothers, staying home from kindergarten. By the late ‘60’s the MMR (Measles, Mumps and Rubella) vaccine was developed and with it, the purge of the disease from the US. Nowadays, one single case of Measles is a reportable contagious disease and followed up closely by Public Health Departments across the country. Not so in the developing world where Measles is the leading cause of vaccine preventable childhood mortality per the World Health Organization.
The global Measles eradication strategy is called The Measles Initiative – a collaboration between WHO, UNICEF, American Red Cross, Centers for Disease Control, UN Foundation and other private and public partners. There are 4 tenants:
- Immunize all children by their first birthday
- Have a second opportunity to “catch up” on vaccination
- Disease surveillance
- Treat all Measles cases with Vitamin A, plus antibiotics if needed (TREATMENT protocols below are based on WHO recommendations)
As a nurse working in the developing world, especially if you work with vulnerable populations such as displaced persons, you should know how to recognize, diagnose and treat Measles.
Measles is a respiratory infection caused by a virus. Another name is Rubeola, which should not be confused with Rubella/German Measles (an unrelated disease). Measles is spread by droplets from an infected person’s cough or sneeze. It is highly contagious and can gain epidemic/outbreak status quickly. An estimated 90% of unvaccinated people sharing a living space will catch it from an infected person. It is a killer in displaced populations. Measles has a mortality rate of 10% in Sub-Saharan Africa and nearly 30% if there are complications such as HIV/AIDS. Increased population density equals higher risk. The good news? Once recovered, the individual is immune for life.
The incubation period is about 2 weeks (reported range from 6 – 19 days). After exposure, the virus grows in cells in the back of the throat and lungs. Children are the most vulnerable. Up to about 6 months, the newborn will have antibodies from the mother, if indeed she had immunity. After 6 – 9 months, the child needs to be vaccinated to be protected (see below VACCINATION).
COURSE OF THE DISEASE
High fever up to 40C/104F is a hallmark. After the fever begins, the patient appears to have what can be mistaken for an upper respiratory infection: dry cough, runny nose, conjunctivitis. Three days later a maculopapular rash appears (which might be difficult to see on black skin). This rash is red, flat and has small raised bumps. Unfortunately, the patient is infectious 2 – 4 days before the rash appears and remains infectious 2 – 5 days after the onset of the rash. The rash begins on the face and spreads downward over the course of 3 – 4 days. It fades in the reverse direction around Rash Day 5.
The literature will tell you look for Koplik’s Spots. Yes, they are diagnostic of Measles, but rarely seen since they only last one day and are hard to see in a mouth with dark mucosa. These spots are small and red with a bluish-white center, found on the back of the throat or inner cheek by the gum line.
You can confirm Measles with blood tests if there is a lab capable of testing (usually only in capital cities with a reference lab). There are no field rapid tests. In the case of a potential outbreak, the Ministry of Health and WHO may want serum samples prior to mounting an expensive and labor intensive vaccination campaign. In most other situations, the diagnosis is made by classic symptoms:
Fever and rash plus one of the following 3: cough, runny nose, and/or conjunctivitis.
- Stomatitis (making eating and drinking difficult) and diarrhea which can lead to dehydration.
- Pneumonia, bronchitis, otitis, sinusitis.
- Neurological: headache, change in level of consciousness, encephalitis (15% mortality), meningitis, febrile seizures.
- Corneal ulceration and scarring, keratitis, xerophthalmia (failure to produce tears leading to dryness of the conjunctiva and cornea) from Vitamin A deficiency.
- Acute malnutrition (see One Nurse At A Time module MALNUTRITION) with high mortality rate.
- Skin peeling for 1 – 2 weeks after the rash.
- Rest, fluids, good nutrition and hydration (Dehydration treatment guidelines at the end of this section).
- Fever control – take axillary temperatures. Remember, these patients typically have sore mouths so oral thermometers may cause pain.
Acetaminophen/Tylenol (also called Paracetamol, PCM or Panadol in other countries). Pediatric dose: 15 mg/kg orally every 6 hours as needed with maximum of 60 mg/kg per day. Adult dose: 3 – 4 grams in 3 or 4 divided doses with maximum of 4 grams per day.
