Lack of diverse training, nonspecific symptoms leave physicians challenged to identify measles

Key takeaways:

• Measles cases have reached historic highs in recent years.
• Experts detailed how to spot the disease and the importance of vaccination.

A combination of several factors makes it tough for providers to identify measles cases as the disease makes a comeback, according to experts.

Measles cases have continuously increased in recent years. Both globally and in the United States, there has been a well-documented rise in cases that has an inverse relationship to vaccination status.

In 2019, cases hit a 23-year high with 207,000 global illnesses, and although cases dropped in 2020, 22 million infants did not receive their first vaccine doses because of the COVID-19 pandemic. The next year, a record 40 million children missed either the first or second dose of their recommended measles vaccine.

In 2022, measles deaths increased by about 40%. In 2023, researchers reported more than 320,000 global cases of measles — an 88% increase from the previous year. And in 2024, the trends show no sign of stopping. In fact, almost one-third of all U.S. measles cases reported since 2020 were seen in the first quarter of this year alone, threatening the country’s measles elimination status.

As of Oct. 10, there have been 14 outbreaks, and 267 total cases of measles have been reported in 32 states, according to the CDC. Of these, 88% were unvaccinated or their vaccination status was unknown, 41% were aged younger than 5 years and 40% were hospitalized.

“It is really important for primary care providers to be able to identify measles since it is highly contagious and can lead to serious complications,” Krutika Kuppalli, MD, FIDSA, an associate professor in the Division of Infectious Diseases, Department of Medicine and the Peter O’Donnell Jr. School of Public Health at the University of Texas Southwestern, told Healio. “Being able to identify cases early and reporting to public health allows public health agencies to respond with appropriate quarantine and vaccination measures to prevent further spread.”

Educating providers on measles is especially important, “given changes to population-based immunity and our increasingly more connected world,” Kuppalli, who is also a Healio Primary Care Peer Perspective Board Member, said.

However, PCPs can run into major challenges when diagnosing the disease.

Rarity, education, nonspecific symptoms

Despite the recent surging numbers, many PCPs, pediatricians and other physicians have not often seen measles cases, which can make them much tougher to catch, Peter Hotez, MD, PhD, FASTMH, FAAP, co-director of Texas Children’s Hospital Center for Vaccine Development and dean of Baylor College of Medicine’s National School of Tropical Medicine, told Healio.

“Even someone like me trained in pediatric infectious diseases in the late 1980s, early 1990s has not seen a lot of measles, and when I have it's mostly because of my global health work,” Hotez said.

Additionally, many educational materials feature images of measles in white children.

“The rash which causes measles can be harder to see on persons with brown or black skin,” Kuppalli said. “It can also be due to other things such as lack of training and less experience on the part of health care providers in caring for persons of color who have dermatologic manifestations.”

Nonspecific symptoms that could indicate a number of diseases can also make measles tough to spot.

People typically begin developing and showing symptoms 1 to 2 weeks after initial contact with the virus, Kuppalli said. These first symptoms include:

• cough;
• high fever;
• Koplik spots (white spots inside the cheeks);
• runny nose;
• sore throat; and
• watery, red eyes.

Roughly 3 to 5 days after the first symptoms present, “a nonpruritic macular erythematous rash develops typically on the face and extending to the neck, torso, arms, legs and feet,” Kuppalli said.

Even with the characteristic rash, these symptoms can be attributed to a number of other health issues. So, she said “it’s important to triangulate clinical symptoms with a good history” like recent travel, exposure to someone else with rash and fever and vaccination history.

“It can look like many other infections such as rubella, mpox, chicken pox, parvovirus B-19, dengue, scarlet fever and many others,” Kuppalli said. “The biggest difficulty in diagnosing measles is for physicians to consider it as part of the differential diagnosis in a person who presents with rash and fever.”

Hotez noted that today, many providers might consider conditions like COVID-19 before measles.

As a result, when a patient comes in with an unknown rash, he said it is important that providers keep measles in the back of their mind, “particularly if they know the child is not vaccinated or boosted.”

Vaccination

Hotez and Kuppalli emphasized the importance of vaccination in measles prevention because of the disease’s highly transmissible nature.

“Ensuring people are appropriately vaccinated helps them from contracting the disease and therefore spreading it,” Kuppalli said. “It is important to remember that persons of all ages can get infected — not just kids — and to ensure vaccine status is up to date with current guidelines.”

Kuppalli referred to data from the WHO that underscored this point. The organization has estimated that between 2000 and 2022, the measles vaccine has prevented 57 million deaths.

Hotez said keeping vaccination rates up is key, “since measles is often one of the first breakthrough childhood infections we see when” they drop.

“Sadly, the anti-vaccine activism that accelerated during the COVID-19 pandemic may now be spilling over to childhood immunizations,” he said.

Hotez referenced a recent Gallup poll, which reported that just 40% of Americans believe childhood vaccination to be extremely important. (In 2019, that number was 58%, and in 2001, it was 64%.) It is critical to “to find ways to counter these new trends and prevent further immunization declines,” he said.

“The consequences go beyond the U.S., as anti-vaccine activism is now globalizing even to low- and middle-income countries,” he added. “If this happens, our entire global ecosystem will be at risk, and we could even reverse 20 years of progress of the Gavi alliance.”

But conversations with patients who are hesitant about vaccination could help shift this trend.

In a previous interview with Healio, William Schaffner, MD, a professor of preventive medicine and infectious diseases at Vanderbilt University Medical Center, discussed how to navigate conversations with vaccine-hesitant patients within the context of recent outbreaks.

“Don't express alarm, don't diss the patient in any way or make them feel uncomfortable or inappropriate for having asked the question,” he said. “Acknowledge that you have heard the patient and that these sorts of questions are actually rather common. ... That puts the patient at ease, and then the conversation can continue.”

He said then that, in these conversations, PCPs should go beyond information to try and influence the patient’s attitude toward vaccinations.

“It's not how they think about a problem, it's how they feel about a problem,” Schaffner said. “When I, as an internist, deal with patients, I immediately become very self-referential. I say, 'You know, I've been vaccinated, and so [has] my wife.' So what I'm doing in that context, those words, are trying to make vaccination the social norm. The goal is to reduce the anxiety and make people feel comfortable with getting vaccinated. That, more than statistics, will play a role.”

References:

• Far fewer in U.S. regard childhood vaccinations as important. Available at: https://news.gallup.com/poll/648308/far-fewer-regard-childhood-vaccinations-important.aspx. Published Aug. 7, 2024. Accessed Oct. 15, 2024.
• Measles cases and outbreaks. Available at: https://www.cdc.gov/measles/data-research/index.html. Updated Oct. 11, 2024. Accessed Oct. 11, 2024.
• WHO. Measles. Available at: https://www.who.int/news-room/fact-sheets/detail/measles. Published July 2, 2024. Accessed Oct. 15, 2024.