Reports of measles go back to at least 700, however, the first scientific description of the disease and its distinction from smallpox is attributed to the Muslim physician Ibn Razi (Rhazes) 860-932 who published a book entitled "Smallpox and Measles" (in Arabic: Kitab fi al-jadari wa-al-hasbah). In 1954, the virus causing the disease was isolated, and licensed vaccines to prevent the disease became available in 1963.

Measles is spread through respiration (contact with fluids from an infected person's nose and mouth, either directly or through aerosol transmission), and is highly contagious - 90% of people without immunity sharing a house with an infected person will catch it. Airborne precautions should be taken for all suspected cases of measles.

The incubation period usually lasts for 10-12 days (during which there are no symptoms).

Infected people remain contagious from the appearance of the first symptoms until 3-5 days after the rash appears.

Symptoms

The classical symptoms of measles include a fever for at least three days duration, and the three C's - cough, coryza (runny nose) and conjunctivitis (red eyes). The fever may reach up to 40 degrees Celsius (105 Fahrenheit). Koplik's spots seen inside the mouth are pathognomic (diagnostic) for measles but are not often seen, even in real cases of measles, because they are transient and may disappear within a day of arising.

The rash in measles is classically described as a generalised, maculopapular, erythematous rash that begins several days after the fever starts. It starts on the head before spreading to cover most of the body. The measles rash also classically "stains" by changing colour to dark brown from red before disappearing later. The rash can be itchy.

Diagnosis

A detailed history should be taken including course of the disease so far, vaccination history, contact history, and travel history.

Clinical diagnosis of measles requires a history of fever of at least three days together with at least one of the three Cs above. Observation of Koplik's spots is also diagnostic of measles.

Alternatively, laboratory diagnosis of measles can be done with confirmation of positive measles IgM antibodies or isolation of measles virus RNA from respiratory specimens.

Positive contact with other patients known to have measles adds strong epidemiological evidence to the diagnosis.

Treatment

There is no specific treatment for uncomplicated measles. Patients with uncomplicated measles will recover with rest and supportive treatment.

Complications

Complications with measles are relatively common, ranging from relatively common and less serious diarrhea, to pneumonia and encephalitis (subacute sclerosing panencephalitis). Complications are usually more severe amongst adults who catch the virus.

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Preventable measles among U.S. residents, 2001-2004
From Morbidity and Mortality Weekly Report, 8/26/05 by S. Smith

Elimination of endemic measles has been achieved in the United States (1); however, measles continues to be imported from areas of the world where the disease remains endemic, resulting in substantial morbidity and expenditure of local, state, and federal public health resources (2,3). Measles among U.S. residents results from returning residents who become infected while living or traveling abroad, from contact or association with an infected traveler, or from an unknown source. This report summarizes surveillance data reported to CDC by state and local health departments regarding confirmed measles cases among U.S. residents during 2001-2004; an illustrative case report is included. The majority of measles cases occurring among U.S. residents can be prevented by following current recommendations for vaccination, including specific guidelines for travelers (4).

Confirmed measles cases (4) were defined as preventable if they occurred among persons for whom vaccination is recommended by the Advisory Committee on Immunization Practices (ACIP) but who had not received 1 or more doses of measles-containing vaccine (MCV). Cases were considered nonpreventable if they occurred among persons who 1) had received 1 or more doses of MCV, 2) were not vaccinated and for whom vaccination is not recommended, or 3) were born before 1957 (presumed immune from natural disease in childhood). Persons with unknown vaccination status were considered unvaccinated. Outbreaks were defined as three or more epidemiologically linked cases.

During 2001-2004, a total of 251 * measles cases were reported to CDC, of which 177 (71%) occurred among U.S. residents, and 74 (29%) occurred among nonresidents. Of the 177 cases among U.S. residents, 100 (56%) were preventable, and 77 (44%) were nonpreventable (Table 1).

