CPD
4 Page 60
Measles multiple choice questionnaire
CONTINUING PROFESSIONAL DEVELOPMENT
4 Page 61
Read Anita Skinner’s practice profile on caring for patients with a stoma
4 Page 62
Guidelines on how to write a practice profile
Measles: pathology, management and public health issues NS744 Bentley J et al (2014) Measles: pathology, management and public health issues. Nursing Standard. 28, 38, 51-58. Date of submission: January 17 2014; date of acceptance: March 13 2014.
Aims and intended learning outcomes
Abstract Measles is a highly contagious viral disease that continues to occur in epidemics in the UK despite efforts to eradicate it. In the acute stage, measles is associated with several complications including otitis media, but some of the most severe consequences of the disease occur months and even years after the initial infection. Worldwide, measles contributes significantly to deaths in childhood and places an additional burden on families already living with the consequence of poverty and conflict. This article aims to develop the reader’s understanding of measles, including its pathophysiology, management and associated public health issues.
Authors Jackie Bentley Senior lecturer in child health, University of Worcester, Worcester. Jo Rouse Principle lecturer, University of Worcester. Jenny Pinfield Senior lecturer, University of Worcester. Correspondence to: [email protected]
Keywords Measles, immunisation, infection prevention, paediatric nursing, pathology, public health, vaccination, viral disease
Review All articles are subject to external double-blind peer review and checked for plagiarism using automated software.
Online Guidelines on writing for publication are available at www.nursing-standard.co.uk. For related articles visit the archive and search using the keywords above.
The aim of this article is to highlight strategies to aid recognition, management and prevention of measles. After reading this article and completing the time out activities you should be able to: 4Describe the pathophysiology of measles. 4Explain how measles is transmitted. 4Identify individuals at increased risk of developing measles and associated complications. 4Discuss the identification, assessment and management of individuals with measles. 4Outline the role that vaccination plays in the prevention of measles.
Introduction Before measles vaccination was introduced, the disease occurred in 95-98% of children by the age of 18 years and was considered an inevitable part of childhood (Perry and Halsey 2004). However, measles can affect people of all ages (Chen and Fennelly 2014) and the complications associated with the infection present a rationale for its eradication (World Health Organization (WHO) 2009a).
Measles virus Measles, also known as rubeola, is an acute infection caused by a morbillivirus from the paramyxovirus group (DiPaola et al 2012). It is a spherical virus of diameter 100-200mm, and contains a single strand of ribonucleic acid (RNA) (Dardis 2012, DiPaola et al 2012), enclosed within a lipid envelope (Griffin et al 2012). Humans are the only host for measles (WHO 2014).
©Downloaded NURSINGfrom STANDARD / RCN PUBLISHING may 21:: vol 28 no 38 :: 2014 51 RCNi.com by ${individualUser.displayName} on Nov 18, 2015. For personal use only. No other uses without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
CPD infectious disease
2 Gao et al (2013) documented an epidemic of measles in Wenzhou city, China, after a nationwide immunisation programme. The incidence was particularly high in babies who had been too young to immunise during the campaign and the researchers suggested an inappropriate relaxation in routine immunisation had followed the campaign. Before infection, a high proportion of affected infants received treatment in a hospital intravenous rehydration room that was described as overcrowded with parents and children, and disinfected once per day, but not during clinic hours. Consider the infection control strategies that might help to reduce the risk of cross-infection with measles.
last for several weeks (DiPaola et al 2012, Chen and Fennelly 2014). Complete time out activity 1
Transmission Measles is one of the most highly communicable infectious diseases, with 75-90% of household contacts developing the disease (Salisbury and Ramsay 2013). Virions are transmitted by contact with nasal and throat secretions that become airborne as droplets, especially through coughing or sneezing. Because the virus survives on surfaces for up to two hours, transmission requires no direct contact with an infected person (Newson 2012, Chen and Fennelly 2014). The incubation period is eight to 12 days (DiPaola et al 2012). A person is most contagious one to two days before the onset of symptoms, with risk of infection greatest three days before the onset of the rash (DiPaola et al 2012) until four days after the rash appears (WHO 2014). The vagueness of early symptoms means individuals are often unaware they are infected and continue with social activities, thereby increasing the risk of transmission (Perry and Halsey 2004). Complete time out activity 2
FIGURE 1 Exanthema on the face
ALAMY
1 How would you describe the measles rash, its development and resolution to a parent?
Clinical features indicative of measles include (Salisbury and Ramsay 2013, Chen and Fennelly 2014): 4Rash lasting at least three days. 4Fever for at least one day, with temperature often above 40°C. 4At least one of the three Cs: cough, coryza or conjunctivitis. DiPaola et al (2012) identified four clinical stages associated with measles: incubation, prodromal, exanthema (rash) and recovery. Symptoms associated with the prodromal phase normally begin about ten days after exposure to the virus (Salisbury and Ramsay 2013). Prodromal The prodromal phase lasts two to four days and is characterised by increasing fever, malaise, cough, coryza, conjunctivitis, photophobia, anorexia and peri-orbital oedema (Newson 2012). Koplik’s spots occur in 60-70% of individuals with measles (Zenner and Nacul 2012), but because they occur on the buccal mucosa, usually near the first and second molars, they may go unnoticed (Newson 2012). They may also form on the soft palate, conjunctiva and vaginal mucosa (Perry and Halsey 2004). These bluish-white, slightly raised 2-3mm lesions may look like grains of sand or grains of rice and last one to three days (Newson 2012, Chen and Fennelly 2014). Exanthema A rash will appear usually 14 days after exposure to the virus and may last for three to seven days (WHO 2014). It appears first on the face, around the hairline, on the sides of the neck and behind the ears, but over a period of two to three days, spreads downwards to the trunk and extremities, including the palms of the hands and soles of the feet (Figure 1 and Figure 2). The lesions are most dense around the shoulders (Newson 2012). Generally, the rash takes the form of blanching erythematous macules and papules, although it may also be petechial or ecchymotic and may be itchy (Chen and Fennelly 2014). The rash fades gradually in the same order as it appeared and leaves a brownish discolouration, sometimes finishing with a fine desquamation (Newson 2012). During this stage, cervical lymphadenitis, splenomegaly and mesenteric lymphadenitis with abdominal pain may also occur (DiPaola et al 2012). Recovery Clinical improvement can be seen 48 hours after the rash appears. In the absence of any complications, the period from late prodrome to the resolution of fever and rash lasts seven to ten days, although cough may
FIGURE 2 Measles lesions
ALAMY
Clinical features
52 may 21 :: vol 28 no 38 :: 2014 © NURSING STANDARD / RCN PUBLISHING Downloaded from RCNi.com by ${individualUser.displayName} on Nov 18, 2015. For personal use only. No other uses without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
Pathophysiology According to Rodrigo (2012), infection with measles involves four stages: 1. Attachment. 2. Fusion. 3. RNA replication. 4. Assembly of viral particles and their release. Initially, tracheal and bronchial epithelial cells are invaded and after two to four days the infection spreads to local lymphatic tissue. A primary viraemia allows the virus to replicate in epithelial and reticuloendothelial system tissue (Griffin 2010). A secondary viraemia (five to seven days post infection) facilitates circulation of the virus to the skin, gastrointestinal tract, kidneys and bladder seven to 11 days post infection (Rodrigo 2012). Antibodies appear ten to 14 days after exposure (Rodrigo 2012), and viraemia ceases by day 20 (Griffin 2010). However, Moss and Griffin (2012) argued that viral RNA persists in many sites. Infection triggers both humoral and cellular immune responses and once the virus resolves, it confers lifelong immunity (DiPaola et al 2012). During the acute infection and for several weeks or months afterwards, immunosuppression occurs. This is marked by a decrease in delayed-type hypersensitivity, lymphocytopenia, interleukin production and impaired antigen specific lymphoproliferation, leaving the individual at risk of opportunistic infection (Rodrigo 2012, Chen and Fennelly 2014). Griffin (2010) suggested the rash is a result of an adaptive antiviral immune response.
