Measles in children

In 2017 I had the unfortunate chance to experience my first outbreak of measles as a doctor. I see the annual flu epidemic and the typical viral "creatures" that circulate throughout the year, but this was different. I live and practice in Minnesota in the epicenter where a measles epidemic occurred. My clinic provides two populations that were at high risk during this outbreak: a large Somali-American population (which affected the primary population) and children who were vaccinated too little due to their parents' refusal.

The impact of the outbreak was significant, not only for the children and adults who were exposed and infected with the disease, but also for the health care system and the community as a whole. There was an increase in the number of calls from concerned parents, an increase in vaccination visits, an increase in health education and epidemiological resources used, and a lot of anxiety in the whole community, which prevented people from avoiding public places.

Because of this outbreak, I realized how much misinformation circulates and how the decision not to immunize your own children affects an entire community. I thought that a review of measles and MMR (measles, mumps and rubella) and MMRV (measles, mumps, rubella and varicella) vaccines would be useful, as outbreaks in the United States are becoming more frequent. Mumps and rubella are also touched, but the primary focus of this article is measles.

What are measles, mumps and rubella?

The measles

Measles is a viral disease that causes an acute infection with a wide range of symptoms. The disease progresses in four phases: an incubation phase, a prodromal phase, a rash phase and a resolution phase.1 The incubation phase lasts 9 to 10 days and is asymptomatic.1 During the prodromal phase, patients are generally quite ill with fever, cough, coryza, malaise and conjunctivitis.2 They can also develop more serious complications such as pneumonia, encephalitis, brain damage and even death.2.3 The third phase is determined by a bleaching erythematous macular rash that starts on the head and spreads downwards.1,2 Patients also develop Koplik spots in the mouth, which are bluish-white papules with an erythematous halo and are pathognomonic for measles.1,2 Measles are highly contagious and can be transmitted approximately 4 days prior to the development of the result up to 4 days thereafter.1.4 The contamination rate for sensitive individuals who are exposed is about 90%.1


Mumps is also an acute viral syndrome characterized by fever, body pain, swelling of the parotid, orchitis, oophoritis and in rare cases aseptic meningitis and encephalitis.2.3 Mumps can be easily distributed in busy environments such as classrooms, locker rooms and dormitories, and is spread through exchange of saliva.5


Rubella, also known as German measles, is an acute disease that is milder than measles and mumps. In children there is often little to no fever or other symptoms, although adolescents and adults get mild to moderate generalized viral symptoms.1 Up to 25% of infected people will have no symptoms at all, but are still able to spread the disease.1 The rubella is characterized by a weak rash that starts on the face and spreads down, along with sore throat, conjunctivitis and mild fever.1.3 The main concern with regard to rubella is related to high birth defects and fetal decline when pregnant women contract the disease.2.3 Some of the birth defects that occur are hearing loss, cataracts, heart conditions, neurological effects, intellectual disabilities and even autism.2

History of mowers

One of the first written reports of measles disease is from a Persian physician in the ninth century AD.6 It was not until 1757 that Francis Home, a Scottish physician, reliably demonstrated that the measles were caused by an infection.6 By the 1950s, more data was collected and an estimated 3 to 4 million people in the US were infected with the measles virus every year.6 About 400 to 500 patients died, 1,000 progressed to encephalitis and 48,000 were admitted to hospital every year.6 Around this time, Drs. John Enders and Thomas Peebles isolated the virus and in 1963 Enders received a permit for the first vaccine against measles.6 In 1968 Dr. began. Maurice Hilleman to distribute a new and improved version of the vaccine.6 Only 3 years later, in 1971, the vaccine was combined with mumps and rubella vaccines, MMR vaccine became the standard choice. The effects of mass vaccination became apparent in 1981, when there was a dramatic drop in cases of measles, with 80% fewer reported cases than the previous year.6 In 1989, an outbreak of measles among vaccinated school children led to the addition of a second dose of MMR prior to entering the school.6 In the year 2000, endemic measles were declared extinct from the US.6 We are currently seeing a resurgence of this once-eliminated disease as a result of higher rates for international travel and poor vaccination rates, allowing the virus to spread rapidly due to a lack of immunity of the herd.2.7 (table 1).