Preventable Cases. Of the 100 preventable cases, 43 (43%) occurred among international travelers (imported cases), and 57 (57%) among nontravelers (indigenous cases). Of the 17 (17%) preventable cases among infant travelers aged 6-15 months, 12 occurred among infants aged 6 11 months, and five occurred among children aged 12-15 months. Of the 83 (83%) preventable cases among persons aged >16 months, 26 were in persons who became infected during international travel, and 57 were in persons infected in the United States (Table 1).

Nonpreventable Cases. Of" the 77 cases that were nonpreventable, 12 (16%) occurred among international travelers; 11 of the 12 travelers had received at least 1 dose of MCV, and the other was born before 1957 and had not been vaccinated. A total of 65 (84%) cases occurred among nontravelers; all were in persons previously vaccinated, except 29 cases in infants aged [less than or equal to] 15 months (routine MCV may be administered as late as age 15 months) and six in persons born before 1957. Seven of the unvaccinated infants were aged 12-15 months and thus were eligible for vaccination.

Outbreaks. Of the 14 outbreaks identified during 20012004, nine involved three or more U.S. residents; of these, seven originated with a U.S. resident traveler. In one outbreak, 10 cases in a daycare center resulted from exposure to an unvaccinated daycare attendee (an infant aged 9 months) who was infected during travel abroad (2).

Case Report. During June 20-22, 2004, a North Carolina resident aged 11 years traveled from the United Kingdom to North Carolina via New York and Connecticut. After her arrival in North Carolina on June 22, she had cough, coryza, and fever, followed by onset of a rash on June 25. She had suspected measles diagnosed on June 28. She had not received MCV; her parents had declined to have her vaccinated for religious beliefs. One day before her rash onset, the girl had close contact with a male infant aged 11 months. The infant subsequently had measles with rash onset on July 4. Two days before his rash onset, the infant visited a summer camp, where he potentially had contact with up to 234 persons, including 113 campers, 63 parents/visitors, and 58 staff members. Several campers returned home at the end of-the camp session, the day after the exposure. Multistate and multinational investigation and control efforts to prevent further spread were conducted. Potentially infected persons subsequently traveled to Arizona, Arkansas, Florida, New York, Australia, Costa Rica, New Zealand, South Africa, and Wales. No additional cases of measles were subsequently identified.

Editorial Note: Travel anywhere outside of the United States, including to industrialized regions such as Western Europe, presents a risk for measles exposure. 1, 2003, approximately 24 million U.S. residents traveled abroad, and 40 million international visitors entered the United States (5,6). Importation of measles from foreign visitors is unavoidable because no regulations are in effect requiring vaccination of visitors. However, as other countries reduce the burden of" measles, the risk of travelers bringing measles into the United States will decrease.

Measles can cause serious complications and death, particularly among children aged <5 years. All U.S. residents should be vaccinated in accordance with AC1P recommendations (40, with special attention to international travelers who now account for a substantial proportion of the measles disease burden in the United States. Health-care providers who serve populations that travel should be aware of the vaccination recommendations for international travelers (7). Current measles recommendations for travelers include vaccination for infants aged 6 11 months and 2 doses of MCV for travelers aged [greater than or equal to] 12 months (Table 2). Despite these recommendations, 17% of the preventable cases described in this report occurred among unvaccinated travelers aged 6 15 months. The reasons for these children not receiving MCV are unknown but might include lack of awareness among parents and health-care providers regarding recommendations for inf:ants aged 6-11 months, refusal because of personal or religious beliefs, or lack of perceived risk, especially for children of foreign-born U.S. residents who travel to their country of origin (8,9). Imported and secondary cases among U.S. residents who refuse vaccination because of personal or religious beliefs can result in the introduction of measles into communities with other susceptible persons who share the same beliefs, thereby posing a risk for substantial spread of disease (3, 10). In addition, seven cases in nontravelers aged 12-15 months might have been prevented if these children had been vaccinated as soon as they became eligible for MCV (e.g., MMR) at age 12 months.

Measles cases among persons born before 1957 for whom vaccination is not recommended are rare. However, persons in this age group who travel internationally might wish to consider vaccination to minimize their risk for measles.

