Measles is a febrile infection with severe and potentially fatal consequences. Historically, measles has been a prevalent disease affecting mainly children. Low vaccination rates in particular areas are associated with increased measles outbreaks. In addition to outbreaks in areas with lower vaccination rates, individuals’ capability to transmit the virus prior to being symptomatic increases the probability of the outbreaks. Measles is caused by the Paramyxoviridae virus (genus Morbillivirus) -one of the most infectious identifiable viruses in humans. The condition is transmitted through multiple methods of viral spread including, inhaling virus-laden airborne droplets, coming into direct contact with infected secretions and contacting contaminated fomites. When aerosolized viral particles remain suspended for extended periods, non-immune individuals may be predisposed to the infection by just walking into a room where an infected person had recently been. The measles virus survival rate can reach up to 2 hours on fomites such as linen soiled with infected secretions, table tops and handles. An individual with measles produces contagious particles before the manifestation of clinical symptoms, and is therefore contagious from 4 days before and after the rash appears. Research affirms that the virus is highly contagious to extents that approximately 90% of non-immune individuals exposed to it will acquire the disease. This ease of viral spread and high infectious rates pose detrimental effects to the community and particularly for primary health care centers.
Signs and Symptoms
Prodromal symptoms of cough, conjunctivitis and high fever manifest after an incubation period of 10 to 12 days. Fever rates are typically high on the 4th day ranging between 39 °C and 40.5 °C. Vomiting and diarrhea may occur. The characteristic morbilliform rash may develop about 7–21 days from initial exposure. The rash initially appears on the face and spreads towards the torso and extremities. It lasts for about 3- 7 days before fading in the similar directional pattern as it occurred. Initially, the rash appearance is perceived as discrete red macules that become conﬂuent. In several instances, a regular desquamation may occur as the rash fades. Generally, the Koplik spots, particularly distinct to measles are 2mm- 3 mm and contain bluish-white lesions on a red base. These lesions present either on the posterior buccal mucosa, or the conjunctiva. In rare cases, they may develop on the vaginal mucosa. Koplik spots manifest approximately 2 days before the onset of the infection in at least 70% of patients (Lindberg, Lanzi & Lindberg, 2015). The characteristic Koplik spots differentiate measles from like exanthems such as rubella and roseola. Whereas the rash and the spots are pathognomonic of measles, the cough persists throughout the period of infection. Other symptoms constituting abdominal pain, headache, iridocyclitis and mild lymphadenopathy may be present.
Morbidity and Mortality
Globally, the condition’s mortality rate is estimated at 5%. Since 1997, measles incidence has remained below one case per million. However, in 2014, about 667 measles cases were reported, reflecting an incidence of 2.08 cases per million. Despite remarkable achievements towards global measles mortality reduction, in 2015, an estimated 254,928 measles cases and 134,200 measles fatalities were reported (Rivadeneira Guerrero, Bassanesi & Fuchs,2018).
Mode of Transmission
The high levels of viremia evident when a patient has greater intense of coughing coryza increase the likelihood of spreading the virus through the droplets. Measles virus can be maintained in human populations mainly through uninterrupted transmission chains because it is not associated with any identified latent infectious states, neither is it detectable in animal populations (Misin et.al., 2020).The disease is characterized by seasonal endemics especially during the winter and by extended cycles resultant from migration of non-immunized persons. Birth rate is yet another significant factor that determines cyclicality and period of an epidemic. Recently, measles transmissibility has been highlighted among vaccinated persons with immune system abnormalities.
Complications are prevalent in young children, in adults above 20 years old, and individuals suffering from immunocompromising conditions. An estimated 30% of cases result in complications such as otitis media, diarrhea and pneumonia .Children who develop otitis can have permanent hearing loss. Ocular complications including keratitis may trigger eye impairment, corneal ulcers and even blindness. At least 1 in a 1000 patients develop encephalitis and seizures. Most fatalities among children with measles are linked to pneumonia.
