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Measles in a Modern World

2 Contact Hours including 2 Pharmacology Hours
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This peer reviewed course is applicable for the following professions:
Advanced Practice Registered Nurse (APRN), Certified Nurse Midwife, Certified Nurse Practitioner, Certified Registered Nurse Anesthetist (CRNA), Certified Registered Nurse Practitioner, Clinical Nurse Specialist (CNS), Licensed Practical Nurse (LPN), Licensed Vocational Nurses (LVN), Midwife (MW), Nursing Student, Registered Nurse (RN), Registered Nurse Practitioner
This course will be updated or discontinued on or before Sunday, September 28, 2025

Nationally Accredited

CEUFast, Inc. is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center's Commission on Accreditation. ANCC Provider number #P0274.


This course aims to familiarize healthcare professionals with the pathophysiology of measles, its risks and complications, and the progression of this disease's effects on society throughout history, both before and after available vaccination. While measles is much less prevalent than it once was, it still circulates through at-risk populations, and healthcare professionals must not forget its signs, symptoms, and potentially devastating effects.


Upon completion of this course, the learner will be able to: 

  1. Identify risk factors for measles infection.
  2. Explain the effects on global and local infection rates after introducing the measles vaccine.
  3. Summarize the history of measles in North America.
  4. Characterize how measles outbreaks continue to occur in the United States.
  5. Describe how the measles virus was first isolated for vaccine development.
  6. Differentiate between the original measles vaccine and the one currently used today.
  7. Utilize current recommendations to create a vaccine plan.
  8. Explain how the measles virus attacks and spreads through a host.
  9.  Paraphrase the transmissibility of measles.
  10.  Identify signs and symptoms of measles at various points in the infection process.
  11.  Explain the diagnostics used to confirm suspected measles cases.
  12.  Identify treatment interventions for patients with acute measles infection.
  13.  Explain the effects of the anti-vaccine movement on measles infection rates.
  14.  Outline how the COVID-19 pandemic has affected vaccination rates for measles.
CEUFast Inc. and the course planners for this educational activity do not have any relevant financial relationship(s) to disclose with ineligible companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.

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Measles in a Modern World
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Author:    Sarah Schulze (MSN, APRN, CPNP)


Measles has been a common and often serious childhood illness for hundreds of years, with one of the first documented cases recorded by a 9th-century Persian physician. The United States began mandatory reporting of measles cases and monitoring trends related to the disease in 1912. In the first decade of reporting, around 6,000 measles-related deaths were reported yearly. By the 1950s, it was recognized that nearly all children experienced the disease by age 15. An estimated 3-4 million cases occurred in the United States yearly towards the end of the pre-vaccine era, with 400-500 deaths annually and over 1,000 cases of measles encephalitis, one of the most dangerous complications (Centers for Disease Control and Prevention, 2020b).

Over the last several decades, the development and wide distribution of the measles vaccine have dramatically decreased the prevalence of measles and its complications. However, the disease still exists and reappears in isolated outbreaks nationwide almost yearly. Measles spreads incredibly easily through unvaccinated or under-vaccinated populations, demonstrating the delicate balance of herd immunity that relies on high levels of vaccine compliance throughout the population.

The high transmission rate, paired with the quick onset of viral symptoms and hallmark rash, as well as the large list of potentially serious complications, emphasizes that healthcare professionals cannot afford to be careless in their knowledge of this disease. They must remain current in recent and local trends of vaccination and disease outbreaks, be familiar with symptoms to identify measles if they come across it, and serve as knowledgeable resources when advocating for vaccination for infants and children.

This course aims to ensure healthcare professionals are adequately prepared to recognize measles, care for patients experiencing complications of the disease, and combat misinformation to preserve the near-eradication of this disease afforded to the United States through vaccines.

Epidemiology of Measles

Measles, historically, has been thought to be a disease of childhood. However, measles infection can occur in unvaccinated or partially vaccinated individuals or those with compromised immunity.

Unvaccinated young children are at the highest risk. Depending on local immunization practices and the incidence of the disease, age-specific infection rates may be highest in susceptible infants younger than 12 months, school-aged children, or young adults. In densely populated, underdeveloped countries, measles is most common in children younger than two years (World Health Organization [WHO], 2019).

