Measles – catching your death

Clusters of measles cases have appeared in many parts of the country after an initial outbreak in the West Midlands, and numbers of cases are still rising. The latest figures from the UK Health Security Agency reveal there have been more than 1,100 confirmed cases of measles since October 2023, with more than 300 since March 2024 alone. While the majority of cases were in children under the age of 10, 29% were found in young people and adults over the age of 15.

WHAT IS MEASLES?

Measles is a highly infectious viral illness. The measles virus is found in the myriad of almost imperceptible droplets that come out of our noses and mouths when an infected person coughs or sneezes. Measles is contracted by breathing in these droplets or touching surfaces where the droplets might have landed (the virus can survive on surfaces for several hours).

People with measles are infectious from when the symptoms develop until about four days after the rash first appears. Initial symptoms occur around 10 days after the person has become infected, and usually include cold-like symptoms, sensitivity to light, sore red eyes, fever, and sometimes spots on the inside of the cheeks. A few days later, a reddish-brown rash will appear spreading across the body.

Measles can be unpleasant to endure even without serious complications setting in. Like other highly infectious illnesses such as smallpox, polio and Hib meningitis, measles was until recently, uncommon in the many countries where vaccination programmes existed. This however seems to be changing and is a point to which we will return.

Most people recover from measles around a week to two weeks after they became ill, however it can lead to serious complications, including life-changing disabilities and death.¹ These include, for example, ear and eye disorders, pneumonia, and neurological disorders (see Measles complications below). There may also be other complications in pregnancy if the mother is not vaccinated against the condition.

Measles is incredibly infectious, with 90% of unvaccinated people exposed to measles becoming infected.² A single person with measles will be able to infect nine other people who are not immune, and between one and three people in every 1,000 who catch measles will die.³

DIAGNOSIS

Diagnosis is usually made clinically based on symptoms,1 which include:

• A runny or blocked nose
• Sneezing
• Watery eyes
• Swollen eyelids
• Sore, red eyes that may be sensitive to light
• A high temperature (fever), which may reach around 40c (104f)
• Small greyish-white spots in the mouth
• Aches and pains
• A cough
• Loss of appetite
• Tiredness, irritability, and a general lack of energy
• A measles rash appearing a few days after initial symptoms.

Clinical diagnosis can be confirmed with laboratory testing of serum.¹

Early recognition is important to help stop the spread of the disease. Measles is a notifiable disease throughout the UK, the EU, the US, Australia and elsewhere.

TREATMENT

As is the case for many viruses, there is no specific treatment for measles, and the condition usually improves with rest and fluids at home within seven to 10 days. Over-the-counter remedies may help treat some of the symptoms. People infected with measles should stay away from places of work and education for at least four days from when the rash first appears in order to avoid spreading this most virulent of infections.⁴ In particular those infected should endeavour to avoid contact with those who may be more vulnerable such as young children and pregnant women.

Vulnerable groups such as those who are pregnant, unvaccinated or who are immune-compromised may require further treatment such as with the vaccine, intravenous immunoglobulin, Vitamin A and in some cases ribavarin, an anti-viral treatment.¹

PREVENTION

Anyone can get measles if they haven’t been vaccinated or haven’t had it before, although it’s most common in young children. Measles can be prevented by having the MMR (measles, mumps and rubella) vaccination given in two doses when a child is around 13 months old, and a second dose at 3 years and 4 months.⁴ Adults and older children can be vaccinated at any age if they haven’t been fully vaccinated before.

VACCINE SAFETY

A Cochrane review of 138 studies and more than 23 million children worldwide in 2020 which looked at whether the MMR vaccine was safe and effective in preventing measles, mumps and rubella, concluded there were high rates of effectiveness associated with the vaccination, and no evidence MMR vaccines were associated with an increased risk of other conditions such as autism, diabetes, and Crohn’s disease, among a range of other identified conditions.⁵

MEASLES COMPLICATIONS

Complications from measles are not uncommon and occur in around 40% of patients.¹ Inflammation or infections of the eyes and ear are common particularly in younger children, and pneumonia is a common and severe complication of the condition. Measles can also cause meningitis and encephalitis in varying forms resulting in significant morbidity and mortality. These are important complications for any measles patients who may be presenting with neurological symptoms. Measles encephalitis is cited as the most common neurological complication of measles virus infection.⁶ A patient-story of a measles encephalitis can be viewed here.

In addition to primary measles encephalitis, three further variations of measles encephalitis can occur: abnormal immune responses such as acute disseminated encephalomyelitis (ADEM) attacking the central nervous system, which can occur in immune-competent patients, again resulting in the potential for significant life-changing sequelae. Subacute sclerosing panencephalitis (SSPE) occurs in a small subset of patients, often many years after the acute infection, and can be more common in males and where infection occurred under the age of two. A patient-story of SSPE can be viewed here. Finally, like SSPE, measles-inclusion body encephalitis is a progressive neurological complication which can progress to death within weeks or months.