Subacute sclerosing panencephalitis (SSPE) is a fatal neurological disease that can develop 7- 10 years after recovery from measles. It is caused by the persistence of rare complications of the disease whereby the virus moves into the central nervous system and affects the brain. Pregnant women with measles have increased rates of intrauterine fetal death compared to pregnant women who are not suffering from measles.
Treatment involves consistent monitoring and management of dehydration, fever and any other complications (Parker Fiebelkorn & Goodson, 2014). Patients should be stay away from bright lighting to alleviate discomfort caused by photophobia. Complications such as pneumonia and otitis media should be treated in accordance with current guidelines. Vitamin A levels should be managed to reduce the severity of the disease. It is recommended that vitamin A be administered orally for 2 days or once each day through parenteral methods. Infants less than 6 months should receive 50,000 IU, infants 6 to 12 months old should receive 100,000 IU and 200,000 IU should be administered to children above 12 months old. Patients with vitamin A deficiency should receive a vitamin A dose 2-4 weeks after first dosage.
Rapid identification, reporting, and investigation of measles is crucial to impede the spread of the disease. The condition, whether presumptive or confirmed, should be reported immediately to the suitable healthcare department or pathological services (health.vic.gov.au, n.d.).Afterward, pathology services conduct a follow up with a recorded announcement within 5 days. The local health departments and CDC track the measles incidence and engage in contact tracing when suitable.
Social Determinants of Health and Influence on Measles
Study findings assert that vaccination coverage is directly linked to large number of children in a household and indirectly linked to the level of education of the care-givers. The number of children in a household is regarded the primary mediating factor of vaccination coverage (Stronegger & Freidl, 2010). Women with limited education have the lowest levels of vaccination coverage. Therefore, children in households with caregivers who are illiterate are not likely to be vaccinated against measles, increasing the possibility of its transmission.
Low income and limited resources is associated with increased incidences of measles outbreaks. The developing nations lack the capacity to produce vaccine and the governments struggle with unreliable immunization funding. Moreover, an interplay of various factors such as long distances to vaccination centers, malnutrition and inter-current infections further interfere with immunization services. In both developed and under-developed nations, low public confidence in vaccination can limit immunization activities. Spatial clustering of unvaccinated children encourages disease spread, even when high immunization coverage is attained. Consequently, its cyclicality is influenced due to missing age cohorts when vaccination activities are undertaken.
Social support and community inclusivity ascertain proper vaccination coverage. Through social support, appropriate planning that involves outreach and procurement activities and post-outbreak monitoring are fostered. It is vital to strengthen the culture of acceptance of vaccination, to promote “herd immunity” (reliefweb.int, 2019).When community members feel involved they are likely to embrace the culture of allowing their children to be vaccinated thus reducing measles incidences.
The host is the organism that becomes sick or acquires the infection, in this case, an individual infected with measles. The infection mainly affects young children. Initially, the host is unaware that he or she contains the disease because there are no signs and symptoms. The “host” may present different symptoms .For example several patients may have the Koplik spots while others may not. The disease can then be transmitted from one person to another through inhalation and direct contact with secretions of infected persons. Most non-immune individuals exposed to the host become infected.
Paramyxoviridae virus enters the body of the host. The virus infects the cells and takes over and begins to reproduce. Once the agent multiplies in the cells, then the disease starts to spread and the signs and symptoms manifest. Incubation period mainly lasts between 8-14 days.
The main mode of transmission is through inhalation. Measles outbreaks are common during cold seasons. When individuals migrate from nations where measles is endemic to nations with fewer cases such as the USA, the rise in measles outbreaks may occur. Areas that contain high numbers of persons who have not been vaccinated against the disease also have high incidences of the disease.
Special Considerations for the Community, Schools and General Population
The general population should promote routine vaccination to ensure that all children are protected against the probability of acquiring the disease. As aforementioned, through social support and community involvement, health care officials are strengthened and immunization activities can persist. Schools can also campaign on the significance of immunization against measles. This can help children and their care-givers to be more receptive towards vaccination activities.