At-risk groups WHO (2014) suggests that measles is a leading cause of death in young children globally. The burden of disease is highest in developing countries, and is associated with increased mortality in countries experiencing or recovering from natural disaster or conflict (Perry and Halsey 2004, WHO 2014). Furthermore, malnutrition and vitamin A deficiency increase the risk of developing severe cases of measles (Chen and Fennelly 2014). Travelling to areas where measles is endemic, overcrowding and household exposure also increase risk (Perry and Halsey 2004, Chen and Fennelly 2014). Children with immunodeficiency, particularly those with human immunodeficiency virus (HIV), leukaemia and those receiving corticosteroid therapy, are also at increased risk of developing measles. Children born to HIV-infected mothers are more vulnerable to infection
because of the lower number of maternal antibodies transferring to the baby in utero (Chen and Fennelly 2014). Salisbury and Ramsay (2013) indicated that case fatality is age related, being highest in infants and lowest in children aged one to nine years, rising again in teenagers and adults. However, DiPaola et al (2012) suggested that rates of infection are highest in those aged five to nine years. Historically, boys have an increased risk of fatality compared with girls, but UK data suggest equal rates of complications (Perry and Halsey 2004). According to Rodrigo (2012), a ‘window of infection’ exists between the loss of maternally acquired antibodies and vaccination. Antibody levels are lower in babies born to immunised mothers compared with those whose mothers experience naturally acquired infection (Elliman et al 2009). Pregnant women are also a high-risk group for developing severe measles (Chen and Fennelly 2014), with Salisbury and Ramsay (2013) suggesting that measles infection in pregnancy can lead to intrauterine death and premature delivery, but that it is not associated with congenital infection or damage. Complete time out activity 3
Nursing care and management Patients with measles can appear quite unwell, but since there is no specific antiviral treatment (WHO 2014), management aims to reduce the risk of complications and relieve symptoms. Symptoms of fever, cough and rash are usually self-limiting, resolving in about one week, with the patient making a full recovery within ten days (National Institute for Health and Care Excellence (NICE) 2013a). However, one in ten children with measles requires inpatient hospital treatment (NHS Choices 2013). Effective history taking is essential for those exhibiting signs and symptoms of measles to ensure the correct nursing diagnosis is made and appropriate care initiated. Rudolf and Levene (2006) recommended using a systematic approach to ensure holistic care; however, the approach should be flexible to allow the nurse to pursue all routes of enquiry. The patient’s immunisation history is relevant, as is recent history of contact with an infected person or travel to a country where measles is endemic (Watkins 2011, Public Health England (PHE) 2013a) (Box 1 and Box 2).
3 In your own words, explain why measles is associated with increased mortality in developing countries.
©Downloaded NURSINGfrom STANDARD / RCN PUBLISHING may 21 :: vol 28 no 38 :: 2014 53 RCNi.com by ${individualUser.displayName} on Nov 18, 2015. For personal use only. No other uses without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
CPD infectious disease Complications of measles The most common complications of measles infection are otitis media, pneumonia, diarrhoea and febrile convulsions (PHE 2013a). NICE (2013a) states that rare complications include encephalitis, with subacute sclerosing
BOX 1 Case study 1 Chloe is five years old. For the last few days she has had a temperature, runny nose, and red and inflamed conjunctiva. Chloe’s mother contacted the GP practice for advice when Chloe developed a rash which started on her face and neck, but had spread down her body. Chloe was seen by her practice nurse in a private room to reduce the risk of cross-infection. On examination, Chloe had Koplik’s spots inside her mouth, on the buccal mucosa. Chloe’s mother confirmed she had not taken Chloe for her measles, mumps and rubella (MMR) vaccination because of concerns she had at the time about the safety of the vaccine. The nurse confirmed a diagnosis of measles, and as Chloe was relatively well and not exhibiting complications, the nurse advised that Chloe should return home. The nurse also suggested that Chloe should be given paracetamol and ibuprofen for symptomatic relief (National Institute for Health and Care Excellence (NICE) 2013b), noting that aspirin should be avoided in children under 16 years of age (NICE 2013b) because of a suspected link to Reye’s syndrome (Medicines and Healthcare products Regulatory Agency 2009). The nurse also advised that Chloe should try to drink plenty of fluids (Watkins 2011), should not return to school until four days after the initial development of the rash and should avoid contact with unvaccinated or immunosuppressed people or pregnant women (NICE 2013b). The nurse made a note in Chloe’s records to contact her mother by telephone in one week to ensure Chloe’s symptoms had resolved and to discuss the opportunities for Chloe to receive outstanding vaccinations. During the follow-up telephone call, Chloe’s mother reported that while the rash was subsiding, Chloe was still experiencing high temperatures and complaining of earache. The nurse made arrangements for Chloe to be examined at the practice, where a diagnosis of otitis media was made. Chloe was prescribed oral antibiotics (NICE 2013b) and her symptoms improved within 48 hours.
BOX 2 Case study 2 Julie is a primary school teacher and is 32 weeks pregnant. Julie telephoned her midwife because she was concerned that one of the children in her class had been diagnosed with measles. During the conversation, it became clear that Julie could not recall whether she had received the measles vaccination as a child. Julie’s midwife advised her to request an urgent GP appointment. The Royal College of Obstetricians and Gynaecologists (2008) suggests that if left untreated during pregnancy in women who are not vaccinated, measles can cause miscarriage, stillbirth or preterm labour. Manikkavasagan and Ramsay (2009) stated that measles in late pregnancy can lead to perinatal infection in the infant; however, they also suggested that there is no evidence of an association between measles in pregnancy and congenital defects. With Julie’s consent, the GP took a blood sample for serology testing for measles immunisation status (immunoglobulin G antibodies) (National Institute for Health and Care Excellence 2013c). The test results indicated that Julie was immune and no further intervention was required. Had this not been the case, Julie would have been prescribed 2,250mg of subcutaneous human normal immunoglobulin by intramuscular injection (Salisbury and Ramsay 2013).
panencephalitis (SSPE) occurring in about one in 25,000 people infected by measles. SSPE is a progressive neurological disorder caused by persistent measles virus infection. Initial symptoms typically occur some years after natural measles infection and are initially subtle, with intellectual decline and behavioural changes which may only be recognised as symptoms in retrospect (Campbell et al 2007). Progression of the illness varies, but indications of seriousness may be loss of motor control and co-ordination, and seizures (Appleton 2012). The average time between a person having measles and developing the first symptoms of SSPE is around eight years (Crowcroft 2011). However, the majority of individuals die five to ten years after the onset of symptoms (Appleton 2012). Those who survive may live with severe intellectual and physical impairment.
Immunisation Before the introduction of the measles vaccine, more than 90% of children contracted the infection by the time they reached their tenth birthday (WHO 2009a), and an estimated five to eight million deaths from measles occurred worldwide each year (WHO 2009b). In the UK, measles has been a ‘notifiable’ disease since 1940, providing the data required to trace the incidence of the disease and the effect of immunisation programmes (Salisbury and Ramsay 2013). Before the introduction of measles vaccinations in the UK in 1968, the annual incidence of measles ranged from 160,000-800,000 cases, resulting in approximately 100 acute deaths per year (Salisbury and Ramsay 2013). Uptake of vaccination was relatively poor until the 1980s and the incidence of measles remained high at levels of between 50,000 and 100,000 cases per year (Salisbury and Ramsay 2013). Many of the deaths associated with measles during this time occurred in children who were immunocompromised, but 50% of deaths occurred in otherwise healthy but unvaccinated children (Salisbury and Ramsay 2013). Vaccinations have been effective in reducing the incidence of measles, and endemic infections no longer occur in the United States or in Finland (Salisbury and Ramsay 2013). The combined measles, mumps and rubella (MMR) vaccine was introduced in the UK in 1988. In 1994, following several small outbreaks, a national campaign was
54 may 21 :: vol 28 no 38 :: 2014 © NURSING STANDARD / RCN PUBLISHING Downloaded from RCNi.com by ${individualUser.displayName} on Nov 18, 2015. For personal use only. No other uses without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
implemented to vaccinate eight million children aged five to 16 years. The aim of this campaign was to reduce the number of individuals who remained susceptible to the disease because they had been neither vaccinated nor exposed to the infection (Salisbury and Ramsay 2013). One dose of the MMR vaccine is estimated to be 95% effective in protecting against measles and infections are extremely unlikely in individuals who have received two doses of the vaccine (Demicheli et al 2012). Following WHO (2009a) recommendations, a second dose of the MMR vaccine was introduced in 1996 in the UK. Between 1995 and 2003 there were 12 measles-related deaths, all of which were attributed to late complications resulting from measles infections acquired before 1995 (Salisbury and Ramsay 2013). From 2004 to 2013, the Office for National Statistics recorded nine measles-related deaths in England and Wales, mostly in those over the age of 15 (PHE 2014).
