Measles

Background

Measles, also known as rubeola, is one of the most contagious infectious diseases, with at least a 90% secondary infection rate in susceptible domestic contacts. It can affect people of all ages, despite being considered primarily a childhood illness. Measles is marked by prodromal fever, cough, coryza, conjunctivitis, and pathognomonic enanthem (ie, Koplik spots), followed by an erythematous maculopapular rash on the third to seventh day. (See the image below.) Infection confers lifelong immunity.

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Face of boy with measles.

A generalized immunosuppression that follows acute measles frequently predisposes patients to bacterial otitis media and bronchopneumonia. In approximately 0.1% of cases, measles causes acute encephalitis. Subacute sclerosing panencephalitis (SSPE) is a rare chronic degenerative disease that occurs several years after measles infection.

After an effective measles vaccine was introduced in 1963, the incidence of measles decreased significantly. Nevertheless, measles remains a common disease in certain regions and continues to account for nearly 50% of the 1.6 million deaths caused each year by vaccine-preventable childhood diseases. The incidence of measles in the United States and worldwide is increasing, with outbreaks being reported particularly in populations with low vaccination rates.^[1]

Maternal antibodies play a significant role in protection against infection in infants younger than 1 year and may interfere with live-attenuated measles vaccination. A single dose of measles vaccine administered to a child older than 12 months induces protective immunity in 95% of recipients. Because measles virus is highly contagious, a 5% susceptible population is sufficient to sustain periodic outbreaks in otherwise highly vaccinated populations.

A second dose of vaccine, which is recommended for all school-aged children in the United States,^[2]  induces immunity in about 95% of the 5% who do not respond to the first dose. Slight genotypic variation in circulating strains has not affected the protective efficacy of live-attenuated measles vaccines.

Unsubstantiated claims that suggest an association between the measles vaccine and autism have resulted in reduced vaccine use and contributed to a recent resurgence of measles in countries where immunization rates have fallen to below the level needed to maintain herd immunity.^{[3, 4]}

Considering that for industrialized countries, endemic transmission of measles can be reestablished if measles immunity falls to less than 93-95%, efforts to ensure high immunization rates among people in both developed and developing countries must be sustained.

Supportive care is normally all that is required for patients with measles. Vitamin A supplementation during acute measles significantly reduces risks of morbidity and mortality.

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Pathophysiology

In temperate areas, the peak incidence of infection occurs during late winter and spring. Infection is transmitted via respiratory droplets, which can remain active and contagious, either airborne or on surfaces, for up to 2 hours. Initial infection and viral replication occur locally in tracheal and bronchial epithelial cells.

After 2-4 days, measles virus infects local lymphatic tissues, perhaps carried by pulmonary macrophages. Following the amplification of measles virus in regional lymph nodes, a predominantly cell-associated viremia disseminates the virus to various organs prior to the appearance of rash.

Measles virus infection causes a generalized immunosuppression marked by decreases in delayed-type hypersensitivity, interleukin (IL)-12 production, and antigen-specific lymphoproliferative responses that persist for weeks to months after the acute infection. Immunosuppression may predispose individuals to secondary opportunistic infections,^[5] particularly bronchopneumonia, a major cause of measles-related mortality among younger children.

In patients with deficiencies in cellular immunity, measles virus can cause a progressive and often fatal giant cell pneumonia.^[6]

In immunocompetent individuals, wild-type measles virus infection induces an effective immune response, which clears the virus and results in lifelong immunity.^[7]

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Etiology

The cause of measles is the measles virus, a single-stranded, negative-sense enveloped RNA virus of the genus Morbillivirus within the family Paramyxoviridae. Humans are the natural hosts of the virus; no animal reservoirs are known to exist. This highly contagious virus is spread by coughing and sneezing via close personal contact or direct contact with secretions.

Risk factors for measles virus infection include the following:

• Children with immunodeficiency due to HIV or AIDS, leukemia, alkylating agents, or corticosteroid therapy, regardless of immunization status
• Travel to areas where measles is endemic or contact with travelers to endemic areas
• Infants who lose passive antibody before the age of routine immunization

Risk factors for severe measles and its complications include the following:

• Malnutrition
• Underlying immunodeficiency
• Pregnancy
• Vitamin A deficiency

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Epidemiology

United States statistics

Before the first measles vaccine was licensed in 1963, an estimated 3-4 million cases occurred each year in the United States.^[8]  The immunization program resulted in a decrease of more than 99% in reported incidence.