Unvaccinated males and females are equally susceptible to infection by the measles virus. Following acute measles, increased mortality has been observed among females of all ages, but it is most marked in adolescents and young adults. Measles affects people of all races (WHO, 2023a).

There is some seasonal variation, and in temperate areas, the peak incidence of measles infection occurs during late winter and early spring. Humans are the only known host to measles, and it does not spread among animals.

Aside from being unvaccinated or under-vaccinated, risk factors for contracting and developing complications from measles include young age, being immunocompromised from HIV/AIDS, chemotherapy, organ transplant, or other reasons, living close to a large number of people, malnutrition, pregnancy, and international travel. Measles remains endemic in countries in five out of the six WHO regions of the world, which underscores the importance of ensuring age-appropriate vaccination for all individuals before international travel to any region (WHO, 2023a).

Development and distribution of the measles vaccine have been so overwhelmingly successful that patterns and prevalence of the disease should be divided into pre- and post-vaccine data. Between 2000 and 2018, there was a 73% decrease in the prevalence of measles worldwide, and the WHO estimates that over 23 million measles-related deaths were avoided during that time (WHO, 2023a).

Prior to the Vaccine

Measles was clearly differentiated from smallpox as early as the 9th century by Persian physicians. The disease was rampant in crowded and unhygienic conditions throughout Europe for centuries, with a Scottish physician demonstrating it was infectious in the 1750's. In the 1760s, the disease was brought to North America by European settlers and devastated native people who had not encountered the disease and had no immunity. The same occurred with additional diseases such as smallpox, influenza, and varicella (Centers for Disease Control and Prevention [CDC], 2020b).

Measles spread easily through the population for over one hundred years in the American colonies. In 1912, the United States began formally reporting and tracking infectious diseases. At this time, it was learned that 3-4 million measles infections occurred annually and resulted in around 6,000 deaths (CDC, 2020b).

By the 1920s, some hygiene and living conditions had improved, as well as available healthcare; as a result, the number of measles-related deaths each year dropped to around 400-500. Still, nearly all children contracted the disease by age 15, and measles maintained its foothold on the population (CDC, 2020b).

Post-vaccine Prevalence

The rates of measles over the last few decades have fluctuated, with outbreaks and resurgences occurring here and there. Still, overall, measles is no longer the overwhelming public health concern it used to be. However, it still warrants vigilance with early detection of outbreaks and knowledgeable promotion of vaccination, so healthcare workers must remain informed on current evidence and best practices. In the following discussion, an outbreak refers to a chain of transmission with three or more confirmed cases.

After the development and widespread availability of the vaccine, there was a sharp drop in the annual number of cases, as well as complications and long-term disabilities resulting from measles, almost immediately. In 1978, a goal was set by the CDC to eliminate measles from the United States by 1982; the goal was not met. However, measles cases were down by 80%, which was still an overwhelming success (CDC, 2020b).

Starting in the late 1980s, there were a few years of notable outbreaks among vaccinated school-aged children, which brought about the current recommendation for a second dose of the measles, mumps, and rubella (MMR) vaccine between ages four and six years. After this updated recommendation and vaccine development improvements, annual measles rates continued to decline (CDC, 2020b).

In the year 2000, the United States declared measles eliminated. Disease elimination means no endemic virus transmission occurred throughout a region (in this case, the entire country) over 12 months. Sustaining elimination status is very difficult for highly contagious diseases like measles because high vaccination rates (around 95%) must be maintained, especially among children. Vaccination rates experience periodic fluctuation for various reasons, one being that the MMR vaccine is particularly controversial among the anti-vaccine community. Another reason vaccine rates have wavered in recent years is due to disruptions in typical preventative care during the COVID-19 pandemic. Both of these issues and their effects on measles vaccination rates will be discussed later on (The College of Physicians of Philadelphia, n.d.).

In 2004, measles reached an all-time low in the United States, with only 34 cases reported to the CDC for the entire year. However, as the new century progressed, several outbreaks occurred, most often linked to international travel and spreading in areas with low vaccination rates (The College of Physicians of Philadelphia, n.d.).