Body’s response to the measles vaccine
The measles vaccine is a live vaccine that stimulates the body to mount an immune response and produce antibodies and ‘memory cells’ that will enable a prompt response should the virus be encountered again. As a result, it is said to confer active immunity that will provide long-lasting protection against measles (WHO 2009a). If it is given with other live vaccines, the immune system will successfully mount a response to all the infective agents included in the vaccines. Consequently, the MMR vaccine can be given at the same time as other live vaccines such as diphtheria, tetanus and polio, as separate injections administered at different sites on the body. However, if the vaccine is given during the period when the immune system is responding to another live vaccine, then the production of interferon specific to the second vaccine is inhibited. As a result, live vaccines should be given either together or at intervals of four weeks or more (Salisbury and Ramsay 2013). Administration of the MMR vaccine can inhibit the response to the tuberculin test, with the risk that an infected individual will be thought to be free of tuberculosis (TB) (WHO 2009a). Testing for TB should be avoided for four weeks after MMR vaccine administration. Blood products may contain ready-formed measles antibodies, the presence of which will impair the development of active immunity. If blood products are administered within three months of receiving the MMR vaccine,
© NURSING STANDARD / RCN PUBLISHING
it has been recommended that a second dose of the MMR vaccine is given (Salisbury and Ramsay 2013). Factors that help to maximise the effectiveness of the MMR vaccine are summarised in Table 1 (WHO 2009a, 2009b, Salisbury and Ramsay 2013). The MMR vaccine contains freeze-dried live and attenuated strains of the viruses responsible for causing MMR. The preservative-free vaccine should be stored at temperatures of between 2°C and 8°C, and exposure to light should be avoided. Once reconstituted, the vaccine should be used within one hour (Salisbury and Ramsay 2013). The MMR vaccine is administered intramuscularly, generally into the deltoid muscle of the upper arm or the vastus lateralis (upper outer aspect of the thigh).
Protection of infants
Infants may acquire antibodies against measles from their mother during intrauterine life and this will afford some protection against measles for the first six to nine months (WHO 2009a). However, this passive immunity requires the transmission of antibodies in quantities sufficient to manage exposure to a potentially large number of virions, because the individual does not have the immunological memory required to produce more antibodies. Mothers who have not been exposed to measles either naturally or through vaccination will not have antibodies to transfer to their infant, and levels may be low in mothers who have been
TABLE 1 Factors maximising the effectiveness of the measles, mumps and rubella (MMR) vaccine Factor
Action
Once the immune response has initiated a response to live vaccine(s), its response to subsequent vaccines will be inhibited.
Ensure an interval of at least four weeks between the administration of live vaccines.
The MMR vaccine can inhibit the response to the tuberculin test.
Schedule MMR and tuberculin tests at least four weeks apart.
Administration of blood products can prevent the body mounting an immune response to the MMR vaccine.
If blood products are given within three months of the MMR vaccine, then the vaccine should be repeated.
Maternally acquired antibodies can deter the development of active immunity during the first year of life.
The MMR vaccine is only given to infants if the risk of exposure to measles is high. Subsequently, a further two doses of the MMR vaccine are administered.
(World Health Organization 2009a, 2009b, Salisbury and Ramsay 2013)
may 21 :: vol 28 no 38 :: 2014 55
Downloaded from RCNi.com by ${individualUser.displayName} on Nov 18, 2015. For personal use only. No other uses without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
CPD infectious disease vaccinated (WHO 2009a), therefore natural immunity in infants should not be assumed. In the UK, the first dose of the MMR vaccine is currently scheduled for administration when a child reaches the age of 12-13 months and a booster is administered at the age of three years and four months (Salisbury and Ramsay 2013). The effect of the measles vaccine is limited in infants because the presence of maternally acquired antibodies deters the development of active immunity (WHO 2009a). As a result, the vaccine is not given routinely before the age of 12 months. However, if it is likely that an infant has been exposed to measles or is to travel to a country where measles is endemic, then the MMR vaccine is given to provide the best chance of protection. Doses administered in the first year of life are effectively discounted and so two further doses are delivered (Salisbury and Ramsay 2013). Infants may perhaps best be protected by minimising the risk of exposure to the disease by securing immunity in older age groups.
Protection post infancy
4 What advice should be given to healthcare staff about their own measles vaccination status? It may be helpful to consult chapter 21 of The Green Book (Salisbury and Ramsay 2013), which is also available online at: http://tinyurl.com/ khwnprz 5 Prepare information for parents about expected reactions to the MMR vaccine. How might you allay their concerns?
The MMR vaccine can be given at any age and it can be administered safely to those who already have antibodies against the virus and therefore to those whose immunisation status or infection history is uncertain (Salisbury and Ramsay 2013). In the UK, the objective is to ensure that all children have received two doses of the MMR vaccine before leaving school. Shan (2011) cautioned that older children and adolescents may have missed one or both pre-school doses of the MMR vaccine, because of parental concerns relating to the safety of the vaccine following unfounded reports of links between the vaccine and autism. PHE (2013b) suggested that those most likely to be at risk of measles infection are those who have not received two doses of the MMR vaccine. During the winter of 2012/13 in the UK, there was there was an increase in reported cases of measles, reaching almost 2,000 cases during 2012 and culminating in an outbreak of measles in South Wales (PHE 2013b). In April 2013, PHE estimated that although the uptake of the MMR vaccine in pre-school children had reached the highest level recorded, 8% of children aged 10-16 were unvaccinated and a further 8% were undervaccinated – they had not received two scheduled doses of the MMR vaccine. With a view to improving the vaccination status of this age group, PHE
announced a catch-up programme in April 2013 (PHE 2013b). This programme required the participation of GP practices and involved the distribution of around 300,000 letters to parents of children aged 10-16 (PHE 2013c). In October 2013, PHE (2013d) reported a 2.5% increase in the number of 10-16 year olds who had received two doses of the MMR vaccine and noted that an additional 200,000 doses of the vaccine had been administered. Complete time out activity 4
Adverse reactions to the measles, mumps and rubella vaccine
Salisbury and Ramsay (2013) estimated that anaphylactic reactions to the MMR vaccine are rare. Idiopathic thrombocytopenia – depletion of platelet levels that is thought likely to result from an immunological process (Rudolf and Levene 2006) – is a potential consequence, but the risk is much lower than that attributed to natural measles infection (Salisbury and Ramsay 2013). Minor reactions reflect the body’s natural immune response to the viruses in the vaccine (Salisbury and Ramsay 2013) and are not generally considered a contraindication for subsequent immunisation. The most common reactions to the MMR vaccine are fever, malaise and a rash lasting two to three days (Salisbury and Ramsay 2013), as well as redness and tenderness at the injection site (WHO 2009b). An estimated one in 1,000 children experience febrile convulsion post vaccination and swelling of the parotid gland occurs in about 1% of children (WHO 2009b). In a Canadian study, Wilson et al (2011) found that hospital admissions and emergency department visits increased in the period following the first dose of the MMR vaccine, but this effect was less evident after the second dose of the vaccine. The incidence of adverse effects peaked on the eighth day following immunisation, leading the researchers to suggest that parents may fail to associate such a ‘late’ reaction with immunisation and to advocate that parents are better informed about the likely responses to the MMR vaccine. Complete time out activity 5
Contraindications to the measles, mumps and rubella vaccine
WHO (2009a) indicates that there are few reasons for withholding the MMR vaccine (Box 3). Children with chronic health problems such as cystic fibrosis, congenital heart defects, Down’s syndrome, nutritional disorders and
56 may 21 :: vol 28 no 38 :: 2014 © NURSING STANDARD / RCN PUBLISHING Downloaded from RCNi.com by ${individualUser.displayName} on Nov 18, 2015. For personal use only. No other uses without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
kidney disease may have limited resources to cope with a measles infection and as a result, Salisbury and Ramsay (2013) recommended that these children receive the MMR vaccine. A low-grade fever should not deter or delay the administration of the vaccine, although severe fever or illness may provide justification for deferring vaccination until the child has recovered (WHO 2009a). WHO (2009a) also recommends that vaccinations should be given to HIV-positive children if they are asymptomatic.
Promoting uptake of the measles, mumps and rubella vaccine
Preventing epidemics requires the immunisation of between 93% and 95% of the population, and WHO (2009a) suggests the best way of achieving this is through the immunisation of all children, unless contraindications exist, with two doses of the MMR vaccine. Vaccination against measles is widely considered a cost effective and desirable strategy (NICE 2014, Demicheli et al 2012). Jacobson Vann and Szilagyi (2005) concluded that reminders by letter, telephone and face-to-face contact could all be justified on the basis that they
BOX 3 Contraindications to the measles, mumps and rubella vaccine 4Immunocompromised individuals. 4Confirmed history of an anaphylactic reaction to a previous vaccine containing measles, mumps or rubella. 4Confirmed anaphylactic reaction to neomycin or gelatin. 4High grade fever or severe (acute) illness. 4Pregnancy. (Salisbury and Ramsay 2013)
increased uptake of vaccines and that repeated reminders were more effective than single reminders. As with other vaccinations, the uptake of the MMR vaccine varies and particular groups are at relatively high risk of remaining unprotected. NICE (2014) stressed the need to identify groups where uptake of vaccines was low and to develop strategies to improve uptake among these individuals. Patient groups frequently at risk of low immunisation uptake were identified by NICE (2014) (Box 4). However, NICE (2014) also cautions that at-risk groups vary according to the immunisation and somewhat unusually in the late 1990s and early
References Appleton R (2012) Subacute-Sclerosing Panencephalitis. tinyurl.com/p4e4uzt (Last accessed: May 2 2014.) Brown K, Fraser G, Ramsay M et al (2011) Attitudinal and Demographic Predictors of Measles-Mumps-Rubella Vaccine (MMR) Uptake During the UK Catch-Up Campaign 2008-09: Cross-Sectional Survey. tinyurl.com/ kzh7ha9 (Last accessed: May 2 2014.)
