Measles (Rubeola)

Introduction

Measles is an acute viral illness that is one of the most

common diseases of childhood, along with mumps and
German measles (rubella). The clinical name for measles
is rubeola, which comes from the Latin word ruber
meaning red, and is a reference to the pinkish-red rash
that is characteristic of the disease. Measles is a highly
infectious disease, spread by coughs, sneezes, and person-to-person contact. It will occasionally lead to serious
and even potentially fatal complications, such as pneumonia and encephalitis. Once someone has had measles,
they are usually immune for life. Vaccination was introduced in the 1960s in the Western world and has led to a
dramatic reduction in the number of children contracting measles. Since humans are the only hosts for the

measles virus, it should be possible to eradicate measles,

through universal vaccination. This requires a global
effort to bring the vaccine to children everywhere.

Disease History, Characteristics,

and Transmission

Measles is caused by a virus from the Paramyxoviridae

family, which also includes the influenza and mumps
viruses. It is a single stranded, enveloped, RNA virus
that is, its genetic material is RNA rather than DNA. The
incubation time of the measles virus is 912 days. The
virus first infects the epithelial cells lining the upper
respiratory tract and then spreads to the rest of the body.

Paramyxoviruses are a group of viruses that include the agents of human measles (rubeola), mumps, and
respiratory diseases, as well as canine distemper. Visuals Unlimited/Corbis.

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Measles (Rubeola)

The measles (rubeola) rash as seen on a childs face. CNRI/Photo Researchers, Inc.

In typical or natural measles, the early symptoms are like

those of a common cold and include coughing, sneezing, sore throat, and fever. Within a few days, characteristic small white spots called Kopliks spots develop
inside the mouth. A day or so later, a rash appears,
starting behind the ears and spreading to the face and
down the body and lasting for three or four days. Complications occur in up to 30% of cases of measles, and
include pneumonia and otitis media, a middle ear infection that can lead to deafness. Encephalitis, an inflammation of the brain, is a complication in around one out
of 1,000 cases of measles and has a 10% mortality rate.
Mortality (death) from measles complications is highest
among infants under two years old and in adults.
There is also a modified form of measles that occurs
among those who have been incompletely vaccinated.
Modified measles is less severe than typical measles and
Kopliks spots may be absent. However, the risk of complications is the same. Rarely, a form of the disease called
atypical measles may occur, usually among those who
received vaccine in the 1960s. Atypical measles is characterized by sudden onset of fever, muscle pain, abdominal
pain, and headache. Kopliks spots are rarely present and
pneumonia is a common complication. Subacute sclerosing panencephalitis is an extremely rare degenerative disease of the brain and nervous system that is thought to
arise from persistent measles infection in the brain. It
occurs at a rate of around one per 100,000 cases and
develops several years after measles exposure.

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Measles is spread through the aerosol routethat is,

through coughs and sneezesand also by person-to-person
contact. It is one of the most infectious diseases known, with
around 90% of those being exposed becoming infected. A
person is infectious for three to four days before the rash
appears and for up to four days while the rash is present.

Scope and Distribution

Practically all children developed measles at some stage

before vaccination, with the disease being most common
in the winter and early spring. Before the introduction of
the measles vaccine in 1963, there were 200,000600,000
cases of measles a year in the United States, and this was
probably a gross underestimate of the true scale of the
disease. Before vaccination, measles killed more children
than polio did. There was a sharp decline in measles cases
following mass vaccination, followed by resurgence from
1983. This occurred among those who had not been
vaccinated and among previously vaccinated teenagers. By
1989, there were 19,000 reported cases. A revised vaccination strategy, involving two doses instead of one,
brought measles under control again. By 1993, cases were
down to fewer than 1,000 annually in the United States.
Measles has always been a global problem and has a major
impact upon child health in developing countries, where
vaccination is not readily available. According to the World
Health Organization (WHO), there were around 30 million cases of measles around the world in 2004, of which
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Measles (Rubeola)

454,000 proved fatal. Measles can be dangerous to the

fetus if a pregnant woman contracts measles in the first
three months of pregnancy. Patients with weakened
immunity, such as those with HIV/AIDS, are also at risk
of complications from measles.

WORDS TO KNOW
AEROSOL: Particles of liquid or solid dispersed as a

suspension in gas.