In 2008, there were 131 cases reported from 15 different states; this was the highest number of cases reported since 1996. In 2014, there were 644 cases reported. The outbreak continued into early 2015 when 125 measles cases were traced back to the Disney theme park in California. A review of the cases since the turn of the century indicates that about 90% of reported cases were unvaccinated individuals (The College of Physicians of Philadelphia, n.d.).

Globally, the WHO reports a 75% reduction in measles deaths at the turn of the century. However, up to 200,000 people worldwide still die from the disease annually (The College of Physicians of Philadelphia, n.d.).

The overview of measles in recent years highlights both the vaccine's overwhelming success and the very fragile control we currently have over the disease, with even the slightest disruption in adequate vaccination rates allowing the rapid spread of the illness once more.

Vaccine Development and Current Recommendations

In 1954, at a boarding school near Boston, Massachusetts, a measles outbreak gained attention from doctors at Boston Children's Hospital, who collected throat swabs and blood samples from infected students to try and isolate the virus. Dr. Thomas Peebles and Dr. John Enders did just that, with a blood sample from an adolescent student named David Edmonston, resulting in an isolated strain of the measles virus, known afterward as the "Edmonston B strain" (WHO, n.d.).

These doctors developed a vaccine from the Edmonston B strain and tested it on small groups of children between 1958 and 1960. Once those trials were successful, they began testing on larger groups, vaccinating thousands of children in New York City and Nigeria. The vaccine was wildly effective and licensed for widespread distribution to the public in 1963 (WHO, n.d.).

The early vaccine had many side effects, so in 1968, Dr. Maurice Hillman attempted to weaken the virus contained within the vaccine while maintaining its overall effectiveness. He accomplished this by passing the virus through chick embryo cells many times, reducing the severity of side effects while not affecting the vaccine's efficacy; this improved vaccine is the one we still use today (WHO, n.d.).

In 1971, Hillman also combined the measles vaccine with existing inoculations for mumps and rubella, so all three could be given in one injection, known as the MMR. The measles vaccine is always combined with mumps and rubella in the United States. Standalone measles vaccines are sometimes used in other countries (WHO, n.d.).

Photo of mmr vaccine in bottle

MMR Vaccine

The current recommendation for MMR vaccination is an initial dose at 12-15 months and a second dose between the ages of 4-6 before school entry. The MMR can be given as early as six months of age and is recommended earlier than the standard 12 months for children traveling outside of the United States, particularly to areas with high rates of measles, or also when outbreaks occur, especially if children are at high risk or living in a community affected by an outbreak (CDC, 2022).

A 2-dose series at least four weeks apart is recommended for previously unvaccinated children on a catch-up schedule. A single booster dose is recommended for adults who do not demonstrate immunity on titers. A two-dose series is recommended for adults with no immunity who are considered at high risk of exposure, such as healthcare professionals or those traveling internationally (CDC, 2022).

A combination vaccine for MMR and varicella (MMRV) was created in 2005 for school-aged children receiving their second dose to only receive one injection. For children younger than age four or older than age 12, the MMR and varicella components should be administered separately (CDC, 2022).

Pathophysiology of Measles

What is Measles?

Measles is a disease caused by the highly contagious measles virus, a single-stranded enveloped ribonucleic acid (RNA) virus. It is part of the morbillivirus genus and paramyxoviridae family. Once the virus comes in contact with a host's mucosa, usually after inhaling, it infects the epithelial lining of the airway. It binds itself to host cells using hemagglutinin proteins. Once attached to host cells, it uses a fusion protein to fuse with the cell and get inside, where it transcribes its genome and replicates, creating new viruses and wrapping them in a lipid layer before sending them outside of the cell to circulate in the body and continue this process over and over. It only takes a few days before the virus spreads throughout the lungs and eventually to the rest of the body through the lymph system and bloodstream. It continues to spread, infecting organs such as the intestine and brain. During this process, the measles virus also causes immunosuppression that can last weeks, months, or even years; this increases the risk of secondary infections and complications (Kondamudi and Waymack, 2023).