One of the most famous cases of measles encephalitis is that of Roald Dahl’s daughter Olivia. He famously wrote:⁷

‘Olivia, my eldest daughter, caught measles when she was seven years old. As the illness took its usual course I can remember reading to her often in bed and not feeling particularly alarmed about it. Then one morning, when she was well on the road to recovery, I was sitting on her bed showing her how to fashion little animals out of coloured pipe-cleaners, and when it came to her turn to make one herself, I noticed that her fingers and her mind were not working together and she couldn’t do anything.

“Are you feeling all right?” I asked her.

“I feel all sleepy,” she said.

In an hour, she was unconscious.

In twelve hours she was dead.

The measles had turned into a terrible thing called measles encephalitis and there was nothing the doctors could do to save her.’

More recently the Sky Cinema Movie ‘To Olivia’ starring Hugh Bonneville and Keeley Hawes covered this traumatic period of Dahl’s life.⁸

MEASLES AND TRAVEL HEALTH

Measles is endemic in many countries. Individuals who have never had measles infection or who are unvaccinated or incompletely vaccinated, may therefore be at risk from measles when travelling, in particular where they are staying with friends, family and/or mixing with the local population. All travellers over the age of 6 months should seek travel health advice and ensure they are up-to-date with the MMR vaccination.⁹ There is most likely a significant underestimate of the number of measles cases globally.

MEASLES – A PUBLIC HEALTH CRISIS?

Worldwide, measles is still a major cause of death, especially among children in resource-poor countries. Over the last two decades however, vaccination has dramatically reduced the number of deaths from measles.

In 1990 measles killed 872,000 people worldwide, in contrast to 2018 when it is estimated about 140,000 people died of measles. However, more recently, measles cases have surged: the World Health Organization (WHO) estimated that there were almost 900,000 cases of measles in 2019, and 207,500 deaths. It is estimated that over one in five of all child deaths averted have been due to measles vaccination.¹⁰

Since the measles vaccine was introduced in the UK in 1968, Public Health England estimates that 20 million measles cases and 4,500 deaths have been averted in the UK. However, in 2019 there were 808 laboratory confirmed measles cases in England and Wales – a significant increase on 2017 (283 cases),11 and in 2019 the UK lost its measles-free status.¹²

The MMR vaccine was introduced in the US in 1963 when measles cases were an estimated 3–4 million. In 2000, the US declared measles eradicated. In 2019, 1,282 cases were confirmed.¹³

Measles killed 72 children and adults in Europe in 2018. According to monthly country reports for January to December 2018, 82,596 people in 47 of 53 countries contracted measles. Where countries reported their measles hospital data, nearly two-thirds (61%) of cases were hospitalised. The total number of people infected with the virus in 2018 was the highest this decade: three times the total reported in 2017 and 15 times the record low number of people affected in 2016.¹⁴

The increase in measles cases is due to gaps in vaccination coverage, according to WHO, with UNICEF warning us there are nearly 170 million children worldwide (under the age of 10) are unprotected from measles.¹⁵ Half a million of these are in the UK and 2.5 million in the US. In low to middle-income countries the statistics make even bleaker reading.

More recently there is concern that millions of children may have missed their MMR vaccines during the COVID-19 pandemic resulting in concerns of major outbreak potential.¹⁶ The lack of vaccine programmes in some countries and vaccine hesitancy leading to outbreaks of measles look set to be fuelled by this further obstacle to achieving herd immunity in communities.

CONTROVERSIES IN MEASLES

According to UNICEF, the current grim global vaccination picture results from a mixture of complacency, misinformation, scepticism about immunisations, and a lack of access to vaccination.

While fear of vaccines is not new (opposition can be traced as far back as the 18th century) a significant catalyst for the current vaccine-hesitancy and the more mobilised anti-vaccine movement was the publication of a paper in 1998 by disgraced doctor Andrew Wakefield. In the bad science of the paper (he had undisclosed conflicts of interest and his research methods were unethical) he asserted that, in a study of only 12 children the MMR vaccine was responsible for autism-like behaviours.¹⁷ In 2010, over a decade on from its publication, and in large part thanks to a reporter called Brian Deer, The Lancet finally retracted the paper, and Wakefield was struck off the Medical Register by the General Medical Council.