Treatment of measles is often unnecessary, although

antibiotics may be given for secondary bacterial infections. Vitamin A may be useful in very severe cases and in
countries where this vitamin deficiency is common. The
antiviral drug ribavirin may be used in very severe cases
also, and in patients with weakened immunity.
The spread of measles can be prevented by good
hygiene, including handwashing. People with measles
should isolate themselves while they are infectious and
not attend school or day care. The best way of preventing measles is by vaccination. A killed vaccine was introduced in 1963, followed by a live vaccine from the late
1960s. It is now usual to give a combined measles,
mumps, and rubella (MMR) vaccineone dose between
12 and 15 months and a second before a child enters
school. Most people can take MMR, but it is not usually
recommended for people with weakened immunity or
for pregnant women. Some parents have concerns over
the safety of the MMR vaccine, because it has been
linked with autism, and have refused vaccination for
their children. In areas where vaccination rates have
fallen, for this and other reasons, there have been new
and significant measles outbreaks.

KOPLIKS SPOTS: Kopliks spots, named after Amer-

Treatment and Prevention

Impacts and Issues

Measles is the leading cause of vaccine-preventable death

among children. The death rate from measles in developed countries is very low but reaches 15% in developing countries. The death rate from measles can be as
high as 1030% among malnourished children or those
in refugee situations. Around 400,000 children under
five years of age die from measles each year. But measles
is a disease that could be eradicated from the planet,
since humans are the virus only host. In 2001, the
Measles Initiative was established by the American Red
Cross, the Centers for Disease Control and Prevention,
UNICEF (the United Nations Childrens Fund), and
the WHO. The Initiative aims to cut deaths from measles
by 90% by 2010 compared to figures from the year 2000,
using vaccination that can cost less than a dollar per child.
In the first five years, the Initiative supported campaigns,
with national governments, that led to the vaccination of
more than 217 million children, mainly in Africa. This
saw measles deaths in Africa drop by 75%from 506,000
in 1999 to 126,000 in 2005. The Initiative has now
expanded its vaccination activities to Asia and is working
INFECTIOUS DISEASES: IN CONTEXT

ican pediatrician Henry Koplik (18581927)

and also called Kopliks sign, are red spots with
a small blue-white speck in the center found
on the tongue and the insides of the cheeks
during the early stages of measles.
MORTALITY: Mortality is the condition of being

susceptible to death. The term mortality

comes from the Latin word mors, which means
death. Mortality can also refer to the rate of
deaths caused by an illness or injury, i.e.,
Rabies has a high mortality.

in all six WHO regions of the world in an attempt to

eradicate measles and its impact on child health.

Primary Source Connection

During the late 1970s and early 1980s, the rise of individualism and the popularity of self-help movements in
the United States and Western Europe provided a new
challenge to public health officials. Individuals began to
take control of their own heath care and, in essence, some
control and responsibility was wrested away from the
physician and other health care workers. This presented
a special challenge to public health agencies because a
manifestation of the movement toward self directed
health care also involved the rejection of traditional vaccinations such as the MMR vaccine.
Over the last decade, many parents further rejected
using the MMR vaccine out of fears that the vaccine was
linked to autism.
The newspaper article by Mark Porter and commentary below demonstrate different aspects of the scientific
and social debate over the MMR vaccine. The article also
demonstrates the attempts by scientific community to be
both self-correcting and to discipline breeches of ethics.
The commentary offers a view that although the original
research linking the MMR vaccine to autism appears
tainted, the vigorous investigation might lead to future
benefits in the way vaccines are developed and tested.
Mark Porter is is a medical doctor who provides regular advice and commentary on medical issues for radio
and television programming in the United Kingdom.

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Measles (Rubeola)

A United Nations Childrens Fund (UNICEF) doctor vaccinates a child against measles as part of a
national immunization campaign in the Philippines in February 2004. Jay Directo/AFP/Getty Images.

Doctor Who Sparked the MMR

Debate Faces Misconduct Charge
THE doctor whose research sparked the international
scare over the safety of the MMR vaccine is to be
charged with serious professional misconduct.
Andrew Wakefield is to be ordered in front of the General Medical Council after publishing a paper in The
Lancet in 1998 that suggested a link between the jab
and autism as well as Crohns, a bowel disease.
A sheet of preliminary charges accuses him of putting out
inadequately founded research, of failing to obtain ethical committee approval, obtaining funding improperly
and of subjecting children to unnecessary and invasive
investigations.
Dr. Wakefields study is held responsible by many doctors for a dramatic slump in the number of parents
allowing their children to have the combined injection
against measles, mumps and rubella.
Take-up of the vaccination has fallen to only 12 per cent
of children in some areas of London, while city-wide little
more than half are having the jab - putting an estimated
100,000 of London children at risk of infection.
In 2004, The Lancet withdrew the paper, with the editor
declaring it fatally flawed after it emerged Dr. Wakefield
had been paid [pounds sterling]55,000 (more than
$100,000) by lawyers for parents of children who claimed
they had been damaged by the MMR vaccine to look for
evidence that could be used in legal action. GMC lawyers
are working on the list of charges with a hearing expected