How is it Spread?

The airborne virus is incredibly contagious and lives in an infected individual's nose and throat mucus. Measles spreads when an infected individual breathes, coughs, or sneezes. The measles virus can live for up to two hours in an airspace where the infected individual breathes, coughs, or sneezes. If other individuals breathe the contaminated air or touch an infected surface, then touch their eyes, nose, or mouth, they can become infected. Thus, the virus can be transmitted by direct contact with infectious droplets on surfaces and in the air for two hours after an infected individual leaves an area. Infected individuals can spread the virus from four days before to four days after the start of the rash. Nine out of ten individuals (90%) who share a living space with an infected individual and are not immune will catch measles. Individuals usually only get measles once (CDC, 2020e).

Airborne precautions should be utilized for healthcare professionals caring for patients with suspected or confirmed measles; this includes gowns, gloves, face shields, eye protection, and an N95 or higher respirator. Powered air-purifying respirators (PAPR) are ideal, and negative pressure isolation rooms help prevent the spread throughout the facility. Patients with measles should not share rooms with other patients unless they are also infected (United States Department of Labor, n.d.).

Signs and Symptoms

While measles is known for its hallmark red, macular rash spreading from the face down to the toes, it includes many other symptoms of varying severity that progress in a predictable fashion.

Incubation period:

  • The first 10-14 days after exposure, the virus replicates and spreads throughout the body. There are no symptoms at this time.

First symptoms appear 7-14 days after initial exposure and include the following:

  • High fever (may be greater than 104°F)
  • Fatigue and malaise
  • Cough
  • Runny nose
  • Sore throat
  • Conjunctivitis 

2-3 days after initial symptoms:

  • Koplik's spots (white spots inside the mouth) may develop

3-5 days after initial symptoms:

  • Measles rash develops
    • Red macules beginning at the hairline and spreading downward to the thighs and feet
    • Macules may be so numerous that they blend together
    • Fever may spike up to 104-105°F as rash appears and spreads


  • The rash may last seven days and fades in the order it appeared, with the face fading first and lower extremities fading last
  • Cough and other symptoms may last for around ten days
  • Peeling of the skin where the rash was may occur (CDC, 2020d)

photo of male with measles rash on chest

Measles Rash


While the typical symptoms can be miserable and leave children and adults alike bedridden for up to 2 weeks, the real risk of measles is the numerous complications that can occur and affect around 30% of all measles cases (CDC, 2020a). Risk factors for complications include the following:

  • Children under the age of five
  • Adults over the age of 20
  • Pregnancy
  • Compromised immune system (such as HIV or leukemia)(CDC, 2020a)

Common complications include ear infections and diarrhea, with around 10% of all measles cases experiencing one or both (CDC, 2020a). More serious complications often require hospitalization and may result in long-term disabilities or death. Serious complications include the following:

  • Hospitalization: Around 20% of unvaccinated measles cases require hospitalization.
  • Pneumonia: This complication is the most common cause of measles-related death in children. 1 in 10 children experiences this complication.
  • Encephalitis: This dangerous complication causes brain swelling, resulting in acute seizures or long-term disabilities such as permanent brain damage, learning disabilities, or deafness. 1 in every 1,000 children with measles experiences this complication.
  • Death: Up to 3 of every 1,000 children with measles will die from respiratory or neurological complications.
  • Pregnancy complications: Women who contract measles while pregnant are at an increased risk of miscarriage, premature birth, or low birth weight infants. Measles infection during pregnancy does not cause congenital disabilities in the fetus.
  • Subacute sclerosing panencephalitis (SSPE): This long-term complication is very rare but can be fatal. SSPE typically develops seven to 10 years after the initial measles infection from long-term inflammation and irritation to the brain. People infected with measles during the first two years of life are most at risk for developing SSPE, usually as teenagers. When measles was more widely circulated, only around seven to 11 of every 100,000 cases would result in SSPE later in life. With the current low levels of measles in the United States annually, SSPE is seldom reported. (CDC, 2020a)

Diagnosis and Treatment

It is important for any healthcare professionals working in pediatrics, urgent care, or emergency departments to be familiar with the symptoms and disease progression of measles and to keep it on their differential list when encountering patients with a high fever and rash. Patients should be asked about their vaccination status and recent travel, particularly to developing countries, as up to 90% of measles outbreaks in the United States can be traced back to recent international travel (CDC, 2020c).

