www.elitecme.com | 2019 | INFECTIOUS DISEASE, DISASTER PLANNING & WOUND CARE 21 no cost. The result of these efforts to reduce the incidence of measles infection was a signif- icant reduction to 309 reported cases of mea- sles in 1995 (CDC, 2016). Measles cases reported annually contin- ued to decrease until measles was verified and declared eliminated from the U.S. in 2000. “Elimination” is defined as an interruption of continuous endemic transmission of measles lasting more than 12 months. In 2014, the Centers for Disease Control and Prevention recorded 667 cases of mea- sles—the greatest number of infected people since the 2000 eradication of the disease. In 2017, instances of measles were reported in 120 individuals residing in 15 different states and the District of Columbia. In both cases, the most afflicted population was people who had never been vaccinated. It is critical to note that measles is still com- mon in many parts of the world. This has allowed the spread of the disease among the unvaccinated in cases where a traveler brings the virus into the U.S. In 2016, an outbreak of note was linked to an amusement park in California; this led to incidences of measles in multiple states. It is hypothesized that the string of infections originated with a traveler who had become infected overseas, prior to visiting the park. A genetic analysis of the virus linked the pathogen to a virus type responsible for a 2014 outbreak in the Philippines (CDC, 2017). Of the California residents, 45% were unvaccinated; five percent had received one dose of measles-containing vaccine, six per- cent received six doses of measles-containing vaccine, and 43% had an unknown vaccina- tion status. Approximately 25% of the unvaccinated patients were infants who were too young to receive measles vaccination; 67% of the unvac- cinated patients had not been vaccinated due to personal beliefs. Outbreaks of this type highlight the importance of increasing aware- ness on the safety of immunizations and improved compliance with childhood vacci- nation schedules (McLean, 2013). SYMPTOMS OF CLASSIC MEASLES Generally, measles first manifests itself with fever and concurrent cold-like symptoms that appear approximately 10 days after viral exposure. Clinicians can expect these patients to present with rhinorrhea, sneez- ing, swollen eyelids, watery and/or sore eyes, a high fever (=104°F), aches and pains, anorexia, irritability, and fatigue. In some patients, small, gray spots (Koplik spots) may develop inside the patients’ mouth that typically persist for a few days. While these spots do not appear in all afflicted patients, their presence is highly correlated with an active measles infection. Within a few days a maculopapular rash that presents as blotchy patches will appear. These blotches are made up of a series of small reddish-brown spots that can be either flat or slightly raised. In many instances, the rash first appears on the head or neck, then spreads outwards, and sometimes covers the entire body. A number of patients find the rash to be slightly itchy. Most patients will feel unwell on the first or second day that the rash appears. In most cases, the rash will fade away after about one week. It is critical to note that the rash resem- bles conditions generated by other childhood conditions, such as “slapped cheek syndrome,” rubella, or roseola. These conditions should be considered, particularly in cases where the patient has been properly immunized or has been previously stricken by the measles. Lesions caused by measles will initially (first three to four days of an infection) turn white under the pressure of a fingertip. The measles virus is actively shedding, beginning at time coincident with early symptoms of the infec- tion until approximately the fourth day of rash. This period marks the most contagious point of infection (NHS, 2015). SELF-ASSESSMENT QUESTION Answers are listed on the last page of the course. 2. The first symptom of measles is commonly: a) Fever. b) Headache. c) Upset stomach. d) Insomnia. In addition to classic measles, atypical mea- sles may also occur in patients exposed to the virus who received an inactive form of measles vaccine that was in use between 1963-1967. Atypical measles can be distin- guished from classic measles by a different set of symptoms: pneumonia, pleural effusions, edema (or petechial) rash with urticarial, and purpuric or vesicular components that initially appear on the wrists or ankles. Another variant, termed modified measles, is usually seen in patients who were adminis- tered immune globulin as a post-exposure pro- phylaxis treatment. Modified measles is also seen in young children who maintain some level of maternal antibodies to the virus. It is distinguished from classic measles by a pro- longed period of incubation, a mild prodrome, and a unique rash that is sparse and discrete— compared to the typical rash that results from classic measles. A similar, more benign illness has also been reported in patients who have been previously vaccinated for the measles (Minnesota Department of Health, 2016). Hemorrhagic (black) measles is rarely reported in the U.S. However, it can be a severe form of the illness marked by dark, hemor- rhagic skin eruptions. Symptoms of hemor- rhagic measles include high fever of 105°F to 106°F, hemorrhage into the skin and mucous membranes, delirium, seizures, and respira- tory distress (CDC, 2015). In cases of immunocompromised patients, measles is often more severe. It can include an atypical rash and an extended course. In the majority of cases, immunocompromised patients with T-cell deficiencies are at greatest risk (Minnesota Department of Health, 2016). COMPLICATIONS OF MEASLES Even though measles is often self-limiting and does not lead to serious problems, this disease can be associated with concerning outcomes in patients of all ages. Nonetheless, data suggests that complications are most likely to occur in patients less than five years of age or older than 20 years. Measles com- plications fit into two categories: common and severe. While ear infections occur in about 10% of children, ear infections asso- ciated with measles can become especially serious and can ultimately result in hearing loss. Diarrhea is reported in somewhat less than 10% of patients. Clinicians must be vigilant for severe com- plications, such as pneumonia. Pneumonia can occur in children with incidence rates as high as five percent, particularly in younger pediatric patients. Approximately one pedi- atric patient out of 1,000 with measles will go on to develop encephalitis. This condition can |  CONTINUING EDUCATION