As a result, certainly in the UK, a public health scare around the vaccine ensued and it is this that fed much of the vaccine-hesitancy we see today. This scare spread across Europe, and over the Atlantic and to North America. Further misleading papers, movies and theories emerged suggesting further vaccine-autism links such as mercury poisoning related to a preservative found in some vaccines, aluminium poisoning, and ‘antigenic overload’ (a misconceived belief in the need to spread out vaccines in order not to overload children’s immune systems).

Of course we must recognise that some people exercise their autonomy, legitimately opposing vaccination due to personal or religious beliefs. If vaccination rates provide herd immunity to diseases such measles, wider society can – just about – continue to accommodate these genuine personal choices.

Some people have understandably questioned why the vaccine hesitancy movement’s beliefs are not given the same acceptance as people who choose not to vaccinate due to their personal or religious beliefs. Hussain and colleagues state:

‘Online anti-vaccination authors’… tactics include… skewing science, shifting hypotheses, censoring opposition, attacking critics, claiming to be “pro-safe vaccines” and not “anti-vaccine”, claiming that vaccines are toxic or unnatural, and more. Not only are these tactics deceitful and dishonest, they are also very effective on many parents.’¹⁸

This final and very important point is that at the heart of this debate are often the most vulnerable – parents who have lost children, or whose children have life-changing disabilities – are led to believe vaccination was the cause.

CONCLUSION

Measles is a highly infectious and vaccine-preventable disease which can have profound consequences resulting in mortality and life-changing morbidity. The MMR vaccine is highly effective and despite an unrelenting movement that continues to cast doubt on it, it remains the primary strategy to prevent hundreds of thousands of cases and deaths each year.

We must continue to strive in making vaccination as affordable and accessible as possible wherever people live in the world.

REFERENCES

1. Alves Graber EM, Andrade FJ Jr, Bost W, Gibbs MA. An Update and Review of Measles for Emergency Physicians. J Emerg Med. 2020 Apr;58(4):610-615.

2. Sanyaolu A, Okorie C, Marinkovic A, et al. Measles Outbreak in Unvaccinated and Partially Vaccinated Children and Adults in the United States and Canada (2018-2019): A Narrative Review of Cases. Inquiry. 2019;56:46958019894098.

3. Centers for Disease Control and Prevention (CDC). Measles (rubeola). https://www.cdc.gov/measles/hcp/index.html

4. NHS. Prevention: Measles. https://www.nhs.uk/conditions/measles/prevention/

5. Di Pietrantonj C, Rivetti A, Marchione P, et al. Vaccines for measles, mumps, rubella, and varicella in children. Cochrane Database Syst Rev. 2020 Apr 20;4(4):CD004407. doi: 10.1002/14651858.CD004407.pub4. PMID: 32309885; PMCID: PMC7169657.

6. Fisher DL, Defres S, Solomon T. Measles-induced encephalitis. QJM. 2015 Mar;108(3):177-82.

7. Encephalitis Society. Measles infection and encephalitis https://www.encephalitis.info/measles-infection-and-encephalitis

8. Encephalitis Society. To Olivia – Blog; 19 February 2021. https://www.encephalitis.info/blog/to-olivia.

9. Travel Health Pro. Measles. https://travelhealthpro.org.uk/disease/116/measles

10. World Health Organization. Measles Fact Sheet. https://www.who.int/news-room/fact-sheets/detail/measles

11. UK Health Security Agency. Confirmed cases of measles, mumps and rubella in England and Wales: 1996 to 2020 https://www.gov.uk/government/publications/measles-confirmed-cases/confirmed-cases-of-measles-mumps-and-rubella-in-england-and-wales-2012-to-2013 Accessed 12th December 2021.

12. Ford S. Loss of ‘measles free’ status by UK sparks widespread concerns; 19 August 2019. https://www.nursingtimes.net/news/primary-care/loss-measles-free-status-uk-sparks-widespread-concerns-19-08-2019/

13. CDC. Measles cases and outbreaks; November 2021 https://www.cdc.gov/measles/cases-outbreaks.html

14. WHO Europe. Measles in Europe: record number of both sick and immunized; February 2019. https://www.euro.who.int/en/media-centre/sections/press-releases/2019/measles-in-europe-record-number-of-both-sick-and-immunized

15. UNICEF. Press release; April 2019. https://www.unicef.org/press-releases/over-20-million-children-worldwide-missed-out-measles-vaccine-annually-past-8-years

16. Gignoux E, Esso L, Boum Y. Measles: the long walk to elimination drawn out by COVID-19. Lancet Glob Health. 2021 Mar;9(3):e223-e224.

17. Deer B. The Doctor Who Fooled the World: Andrew Wakefield’s war on vaccines. 2020; Scribe UK.

18. Hussain A, Ali S, Ahmed M, Hussain S. The Anti-vaccination Movement: A Regression in Modern Medicine. Cureus. 2018 Jul 3;10(7):e2919.