From 1989-1991, a major resurgence occurred, affecting primarily unvaccinated preschoolers. This measles resurgence resulted in 55,000 cases and 130 deaths^[9] and prompted the recommendation that a second dose of measles vaccine be given to preschoolers in a mass vaccination campaign, which led to the effective elimination in the United States of endemic transmission of the measles virus by 2000.^[10]

From 2001-2011, an average of 83 measles cases were reported to the US Centers for Disease Control and Prevention (CDC) each year.^[11] However, the incidence started to rise after that period, with most cases linked either directly or indirectly to international travel. Incomplete vaccination rates facilitated the spread once the virus was imported into the United States.

In 2019, 1274 measles cases, the highest number of cases in the United States since 1992, were reported in 31 states. All cases were linked to traveler importations that reached at-risk US populations, the majority of whom were unvaccinated or undervaccinated.^[12]

The COVID-19 pandemic led to setbacks in immunization efforts. The CDC estimates that measles-mumps-rubella (MMR) vaccine coverage among US kindergarteners has been below the 95% coverage goal since 2020, and the percentages are much lower in some communities.^[13] The US-based outbreaks in 2025 have occurred in undervaccinated counties.^{[8, 14]}  Young children who are not appropriately vaccinated may experience a more than 60-fold increase in the risk of disease following exposure to measles cases.

International statistics

In developing countries, measles affects 30 million children a year and causes 1 million deaths. Measles causes 15,000-60,000 cases of blindness per year.

Worldwide, most reported cases of measles occur in Africa.^[15]  In 2019, the Samoan Ministry of Health declared a measles outbreak, the first Pacific island country to take action against the global resurgence of measles.^[16]

Following a worldwide decline in measles vaccination coverage during the COVID-19 pandemic, measles-related deaths rose by 43% in 2022, compared with 2021. The number of total reported cases increased by 18% during the same period, accounting for about 9 million cases and 136,000 deaths globally, mostly among children.^[17]

According to the World Health Organization (WHO), the total number of measles cases reported for the European region in 2024 was 127,350, which is double the number of cases in 2023 and the highest since 1997.^[18]

Age-related demographics

Although measles is historically a disease of childhood, infection can occur in unvaccinated or partially vaccinated individuals of any age or in those with compromised immunity.

Unvaccinated young children are at the highest risk. Age-specific attack rates may be highest in susceptible infants younger than 12 months, school-aged children, or young adults, depending on local immunization practices and incidence of the disease. Complications such as otitis media, bronchopneumonia, laryngotracheobronchitis (ie, croup), and diarrhea are more common in young children.

Among the 285 US patients reported to have measles in 2024, most were aged younger than 20 years: 120 (42%) were younger than 5 years, 88 (31%) were aged 5-19 years, and 77 (27%) were aged 20 years or older.^[12]

In heavily populated, underdeveloped countries, measles is most common in children younger than 2 years.

Sex- and race-related demographics

Unvaccinated males and females are equally susceptible to infection by the measles virus. Excess mortality following acute measles has been observed among females at all ages, but it is most marked in adolescents and young adults. Excessive non–measles-related mortality has also been observed among female recipients of high-titer measles vaccines in Senegal, Guinea Bissau, and Haiti.^[19]

Measles affects people of all races.

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Prognosis

The prognosis for measles is generally good, with infection only occasionally being fatal. The CDC reports that the childhood mortality rate from measles infection in the United States is 0.1-0.2%. However, many complications and sequelae may develop, and measles is a major cause of childhood blindness in developing countries.

Morbidity/mortality

Globally, measles remains one of the leading causes of death in young children. According to the CDC, measles caused an estimated 107,500 deaths worldwide in 2023, and most occurred in children.^[20]

Case-fatality rates are higher among children younger than 5 years. The highest fatality rates are among infants aged 4-12 months and in children who are immunocompromised because of human immunodeficiency virus (HIV) infection or other causes.

Complications of measles are more likely to occur in persons younger than 5 years or older than 20 years, and morbidity and mortality are increased in persons with immune deficiency disorders, malnutrition, vitamin A deficiency, and inadequate vaccination.

