Monday, February 9, 2015

Measles- What Nurses Need to Know

Measles was declared eliminated in the US in 2000, but now we are in the midst of a measles outbreak that is hovering  close to an epidemic. So what happened?  

There has been a small but growing number of parents who refuse or delay MMR vaccine based on the now discredited study that came out of England some years ago. While the United States has an overall high rate of measles immunization, pockets of unvaccinated children in communities leave everyone vulnerable.  

Measles is the most infectious of all diseases. If you are not immune to the virus and walk into a room previously occupied by a person infected with measles, even if they left 2 hours ago, you WILL most likely get measles. According to the CDC, measles is so contagious that if one person has it, 90% of the people close to that person who are not immune will also become infected.

Unvaccinated people can hide in the herd in the United States because we have been able to vaccinate most of our population. However, if an unvaccinated person travels somewhere where measles is epidemic, that traveler can bring measles back home and trigger a measles outbreak of catastrophic proportions. 

Once measles gets into the community, it can be difficult to eliminate it. 

So what are nurses to do? 

Nurses need to make sure that they are:
  • protected.
  • able recognize signs and symptoms of measles,
  • up-to-date with latest treatments.
  • using a respectful and effective method of education with vaccine-hesitant patients and families.

When it comes to making sure you are protected it means verifying your vaccination status. You should have been vaccinated yourself unless you are old enough to have had the disease yourself. According to the CDC:
If you were born in 1957 or later and have not had the MMR vaccine, or if you don't have an up-to-date blood test that shows you are immune to measles or mumps (i.e., no serologic evidence of immunity or prior vaccination), get 2 doses of MMR (1 dose now and the 2nd dose at least 28 days later). If you were born in 1957 or later and have not had the MMR vaccine, or if you don't have an up-to-date blood test that shows you are immune to rubella, only 1 dose of MMR is recommended. However, you may end up receiving 2 doses, because the rubella component is in the combination vaccine with measles and mumps. For health care workers born before 1957, see the MMR ACIP vaccine recommendations.

Signs and Symptoms of Measles

It can be quite difficult in the winter season, with cold and influenza patients seeking treatment, to differentiate measles patients from others early in the infection. 
  • 7-14 days after incubation, catarrhal symptoms manifest themselves.  They include: cough, soreness, temperature, sore throat, rhinorrhea (runny nose), and conjunctivitis (red eyes).
  • 2-4 days into the infection, Koplik spots (small white spots) resembling grains of salt, appear on the inside of the mouth.
  • 3-5 days after the initial symptoms, an itchy macular rash (reddish flat) and papules (solid, raised spots) develop on the face.
  • Within 1-2 days, the rash spreads to the trunk, arms and legs, while a rash on the face began to fade. At this point of the disease, the patient's temperature can reach as high as 104.
It is important to remember that the patient is infectious 2-4 days before the rash appears and remains infectious 2-5 days after the onset of the rash.


There is no treatment for uncomplicated measles. The interventions below are to provide support and treatment of the symptoms. 
  • Isolation- Patients will need to be on isolation precautions to decrease transmission within the community. Emphasize the need for immediate isolation when early catarrhal symptoms appear 
  • Skin care- Measles causes extreme pruritus. Nursing interventions include keeping the patient's nails short, encourage long pants and sleeves to prevent scratching, keeping skin moist with health care provider recommended lotions, and avoiding sunlight and heat. 
  • Eye care- Treat conjunctivitis with warm saline when removing eye secretions and encourage patient not to rub eyes. Protect the eyes from glare of strong light.
  • Hydration- encourage oral hydration. Medical literature encourages the use of Oral Re-hydration Solution. 
  • Temperature control- Antipyretics should be administered to the patient as ordered for a temperature greater than 100.4 Fahrenheit unless directed elsewise by a healthcare provider. Be sure to remind parents not to administer aspirin due to the risk of Rey's syndrome.
  • Supplements- Vitamin A has been shown to help decrease mortality in children under the age of two years. The American Academy of Pediatrics  provides dosage recommendations here.
Patients should seek emergency medical treatment for the following signs and symptoms-

  • -Intolerance to food and/or unable to drink adequately.
  • -Altered level of consciousness and/or seizures.
  • -Severe respiratory infection.
  • -Severe diarrhea
Patient Education

The best way to treat measles is to prevent it. The best prevention is vaccination. The vaccine used to prevent the measles is the MMR vaccine (measles, mumps, and rubella). According the the National Center for Immunization and Respiratory Diseases, "Two doses of this vaccine are needed for complete protection. Children should be given the first dose of MMR vaccine at 12 to 15 months of age. The second dose can be given 4 weeks later, but is usually given before the start of kindergarten at 4 to 6 years of age." 

Patients and parents will often have questions and concerns about the MMR vaccine used to prevent the illness due to the large amount of misinformation circulating the internet. Be sure to provide up-to-date handouts and patient education materials when the opportunity presents itself. The CDC provides patient education in a range of different languages, such as Spanish. If you're looking for studies that debunk the vaccines/autism myth- here is a list of 107 peer-reviewed, evidence-based research studies that show there is NO LINK between autism and vaccines. We also suggest providing them with this powerful letter written by famous children's author Roald Dahl about his personal (heartbreaking) experience with measles. 

The most important part of addressing and educating vaccine-hesitant patients is listening to the concerns expressed by patients and others who question vaccines. The following is a guided walk-though that allows nurses to effectively respond to frequently asked questions about vaccine safety.

  • Express your understanding of their reservations.
  • Explain to them that you have educated yourself about the dangers of measles disease because you want or be able to help them make healthy decisions for themselves and their children.
  • Tell them stories about measles disease in friends or family if you know any.
  • Then explain the science behind the safety of MMR vaccine and as a scientist yourself you trust the science.
  • Then tell them you are vaccinated yourself and you want to offer the same protection to them or their child and you want to vaccinate them today.
If this framework of conversation sounds familiar, it's based on the CASE method, a framework of conversation many of us at Nurses Who Vaccinate use for communicating with patients and families.  
Try it.

Nurses are the most trusted of all professions. Let's use that trust to help our patients and prevent them from the ravages of the measles. You can save a life doing this. And no one does it better than nurses!

Additional Educational Resources