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Special Interest Group Update

Measles Update

By Pamela Harris-Haman, DNP CRNP NNP-BC

Measles is one of the most contagious human viral diseases and can cause an acute systemic infection, with fever and respiratory compromise often leading to serious complications such as blindness, encephalitis, severe pneumonia, and even death (Dixon et al., 2022). “Some people think of measles as just a little rash and fever that clears up in a few days, but measles can cause serious health complications, especially in children younger than 5 years old” (Centers for Disease Control and Prevention [CDC], 2024a). Measles infection caused more than 440,000 deaths globally in 2018, most of them among children under 5 years of age (Albrecht & Arck, 2020).

The United States had three measles outbreaks—with outbreaks defined as three or more related cases—in 2025. As of March 23, 18 jurisdictions were reporting a total of 378 measles cases. Most cases (75%) are in individuals 19 years of age or younger. Thirty-four (27%) of patients under 5 years of age have been hospitalized (American Academy of Pediatrics [AAP], 2025).

The Centers for Disease Control and Prevention says that the best protection against measles is two doses of the MMR vaccine (2024a). Of the 378 reported cases of measles, only 2% of the infected individuals had had two MMR doses. Another 3% had had a single MMR dose, and the other 95% were either unvaccinated or hadn’t reported their vaccination status (AAP, 2025).

Many may not realize that measles outbreaks have occurred in previous years. In 2024, 285 measles cases were reported in 33 jurisdictions amid 16 outbreaks (AAP, 2025).

Measles is highly contagious. One person with measles infects up to 9 of 10 people nearby if they are not protected, such as through vaccination. Measles spreads through the air when an infected person coughs or sneezes. You can get measles just by being in a room where a person with measles has been because the measles virus has been reported to survive in the air for up to 2 hours after the infected person has left (Albrecht & Arck, 2020; CDC, 2024a). 

“Measles was declared eliminated from the United States in 2000. However, measles is still common in many parts of the world. Every year, measles is brought into the United States by unvaccinated travelers who get measles while they are in other countries. These travelers are mostly Americans and sometimes international visitors” (CDC, 2024a).

“Over the last years, an increasing number of outbreaks of vaccine-preventable infectious diseases has been reported” (Albrecht & Arck, 2020). At highest risk for measles infection are unvaccinated children and adults (less than two doses of MMR), individuals with known exposure to measles or recent travel to areas with active measles, infants and children younger than 5 years of age, pregnant women, and people with compromised immune systems such as from cancer, chemotherapy, or HIV infection (Albrecht & Arck, 2020; AAP, 2025).

Neonatal Vulnerability

After birth and during the first few months of life, human newborns are not equipped with a fully mature immune system, making them more highly susceptible to infectious pathogens such as measles. “This vulnerability during infancy can be mitigated by the transplacental transfer of pathogen-specific antibodies and other mediators of immunity from mother to fetus during pregnancy, followed postnatally by breast milk-derived immunity. Since this largely antibody-mediated passive immunity can prevent the newborn from infections, neonatal immunity depends strongly on the maternal concentration of respective specific antibodies during pregnancy. Neonatal immunity depends strongly on the maternal concentration of antibodies during pregnancy. If (maternal) titers are low or wane rapidly after birth, the protection transferred to the child may not be sufficient to prevent disease” (Albrecht & Arck, 2020). “It is generally believed that most infants are protected by maternal antibodies until 6 to 9 months of age” (Dixon et al., 2022).

Measles infection in the neonatal period can either be due to congenital infection via vertical transmission from the mother, congenital measles, or postnatally acquired infection. Most of the evidence about congenital measles dates back 40 years due to the initiation and implementation of effective vaccine programs and measles elimination strategies. The higher mortality rate associated with congenital measles is related to the occurrence of preterm deliveries, perinatal infections, and neonatal pneumonia. Postnatal measles infections in infants younger than 6 months of age are rare due to the presence of maternally acquired protective antibodies. An unimmunized mother poses a significant threat to the neonate (Albrecht & Arck, 2020).