Dardis MR (2012) A review of measles. Journal of School Nursing. 28, 1, 9-12. Demicheli V, Rivetti A, Debalini MG, Di Pietrantonj C (2012) Vaccines for measles, mumps and rubella in children. Cochrane Database of Systematic Reviews. Issue 2, CD004407.
Griffin DE (2010) Measles virus-induced suppression of immune responses. Immunological Reviews. 236, 176-189. Griffin DE, Lin WH, Pan CH (2012) Measles virus, immune control, and persistence. FEMS Microbiology Reviews. 36, 3, 649-662.
Medicines and Healthcare products Regulatory Agency (2009) Drug Safety Update: Oral Salicylate Gels: Not for Use in Those Younger than Age 16 Years. tinyurl.com/lawtusc (Last accessed: May 2 2014.) Moss WJ, Griffin DE (2012) Measles. The Lancet. 379, 9811, 153-164.
Jackson C, Cheater FM, Harrison W et al (2011) Randomised Cluster Trial to Support Informed Parental Decision-Making for the MMR Vaccine. www.biomedcentral. com/1471-2458/11/475 (Last accessed: May 2 2014.)
National Institute for Health and Care Excellence (2013a) Clinical Knowledge Summaries – Measles: Summary. cks.nice.org.uk/ measles#!topicsummary (Last accessed: May 2 2014.)
Chen SSP, Fennelly G (2014) Measles. emedicine.medscape.com/ article/966220-overview (Last accessed: May 2 2014.)
Elliman D, Sengupta N, El Bashir H, Bedford H (2009) Measles, Mumps, and Rubella: Prevention. tinyurl. com/kmug9wy (Last accessed: May 2 2014.)
Jacobson Vann JC, Szilagyi P (2005) Patient reminder and patient recall systems to improve immunization rates. Cochrane Database of Systematic Reviews. Issue 3, CD003941.
National Institute for Health and Care Excellence (2013b) Clinical Knowledge Summaries – Measles: Management of Contacts. cks.nice. org.uk/measles#!scenariorecommen dation:1 (Last accessed: May 2 2014.)
Crowcroft N (2011) Measles, Mumps and Rubella Infections and Encephalitis. www.encephalitis. info/files/6013/4012/7865/ FS043V1References.pdf (Last accessed: May 2 2014.)
Gao J, Chen E, Wang Z et al (2013) Epidemic of Measles Following the Nationwide Mass Immunization Campaign. www.biomedcentral. com/1471-2334/13/139 (Last accessed: May 2 2014.)
Manikkavasagan G, Ramsay M (2009) The rationale for the use of measles post-exposure prophylaxis in pregnant women: a review. Journal of Obstetrics and Gynaecology. 29, 7, 572-575.
National Institute for Health and Care Excellence (2013c) Clinical Knowledge Summaries – Measles: Immunosuppressed People. cks.nice. org.uk/measles#!scenariorecommen dation:3 (Last accessed: May 2 2014.)
Campbell H, Andrews N, Brown KE, Miller E (2007) Review of the effect of measles vaccination on the epidemiology of SSPE. International Journal of Epidemiology. 36, 1334-1348.
DiPaola F, Michael A, Mandel ED (2012) A casualty of the immunization wars: the reemergence of measles. Journal of the American Academy of Physician Assistants. 25, 6, 50-54.
©Downloaded NURSINGfrom STANDARD / RCN PUBLISHING may 21 :: vol 28 no 38 :: 2014 57 RCNi.com by ${individualUser.displayName} on Nov 18, 2015. For personal use only. No other uses without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
CPD infectious disease
6 List the groups least likely to attend for vaccinations in the area where you work. How might the uptake of the MMR vaccine among these groups be encouraged? 7 Now that you have completed the article, you might like to write a practice profile. Guidelines to help you are on page 62.
years of this century, the uptake of the MMR vaccine fell most rapidly among relatively affluent and well-educated individuals. This demonstrates the need for healthcare professionals to develop an understanding of the factors that influence parental decisions relating to immunisation (Brown et al 2011) and how parents might be supported in making decisions (Jackson et al 2011). Complete time out activity 6
Conclusion Measles is a highly contagious disease that can have severe consequences and may be fatal. For this reason, WHO (2009a) advocates that measures are taken to eradicate the disease. Nurses have a vital role to play in the prevention of measles transmission, reduction of associated complications and alleviation of symptoms of the disease. However, if measles is to be eradicated, then a sustained increase in the uptake of the MMR vaccine will be
National Institute for Health and Care Excellence (2014) Reducing Differences in the Uptake of Immunisations. tinyurl.com/mmgula9 (Last accessed: May 2 2014.) Newson L (2012) Measles. www.patient.co.uk/pdf/2441.pdf (Last accessed: May 2 2014.) NHS Choices (2013) Measles: Treatment. www.nhs.uk/Conditions/ Measles/Pages/Treatment.aspx (Last accessed: May 2 2014.) Perry RT, Halsey NA (2004) The Clinical Significance of Measles: A Review. tinyurl.com/kaj8uml (Last accessed: May 2 2014.) Public Health England (2013a) The Complete Routine Immunisation Schedule 2013/14. tinyurl.com/ q3bzhe3 (Last accessed: May 2 2014.) Public Health England (2013b) National MMR Vaccination Catch-Up
Programme Announced in Response to Increase in Measles Cases. tinyurl.com/nvu2usc (Last accessed: May 2 2014). Public Health England (2013c) Measles in England (Data to End-May 2013) and Impact of MMR Catch-Up Programme. tinyurl.com/oxjf76l (Last accessed: May 2 2014.) Public Health England (2103d) Measles Cases Drop for the Fourth Consecutive Month. tinyurl.com/ qfv9oe5 (Last accessed: May 2 2014.) Public Health England (2014) Measles Deaths by Age Group: 1980-2013 (ONS Data). tinyurl.com/ pqfq6ec (Last accessed: May 2 2014.) Rodrigo (2012) Pathogenesis of Measles Virus Infection. tinyurl.com/ k988dau (Last accessed: May 2 2014.)
BOX 4 Patients at risk of low uptake of the measles, mumps and rubella vaccine 4Those who have missed previous vaccinations. 4Looked after children (those looked after by the state). 4Those with physical or learning disabilities. 4Children of teenage or lone parents. 4Those not registered with a GP. 4Younger children from large families. 4Children who are hospitalised or have a chronic illness. 4Those from some ethnic minority groups. 4Those from non-English speaking families. 4Vulnerable children, such as those whose families are travellers, asylum seekers or homeless. (National Institute for Health and Care Excellence 2014)
required, necessitating the co-ordinated action of a range of well-informed health practitioners and agencies NS Complete time out activity 7
Royal College of Obstetricians and Gynaecologists (2008) RCOG Statement on Measles During Pregnancy. tinyurl.com/pfq7d5y (Last accessed: May 2 2014.) Rudolf M, Levene MI (2006) Paediatrics and Child Health. Second edition. Blackwell Publishing, Oxford. Salisbury D, Ramsay M (Eds) (2013) Measles: The Green Book, Chapter 21. tinyurl.com/khwnprz (Last accessed: May 2 2014.) Shan Y (2011) Strategies to improve vaccination uptake rates. Primary Health Care. 21, 2, 16-21. Watkins J (2011) Diagnosis, management and prevention of measles. British Journal of School Nursing. 6, 8, 375-378. Wilson K, Hawken S, Kwong JC et al (2011) Adverse Events Following 12 and 18 Month
Vaccinations: A Population-Based, Self-Controlled Case Series Analysis. tinyurl.com/qgg2vcl (Last accessed: May 2 2014.) World Health Organization (2009a) Measles Vaccines: WHO Position Paper. www.who.int/wer/2009/ wer8435.pdf (Last accessed: May 2 2014.) World Health Organization (2009b) The Immunological Basis for Immunization Series. Module 7: Measles. tinyurl.com/olgn3od (Last accessed: May 2 2014.) World Health Organization (2014) Measles: Fact Sheet No 286. tinyurl. com/om9b989 (Last accessed: May 2 2014.) Zenner D, Nacul L (2012) Predictive power of Koplik’s spots for the diagnosis of measles. Journal of Infection in Developing Countries. 6, 3, 271-275.