Role of the Community Health Nurse
The community health nurse designates a rapid response team. The team should be selected based on expertise before undergoing adequate training .Team members should be assigned responsibilities, containment strategies should be implemented and local authorities updated. The nurse may involve a few local personnel who are familiar with the target population, have sufficient training in the investigation of outbreaks, to contribute to the decision-making process. When a case is identified, further assessments should be conducted to determine whether there is risk of transmission. The nurse should report to the health department or CDC. The coverage in areas affected should be determined to identify other potential cases. Enhanced surveillance through active case-finding should be utilized to identify new cases. The nurse engages in data collection while focusing on demographic details, clinical and pathological data. Demographic information will enable the detection of transmission modes and patterns of spread, and the determination of the scope of rapid response activities and vaccination coverage. Proper documentation of vaccine doses, courses of immunoglobulin provided, the number of contacts per case, and information on quarantine strategies implemented as response measures, is necessary for the assessment of the outcomes of control measures (Gastañaduyet.al., 2018). Data analysis should be performed to characterize susceptible persons and response strategies that can identify vulnerable groups and optimize public health interventions. The nurse can improve data analysis by including both numerator and denominator data on those immunized. The community health nurse also conducts a follow-up to assess the effectiveness of response strategies. He or she examines quarantined persons to detect any changes in their health status. Patients with vitamin A deficiency may also be examined to assess any improvements in their vitamin A status.
An Organization That Addresses Measles
The Measles & Rubella Initiative (M&RI) is founded by the collaboration of various organizations including the American Red Cross, the United Nations Foundation, World Health Organization, UNICEF and the U.S. Centers for Disease Control and Prevention. The organization targets to eradicate measles and rubella through endorsing nations to create awareness of their coverage, provide monetary support for appropriate response measures and strengthen immunization delivery. Since 2001, the organization has endorsed 88 nations in the delivery of 2 billion doses of measles vaccine to educate and support measles vaccination coverage around the world. It has also contributed to mortality reduction related to measles and rubella by 73%. Currently, the initiative has invested over US $1.2 in control activities focusing on rubella and measles. In 2018, the initiative launched several campaigns and delivered technical assistance and bundled vaccines to 37 nations. Over 350 million children benefited from the project (measlesrubellainitiative.org, n.d.). The organization utilizes various media channels such as social media to access a wide audience and ensures that it continually disseminates information on the significance of vaccination against measles.
Global Implication of the Disease and How It Is Addressed In Other Countries
Measles is among the most infectious human diseases that continue to cause endemics around the world, even in nations that implement high vaccination coverage. The disease is related to lifelong disabilities such as, blindness, deafness and brain damage. It contributes about 44% of total fatalities due to vaccine preventable diseases (VPD), in children below 15 years (Okonko et.al., 2013).Various conditions in different parts of the world including high risk of concurrent infection, inadequate case management and malnutrition promote the likelihood of complications and adverse effects of the disease.
In non-immunized populations, mainly found in under-developed nations, there is passive acceptance of the disease as an inevitable risk in childhood. However, more developed nations implement the measles vaccine as an effective strategy to prevent disease at an individual level, and in managing the disease at community level by administering it at the critical period when maternal antibodies are at lower levels and the risk of natural infection heightens; such nations ensure the maintenance of high immunization rates at targeted populations. Nevertheless, more under-developed nations are embracing immunization coverage. For example, more women in sub-saharan Africa, who had previously regarded measles as an unavoidable childhood condition, are currently supporting immunization after identifying its demonstrated benefits.
South Africa is one of the countries that has reported several measles outbreaks. A measles outbreak involving about 1700 cases occurred in the country from 2003 to 2005. Recently, another endemic that affected more than 18 000 individuals occurred between 2009 and 2011 (Sartorius et.al., 2013). Children infected with HIV are unlikely to respond to vaccines or maintain protective antibody levels because they may have acquired low antibody levels from a HIV-positive mother. Thus, such children require repeated vaccination to minimize measles incidence.