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Referral and warning signs
When to refer
Refer to Hospital (HC4/H) if: Signs of complications (pneumonia, dehydration, croup, encephalitis, seizures, corneal ulceration). Severe malnutrition. Immunocompromised child. Infant <6 months.
Red flags
- Difficulty breathing / Respiratory distress / Chest indrawing.
- Altered consciousness / Lethargy / Seizures.
- Signs of severe dehydration.
- Corneal clouding or ulceration.
- Inability to drink or feed.
- Persistent vomiting.
- Bleeding.
Signs and symptoms
- Incubation period: 10-14 days.
- Prodromal (Catarrhal) Stage (2-4 days):
- - High fever.
- - The '3 Cs': Cough (often barking), Coryza (runny nose), Conjunctivitis (red, watery eyes, photophobia).
- - Koplik's Spots: Pathognomonic sign. Small white/bluish-white spots on an erythematous base on the buccal mucosa (opposite molars). Appear 1-2 days before rash, fade quickly.
- - Malaise, anorexia.
- Eruptive (Rash) Stage:
- - Maculopapular rash (red, blotchy, slightly raised spots that may coalesce).
- - Typically starts behind ears and on hairline -> spreads downwards to face, trunk, and limbs over 2-3 days.
- - Rash often accompanied by peak fever.
- - Rash fades in order of appearance after 3-7 days, may leave brownish discoloration and fine desquamation (peeling).
- Other symptoms: Diarrhoea, vomiting, lymphadenopathy.
Risk factors
- Lack of immunization (MMR/Measles vaccine).
- Infancy (especially after maternal antibodies wane ~6-9 months, before first vaccine dose).
- Immunocompromised individuals (HIV, malnutrition) - risk of severe disease.
- Vitamin A deficiency.
- Crowded living conditions.
- Travel to endemic areas.
Diagnosis
Clinical assessment
Diagnosis usually clinical, based on characteristic prodrome (fever + 3 Cs), presence of Koplik's spots (if seen), followed by typical descending maculopapular rash.
Differential diagnosis
- Rubella (German Measles) (milder prodrome, rash spreads faster, postauricular/suboccipital nodes).
- Roseola Infantum (Exanthem Subitum) (high fever first, rash appears as fever breaks).
- Scarlet Fever (sandpaper rash, strawberry tongue, Pastia's lines).
- Kawasaki Disease (prolonged fever, conjunctivitis, rash, lymphadenopathy, changes in extremities, coronary aneurysms).
- Drug eruptions.
- Other viral exanthems (Enterovirus, Adenovirus).
- Dengue Fever (rash variable).
Investigations
- Clinical diagnosis usually sufficient, especially during outbreaks.
- Serology: Detection of Measles-specific IgM antibodies in serum (confirms acute infection, appears few days after rash onset). IgG for immunity status.
- RT-PCR: Detection of measles virus RNA from throat swab, nasopharyngeal aspirate, or urine (useful early in illness or for outbreak confirmation).
Diagnostic criteria
Clinical case definition (fever + maculopapular rash + at least one of Cough/Coryza/Conjunctivitis) +/- Laboratory confirmation (IgM/PCR).
Management
Non-pharmacological management
- Supportive Care:
- - Maintain hydration (oral fluids, IV if needed).
- - Nutritional support (encourage feeding, manage malnutrition).
- - Rest.
- - Tepid sponging for high fever.
- - Eye care: Clean eyes gently. Tetracycline eye ointment 1% BID for 5 days (as per UCG) if conjunctivitis severe or secondary infection suspected.
- Isolation: Prevent spread (highly contagious via respiratory droplets). Isolate for 4 days after rash onset.
Pharmacological treatment
- Vitamin A Supplementation: Crucial. Reduces morbidity (pneumonia, diarrhoea, blindness) and mortality. Give to ALL children diagnosed with measles.
- - Dosing (WHO/UCG Protocol): Give 2 doses 24 hours apart.
- - Age <6 months: 50,000 IU PO daily x 2 doses.
- - Age 6-11 months: 100,000 IU PO daily x 2 doses.
- - Age ≥12 months: 200,000 IU PO daily x 2 doses.
- - Give a third dose 2-4 weeks later (Day 14 per UCG) if signs of Vitamin A deficiency present (xerophthalmia).
- Antipyretics: Paracetamol for fever/discomfort. (LOC: HC2)
- Antibiotics: ONLY for treating secondary bacterial complications (e.g., pneumonia, otitis media, diarrhoea with suspected bacterial cause). NOT for uncomplicated measles. Choice depends on complication (e.g., Amoxicillin for pneumonia/otitis).
- Antivirals (Ribavirin): Investigational, may be considered in severe cases in immunocompromised (specialist use).
Monitoring
Monitor for complications, especially respiratory distress (pneumonia), dehydration (diarrhoea/vomiting), neurological signs (encephalitis), eye signs (keratitis), and nutritional status.
Complications
- Diarrhoea (common).
- Otitis Media (common).
- Pneumonia (most common cause of death - viral or secondary bacterial).
- Laryngotracheobronchitis (Croup).
- Keratoconjunctivitis / Corneal ulceration / Blindness (esp. if Vit A deficient).
- Encephalitis (Acute post-infectious).
- Subacute Sclerosing Panencephalitis (SSPE) (rare, fatal degenerative CNS disease years later).
- Thrombocytopenia.
- Myocarditis.
- Exacerbation of Tuberculosis.
- Severe Acute Malnutrition (SAM).
- Noma (Cancrum oris).
Prevention
- Vaccination: Highly effective Measles-containing vaccine (MCV - typically MMR or MR) given as part of routine childhood immunization schedule (e.g., at 9 months and 15-18 months). Supplementary Immunization Activities (SIAs)/Campaigns crucial.
- Post-Exposure Prophylaxis (PEP):
- - Vaccine: If given within 72 hours of exposure to susceptible individuals.
- - Immunoglobulin (IG): For susceptible high-risk contacts (infants <6-12m, pregnant women, immunocompromised) given within 6 days of exposure.
- Isolation of cases.
- Vitamin A supplementation in endemic areas.
Patient education
- Explanation of measles as contagious viral illness.
- Importance of supportive care (fluids, nutrition).
- Role of Vitamin A.
- Antibiotics only needed for complications.
- Isolation to prevent spread.
- Recognizing danger signs requiring immediate return.
- Importance of completing routine vaccinations for prevention.
Uganda-specific notes
Measles outbreaks still occur despite vaccination efforts, often affecting unvaccinated or malnourished children. Pneumonia and diarrhoea are major causes of mortality. Vitamin A administration is a critical intervention. Case-based surveillance and reporting essential.
References
- Uganda Clinical Guidelines (UCG) 2023
Chapter 2, Section 2.3.3
- Uganda Clinical Guidelines (UCG) 2023
Chapter 17 (IMCI)
- Uganda Clinical Guidelines (UCG) 2023
Chapter 18 (Immunization)