Measles: Clinical review

Signs and symptoms of measles, its treatment and prognosis, including information on mode of transmission, taking a history, progress of the disease and potential complications.

Measles rash is erythematous and maculopapular
Measles rash is erythematous and maculopapular

Section 1: Epidemiology and aetiology

Measles is a preventable viral illness, but remains one of the leading causes of infection-related mortality worldwide. Mortality from measles is highest in children under 12 months old and in the developing world.


Measles is one of the most contagious infectious diseases. Each infected child is capable of infecting a further 15-20 children.

The virus remains transmissible in air or on infected surfaces for up to two hours, obviating the need for direct person-to-person contact. GPs should aim for early diagnosis to minimise the spread of disease.

Measles has been a notifiable disease in England and Wales since 1940. It reappeared in the UK early in this decade, with a reported 2,016 confirmed cases in England and Wales in 2012, the highest annual total since 1994. There were 1,287 cases in the first half of 2013 but numbers fell in 2014. In 2015 there were 91 confirmed cases in England.

Vaccination of 90-95% of the population with a two-dose schedule is required to attain an effective reproduction number of less than one and halt endemic transmission.

In the late 1990s, controversy over the safety of the MMR vaccine contributed to declining uptake. Coverage with a first dose of vaccine fell to 80% among two-year-olds in England in 2003, raising the likelihood of outbreaks.

Measles symptoms and relevant tests

Although vaccination rates in two-year-olds in the UK have begun to recover, uptake still falls short of requirements. Recent years have seen a substantial increase in the pool of susceptible people required to sustain an outbreak. Susceptible groups in the UK include:

  • Unvaccinated children, including those in marginalised communities, such as Travellers, with reduced access to healthcare.
  • Young adults from Europe and other countries where measles, mumps and rubella vaccination was introduced at various times and with variable uptake.
  • Recipients of a single dose of measles-containing vaccine, including those born before the introduction of MMR.
  • Children aged less than 12 months
  • Immunocompromised patients

Section 2: Making the diagnosis

Signs and symptoms

Early diagnosis remains the cornerstone of successful management of measles. A detailed history is crucial to establish if infection is likely. 

The prodromal phase (days zero to four) is characterised by fever, malaise, coryza, non-purulent conjunctivitis and a hacking cough. The rash (days four to five) is erythematous and maculopapular, starting at the peak of respiratory symptoms on the head and spreading to the trunk and limbs over three to four days.

Koplik spots may appear one to two days before the rash

Koplik spots (small red spots with white centres classically occurring opposite the lower premolars) may appear on the mucous membranes one to two days before the rash. Desquamation follows.

Symptoms during the rash phase include a high fever (up to 40C) that peaks two to three days after the development of the rash, continued respiratory symptoms, pharyngitis and cervical adenopathy. Once the fever peaks, it resolves rapidly. Persistent fever is a possible indication of secondary bacterial infection. Occasionally, GI symptoms occur, including diarrhoea and vomiting.

Individuals are infectious from the onset of the prodromal period until four days after the appearance of the rash. Incubation ranges from seven to 18 days.


The gold standard investigation for measles is non-invasive. Detection of specific IgM or viral RNA in saliva should be taken as soon as possible after the onset of rash.Local health protection teams can provide specialist public health advice and support.

Section 3: Managing the condition

Prompt notification of measles, mumps and rubella to the local Public Health England team is required to ensure public health action can be taken promptly.

Notification should be based on clinical suspicion and should not await laboratory confirmation.

Treatment is mainly supportive and includes regular antipyretics and oral fluids. GPs should be vigilant for complications, including secondary bacterial infections in children with persistent fevers.

Prevention of measles

The current UK schedule is for the first MMR to be given at the age of 12-15 months, with a second dose at three years and four months of age. Areas with high measles incidence are however encouraging children to have a second dose MMR vaccine at 15-16 months.

MMR is an attenuated live vaccine. One of the common side-effects of MMR vaccination is the appearance of mild measles-like symptoms (including rash) approximately six to 10 days following vaccination, lasting two to three days.

Protection of contacts

As vaccine-induced measles antibodies develop more rapidly than they would following natural infection, MMR vaccine should be used to protect susceptible contacts from suspected measles.

To be effective against this exposure, vaccine must be administered very promptly, ideally within three days of exposure. Even when it is too late to provide effective post-exposure prophylaxis with MMR, the vaccine can still provide protection against any future exposure.

If the individual is already incubating measles, MMR vaccination will not exacerbate the symptoms. In these circumstances, the individuals should be advised that a measles-like illness occurring shortly after vaccination is likely to be due to natural infection.

Immunoglobulin is available for post-exposure prophylaxis in individuals for whom vaccine is contraindicated (see box).

Where immediate protection against measles is required, for example, following exposure to someone with the disease, MMR may be given from six months old.