58 may 21 :: volfrom 28 no 38 :: 2014 NURSING STANDARD / RCN Downloaded RCNi.com by ${individualUser.displayName} on Nov 18, 2015.©For personal use only. No other usesPUBLISHING without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
4 Page 60
Measles multiple choice questionnaire
CONTINUING PROFESSIONAL DEVELOPMENT
4 Page 61
Read Anita Skinner’s practice profile on caring for patients with a stoma
4 Page 62
Guidelines on how to write a practice profile
Measles: pathology, management and public health issues NS744 Bentley J et al (2014) Measles: pathology, management and public health issues. Nursing Standard. 28, 38, 51-58. Date of submission: January 17 2014; date of acceptance: March 13 2014.
Aims and intended learning outcomes
Abstract Measles is a highly contagious viral disease that continues to occur in epidemics in the UK despite efforts to eradicate it. In the acute stage, measles is associated with several complications including otitis media, but some of the most severe consequences of the disease occur months and even years after the initial infection. Worldwide, measles contributes significantly to deaths in childhood and places an additional burden on families already living with the consequence of poverty and conflict. This article aims to develop the reader’s understanding of measles, including its pathophysiology, management and associated public health issues.
Authors Jackie Bentley Senior lecturer in child health, University of Worcester, Worcester. Jo Rouse Principle lecturer, University of Worcester. Jenny Pinfield Senior lecturer, University of Worcester. Correspondence to: [email protected]
Keywords Measles, immunisation, infection prevention, paediatric nursing, pathology, public health, vaccination, viral disease
Review All articles are subject to external double-blind peer review and checked for plagiarism using automated software.
Online Guidelines on writing for publication are available at www.nursing-standard.co.uk. For related articles visit the archive and search using the keywords above.
The aim of this article is to highlight strategies to aid recognition, management and prevention of measles. After reading this article and completing the time out activities you should be able to: 4Describe the pathophysiology of measles. 4Explain how measles is transmitted. 4Identify individuals at increased risk of developing measles and associated complications. 4Discuss the identification, assessment and management of individuals with measles. 4Outline the role that vaccination plays in the prevention of measles.
Introduction Before measles vaccination was introduced, the disease occurred in 95-98% of children by the age of 18 years and was considered an inevitable part of childhood (Perry and Halsey 2004). However, measles can affect people of all ages (Chen and Fennelly 2014) and the complications associated with the infection present a rationale for its eradication (World Health Organization (WHO) 2009a).
Measles virus Measles, also known as rubeola, is an acute infection caused by a morbillivirus from the paramyxovirus group (DiPaola et al 2012). It is a spherical virus of diameter 100-200mm, and contains a single strand of ribonucleic acid (RNA) (Dardis 2012, DiPaola et al 2012), enclosed within a lipid envelope (Griffin et al 2012). Humans are the only host for measles (WHO 2014).
©Downloaded NURSINGfrom STANDARD / RCN PUBLISHING may 21:: vol 28 no 38 :: 2014 51 RCNi.com by ${individualUser.displayName} on Nov 18, 2015. For personal use only. No other uses without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
CPD infectious disease
2 Gao et al (2013) documented an epidemic of measles in Wenzhou city, China, after a nationwide immunisation programme. The incidence was particularly high in babies who had been too young to immunise during the campaign and the researchers suggested an inappropriate relaxation in routine immunisation had followed the campaign. Before infection, a high proportion of affected infants received treatment in a hospital intravenous rehydration room that was described as overcrowded with parents and children, and disinfected once per day, but not during clinic hours. Consider the infection control strategies that might help to reduce the risk of cross-infection with measles.
last for several weeks (DiPaola et al 2012, Chen and Fennelly 2014). Complete time out activity 1
Transmission Measles is one of the most highly communicable infectious diseases, with 75-90% of household contacts developing the disease (Salisbury and Ramsay 2013). Virions are transmitted by contact with nasal and throat secretions that become airborne as droplets, especially through coughing or sneezing. Because the virus survives on surfaces for up to two hours, transmission requires no direct contact with an infected person (Newson 2012, Chen and Fennelly 2014). The incubation period is eight to 12 days (DiPaola et al 2012). A person is most contagious one to two days before the onset of symptoms, with risk of infection greatest three days before the onset of the rash (DiPaola et al 2012) until four days after the rash appears (WHO 2014). The vagueness of early symptoms means individuals are often unaware they are infected and continue with social activities, thereby increasing the risk of transmission (Perry and Halsey 2004). Complete time out activity 2
FIGURE 1 Exanthema on the face
ALAMY
1 How would you describe the measles rash, its development and resolution to a parent?
Clinical features indicative of measles include (Salisbury and Ramsay 2013, Chen and Fennelly 2014): 4Rash lasting at least three days. 4Fever for at least one day, with temperature often above 40°C. 4At least one of the three Cs: cough, coryza or conjunctivitis. DiPaola et al (2012) identified four clinical stages associated with measles: incubation, prodromal, exanthema (rash) and recovery. Symptoms associated with the prodromal phase normally begin about ten days after exposure to the virus (Salisbury and Ramsay 2013). Prodromal The prodromal phase lasts two to four days and is characterised by increasing fever, malaise, cough, coryza, conjunctivitis, photophobia, anorexia and peri-orbital oedema (Newson 2012). Koplik’s spots occur in 60-70% of individuals with measles (Zenner and Nacul 2012), but because they occur on the buccal mucosa, usually near the first and second molars, they may go unnoticed (Newson 2012). They may also form on the soft palate, conjunctiva and vaginal mucosa (Perry and Halsey 2004). These bluish-white, slightly raised 2-3mm lesions may look like grains of sand or grains of rice and last one to three days (Newson 2012, Chen and Fennelly 2014). Exanthema A rash will appear usually 14 days after exposure to the virus and may last for three to seven days (WHO 2014). It appears first on the face, around the hairline, on the sides of the neck and behind the ears, but over a period of two to three days, spreads downwards to the trunk and extremities, including the palms of the hands and soles of the feet (Figure 1 and Figure 2). The lesions are most dense around the shoulders (Newson 2012). Generally, the rash takes the form of blanching erythematous macules and papules, although it may also be petechial or ecchymotic and may be itchy (Chen and Fennelly 2014). The rash fades gradually in the same order as it appeared and leaves a brownish discolouration, sometimes finishing with a fine desquamation (Newson 2012). During this stage, cervical lymphadenitis, splenomegaly and mesenteric lymphadenitis with abdominal pain may also occur (DiPaola et al 2012). Recovery Clinical improvement can be seen 48 hours after the rash appears. In the absence of any complications, the period from late prodrome to the resolution of fever and rash lasts seven to ten days, although cough may
FIGURE 2 Measles lesions
ALAMY
Clinical features
52 may 21 :: vol 28 no 38 :: 2014 © NURSING STANDARD / RCN PUBLISHING Downloaded from RCNi.com by ${individualUser.displayName} on Nov 18, 2015. For personal use only. No other uses without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
Pathophysiology According to Rodrigo (2012), infection with measles involves four stages: 1. Attachment. 2. Fusion. 3. RNA replication. 4. Assembly of viral particles and their release. Initially, tracheal and bronchial epithelial cells are invaded and after two to four days the infection spreads to local lymphatic tissue. A primary viraemia allows the virus to replicate in epithelial and reticuloendothelial system tissue (Griffin 2010). A secondary viraemia (five to seven days post infection) facilitates circulation of the virus to the skin, gastrointestinal tract, kidneys and bladder seven to 11 days post infection (Rodrigo 2012). Antibodies appear ten to 14 days after exposure (Rodrigo 2012), and viraemia ceases by day 20 (Griffin 2010). However, Moss and Griffin (2012) argued that viral RNA persists in many sites. Infection triggers both humoral and cellular immune responses and once the virus resolves, it confers lifelong immunity (DiPaola et al 2012). During the acute infection and for several weeks or months afterwards, immunosuppression occurs. This is marked by a decrease in delayed-type hypersensitivity, lymphocytopenia, interleukin production and impaired antigen specific lymphoproliferation, leaving the individual at risk of opportunistic infection (Rodrigo 2012, Chen and Fennelly 2014). Griffin (2010) suggested the rash is a result of an adaptive antiviral immune response.