If measles is suspected, laboratory confirmation is essential. Several laboratory tests are used to confirm a measles diagnosis- a respiratory swab for real-time polymerase chain reaction (RT-PCR) provides quick and specific results, and a serum sample can be assessed for immunoglobulin M (IgM) antibodies, indicating a current measles infection. The virus may also be present in urine samples. When possible, a respiratory swab and urine sample increase the chances of detecting the virus for diagnosis confirmation (CDC, 2020c).

When measles outbreaks occur, molecular analysis of confirmed samples helps map the virus's genetic data and link cases together. In the United States, all suspected and confirmed measles cases must be reported to state public health departments, which report to the CDC (CDC, 2020c).

Treatment for measles is entirely supportive as there is no antiviral for the disease. Fever reducers such as Tylenol or ibuprofen, antibiotics for secondary pneumonia or ear infections, and even a concentrated dose of Vitamin A may be indicated to reduce symptom severity. Hospitalization for additional supportive care such as IV fluids, oxygen support, or neurologic monitoring and treatment is indicated for severe cases. Immunoglobulin therapy is available after measles exposure for special populations (such as pregnant women, unvaccinated infants, and immune-compromised individuals) to prevent or lessen the severity of illness after exposure (Mayo Clinic, 2022).

Effects of Vaccine Hesitancy and Delays

Unfortunately, the success of the measles vaccine has met challenges as the MMR, in particular, is at the center of the anti-vaccine movement that gained traction in the 1990s. Vaccine hesitancy is not new; the Anti-Vaccination Society of America was founded in 1879. However, the availability of the internet and social media in recent years has provided an easily accessible platform and means of connection for vaccine-hesitant families to connect and feel more confident in their resistance (Schwartz, 2012).

In the 1990s, then-doctor Andrew Wakefield (whose medical license has since been revoked) headed a publication in The Lancet that claimed a direct link between the MMR vaccine and the development of autism in children. There were many problems with this publication, and swift legal action against the authors occurred (10 of the 13 withdrew their opinion). There have since been many additional studies and thousands of research dollars spent investigating this potential link with no evidence found. Thimerosal, a preservative used in multidose vials, was supposedly the culprit in autism development, and despite this connection being repeatedly disproved, it was removed from vaccines in the 1990s. Additionally, most MMR vaccines are now single-dose vials that need not be preserved once open (Barrows et al., 2015).

Despite the time and money spent disproving this theory, the damage has been done, and the risk of autism and other neurologically damaging side effects remains a common ideology, among others, for vaccine hesitancy (Barrows et al., 2015). Unfortunately, because of the high transmissibility rate of measles, maintaining around 95% vaccination rate of the general population is needed to prevent easy virus transmission and large outbreaks. Even small drops in routine adherence to the recommended vaccine schedule, particularly when concentrated within the same geographic area, can lead to quick and devastating consequences that are difficult to control (WHO, 2023b).

Nonadherence is important to understand, not only because of pockets of anti-vaccine groups that have been at the center of the United States measles outbreaks in recent years but also because of the effects of the COVID-19 pandemic on routine well-child visits and vaccination rates. Particularly at the beginning of the pandemic, much routine well-care was being delayed or completed virtually as shelter-in-place orders were implemented or people avoided going to healthcare facilities for fear of coronavirus exposure. Up to 70% of children experienced delays in routine vaccinations during the first few months of the pandemic (Ota et al., 2021).

Three years later, data indicates that many children were able to catch up and are back on track with their vaccines. However, the full extent of the delays is still unfolding, and specific populations remain at risk of being under-vaccinated. At-risk populations include families of low socioeconomic status or who are unvaccinated or underinsured, those with disabilities, immigrant families, and those in rural locations or with difficult access to healthcare (Ota et al., 2021). The WHO has expressed great concern that improved data assessment and catch-up campaigns are needed to identify at-risk populations and implement policies that will help return vaccination rates to their pre-pandemic rate and prevent the resurgence of measles (WHO, 2023b).