Signs and Symptoms

Signs and symptoms of measles usually begin with a high fever, up to and over 104°F, a cough, runny nose, and conjunctivitis. Following these prodromal symptoms, a rash develops. This usually starts about 2-4 days after the symptoms begin. The rash starts at the hairline and travels downward to the face, neck, and trunk. The rash usually lasts about 5-6 days. A fever is usually present when the rash appears. The incubation period between exposure and initial symptoms is about 8-12 days after contact with the virus. Koplik spots, which are tiny white spots that appear inside the mouth, occur 2-3 days after symptoms begin (CDC, 2024c).

Measles should be considered in patients who have a fever and rash especially if they have traveled internationally (AAP, 2025; CDC, 2024a). Clinical manifestations include nonspecific symptoms, such as fever, cough, and respiratory symptoms, which overlap with most viral infections thus making an early diagnosis difficult.

“Measles virus infection testing can be confirmed by (1) detection of measles viral RNA by reverse transcriptase-polymerase chain reaction (RT-PCR); (2) detection of measles virus-specific immunoglobulin (Ig) M; (3) a fourfold increase in measles IgG antibody concentration in paired acute and convalescent serum specimens (collected at least 10 days apart); or (4) isolation of measles virus in cell culture” (AAP, 2025).

Complications

Measles can cause serious health complications, especially in children younger than 5 years of age. Common complications related to measles include fever, cough, pneumonia either from the measles virus or from bacterial super infection, diarrhea and respiratory symptoms. Postmeasles complications include pneumonia, diarrhea, otitis media, blindness, post-infectious encephalitis, death, and others. Pneumonia, croup and encephalitis are common causes of mortality, and encephalitis is the most common cause of long-term sequalae (AAP, 2025; CDC, 2024a; Sharma et al., 2023).

About 1 child out of every 1,000 who gets measles will develop encephalitis. Nearly 1-3 children per 1,000 infected with measles will die from respiratory and neurologic complications (CDC, 2024c). Complications related to measles can cause serious illness, even in previously healthy children. “Measles infection increases the risk of other severe infections for months or years after measles through the mechanisms of immune amnesia” (AAP, 2025). “There is no specific antiviral agent for treatment of measles infections” (AAP, 2025).
Protecting Newborns

“The best protection against measles is [MMR] vaccine,” which “provides long-lasting protection against all strains of measles (CDC, 2024a, 2024b). Promoting the immunity of newborns via maternal vaccination holds the potential to become an effective and low-cost approach to prevent neonatal morbidity and mortality from measles (Albrecht & Arck, 2020).

References

  1. Dixon, M. G., Tapia, M. D., Wannemuehler, K., Luce, R., Papania, M., Sow, S., Levin, M. M., Pasetti, M. F. (2022). Measles susceptibility in maternal infant dyads-Bamko, Mali. Vaccine, 40(9). https://doi.org/10.1016/j.vaccine.2022.01.012
  2. Albrecht, M., & Arck, P. C. (2020). Vertically transferred immunity in neonates: Mothers, mechanisms and mediators. Frontiers in Immunology, 11, 555. https://doi.org/10.3389/fimmu.2020.00555
  3. American Academy of Pediatrics. (2025, March 23). Red book online outbreaks: measles. https://publications.aap.org/redbook/resources/15187/Red-Book-Online-Measles  
  4. Centers for Disease Control and Prevention. (2024a, March 29). About measles. www.cdc.gov/measles/about
  5. Centers for Disease Control and Prevention. (2024b, April 12). Interim infection prevention and control recommendations for measles in healthcare settings. https://www.cdc.gov/infection-control/hcp/measles/index.html
  6. Centers for Disease Control and Prevention. (2024c, May 9). Measles symptoms and complications. https://www.cdc.gov/measles/signs-symptoms/index.html
  7. Sharma, S. R., Sawant, V., Save, S. U., & Kondekar, A. S. (2023). A rare presentation of measles and post-measles complications in a neonate: Case report. Egyptian Pediatric Association Gazette, 71(1). https://doi.org/10.1186/s43054-023-00203-9