At-risk groups WHO (2014) suggests that measles is a leading cause of death in young children globally. The burden of disease is highest in developing countries, and is associated with increased mortality in countries experiencing or recovering from natural disaster or conflict (Perry and Halsey 2004, WHO 2014). Furthermore, malnutrition and vitamin A deficiency increase the risk of developing severe cases of measles (Chen and Fennelly 2014). Travelling to areas where measles is endemic, overcrowding and household exposure also increase risk (Perry and Halsey 2004, Chen and Fennelly 2014). Children with immunodeficiency, particularly those with human immunodeficiency virus (HIV), leukaemia and those receiving corticosteroid therapy, are also at increased risk of developing measles. Children born to HIV-infected mothers are more vulnerable to infection
because of the lower number of maternal antibodies transferring to the baby in utero (Chen and Fennelly 2014). Salisbury and Ramsay (2013) indicated that case fatality is age related, being highest in infants and lowest in children aged one to nine years, rising again in teenagers and adults. However, DiPaola et al (2012) suggested that rates of infection are highest in those aged five to nine years. Historically, boys have an increased risk of fatality compared with girls, but UK data suggest equal rates of complications (Perry and Halsey 2004). According to Rodrigo (2012), a ‘window of infection’ exists between the loss of maternally acquired antibodies and vaccination. Antibody levels are lower in babies born to immunised mothers compared with those whose mothers experience naturally acquired infection (Elliman et al 2009). Pregnant women are also a high-risk group for developing severe measles (Chen and Fennelly 2014), with Salisbury and Ramsay (2013) suggesting that measles infection in pregnancy can lead to intrauterine death and premature delivery, but that it is not associated with congenital infection or damage. Complete time out activity 3
Nursing care and management Patients with measles can appear quite unwell, but since there is no specific antiviral treatment (WHO 2014), management aims to reduce the risk of complications and relieve symptoms. Symptoms of fever, cough and rash are usually self-limiting, resolving in about one week, with the patient making a full recovery within ten days (National Institute for Health and Care Excellence (NICE) 2013a). However, one in ten children with measles requires inpatient hospital treatment (NHS Choices 2013). Effective history taking is essential for those exhibiting signs and symptoms of measles to ensure the correct nursing diagnosis is made and appropriate care initiated. Rudolf and Levene (2006) recommended using a systematic approach to ensure holistic care; however, the approach should be flexible to allow the nurse to pursue all routes of enquiry. The patient’s immunisation history is relevant, as is recent history of contact with an infected person or travel to a country where measles is endemic (Watkins 2011, Public Health England (PHE) 2013a) (Box 1 and Box 2).
3 In your own words, explain why measles is associated with increased mortality in developing countries.
©Downloaded NURSINGfrom STANDARD / RCN PUBLISHING may 21 :: vol 28 no 38 :: 2014 53 RCNi.com by ${individualUser.displayName} on Nov 18, 2015. For personal use only. No other uses without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
CPD infectious disease Complications of measles The most common complications of measles infection are otitis media, pneumonia, diarrhoea and febrile convulsions (PHE 2013a). NICE (2013a) states that rare complications include encephalitis, with subacute sclerosing
BOX 1 Case study 1 Chloe is five years old. For the last few days she has had a temperature, runny nose, and red and inflamed conjunctiva. Chloe’s mother contacted the GP practice for advice when Chloe developed a rash which started on her face and neck, but had spread down her body. Chloe was seen by her practice nurse in a private room to reduce the risk of cross-infection. On examination, Chloe had Koplik’s spots inside her mouth, on the buccal mucosa. Chloe’s mother confirmed she had not taken Chloe for her measles, mumps and rubella (MMR) vaccination because of concerns she had at the time about the safety of the vaccine. The nurse confirmed a diagnosis of measles, and as Chloe was relatively well and not exhibiting complications, the nurse advised that Chloe should return home. The nurse also suggested that Chloe should be given paracetamol and ibuprofen for symptomatic relief (National Institute for Health and Care Excellence (NICE) 2013b), noting that aspirin should be avoided in children under 16 years of age (NICE 2013b) because of a suspected link to Reye’s syndrome (Medicines and Healthcare products Regulatory Agency 2009). The nurse also advised that Chloe should try to drink plenty of fluids (Watkins 2011), should not return to school until four days after the initial development of the rash and should avoid contact with unvaccinated or immunosuppressed people or pregnant women (NICE 2013b). The nurse made a note in Chloe’s records to contact her mother by telephone in one week to ensure Chloe’s symptoms had resolved and to discuss the opportunities for Chloe to receive outstanding vaccinations. During the follow-up telephone call, Chloe’s mother reported that while the rash was subsiding, Chloe was still experiencing high temperatures and complaining of earache. The nurse made arrangements for Chloe to be examined at the practice, where a diagnosis of otitis media was made. Chloe was prescribed oral antibiotics (NICE 2013b) and her symptoms improved within 48 hours.
BOX 2 Case study 2 Julie is a primary school teacher and is 32 weeks pregnant. Julie telephoned her midwife because she was concerned that one of the children in her class had been diagnosed with measles. During the conversation, it became clear that Julie could not recall whether she had received the measles vaccination as a child. Julie’s midwife advised her to request an urgent GP appointment. The Royal College of Obstetricians and Gynaecologists (2008) suggests that if left untreated during pregnancy in women who are not vaccinated, measles can cause miscarriage, stillbirth or preterm labour. Manikkavasagan and Ramsay (2009) stated that measles in late pregnancy can lead to perinatal infection in the infant; however, they also suggested that there is no evidence of an association between measles in pregnancy and congenital defects. With Julie’s consent, the GP took a blood sample for serology testing for measles immunisation status (immunoglobulin G antibodies) (National Institute for Health and Care Excellence 2013c). The test results indicated that Julie was immune and no further intervention was required. Had this not been the case, Julie would have been prescribed 2,250mg of subcutaneous human normal immunoglobulin by intramuscular injection (Salisbury and Ramsay 2013).
panencephalitis (SSPE) occurring in about one in 25,000 people infected by measles. SSPE is a progressive neurological disorder caused by persistent measles virus infection. Initial symptoms typically occur some years after natural measles infection and are initially subtle, with intellectual decline and behavioural changes which may only be recognised as symptoms in retrospect (Campbell et al 2007). Progression of the illness varies, but indications of seriousness may be loss of motor control and co-ordination, and seizures (Appleton 2012). The average time between a person having measles and developing the first symptoms of SSPE is around eight years (Crowcroft 2011). However, the majority of individuals die five to ten years after the onset of symptoms (Appleton 2012). Those who survive may live with severe intellectual and physical impairment.
Immunisation Before the introduction of the measles vaccine, more than 90% of children contracted the infection by the time they reached their tenth birthday (WHO 2009a), and an estimated five to eight million deaths from measles occurred worldwide each year (WHO 2009b). In the UK, measles has been a ‘notifiable’ disease since 1940, providing the data required to trace the incidence of the disease and the effect of immunisation programmes (Salisbury and Ramsay 2013). Before the introduction of measles vaccinations in the UK in 1968, the annual incidence of measles ranged from 160,000-800,000 cases, resulting in approximately 100 acute deaths per year (Salisbury and Ramsay 2013). Uptake of vaccination was relatively poor until the 1980s and the incidence of measles remained high at levels of between 50,000 and 100,000 cases per year (Salisbury and Ramsay 2013). Many of the deaths associated with measles during this time occurred in children who were immunocompromised, but 50% of deaths occurred in otherwise healthy but unvaccinated children (Salisbury and Ramsay 2013). Vaccinations have been effective in reducing the incidence of measles, and endemic infections no longer occur in the United States or in Finland (Salisbury and Ramsay 2013). The combined measles, mumps and rubella (MMR) vaccine was introduced in the UK in 1988. In 1994, following several small outbreaks, a national campaign was
54 may 21 :: vol 28 no 38 :: 2014 © NURSING STANDARD / RCN PUBLISHING Downloaded from RCNi.com by ${individualUser.displayName} on Nov 18, 2015. For personal use only. No other uses without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
implemented to vaccinate eight million children aged five to 16 years. The aim of this campaign was to reduce the number of individuals who remained susceptible to the disease because they had been neither vaccinated nor exposed to the infection (Salisbury and Ramsay 2013). One dose of the MMR vaccine is estimated to be 95% effective in protecting against measles and infections are extremely unlikely in individuals who have received two doses of the vaccine (Demicheli et al 2012). Following WHO (2009a) recommendations, a second dose of the MMR vaccine was introduced in 1996 in the UK. Between 1995 and 2003 there were 12 measles-related deaths, all of which were attributed to late complications resulting from measles infections acquired before 1995 (Salisbury and Ramsay 2013). From 2004 to 2013, the Office for National Statistics recorded nine measles-related deaths in England and Wales, mostly in those over the age of 15 (PHE 2014).