Timeline of measles and vaccine development

Table 1:

Timeline of measles and vaccine development

Recent trends in vaccination and disease

One of the biggest factors contributing to the increase in outbreaks of measles in the US is the rising speed of non-vaccinated people. The largest number of non-vaccinated population groups live in rural areas; however, there are increasingly large populations of non-vaccinated people living in more urban areas, which calls for a rapid spread of diseases by these densely populated and under-immunized communities.8

According to the National Immunization Survey of 2015, only 72.2% of children aged 19 to 35 months were fully vaccinated according to the recommendations of the Advisory Committee on Immunity Practices.8 There are currently 18 states that allow a non-medical exemption (ie exemption from philosophical beliefs) for vaccines.8 Since 2009, 12 of these states have seen an increase in non-medical exemptions from vaccines.8 These 12 states are Arkansas, Arizona, Idaho, Maine, Minnesota, North Dakota, Ohio, Oklahoma, Oregon, Pennsylvania, Texas and Utah.8 Only three states in the US have an absolute ban on non-medical vaccine exemption: Mississippi, California and West Virginia.8 As a result, these conditions have some of the highest vaccination rates and the lowest incidence of vaccine preventable diseases.8 Policy is starting to change in the US as a result of the escalating figures of vaccine-preventable diseases in recent years. While some states (such as those mentioned above) completely prohibit non-medical exceptions, others make it more difficult to refuse vaccination, such as requiring parents to view an educational module before they receive an exemption.8

Since vaccination coverage has decreased, there has been an increase in the number of outbreaks of measles in recent years (table 2). In 2014, the US reported 667 cases of measles from 27 states, making it the largest number of cases since measles were declared extinct in 2000.7 Contributing to these numbers was an outbreak of high-ranking origin that originated in the Disneyland theme park in Anaheim, California.8 The epidemic probably occurred due to low vaccination rates against measles in California at that time (only 50% -86% in those who were exposed to the virus).8 In response to this outbreak, California has banned non-national exemptions for vaccination against measles.8

Eruptions of great Measles in recent years

Table 2:

Eruptions of great Measles in recent years

Another major outbreak occurred in the year 2017 in Minnesota. The outbreak occurred mainly in the Somali-American population, the majority of which were not vaccinated against measles. The Somali-American community was previously highly vaccinated against measles, with percentages up to 90% in 2008;4 Because of the spread of misleading information and propaganda about the MMR vaccine that causes autism, anxiety and anxiety, it spread through the community, leading to a sharp decrease in vaccination coverage.4 By 2014 only about 35.6% of Somali-American children had received 1 dose of the MMR vaccine.4 These low percentages caused the rapid spread of the disease after it was introduced into the community. In 2011 there was a smaller outbreak of about 21 cases of measles in the same community, with vaccination rates at that time about 54%.4 The outbreak in 2017 resulted in 65 confirmed cases, of which 62 in non-vaccinated people (77% were children over 12 years of age eligible for the vaccine).4 The outbreak mainly affected children, with an average age of 21 months.4 It spread over three provinces, five schools, twelve nurseries and two care institutions.4 Approximately 8,250 people were exposed to the virus and 31% of those who tested positive required hospitalization.4 In response to this outbreak, there was a large increase in the number of MMR vaccines that were given, with weekly doses increasing from 2,700 per week prior to the epidemic to about 9,964 per week during the outbreak.4

Measles Vaccine

The measles vaccine is currently available in two forms: the MMR vaccine (measles, mumps, rubella) and the MMRV vaccine (measles, mumps, rubella, varicella).9 Both are live attenuated vaccines.9 The vaccines are very effective, with 1 dose of the vaccine that gives 93% of the people immunity against measles, 78% immunity to the mumps and 97% immunity against rubella.9 A second dose increases those numbers to 97% for measles and 88% for mumps, and rubella stays at 97%.9 The second dose of the vaccine is given to "catch" people who do not respond to the first dose.9 Two doses are considered to confer lifelong immunity on all three viruses; however, emerging data suggests that there may be decreasing immunity to mumps as time passes.5

The first dose of the vaccine should be given between 12 and 15 months and the second dose between 4 and 6 years.10 There are special circumstances in which these rules can change. Infants aged 6 to 12 months traveling to high-risk areas should receive a dose prior to their trip and will require 2 additional doses after the age of 12 months.10 For travel purposes, during outbreaks and for other special circumstances, the second BMR dose can be given as soon as 28 days after the first dose.2.10 The timing of the vaccine is significant because it can affect how effective the vaccine works. It is important to wait until after 12 months for the first dose to allow a decrease in maternal antibodies that may interfere with the uptake of the vaccine.2 Adverse reactions may also increase slightly if given after the age of 15 months (especially the risk of febrile seizures), and endorse the importance of obtaining vaccines according to the recommended schedule.3