Croup, encephalitis, and pneumonia are the most common causes of death associated with measles. Measles encephalitis, a rare but serious complication, has a 10% mortality.

Complications

Most complications of measles occur because the measles virus suppresses the host’s immune responses, resulting in a reactivation of latent infections or superinfection by a bacterial pathogen. Consequently, pneumonia, whether due to the measles virus itself, to tuberculosis, or to another bacterial etiology, is the most frequent complication. Pleural effusion, hilar lymphadenopathy, hepatosplenomegaly, hyperesthesia, and paresthesia may also be noted.

Complications of measles are more likely to occur in persons younger than 5 years or older than 20 years, and complication rates are increased in persons with immune deficiency disorders, malnutrition, vitamin A deficiency, and inadequate vaccination. Immunocompromised children and adults are at increased risk for severe infections and superinfections.

Common infectious complications include otitis media, interstitial pneumonitis,^[21]  bronchopneumonia, laryngotracheobronchitis (ie, croup), exacerbation of tuberculosis, transient loss of hypersensitivity reaction to tuberculin skin test, encephalomyelitis, diarrhea, sinusitis, stomatitis, subclinical hepatitis, lymphadenitis, and keratitis, which can lead to blindness. In fact, measles remains a common cause of blindness in many developing countries.

Rare complications include hemorrhagic measles, purpura fulminans, hepatitis, disseminated intravascular coagulation (DIC), subacute sclerosing panencephalitis (SSPE), thrombocytopenia, appendicitis, ileocolitis, pericarditis, myocarditis, acute pancreatitis,^[22]  and hypocalcemia.^[23]  Transient hepatitis may occur during an acute infection.

Approximately 1 of every 1000 patients develops acute encephalitis, which often results in permanent brain damage and is fatal in about 10% of patients. In children with lymphoid malignant diseases, delayed-acute measles encephalitis may develop 1-6 months after the acute infection and is generally fatal.

An even rarer complication is SSPE, a degenerative CNS disease that can result from a persistent measles infection. SSPE is characterized by the onset of behavioral and intellectual deterioration and seizures years after an acute infection (the mean incubation period for SSPE is approximately 10.8 years).

The complications of measles in the pregnant patient include pneumonitis, hepatitis, subacute sclerosing panencephalitis, premature labor, spontaneous abortion, and preterm birth of the fetus. Perinatal transmission rates are low.

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History

The patient history is notable for exposure to the virus. The incubation period from exposure to onset of measles symptoms ranges from 7-21 days (average, 10-12 days).^[24] Patients are contagious from 1-2 days before the onset of symptoms. Healthy children are also contagious during the period from 3-5 days before the appearance of the rash to 4 days after the onset of rash. On the other hand, immunocompromised individuals can be contagious during the duration of the illness.

The first sign of measles is usually a high fever (often >104^o F [40^o C]) that typically lasts 4-7 days. This prodromal phase is marked by malaise, fever, anorexia, and the classic triad of conjunctivitis (see the image below), cough, and coryza (the “3 Cs”). Other possible associated symptoms include photophobia, periorbital edema, and myalgias.

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Measles conjunctivitis.

The characteristic enanthem generally appears 2-4 days after the onset of the prodrome and lasts 3-5 days. Small spots (Koplik spots) can be seen inside the cheeks during this early stage (see the image below).

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Koplik spots in measles. Photograph courtesy of World Health Organization.

The exanthem usually appears 1-2 days after the appearance of Koplik spots; mild pruritus may be associated. On average, the rash develops about 14 days after exposure, starting on the face and upper neck (see the image below) and spreading to the extremities. Immunocompromised patients may not develop a rash.

View Image

Face of boy with measles.

The entire course of uncomplicated measles, from late prodrome to resolution of fever and rash, is 7-10 days. Cough may be the final symptom to appear.

Modified and atypical measles

Modified measles is a milder form of measles that occurs in individuals who have received serum immunoglobulin after their exposure to the measles virus. Similar but milder symptoms and signs may still occur, but the incubation period may be as long as 21 days.

Atypical measles occurs in individuals who were vaccinated with the original killed-virus measles vaccine between 1963 and 1967 and who have incomplete immunity. After exposure to the wild measles virus, a mild or subclinical prodrome of fever, headache, abdominal pain, and myalgias precedes a rash that begins on the hands and feet and spreads centripetally. The eruption is accentuated in the skin folds and may be macular, vesicular, petechial, or urticarial. Atypical measles tends to be of longer duration and more severe than regular measles and is marked by a prolonged high fever and pneumonitis.