Body’s response to the measles vaccine
The measles vaccine is a live vaccine that stimulates the body to mount an immune response and produce antibodies and ‘memory cells’ that will enable a prompt response should the virus be encountered again. As a result, it is said to confer active immunity that will provide long-lasting protection against measles (WHO 2009a). If it is given with other live vaccines, the immune system will successfully mount a response to all the infective agents included in the vaccines. Consequently, the MMR vaccine can be given at the same time as other live vaccines such as diphtheria, tetanus and polio, as separate injections administered at different sites on the body. However, if the vaccine is given during the period when the immune system is responding to another live vaccine, then the production of interferon specific to the second vaccine is inhibited. As a result, live vaccines should be given either together or at intervals of four weeks or more (Salisbury and Ramsay 2013). Administration of the MMR vaccine can inhibit the response to the tuberculin test, with the risk that an infected individual will be thought to be free of tuberculosis (TB) (WHO 2009a). Testing for TB should be avoided for four weeks after MMR vaccine administration. Blood products may contain ready-formed measles antibodies, the presence of which will impair the development of active immunity. If blood products are administered within three months of receiving the MMR vaccine,
© NURSING STANDARD / RCN PUBLISHING
it has been recommended that a second dose of the MMR vaccine is given (Salisbury and Ramsay 2013). Factors that help to maximise the effectiveness of the MMR vaccine are summarised in Table 1 (WHO 2009a, 2009b, Salisbury and Ramsay 2013). The MMR vaccine contains freeze-dried live and attenuated strains of the viruses responsible for causing MMR. The preservative-free vaccine should be stored at temperatures of between 2°C and 8°C, and exposure to light should be avoided. Once reconstituted, the vaccine should be used within one hour (Salisbury and Ramsay 2013). The MMR vaccine is administered intramuscularly, generally into the deltoid muscle of the upper arm or the vastus lateralis (upper outer aspect of the thigh).
Protection of infants
Infants may acquire antibodies against measles from their mother during intrauterine life and this will afford some protection against measles for the first six to nine months (WHO 2009a). However, this passive immunity requires the transmission of antibodies in quantities sufficient to manage exposure to a potentially large number of virions, because the individual does not have the immunological memory required to produce more antibodies. Mothers who have not been exposed to measles either naturally or through vaccination will not have antibodies to transfer to their infant, and levels may be low in mothers who have been
TABLE 1 Factors maximising the effectiveness of the measles, mumps and rubella (MMR) vaccine Factor
Action
Once the immune response has initiated a response to live vaccine(s), its response to subsequent vaccines will be inhibited.
Ensure an interval of at least four weeks between the administration of live vaccines.
The MMR vaccine can inhibit the response to the tuberculin test.
Schedule MMR and tuberculin tests at least four weeks apart.
Administration of blood products can prevent the body mounting an immune response to the MMR vaccine.
If blood products are given within three months of the MMR vaccine, then the vaccine should be repeated.
Maternally acquired antibodies can deter the development of active immunity during the first year of life.
The MMR vaccine is only given to infants if the risk of exposure to measles is high. Subsequently, a further two doses of the MMR vaccine are administered.
(World Health Organization 2009a, 2009b, Salisbury and Ramsay 2013)
may 21 :: vol 28 no 38 :: 2014 55
Downloaded from RCNi.com by ${individualUser.displayName} on Nov 18, 2015. For personal use only. No other uses without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
CPD infectious disease vaccinated (WHO 2009a), therefore natural immunity in infants should not be assumed. In the UK, the first dose of the MMR vaccine is currently scheduled for administration when a child reaches the age of 12-13 months and a booster is administered at the age of three years and four months (Salisbury and Ramsay 2013). The effect of the measles vaccine is limited in infants because the presence of maternally acquired antibodies deters the development of active immunity (WHO 2009a). As a result, the vaccine is not given routinely before the age of 12 months. However, if it is likely that an infant has been exposed to measles or is to travel to a country where measles is endemic, then the MMR vaccine is given to provide the best chance of protection. Doses administered in the first year of life are effectively discounted and so two further doses are delivered (Salisbury and Ramsay 2013). Infants may perhaps best be protected by minimising the risk of exposure to the disease by securing immunity in older age groups.
Protection post infancy
4 What advice should be given to healthcare staff about their own measles vaccination status? It may be helpful to consult chapter 21 of The Green Book (Salisbury and Ramsay 2013), which is also available online at: http://tinyurl.com/ khwnprz 5 Prepare information for parents about expected reactions to the MMR vaccine. How might you allay their concerns?
The MMR vaccine can be given at any age and it can be administered safely to those who already have antibodies against the virus and therefore to those whose immunisation status or infection history is uncertain (Salisbury and Ramsay 2013). In the UK, the objective is to ensure that all children have received two doses of the MMR vaccine before leaving school. Shan (2011) cautioned that older children and adolescents may have missed one or both pre-school doses of the MMR vaccine, because of parental concerns relating to the safety of the vaccine following unfounded reports of links between the vaccine and autism. PHE (2013b) suggested that those most likely to be at risk of measles infection are those who have not received two doses of the MMR vaccine. During the winter of 2012/13 in the UK, there was there was an increase in reported cases of measles, reaching almost 2,000 cases during 2012 and culminating in an outbreak of measles in South Wales (PHE 2013b). In April 2013, PHE estimated that although the uptake of the MMR vaccine in pre-school children had reached the highest level recorded, 8% of children aged 10-16 were unvaccinated and a further 8% were undervaccinated – they had not received two scheduled doses of the MMR vaccine. With a view to improving the vaccination status of this age group, PHE
announced a catch-up programme in April 2013 (PHE 2013b). This programme required the participation of GP practices and involved the distribution of around 300,000 letters to parents of children aged 10-16 (PHE 2013c). In October 2013, PHE (2013d) reported a 2.5% increase in the number of 10-16 year olds who had received two doses of the MMR vaccine and noted that an additional 200,000 doses of the vaccine had been administered. Complete time out activity 4
Adverse reactions to the measles, mumps and rubella vaccine
Salisbury and Ramsay (2013) estimated that anaphylactic reactions to the MMR vaccine are rare. Idiopathic thrombocytopenia – depletion of platelet levels that is thought likely to result from an immunological process (Rudolf and Levene 2006) – is a potential consequence, but the risk is much lower than that attributed to natural measles infection (Salisbury and Ramsay 2013). Minor reactions reflect the body’s natural immune response to the viruses in the vaccine (Salisbury and Ramsay 2013) and are not generally considered a contraindication for subsequent immunisation. The most common reactions to the MMR vaccine are fever, malaise and a rash lasting two to three days (Salisbury and Ramsay 2013), as well as redness and tenderness at the injection site (WHO 2009b). An estimated one in 1,000 children experience febrile convulsion post vaccination and swelling of the parotid gland occurs in about 1% of children (WHO 2009b). In a Canadian study, Wilson et al (2011) found that hospital admissions and emergency department visits increased in the period following the first dose of the MMR vaccine, but this effect was less evident after the second dose of the vaccine. The incidence of adverse effects peaked on the eighth day following immunisation, leading the researchers to suggest that parents may fail to associate such a ‘late’ reaction with immunisation and to advocate that parents are better informed about the likely responses to the MMR vaccine. Complete time out activity 5
Contraindications to the measles, mumps and rubella vaccine
WHO (2009a) indicates that there are few reasons for withholding the MMR vaccine (Box 3). Children with chronic health problems such as cystic fibrosis, congenital heart defects, Down’s syndrome, nutritional disorders and
56 may 21 :: vol 28 no 38 :: 2014 © NURSING STANDARD / RCN PUBLISHING Downloaded from RCNi.com by ${individualUser.displayName} on Nov 18, 2015. For personal use only. No other uses without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
kidney disease may have limited resources to cope with a measles infection and as a result, Salisbury and Ramsay (2013) recommended that these children receive the MMR vaccine. A low-grade fever should not deter or delay the administration of the vaccine, although severe fever or illness may provide justification for deferring vaccination until the child has recovered (WHO 2009a). WHO (2009a) also recommends that vaccinations should be given to HIV-positive children if they are asymptomatic.
Promoting uptake of the measles, mumps and rubella vaccine
Preventing epidemics requires the immunisation of between 93% and 95% of the population, and WHO (2009a) suggests the best way of achieving this is through the immunisation of all children, unless contraindications exist, with two doses of the MMR vaccine. Vaccination against measles is widely considered a cost effective and desirable strategy (NICE 2014, Demicheli et al 2012). Jacobson Vann and Szilagyi (2005) concluded that reminders by letter, telephone and face-to-face contact could all be justified on the basis that they
BOX 3 Contraindications to the measles, mumps and rubella vaccine 4Immunocompromised individuals. 4Confirmed history of an anaphylactic reaction to a previous vaccine containing measles, mumps or rubella. 4Confirmed anaphylactic reaction to neomycin or gelatin. 4High grade fever or severe (acute) illness. 4Pregnancy. (Salisbury and Ramsay 2013)
increased uptake of vaccines and that repeated reminders were more effective than single reminders. As with other vaccinations, the uptake of the MMR vaccine varies and particular groups are at relatively high risk of remaining unprotected. NICE (2014) stressed the need to identify groups where uptake of vaccines was low and to develop strategies to improve uptake among these individuals. Patient groups frequently at risk of low immunisation uptake were identified by NICE (2014) (Box 4). However, NICE (2014) also cautions that at-risk groups vary according to the immunisation and somewhat unusually in the late 1990s and early
References Appleton R (2012) Subacute-Sclerosing Panencephalitis. tinyurl.com/p4e4uzt (Last accessed: May 2 2014.) Brown K, Fraser G, Ramsay M et al (2011) Attitudinal and Demographic Predictors of Measles-Mumps-Rubella Vaccine (MMR) Uptake During the UK Catch-Up Campaign 2008-09: Cross-Sectional Survey. tinyurl.com/ kzh7ha9 (Last accessed: May 2 2014.)