The vaccine can also be administered after exposure to the virus. For prophylaxis after exposure to measles, the vaccine should be administered within 72 hours.10.11 Administration of immunoglobulin within the first 6 days may also offer some protection.10.11 Unfortunately, the vaccine is not useful after exposure to the mumps or rubella.2 During a mumps outbreak, however, it is recommended for those at high risk to obtain a third BMR vaccine to provide cover to those whose immunity might be decreasing.2.10 Outbreaks of mumps can occur in highly vaccinated communities due to this potentially reduced immunity, but high vaccination rates help to limit the extent and duration of these outbreaks.5

Side effects and side effects

The MMR and MMRV vaccines are largely safe and effective, and although there are some possible side effects, the vaccine is much safer than getting the measles, mumps, or rubella viruses.3 However, there are some contraindications and precautions that should be considered when administering the vaccine.

Contraindications to the vaccine are limited and rare. They include anaphylaxis of the vaccine, known severe immune deficiency (chemotherapy, congenital severe immune deficiency, long-term immunosuppressive therapy, HIV with immune compromise) and are currently pregnant or trying to conceive.2.10 There are also precautions (which means that you can give the vaccine, but there may be an increased chance of a side effect or interference with the development of immunity). These include moderate or severe disease (the effects of the disease can be confused with the side effects of the vaccine), recent receipt of an antibody-containing blood product, history of thrombocytopenia, need for tuberculosis examination and a personal or family history of seizures. .2.10 Women should also not become pregnant 4 weeks after the vaccine because of the risks associated with the rubella component.10

Many people have misconceptions about who can or can not receive the vaccine. Many mistakenly believe that you can not get the vaccine if the following is true: an egg allergy, HIV infection without serious compromise with the immune system, breastfeeding, contact with pregnant people, family members with immunodeficiency, mild acute disease, previous local reaction to the vaccine, currently using antibiotics, or babies born prematurely.2.10, 11 It is important to inform families that none of these are contraindications and that vaccines should be given according to the recommended schedule.

There are several adverse effects associated with MMR and MMRV vaccines. These are rare and must be weighed against the protective benefit of the vaccine.12 The most common of these are fever (5% -15%), skin rash (5%), lymphadenopathy (5%), painful arm, joint complaints (up to 25%, mainly in teenagers and adult women without previous immunity), allergic reaction, immune thrombocytopenia (temporary and rarely severe) and febrile seizures.2,3,11,12 Of these, the most worrying for parents is often the risk of febrile seizures. It is important to note that the overall risk is still quite low, but that the risk increases with age, so administration of the vaccine at the right time reduces the risk.2.3 Febrile seizures in younger children are also higher in the MMRV compared to the MMR vaccine. It is therefore recommended to give the MMR before the age of 4 years, although the MMRV vaccine is suitable for children older than 4 years.2.3 There is also strong evidence that there is absolutely no link between the vaccine and autism.12

How can we increase vaccination coverage?

There are several things that providers can do to increase vaccine rates and improve education on vaccination. Studies show that open and honest communication between providers and parents with regard to vaccine safety and an emphasis on vaccines as a routine part of the healthcare system promotes compliance with vaccine recommendations and reduces non-medical exceptions.8 Although the importance of company immunity is well known, it has been found that approaching parents with the benefits of vaccination for the community has not changed their views on vaccines.13 However, by focusing on the benefits for the individual child, their vision on vaccines was improved.13 It is also important to know the trends of the community with vaccination. By being able to understand where families get their information from, health professionals can be prepared to address concerns and questions in a way that removes parents' concerns and promotes vaccination.

Different countries are also making it increasingly difficult to refuse vaccination. Countries such as France, Italy and Australia have taken measures that make vaccinations mandatory or have imposed fines on parents who refuse to vaccinate their children.8 The growing uncomfortability of non-medical exemptions offers opportunities to educate families and help improve compliance with vaccines. This will provide more general vaccination and increased livestock immunity in communities in the US.8

Finally, forming a respectful working relationship with families can have a major impact. Obtaining their trust and professional guidance can often reassure parents who try to make the best decisions for their children. Offering personal examples can also be useful. Inform patients about firsthand experiences with the effects of these diseases (eg measles, bacterial meningitis, pertussis), know the most common side effects and how many people they actually experience, and provide certainty about the decision you would make with your own child can go a long way. For example, many parents ask their provider questions such as "did your child get this?" Or "what would you tell your family member?". With my own patients, knowing that I would choose to vaccinate according to the recommended schedule, it helps to encourage the families to vaccinate their own children on time.