The findings in this report are subject to at least three limitations. First, certain measles cases might have been missed or not reported to public health officials, including cases that occurred and resolved during travel abroad. Second, because information on multiple doses of MCV is collected inconsistency, persons who had received at least 1 dose of MCV were considered vaccinated, even though 2 doses are recommended for some age groups and for most international travelers (40, thus potentially underestimating the number of preventable cases. Third, preventable cases might be overestimated because vaccine efficacy is <100%, and vaccination data were missing for 30 (17%) persons. All persons with missing data were considered unvaccinated, although some might have received MCV.

Because of the high infectivity and morbidity associated with measles, contact tracing is a standard public health practice and can require many hours of public health staff-time and can cost thousands of dollars (3). A recent study evaluating the economic impact of an infected U.S. traveler returning from India estimated the costs of locating and vaccinating susceptible contacts at $140,000 (3). Although few cases have been associated with transmission during air travel (3; CDC, unpublished data, 2005), contact tracing of infected air travelers is particularly challenging; a person with measles can be infectious from at least 4 days before through 4 days after rash onset. To avoid outbreaks or a resurgence of measles, as occurred during 1989-1991, when approximately 55,000 cases and 120 measles-related deaths were reported in the United States (4), high population immunity and surveillance must be maintained.

To prevent measles among U.S. residents, health-care providers should follow ACIP vaccination recommendations, ensuring that travelers are vaccinated, particularly infants aged 6-11 months, and that 2 doses are administered for those aged [greater than or equal to] 12 months. In addition, parents should be educated about the risk for measles associated with international travel and the need for vaccination. Information on vaccination recommendations for travelers is available from CDC at http:// www.cdc.gov/travel.

Acknowledgments The data in this report are based on contributions by state and local health departments.

References

(1.) Katz SL, Hinman AR. Summary and conchisions: measles elimination meeting, 16-17 March 2000. J Infect Dis 2004;189(Suppl 1):543-7.

(2.) CDC. Epidemiology of measles--United States, 2001 2003. MMWR 2004;53:713-6.

(3.) Dayan GH, Ortega-Sanchez IR, LeBaron CW. The cost of containing one case of measles: the economic impact on the public health infrastructure, Iowa, 2004. Pediatrics 2005;116:1-4.

(4.) CDC. Measles, mumps, and rubella vaccine use and strategies for elimination of measles, rubella, and congenital rubella syndrome and control of mumps: Recommendations of the advisory committee on immunization practices (ACIP). MMWR 1998;47(No. RR-8):38-9.

(5.) US Department of Commerce, International Trade Administration, Office of Travel and Tourism Industries. 2003 profile of U.S. resident traveler visiting overseas destinations reported from survey of international air travelers. Washington, DC: US Department of Commerce; 2004. Available at http://tinet.ita.doc.gov/view/f-2003-101-001/index.html.

(6.) US Department of Commerce, International Trade Administration, Office of Travel and Tourism Industries. Arrivals to the U.S. 2004 & 2003 (all countries reported by residency and in rank order within region). Washington, DC: US Department of Commerce; 2004. Available at http://tinet.ita.doc.gov/view/f-2004-203-001/index.html.

(7.) CDC. Health information for international travel 2005 2006. Atlanta, GA: US Department of Health and Human Services, CDC: 2005.

(8.) BacanerBacaner N, Stauffer B, Boulware DR, Walker PF, Keystone JS. Travel medicine considerations f-or North American immigrants visiting friends and relatives. JAMA 2004;291:2856-64.

(9.) Angell SY, Cetron MS. Health disparities among travelers visiting friends and relatives abroad. Ann Intern Med 2005:142:67-72.

(10.) Feikin DR, Lezotte DC, Hamman RF, et al. Individual and community risks of measles and pertussis associated with personal exemptions to immunizations. JAMA 2000;284:3145-50.

Reported by: S Smith, North Carolina Dept of Health and Human Svcs. V Averhoff. MD, S Redd, Epidimiology and Surveillance Div, National Immunization Program; A Rue, MPH, EIS Officer, CDC.

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