Case Study


Benjamin is a four-year-old male brought to the emergency department by his parents for chief complaints of a high fever, sore throat, and lethargy. His mother states he has had typical cold symptoms for 3-4 days now and slept for 13 hours the night before, which they hoped meant he would wake up rested and feeling better. Instead, he woke up crying and with an axillary temperature of 104°F.

Upon exam, the emergency department nurse practitioner noted rhinorrhea, injected sclera, and scattered red macules along the child's hairline. An exam of the pharynx reveals Koplik's spots. He is also noted to have an erythematous and bulging right tympanic membrane. Upon further questioning, the child's mother states another child was recently sent home sick from Benjamin's daycare with a bad rash and fever. This child had come home ill after visiting extended family in the Philippines. Benjamin's mother admits he is behind on his vaccinations, as he turned one just as the pandemic started. He has not been back to the pediatrician to catch up yet, as the mother planned to take him before he started kindergarten.


A respiratory swab and a serum draw are collected to assess for measles; both are positive. His lungs are clear, so a chest x-ray is not indicated. Vital signs are stable. He is prescribed an antibiotic for the secondary ear infection and sent home with instructions for supportive care and to follow up with his pediatrician in 2-3 days to reassess. Signs and symptoms that warrant concern and a return to the emergency department are reviewed. The case is reported to the public health department, which follows up with contact tracing and advice for isolating Benjamin at home.


The history information provided by the mother about Benjamin's ill peer and his recent travel, paired with Benjamin's unvaccinated status, made this diagnosis much more obvious. If the emergency department nurse practitioner had not had this information, the symptoms were still very early in their trajectory and not very obviously measles, especially with the rash starting at the hairline, the diagnosis may not have been accurate. This illustrates the importance of thorough history taking and being familiar with the signs and symptoms of measles and the progression of symptoms.


Strength: The rapid identification of this child's measles infection, supportive care, and frequent follow-up helped Benjamin fully recover with no complications other than the ear infection.

Weakness: The case of measles was reported to public health as it should have been. However, more information should have been gathered about Benjamin's family at home and their vaccination status or health risks. Benjamin's mother is in her first trimester of pregnancy but did not mention it because she was vaccinated for measles as a child and assumed she was immune. While this is likely true, she is still at high risk for complications of measles, such as miscarriage or premature birth. Further assessment of these risks and education regarding who Benjamin needs to isolate from were needed.

Ideally, Benjamin would also have been identified by vaccine catch-up campaigns as a child needing additional vaccines in the post-pandemic era.

Also, the initial case from Benjamin's preschool should have been reported so that other families from the preschool could be notified of the exposure to measles.


Though the incidence of measles has significantly decreased, it has not fully disappeared. Many patients are diagnosed with this disease yearly, and some succumb to this diagnosis. It is important that healthcare practitioners continue to monitor for this disease, being aware of the signs and symptoms and researching evidence-based practices.

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Implicit Bias Statement

CEUFast, Inc. is committed to furthering diversity, equity, and inclusion (DEI). While reflecting on this course content, CEUFast, Inc. would like you to consider your individual perspective and question your own biases. Remember, implicit bias is a form of bias that impacts our practice as healthcare professionals. Implicit bias occurs when we have automatic prejudices, judgments, and/or a general attitude towards a person or a group of people based on associated stereotypes we have formed over time. These automatic thoughts occur without our conscious knowledge and without our intentional desire to discriminate. The concern with implicit bias is that this can impact our actions and decisions with our workplace leadership, colleagues, and even our patients. While it is our universal goal to treat everyone equally, our implicit biases can influence our interactions, assessments, communication, prioritization, and decision-making concerning patients, which can ultimately adversely impact health outcomes. It is important to keep this in mind in order to intentionally work to self-identify our own risk areas where our implicit biases might influence our behaviors. Together, we can cease perpetuating stereotypes and remind each other to remain mindful to help avoid reacting according to biases that are contrary to our conscious beliefs and values.


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