The assumed pathogenesis of atypical measles is hypersensitivity to measles virus in a partially immune host. Laboratory tests reveal a very low measles antibody titer early in the course of the disease, followed soon thereafter by the appearance of an extremely high measles immunoglobulin G (IgG) antibody titer (eg, 1:1,000,000) in the serum.

The live-attenuated vaccine replaced the killed vaccine in 1967 and is not associated with atypical measles.

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Physical Examination

Enanthem

Near the end of the prodrome, Koplik spots (ie, bluish-gray specks or “grains of sand” on a red base) appear on the buccal mucosa opposite the second molars (see the image below).

View Image

Enanthem of measles (Koplik spots).

The Koplik spots generally are first seen 1-2 days before the appearance of the rash and last until 2 days after the rash appears. This enanthem begins to slough as the rash appears. Although this is the pathognomonic enanthem of measles, its absence does not exclude the diagnosis.

Exanthem

Blanching, erythematous macules and papules begin on the face at the hairline, on the sides of the neck, and behind the ears (see the images below). Within 48 hours, they coalesce into patches and plaques that spread cephalocaudally to the trunk and extremities, including the palms and soles, while beginning to regress cephalocaudally, starting from the head and neck. Lesion density is greatest above the shoulders, where macular lesions may coalesce. The eruption may also be petechial or ecchymotic in nature.

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Face of boy with measles.

View Image

Morbilliform rash.

Patients appear most ill during the first or second day of the rash. The exanthem lasts for 5-7 days before fading into coppery brown hyperpigmented patches, which then desquamate. The rash may be absent in patients with underlying deficiencies in cellular immunity.

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Approach Considerations

Although the diagnosis of measles is usually determined from the classic clinical picture (see Clinical), laboratory identification and confirmation of the diagnosis are necessary for the purposes of public health and outbreak control. Laboratory confirmation is achieved by means of serologic testing for immunoglobulin G (IgG) and M (IgM) antibodies, isolation of the virus, and reverse-transcriptase polymerase chain reaction (RT-PCR) evaluation.

A complete blood cell (CBC) count may reveal leukopenia with a relative lymphocytosis and thrombocytopenia. Liver function test (LFT) results may reveal elevated transaminase levels in patients with measles hepatitis.

Consult public health or infectious disease specialists for recommendations and guidelines for diagnostic confirmation of cases and prophylaxis of susceptible contacts.

Case reporting

Immediate reporting of any suspected case of measles to a local or state health department is imperative, as is obtaining serum for IgM antibody testing as soon as possible (ie, on or after the third day of rash).

The US Centers for Disease Control and Prevention (CDC) clinical case definition for reporting purposes requires only the following:

• Generalized rash lasting 3 days or longer
• Temperature of 101.0°F (38.3°C) or higher
• Cough, coryza, or conjunctivitis

Furthermore, for reporting purposes for the CDC, cases are classified as follows:

• Suspected - Any febrile illness accompanied by rash
• Probable - A case that meets the clinical case definition, has noncontributory or no serologic or virologic testing, and is not epidemiologically linked to a confirmed case
• Confirmed - A case that is laboratory confirmed or that meets the clinical case definition and is epidemiologically linked to a confirmed case; a laboratory-confirmed case need not meet the clinical case definition

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Antibody Assays

Immunoglobulin M

The measles virus sandwich-capture IgM antibody assay, offered through many local health departments and through the CDC, is the quickest method of confirming acute measles. Because IgM may not be detectable during the first 2 days of rash, obtain blood for measles-specific IgM on the third day of the rash or on any subsequent day up to 1 month after onset to avoid a false-negative IgM result.

Among persons with confirmed measles infection, the seropositivity rate for first samples is about 77% when collected within 72 hours; the rate rises to 100% when collected 4-11 days after rash onset.^[25] Although the measles serum IgM level remains positive 30-60 days after the illness in most individuals, the IgM titer may become undetectable in some subjects at 4 weeks after rash onset. False-positive results can occur in patients with rheumatologic diseases, parvovirus B19 infection, or infectious mononucleosis.