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next year. If found guilty of serious professional misconduct Dr. Wakefield, 50, faces being struck from the medical register. The GMC decided to bring a case against the
doctor contrary to normal procedures. It usually only
brings charges when it receives a complaint, but in this
case it acted without one, following a two-year
investigation.
Why we all owe Wakefield a debt of thanks
COMMENTARY
DR ANDREW WAKEFIELD has had a spectacular fall
from grace.
Eight years after sparking worldwide concern about the
safety of the MMR vaccine, his research has been
rejected by the journal that originally published it, and
most of his fellow researchers have distanced themselves
from his conclusions.
A promising career in the UK has come to an abrupt end
and he has left the country. To cap it all, he is set to be
charged with professional misconduct by the General
Medical Council. While intrigued by Wakefields theory
that exposure to the measles virus could predispose some
children to autism, I have always felt that he was wrong
to cast doubts on the safety of MMR without more
evidence.
But just because we didnt see eye to eye it doesnt mean
that I am comfortable with the public pillorying that he
has recently endured. Indeed, I am distinctly uncomfortable with it. We need mavericks like Andrew Wakefield,
and his plight can only stifle the sort of independent
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Measles (Rubeola)

thinking required to make major breakthroughs in medicine. History has taught us that there is a fine line
between being dismissed as an eccentric and being
lauded as a genius. Nobel Prize winner Dr. Barry Marshall is a case in point.
At first Dr Marshalls claims that stomach and duodenal
ulcers were caused by an infection (H.pylori) and could
be treated with antibiotics, rather than a lifetime of acid
suppressing drugs, were treated with derision.
But he persevered.
Fifteen years later his discovery has transformed the lives
of millions of patients and he has become one of medicines most distinguished academics.
While Dr. Wakefield has achieved notoriety rather than
eminence, his enthusiasm left me in little doubt that he
really did believe he had stumbled across something that
questioned the safety of the MMR vaccine. Time may
have proved him wrong, but back in 1998 when he first
raised the possibility, we simply didnt have enough data
to back the bland reassurances issued by the Department
of Health.
Thanks to him sticking his head above the parapet, we
now know far more about the MMR vaccine than we
ever would have known had he not questioned its safety.
And I suspect the resulting scepticism, both lay and
professional, that now surrounds the introduction of
new vaccines will benefit us all in the long-term.
Mark Porter
PORTER, MARK. DO CTOR WHO SPARKED T HE MMR
D EB A TE FA CE S MIS CON DUCT CH A RG E. T HE E VENI NG
ST AN DARD. JUN E 1 2, 2 0 0 6.

SEE ALSO Childhood Infectious Diseases, Immunization

Impacts; Mumps; Rubella.

IN CONTEXT: SCIENTIFIC,
POLITICAL, AND ETHICAL
ISSUES
With regard to a potential connection between the measles,
mumps, and rubella vaccine (MMR vaccine) and autism, scientists at the National Immunization Program (NIP) at Centers for
Disease Control and Prevention (CDC) state that the weight of
currently available scientific evidence does not support the
hypothesis that MMR vaccine causes autism. CDC recognizes
there is considerable public interest in this issue, and therefore
supports additional research regarding this hypothesis. CDC is
committed to maintaining the safest, most effective vaccine
supply in history.
As of May 2007 the CDC further states that, there is no
convincing evidence that vaccines such as MMR cause long
term health effects. On the other hand, we do know that
people will become ill and some will die from the diseases this
vaccine prevents. Measles outbreaks have recently occurred in
the UK and Germany following an increase in the number of
parents who chose not to have their children vaccinated with
the MMR vaccine. Discontinuing a vaccine program based on
unproven theories would not be in anyones best interest.
Isolated reports about these vaccines causing long term health
problems may sound alarming at first. However, careful review
of the science reveals that these reports are isolated and not
confirmed by scientifically sound research. Detailed medical
reviews of health effects reported after receipt of vaccines have
often proven to be unrelated to vaccines, but rather have been
related to other health factors. Because these vaccines are
recommended widely to protect the health of the public,
research on any serious hypotheses about their safety are
important to pursue. Several studies are underway to investigate still unproven theories about vaccinations and severe side
effects.
SOURCE: Centers for Disease Control and Prevention, National
Immunization Program

BIBLIOGRAPHY

Books

Tan, James S. Expert Guide to Infectious Diseases.

Philadelphia: American College of Physicians, 2002.
Wilson, Walter R., and Merle A. Sande. Current
Diagnosis & Treatment in Infectious Diseases. New
York: McGraw Hill, 2001.

Web Sites

The Measles Initiative. Home Page. March 16, 2007.

<http://www.measlesinitiative.org/index3.asp>
(accessed March 20, 2007).
Susan Aldridge

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