Vaccines are one of the greatest achievements for public health in the past century.12 Since the introduction of vaccines, we have seen a drastic reduction in vaccine diseases and it is important that we do not allow these devastating diseases to return to our communities. Due to misinformation, dissemination of this misinformation via social media and other resources, and increasing concerns about exposure to just about everything, vaccine rates have decreased and the rates of many vaccine-susceptible diseases are increasing. By means of high-quality education, stricter regulations and respectful relationships with patients, providers can reverse this trend and keep these dangerous diseases at bay.


  1. Michaels MG, Nowalk AJ. Infectious disease: infectious exanthema. In: Zitelli BJ, McIntire SC, Nowalk AJ, eds. Atlas of Pediatric Physical Diagnosis. Philadelphia, PA: Saunders Elsevier; 2012: 469-470.

  2. Drutz JE. Immunization of measles, mumps and rubella in infants, children and adolescents. Topical. Hirsch Martin, ed. Accessed August 13, 2018.,%20mumps,%20and%20rubella%20immunization&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1.

  3. Center for Disease Control and Prevention. Measles, mumps and rubella (MMR) vaccine safety. Accessible August 1, 2018.

  4. Hall V, Banerjee E, Kenyon C. Outbreak of measles – Minnesota April-May 2017. MMWR Morb Mortal Wkly Rep. 2017; 66: 713-717. doi: 10.15585 / mmw.mm6627a1 [CrossRef]

  5. Center for Disease Control and Prevention. Hump ​​cases and outbreaks. Accessible August 1, 2018.

  6. Center for Disease Control and Prevention. History of the mower. Accessible August 1, 2018.

  7. Center for Disease Control and Prevention. Hats fallen and outbreaks. Accessible August 1, 2018.

  8. Olive JK, Hotez PJ, Damania A, Nolan MS. The state of the anti-vaccine movement in the United States: a focused investigation of non-medical exemptions in states and provinces. PLoS Med.2018; 15 (6): e1002578. doi:. doi: 10.1371 / journal.pmed.1002578 [CrossRef]

  9. Center for Disease Control and Prevention. About the vaccine. Accessed 13 August 2018.

  10. Center for Disease Control and Prevention. Routine vaccination against measles, mumps and rubella. Accessible August 1, 2018.

  11. Albon J. Immunoprophylaxis. In: Engorn B, Flerlage J, eds. The Harriet Lane handbook. 20th ed. Philadelphia, PA: Saunders Elsevier; 2015: 370-371.

  12. Maglione MA, Das L, Raaen L, Smith A, et al. Safety of vaccines used for routine immunization of American children: a systematic review. Pediatrics. 2014; 134 (2): 325-337. doi:. doi: 10.1542 / peds.2014-1079 [CrossRef]

  13. Hendrix KS, Finnell SM, Zimet GD, Sturm LA, Lane KA, Downs SM. Vaccine message framing and the intent of parents to immunize their babies for MMR. Pediatrics. 2014; 134 (3): e675-e683. doi:. doi: 10.1542 / peds.2013-4077 [CrossRef]

Timeline of measles and vaccine development

Year claim
9th century First written report of the vaccine against measles
1757 Francis Home shows that measles is caused by an infection
1912 Measles becomes a reportable disease
1954 John Enders and Thomas Peebles isolate the virus
1963 John Enders issues the first vaccine for measles
1968 Maurice Hilleman releases and improved vaccine
1971 Introduction of the vaccine against measles / mumps / rubella
1981 80% decrease in cases of measles from last year
2000 Endemic measles declared eradicated in the US.
2010 Revival of the measles virus

Eruptions of great Measles in recent years

Year the outbreak
2008 3 large outbreaks in groups of non-vaccinated people
2011 > 30 countries had an increase in measles and a major outbreak in France brought cases to the US.
2013 11 outbreaks in the US.
3 outbreaks involving> 20 people
2014 23 outbreaks in the US.
1 major outbreak of 383 cases in the Amish community in Ohio
2015 Outbreak originated in the Disneyland amusement park in California
2017 Minnesota experienced an outbreak of 63 individuals, largely in the under-vaccinated Somali-American population