Also may use ibuprofen in children over 3 months 30 mg/kg per day in 3 divided doses. Ibuprofen in children should be used only for fever control and short term (a few days rather than weeks) to avoid kidney concerns. Adult dose: 400 – 600 mg three times daily.
Do not use aspirin as it has been linked to Reye’s Syndrome, which is a potentially fatal disease involving encephalitis and liver dysfunction.
- Respiratory infections (productive cough with fever, otitis) use Amoxicillin 80 – 100 mg/kg per day in two divided doses for 5 days.
- Ophthalmology: Wash both eyes gently with clean water twice daily and apply 1% Tetracycline Ophthalmic Ointment for 7 days. This will prevent as well as treat conjunctivitis, which is common with Measles.
- Vitamin A is given to all Measles patients and has been shown to decrease mortality by 50%. It is an oily preparation, fat soluble, and comes in a soft capsule. One drop is 25,000 iU. Prick the end of the capsule with a needle and squeeze into the child’s mouth:
Under 6 months of age give 50,000 iU (2 drops) once on Day 1 and once on Day 2.
6 – 12 months of age give 100,000 iU (4 drops) once on Day 1 and once on Day 2.
Over 1 year of age give 200,000 (8 drops) once on Day 1 and once on Day 2.
The patient should be isolated, but this is equivalent to shutting the barn door after the horses run away. At home, it’s best to isolate the patient from others without known immunity. But in a typical rural household, this may be impossible since all family members usually sleep together in one room or tukul. In a health facility, try to separate Measles patients from other patients by at least 6 feet (droplet distance). One method is turning the beds so the first Measles patient’s head is at one end, and in the next bed, another patient’s feet are at that end:
Admit for inpatient treatment if:
- Patient is unable to eat or drink adequately.
- Altered level of consciousness and/or seizures.
- Severe respiratory infection.
- Diarrhea with dehydration.
- Acute malnutrition.
DEHYDRATION TREATMENT GUIDE (for non-Malnourished patients)
Patient is alert, eyes are normal, makes tears, mouth and tongue are moist, drinks normally, skin pinch goes back quickly. Use Treatment Plan A – Oral hydration for patients without dehydration.
Mild to Moderate Dehydration:
Patient is restless and irritable, eyes are sunken, does not make tears, mouth and tongue are dry, thirsty and drinks eagerly, skin pinch goes back slowly. Use Treatment Plan B – oral rehydration for patients with mild to moderate dehydration.
Patient is lethargic, unconscious, floppy. The eyes are sunken and eyeballs are dry, does not make tears. Mouth and tongue are very dry. Drinks poorly or is unable to drink at all. Skin pinch goes back very slowly. Use Treatment Plan C – IV rehydration for patients with severe dehydration.
PLAN A – Maintenance of hydration in patients who show no signs of dehydration
Patient should receive enough Oral Rehydration Solution (ORS) to drink at home for 2 days. Instruct caregiver on preparation (in clean container, with clean water, and discard the excess after 24 hrs).
NOTE: If you don’t have ORS packets, you can use 1 liter of clean water and add 6 – 8 teaspoons of sugar and half a teaspoon of salt.
- Less than 24 months of age, drink 50 – 100 ml ORS after each loose stool
- 2 – 9 years, drink 100 – 200 ml ORS after each loose stool
- 10 yrs and older, drink as much as desired after each loose stool.
Instruct to return if condition worsens, vomiting becomes severe or blood in stools.
PLAN B – Rehydration for mild to moderate dehydration. Patient should receive the following amount of ORS in the first FOUR hours:
- Less than 4 months (under 5 kg) : 200 – 400 ml or 1 – 2 cups
- 4 – 11 months (5 – 7.9 kg) : 400 – 600 ml or 2 – 3 cups
- 12 – 23 months (8 – 10.9 kg) : 600 – 800 ml or 3 – 4 cups
- 2 – 4 years (11 – 16 kg) : 800 – 1200 ml or 4 – 6 cups
- 5 – 15 years (16 – 29.9 kg) : 1200 – 2200 ml or 6 – 11 cups
If the patient vomits, wait 10 minutes and try again slowly.
Reassess for dehydration every 2 hours. If after 4 hours, if the patient no longer shows signs of dehydration, move to Plan A. If the patient continues to show signs of dehydration after 4 hours, repeat Plan B for 4 more hours.