Dardis MR (2012) A review of measles. Journal of School Nursing. 28, 1, 9-12. Demicheli V, Rivetti A, Debalini MG, Di Pietrantonj C (2012) Vaccines for measles, mumps and rubella in children. Cochrane Database of Systematic Reviews. Issue 2, CD004407.
Griffin DE (2010) Measles virus-induced suppression of immune responses. Immunological Reviews. 236, 176-189. Griffin DE, Lin WH, Pan CH (2012) Measles virus, immune control, and persistence. FEMS Microbiology Reviews. 36, 3, 649-662.
Medicines and Healthcare products Regulatory Agency (2009) Drug Safety Update: Oral Salicylate Gels: Not for Use in Those Younger than Age 16 Years. tinyurl.com/lawtusc (Last accessed: May 2 2014.) Moss WJ, Griffin DE (2012) Measles. The Lancet. 379, 9811, 153-164.
Jackson C, Cheater FM, Harrison W et al (2011) Randomised Cluster Trial to Support Informed Parental Decision-Making for the MMR Vaccine. www.biomedcentral. com/1471-2458/11/475 (Last accessed: May 2 2014.)
National Institute for Health and Care Excellence (2013a) Clinical Knowledge Summaries – Measles: Summary. cks.nice.org.uk/ measles#!topicsummary (Last accessed: May 2 2014.)
Chen SSP, Fennelly G (2014) Measles. emedicine.medscape.com/ article/966220-overview (Last accessed: May 2 2014.)
Elliman D, Sengupta N, El Bashir H, Bedford H (2009) Measles, Mumps, and Rubella: Prevention. tinyurl. com/kmug9wy (Last accessed: May 2 2014.)
Jacobson Vann JC, Szilagyi P (2005) Patient reminder and patient recall systems to improve immunization rates. Cochrane Database of Systematic Reviews. Issue 3, CD003941.
National Institute for Health and Care Excellence (2013b) Clinical Knowledge Summaries – Measles: Management of Contacts. cks.nice. org.uk/measles#!scenariorecommen dation:1 (Last accessed: May 2 2014.)
Crowcroft N (2011) Measles, Mumps and Rubella Infections and Encephalitis. www.encephalitis. info/files/6013/4012/7865/ FS043V1References.pdf (Last accessed: May 2 2014.)
Gao J, Chen E, Wang Z et al (2013) Epidemic of Measles Following the Nationwide Mass Immunization Campaign. www.biomedcentral. com/1471-2334/13/139 (Last accessed: May 2 2014.)
Manikkavasagan G, Ramsay M (2009) The rationale for the use of measles post-exposure prophylaxis in pregnant women: a review. Journal of Obstetrics and Gynaecology. 29, 7, 572-575.
National Institute for Health and Care Excellence (2013c) Clinical Knowledge Summaries – Measles: Immunosuppressed People. cks.nice. org.uk/measles#!scenariorecommen dation:3 (Last accessed: May 2 2014.)
Campbell H, Andrews N, Brown KE, Miller E (2007) Review of the effect of measles vaccination on the epidemiology of SSPE. International Journal of Epidemiology. 36, 1334-1348.
DiPaola F, Michael A, Mandel ED (2012) A casualty of the immunization wars: the reemergence of measles. Journal of the American Academy of Physician Assistants. 25, 6, 50-54.
©Downloaded NURSINGfrom STANDARD / RCN PUBLISHING may 21 :: vol 28 no 38 :: 2014 57 RCNi.com by ${individualUser.displayName} on Nov 18, 2015. For personal use only. No other uses without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
CPD infectious disease
6 List the groups least likely to attend for vaccinations in the area where you work. How might the uptake of the MMR vaccine among these groups be encouraged? 7 Now that you have completed the article, you might like to write a practice profile. Guidelines to help you are on page 62.
years of this century, the uptake of the MMR vaccine fell most rapidly among relatively affluent and well-educated individuals. This demonstrates the need for healthcare professionals to develop an understanding of the factors that influence parental decisions relating to immunisation (Brown et al 2011) and how parents might be supported in making decisions (Jackson et al 2011). Complete time out activity 6
Conclusion Measles is a highly contagious disease that can have severe consequences and may be fatal. For this reason, WHO (2009a) advocates that measures are taken to eradicate the disease. Nurses have a vital role to play in the prevention of measles transmission, reduction of associated complications and alleviation of symptoms of the disease. However, if measles is to be eradicated, then a sustained increase in the uptake of the MMR vaccine will be
National Institute for Health and Care Excellence (2014) Reducing Differences in the Uptake of Immunisations. tinyurl.com/mmgula9 (Last accessed: May 2 2014.) Newson L (2012) Measles. www.patient.co.uk/pdf/2441.pdf (Last accessed: May 2 2014.) NHS Choices (2013) Measles: Treatment. www.nhs.uk/Conditions/ Measles/Pages/Treatment.aspx (Last accessed: May 2 2014.) Perry RT, Halsey NA (2004) The Clinical Significance of Measles: A Review. tinyurl.com/kaj8uml (Last accessed: May 2 2014.) Public Health England (2013a) The Complete Routine Immunisation Schedule 2013/14. tinyurl.com/ q3bzhe3 (Last accessed: May 2 2014.) Public Health England (2013b) National MMR Vaccination Catch-Up
Programme Announced in Response to Increase in Measles Cases. tinyurl.com/nvu2usc (Last accessed: May 2 2014). Public Health England (2013c) Measles in England (Data to End-May 2013) and Impact of MMR Catch-Up Programme. tinyurl.com/oxjf76l (Last accessed: May 2 2014.) Public Health England (2103d) Measles Cases Drop for the Fourth Consecutive Month. tinyurl.com/ qfv9oe5 (Last accessed: May 2 2014.) Public Health England (2014) Measles Deaths by Age Group: 1980-2013 (ONS Data). tinyurl.com/ pqfq6ec (Last accessed: May 2 2014.) Rodrigo (2012) Pathogenesis of Measles Virus Infection. tinyurl.com/ k988dau (Last accessed: May 2 2014.)
BOX 4 Patients at risk of low uptake of the measles, mumps and rubella vaccine 4Those who have missed previous vaccinations. 4Looked after children (those looked after by the state). 4Those with physical or learning disabilities. 4Children of teenage or lone parents. 4Those not registered with a GP. 4Younger children from large families. 4Children who are hospitalised or have a chronic illness. 4Those from some ethnic minority groups. 4Those from non-English speaking families. 4Vulnerable children, such as those whose families are travellers, asylum seekers or homeless. (National Institute for Health and Care Excellence 2014)
required, necessitating the co-ordinated action of a range of well-informed health practitioners and agencies NS Complete time out activity 7
Royal College of Obstetricians and Gynaecologists (2008) RCOG Statement on Measles During Pregnancy. tinyurl.com/pfq7d5y (Last accessed: May 2 2014.) Rudolf M, Levene MI (2006) Paediatrics and Child Health. Second edition. Blackwell Publishing, Oxford. Salisbury D, Ramsay M (Eds) (2013) Measles: The Green Book, Chapter 21. tinyurl.com/khwnprz (Last accessed: May 2 2014.) Shan Y (2011) Strategies to improve vaccination uptake rates. Primary Health Care. 21, 2, 16-21. Watkins J (2011) Diagnosis, management and prevention of measles. British Journal of School Nursing. 6, 8, 375-378. Wilson K, Hawken S, Kwong JC et al (2011) Adverse Events Following 12 and 18 Month
Vaccinations: A Population-Based, Self-Controlled Case Series Analysis. tinyurl.com/qgg2vcl (Last accessed: May 2 2014.) World Health Organization (2009a) Measles Vaccines: WHO Position Paper. www.who.int/wer/2009/ wer8435.pdf (Last accessed: May 2 2014.) World Health Organization (2009b) The Immunological Basis for Immunization Series. Module 7: Measles. tinyurl.com/olgn3od (Last accessed: May 2 2014.) World Health Organization (2014) Measles: Fact Sheet No 286. tinyurl. com/om9b989 (Last accessed: May 2 2014.) Zenner D, Nacul L (2012) Predictive power of Koplik’s spots for the diagnosis of measles. Journal of Infection in Developing Countries. 6, 3, 271-275.
58 may 21 :: volfrom 28 no 38 :: 2014 NURSING STANDARD / RCN Downloaded RCNi.com by ${individualUser.displayName} on Nov 18, 2015.©For personal use only. No other usesPUBLISHING without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