Immunoglobulin G

Laboratories can confirm measles by demonstrating more than a 4-fold rise in IgG antibodies between acute and convalescent sera, although relying solely on rising IgG titers for the diagnosis delays treatment considerably. The earlier the acute serum is drawn, the more reliable the results. IgG antibodies may be detectable 4 days after the onset of the rash, although most cases have detectable IgG antibodies by about a week after rash onset.

Accordingly, it is recommended that specimens be drawn on the seventh day after rash onset. Blood drawn for convalescent serum should be drawn 10-14 days after that drawn for acute serum, and the acute and convalescent sera should be tested simultaneously as paired sera.

Patients with subacute sclerosing panencephalitis (SSPE) have unusually high titers of measles antibody in their serum and cerebrospinal fluid (CSF). The earliest confirmation of measles using IgG antibodies takes about 3 weeks from the onset of illness, a delay too long to permit implementation of effective control measures.

In atypical measles, laboratory evaluation of serum/blood reveals very low titers of measles antibody early in the course of the disease, followed by extremely high measles IgG antibody titers (eg, 1:1,000,000).

IgG levels can be explained by current infection, immunity due to past infection or vaccination, or maternal antibodies present in infants younger than 15 months.

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Viral Culture

Throat swabs and nasal swabs can be sent on viral transport medium or a viral culturette swab to isolate the measles virus. Urine specimens can be sent in a sterile container for viral culture.

Viral genotyping in a reference laboratory may determine whether an isolate is endemic or imported. In immunocompromised patients, who may have poor antibody responses that preclude serologic confirmation of measles, isolation of the virus from infected tissue or identification of measles antigen by means of immunofluorescence may be the only feasible method of confirming the diagnosis.

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Polymerase Chain Reaction

Reverse-transcription polymerase chain reaction (PCR) evaluation is highly sensitive at visualizing measles virus RNA in blood, throat, nasopharyngeal, or urine specimens and, where available, can be used to rapidly confirm the diagnosis of measles.^[26] According to the CDC, the samples should be collected at the first contact with a suspected case of measles when the serum sample for diagnosis is drawn.

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Studies for Suspected Complications

Chest radiography

If bacterial pneumonia is suspected, perform chest radiography. The frequent occurrence of measles pneumonia, even in uncomplicated cases, limits the predictive value of chest radiography for bacterial bronchopneumonia.

Lumbar puncture

If encephalitis is suspected, perform a lumbar puncture. CSF examination reveals the following:

• Increased protein
• Normal glucose
• Mild pleocytosis with a predominance of lymphocytes

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Tissue Analysis and Histologic Findings

A skin biopsy from a lesion of the morbilliform eruption shows spongiosis and vesiculation in the epidermis with scattered dyskeratotic keratinocytes. Occasional lymphoid multinucleated giant cells (≤ 100 nm in diameter) can be identified in biopsies of Koplik spots, in dermal or epithelial rashes, in hair follicles and acrosyringium and in lung or lymphoid tissue. These findings are not specific, but they are suggestive of a viral exanthem.

Brain biopsies of patients with measles encephalitis can reveal demyelination, vascular cuffing, gliosis, and infiltration of fat-laden macrophages near blood vessel walls.

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Approach Considerations

Treatment of measles is essentially supportive care with maintenance of good hydration and replacement of fluids lost through diarrhea or emesis. Intravenous (IV) rehydration may be necessary if dehydration is severe.

Vitamin A supplementation, especially in children and patients with clinical signs of vitamin A deficiency, should be considered. Postexposure prophylaxis should be considered in unvaccinated contacts; timely tracing of contacts should be a priority.

Patients should receive regular follow-up care with a primary care physician for surveillance of complications arising from the infection.

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Supportive Care

Supportive care is normally all that is required for patients with measles. Hospitalization may be indicated for treatment of measles complications (eg, bacterial superinfection, pneumonia, dehydration, croup).

Secondary infections (eg, otitis media or bacterial pneumonia) should be treated with antibiotics; Patients with severe complicating infections (eg, encephalomyelitis) should be admitted for observation and antibiotics, as appropriate to their clinical condition.

Occasionally, IV rehydration is required; patients may be markedly febrile and consequently may become dehydrated. Fever management with standard antipyretics is appropriate.