In order to avoid an epidemic or outbreak, vaccination coverage should be no less than 95% in a given population. If a significant portion of a population is protected, “herd immunity” will protect the other 5% who are not vaccinated. In other words, the higher the percentage of resistant individuals, the lower the chances that a more susceptible person will come into contact with an infectious person. It is not easy to achieve 95% coverage in populations on the move such as in conflict situations, nomadic populations or nutritional crises where people forage for food.
Some countrys’ Ministries of Health are unable to adequately provide vaccine coverage to the entire population, leaving gaps in Measles protection. Many countries (often with the help of UNICEF) will hold annual “Child Health Days” during the school year (easier access to a large portion of all children). Child Days normally include Measles vaccination, giving of ITN (Insecticide Treated bedNets), de-worming meds and Vitamin A.
The recommended Measles vaccination in a non-outbreak setting is at 9 months of age. However, in the presence of an outbreak/epidemic, children should be vaccinated at 6 months. This will provide some protection, but a 6 month old’s immune system is immature, and this child needs a repeat vaccination at 9 months (give injections at least 4 weeks apart). Statistically, the highest risk for outbreak is in the 6 months to 15 year age range, especially in settings with overcrowding, high HIV rates and widespread malnutrition. Vaccination is not indicated in persons above 15 years of age – chances are they have already been exposed and are immune.
The Measles vaccine is a live attenuated virus vaccine. It comes in a multidose (usually 10 doses) vial with powder that must be reconstituted with the diluent provided. Both should be stored between 2 and 8 degrees C and not frozen. At the time of reconstitution, both the powder and diluent must be at the same temperature for maximum efficacy. Once reconstituted, the mixture should be kept between 2 – 8 degrees C for a maximum of 6 hours and then discarded.
0.5 ml is given in the upper arm or anterolateral thigh, deep subcutaneously or intramuscular. Immunity develops 10 – 14 days after the injection and lasts a minimum of 10 years.
SCREEN FOR MALNUTRITION
At the time of Measles vaccination campaigns, all children 6 months to 5 years should be screened for malnutrition. Malnutrition is an important cause of post-Measles mortality. In the case of time constraints or mass vaccination campaigns, MUAC alone can be used to screen for malnutrition. Malnutrition treatment protocols and the Weight for Height method for measuring malnutrition are discussed in the One Nurse At A Time module MALNUTRITION.
In a context where children’s birthdates are not recorded (you’d be surprised how many places!) or where the age is uncertain, screen all children between 65 and 110 cm in height. Like the rides at an amusement park, mark a board/tree/stick at 110 cm and stand a child against the mark. If he or she is 110 cm or less, measure for malnutrition.
MUAC is a “quick and dirty” approach and measures the degree of muscle wasting. It is a color coded tape used to measure the Middle Upper Arm Circumference of children between the ages of six months and five years – interestingly, the measurements remain consistent from 6 to 60 months of age.
To accurately measure, gently but snugly wrap the MUAC tape around the relaxed arm at the halfway point between shoulder and elbow. For children,
RED measurement of 115 mm or less is considered SEVERELY MALNOURISHED and extremely high mortality risk.
ORANGE measurement of 116 – 124 and is read as MODERATELY MALNOURISHED. (my computer won’t do orange highlighter)
YELLOW measurement of 125 – 134 means AT RISK, but not malnourished.
GREEN measurement of 135mm or above is NOT malnourished.
There is also an adult version of the MUAC tape. Adults (15 years of age or older) are considered severely malnourished with MUAC less than 160 mm. Pregnant/lactating women are severely malnourished if less than 170 mm.
MUAC is an excellent screening tool used in mass vaccination campaigns, rapid assessments of at risk populations, distribution programs and the like, but is not sufficient to diagnose or manage medical treatment of malnutrition. For those, you must use the World Health Organization’s Weight For Height charts found in the One Nurse At A Time MALNUTRITION module.
Although rarely seen in the developing world, Measles is a killer in at-risk settings of overcrowding, population movement, displacement, conflict zones and areas with high HIV rates. It is a vaccine preventable disease with serious and potentially fatal consequences. Nurses working in the humanitarian arena can save lives and limit adverse outcomes by recognizing and appropriately responding to Measles.