Response to MMR in infants is suboptimal, so in cases where the vaccine has been given before 12 months of age, immunisation with two further doses of MMR should be given at the normal ages.

Contraindications Cautions
Those who are immunosuppressed (including children on steroid doses 2mg/kg for >1 week or 1mg/kg for >1 month or other immunosuppressive therapies), and severe primary immunodeficiencies Idiopathic thrombocytopenic purpura
Those who have had a confirmed anaphylactic reaction to a previous dose of MMR Children with allergy to egg should receive MMR in primary care1
Pregnant women (associated with intrauterine death and preterm birth) Pregnancy and breastfeeding Premature infants HIV-positive children (according to CD4 count)
  Poorly controlled epilepsy

Section 4: Prognosis

Complication rates vary by age, geographical region and outbreak, and are increased by immunodeficiency, malnutrition, vitamin A deficiency and intense exposure (household contacts or overcrowding).

The most common complications are otitis media (7-9%), pneumonia (1-6%), diarrhoea (8%) and convulsions (one in 200). Other more rare complications include encephalitis (overall rate of one per 1,000 cases of measles) and subacute sclerosing panencephalitis. Death occurs in one in 5,000 cases in the UK.

Complications are more common and more severe in infants, and poorly nourished and/or chronically ill children, including those who are immunosuppressed.

Severe haemorrhagic measles is most common in infants in developing countries and is characterised by a sudden onset of high fever, accompanied by seizures or altered mental state. Pneumonia and bleeding from the mouth, nose and GI tract, and disseminated intravascular coagulation follow.

Section 5: Case study

A 17-month-old previously healthy but unimmunised child develops fever, malaise and upper respiratory symptoms, including cough, runny nose and conjunctivitis, that worsen over a few days.

His mother visits the GP surgery and is reassured he has a viral URTI. The fever increases gradually to 40C in the following days and the cough worsens. Photophobia is present.

His mother attends A&E because she is concerned about her son's high fever, irritability, photophobia and a new erythematous rash that commenced on his head, subsequently spreading to the body.

On examination, the child has pale lesions on an erythematous buccal mucosa. He is diagnosed with measles and his parents are advised to avoid contact with infants, pregnant women or immunocompromised individuals and to ensure adequate fluid intake and antipyretics.

Over the next two days, his maculopapular rash spreads cephalocaudally, darkening and becoming more confluent in appearance. The fever resolves on the third day of the rash. The rash and cough persist for approximately one week.

On the first day of this child's illness, he attended nursery and subsequently attended the GP surgery and A&E. The local Public Health England unit was notified and an investigation alerted all those at risk to take preventive action to avoid further spread of the disease.

Section 6: Evidence base

Clinical trials

  • Fields R, Dabbagh A, Jain M et al. Moving forward with strengthening routine immunization delivery as part of measles and rubella elimination activities. Vaccine 2013; 31 Suppl 2: B115-21.

This paper outlines the Global Vaccine Action Plan for supplemental immunisation activities to strengthen vaccination programmes.

  • Goodson JL, Chu SY, Rota PA et al. Research priorities for global measles and rubella control and eradication. Vaccine 2012; 30(32): 4709-16.

Identifies key research priorities for the global eradication of measles.

  • Jackson C, Cheater FM, Harrison W et al. Randomized cluster trial to support informed parental decision-making for the MMR vaccine. BMC Public Health 2011; 11: 475.

A two-arm, cluster randomised trial of 142 UK parents of children eligible for MMR to assess the impact of parent-centred, multi-component intervention (balanced information, group discussion, coaching exercise) on parents' decisions about MMR. Conflict was greatest for parents deciding whether to have their first child vaccinated. Significantly more parents in the intervention arm reported vaccinating their child (93% versus 73% p = 0.04).

Key text

  • Long SS, Pickering KL, Prober CG. Principles and Practice of Pediatric Infectious Diseases (fourth edition). Chapter 227, 1137-44. St Louis, Saunders, 2012.


  • Dr Kirsty Le Doare and Dr Nuria Martinez-Alier are paediatric consultants at Evelina London Children's Hospital, London

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  1. Clark AT, Skypala I, Leech SC et al. British Society for Allergy and Immunology. Guidelines for the management of egg allergy. Clin Ex Allerg 2010; 40(8): 1116-29.


  • Asaria P, MacMahon E. Measles in the United Kingdom: can we eradicate it by 2010? BMJ 2006 28; 333 (7574): 890-5.
  • Elliman D, Sengupta N. Measles. Curr Opin Infect Dis 2005; 18(3): 229-34.
  • Perry RT, Halsey NA. The clinical significance of measles: a review. J Infect Dis 2004; 189 Suppl 1: S4-16.
  • Fields R, Dabbagh A, Jain M et al. Moving forward with strengthening routine immunization delivery as part of measles and rubella elimination activities. Vaccine 2013; 31 Suppl 2: B115-21.

This is an updated version of an article that was first published in June 2013

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