Airborne precautions are indicated for hospitalized children during the period of communicability (ie, 3-5 days before the appearance of a rash to 4 days after the rash develops in healthy children and for the duration of illness in patients who are immunocompromised). Susceptible health care workers should be excused from work from the fifth to the 21st day after exposure.

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Antiviral Therapy

Measles virus is susceptible to ribavirin in vitro. Although ribavirin (either IV or aerosolized) has been used to treat severely affected and immunocompromised adults with acute measles or subacute sclerosing panencephalitis (SSPE),^[27] no controlled trials have been conducted; ribavirin is not approved by the US Food and Drug Administration (FDA) for this indication, and such use should be considered experimental.

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Vitamin A Supplementation

Vitamin A supplements have been associated with reductions of approximately 50% in morbidity and mortality and appear to help prevent eye damage and blindness.

Because vitamin A deficiency is associated with severe disease from measles, the World Health Organization recommends all children diagnosed with measles should receive vitamin A supplementation regardless of their country of residence, based on their age,^[28] as follows:

• Infants younger than 6 months – 50,000 IU/day PO for 2 doses
• Age 6-11 months – 100,000 IU/day PO for 2 doses
• Older than 1 year – 200,000 IU/day PO for 2 doses
• Children with clinical signs of vitamin A deficiency – The first 2 doses as appropriate for age, then a third age-specific dose given 2-4 weeks later

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Postexposure Prophylaxis

Postexposure prophylaxis should be considered in unvaccinated contacts. Prevention or modification of measles in exposed susceptible individuals involves the administration of measles virus vaccine or human immunoglobulin (Ig).

Measles virus vaccine

In the United States, the measles virus vaccine is routinely administered along with the mumps and rubella vaccines as the measles-mumps-rubella (MMR) vaccine. The vaccine is preventive if administered within 3 days of exposure.

Contraindications to the vaccine include immunodeficiency; generalized cancers (eg, leukemia, lymphoma); active, untreated tuberculosis; and therapy with immunosuppressants. HIV infection is only a contraindication in the presence of severe immunosuppression (ie, CD4 counts lower than 15%). The vaccine should be deferred until after delivery in pregnant patients and for at least 5 months in anyone who has received antibody (ie, plasma, whole blood, any immune globulin).^{[29, 30]}

Human immunoglobulin

Human Ig prevents or modifies disease in susceptible contacts if administered within 6 days of exposure. Human Ig is given to the following individuals:

• Those who are immunocompromised
• Infants aged 6 months to 1 year (morbidity is high in children younger than 1 year
• Infants younger than 6 months who are born to mothers without measles immunity
• Pregnant women

In contacts for whom the vaccine should be deferred (eg, pregnant patients), human Ig 0.25 mL/kg (not to exceed 15 mL) should be administered intramuscularly (IM) immediately after exposure, and the measles vaccine should be given 6 months later. Exposed immunocompromised patients with a contraindication to vaccination should receive human Ig 0.5 mL/kg (not to exceed 15 mL) IM.

The American Academy of Pediatrics (AAP) recommends that groups who are at higher risk for complications from severe measles should receive intravenous administration of Ig at a dose of 400 mg/kg.^[28]

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Prevention

During their October 2024 session, the Advisory Committee on Immunization Practices (ACIP) endorsed the Recommended Immunization Schedule for Children and Adolescents up to 18 Years Old in the United States for the year 2025.^[2]

The "Special Situations" section has been revised to clarify the recommendation for international travel, now detailing it by both age group and MMR vaccination history.

Recommendations from the AAP for persons with HIV infection are as follows^[28] :

• Measles immunization (in the form of the measles, mumps, and rubella vaccine) is recommended for all patients older than 12 months who have HIV infection, except those who have evidence of severe immunosuppression
• Ig prophylaxis is recommended for HIV-infected children who are exposed to measles, depending on their immune status and measles vaccine history

The ACIP advises that the use of the measles, mumps, rubella, and varicella virus vaccine is contraindicated in persons with HIV infection of any severity.^[2]

Recommendations from the AAP for healthcare personnel are as follows^[28] :

• Immunization programs are advised for healthcare personnel, including students, who may be in contact with patients with measles
• Birth before 1957 is not a guarantee of measles immunity; facilities should consider vaccination of unimmunized healthcare personnel who lack laboratory evidence of immunity who were born before 1957

Further recommendations from the AAP for susceptible individuals are as follows^[28] :

• Children should receive measles vaccination prior to treatment with biological response modifiers, such as tumor necrosis factor antagonists
• Susceptible patients with immunodeficiencies should receive Ig after measles exposure
• Live-virus measles vaccines should not be given to immunocompromised patients with disorders associated with increased severity of viral infections (this warning does not apply to persons with HIV infection who do not have evidence of severe immunosuppression)
• Immunization should be withheld for at least a month after a patient has finished a high-dose course of corticosteroids, such as prednisone

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Guidelines Summary

The following organizations have released guidelines for the management of measles. Key diagnostic and treatment recommendations have been reviewed and integrated throughout the article.

• 2025. Advisory Committee on Immunization Practices Recommended Immunization Schedule for Children and Adolescents Aged 18 Years or Younger — United States, 2025^[2]
• 2024. American Academy of Pediatrics. Measles. In: Red Book: 2024 Report of the Committee on Infectious Diseases^[28]
• 2024. UK Health Security Agency. National measles guidelines^[24]

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Medication Summary

Medications used in the treatment or prevention of measles include vitamin A, antivirals (eg, ribavirin), measles virus vaccine, and human immunoglobulin (Ig).

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Vitamin A (Aquasol A, Retinol, Retinyl acetate)

• Dosing, Interactions, etc.

Clinical Context:  Vitamin A is a fat-soluble vitamin needed for growth of skin, bones, and male and female reproductive organs.

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Class Summary

Vitamin A treatment for children with measles in developing countries has been associated with a marked reduction in morbidity and mortality. The World Health Organization (WHO) recommends vitamin A administration to all children with acute measles, regardless of their country of residence.

Of note, low serum concentrations of vitamin A are found in children with severe measles in the United States. Thus, two doses of vitamin A given 24 hours apart are recommended. A third age-specific dose should be given 2 to 4 weeks later to children with clinical signs and symptoms of vitamin A deficiency.

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Ribavirin (Copegus, Moderiba, Rebetol)

• Dosing, Interactions, etc.

Clinical Context:  Ribavirin, a guanosine analogue, is for experimental use only. Its mechanism of action is not fully defined but relates to alteration of cellular nucleotide pools and of viral messenger RNA information.

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Class Summary

Measles virus is susceptible to ribavirin in vitro. Although ribavirin (either IV or aerosolized) has been used to treat severely affected and immunocompromised adults with acute measles or SSPE (IV plus intrathecal high-dose interferon alfa), no controlled trials have been conducted; ribavirin is not approved by the US Food and Drug Administration (FDA) for this indication, and such use should be considered experimental.

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Measles mumps and rubella vaccine, live (M-M-R II)

• Dosing, Interactions, etc.

Clinical Context:  The live MMR vaccine is used to induce active immunity against viruses that cause measles, mumps, and rubella.

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Measles, mumps, rubella and varicella vaccine, live (ProQuad, MMRV)

• Dosing, Interactions, etc.

Clinical Context:  This is a live vaccine that induces active immunity against viruses that cause measles, mumps, rubella, and varicella.

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Class Summary

In the United States, measles virus vaccine is usually given along with attenuated rubella and mumps viruses as the measles-mumps-rubella (MMR) vaccine. The following measles vaccines are available in the United States:

- Live measles mumps, and rubella virus vaccine (M-M-R II)

- Live measles, mumps, rubella, and varicella virus vaccine (ProQuad)

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Immune globulin IM (IGIM) (GamaSTAN, GamaSTAN S/D, IM Immune Globulins)

• Dosing, Interactions, etc.

Clinical Context:  Immune globulin IM (IGIM) is a transient source of IgG. It is indicated for all susceptible contacts of patients with measles who reside in the same household who are pregnant, immunocompromised, or aged 6-12 months; it is also indicated for infants younger than 6 months who were born to mothers without measles immunity and also all children and adolescents with HIV infection who are exposed to measles, regardless of measles immunization status, unless they have received IV Ig (400 mg/kg as part of routine immunoprophylaxis) within 3 weeks of exposure.

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Immune globulin IV (IGIV) (Alyglo, Asceniv, Bivigam)

• Dosing, Interactions, etc.

Clinical Context: 

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Class Summary

Human Ig prevents or modifies measles in susceptible individuals if administered within 6 days of exposure.

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