Changes

March 2026 — minor update. Wording changed in the diagnosis section to clarify the use of HPT oral fluid kits as a surveillance tool, highlighting that the confirmation of diagnosis through laboratory infection is the responsibility of the clinician.

Update

Goals

To support primary healthcare professionals to:

• Determine the likelihood of measles based on clinical features, immunization history, and contact with measles infection.
• Notify the Health Protection Team of all cases of suspected measles.
• Confirm measles through laboratory testing.
• Give people with measles (or their carers) self-care advice.
• Encourage uptake of the combined measles, mumps, and rubella (MMR) vaccine where appropriate.
• Appropriately refer susceptible immunocompromised people, pregnant women and infants who have developed measles or been in contact with a person with measles for specialist management.
• Refer people with complications of measles with appropriate urgency.

Outcome measures

Audit criteria

QOF indicators

QIPP - Options for local implementation

No QIPP indicators were found during the review of this topic.

NICE quality standards

NICE has specified the following quality standards for feverish children, which may be relevant in measles.

NICE QS64 Fever in under 5s:

• Infants and children under 5 years with unexplained fever have their risk of serious illness assessed and recorded using the traffic light system.
• Infants and children under 5 years who are seen in person by a healthcare professional have their temperature, heart rate, respiratory rate and capillary refill time measured and recorded if fever is suspected.
• Parents and carers who are advised that they can care for an infant or child under 5 years with unexplained fever at home are given safety net advice, including information on when to seek further help.

[NICE, 2022]

What is it?

• Measles is a highly contagious infection caused by a morbillivirus of the paramyxovirus family.
  • Measles has a typical incubation period of about 10 days (with a range of 7 to 21 days), with a further 2–4 days of prodromal symptoms (including malaise, fever, and cough) before the characteristic skin rash develops. 
  • The person is infectious from when symptoms first appear (around four days before the rash appears) to four days after the onset of the rash. Measles is spread by direct contact with infectious droplets or by airborne transmission from breathing, coughing or sneezing. The virus can remain potentially infectious in the air for up to two hours after a person with measles has left.
  • It infects, via the respiratory tract, nearly all susceptible people who come into contact with it (on average, within a susceptible population, 15–20 people will be infected from a single case). Once infected, the person usually develops lifelong immunity.

  [Gershon, 2019; PHE, 2019a; PHE, 2019b; WHO, 2019; CDC, 2020]

How common is it?

• Prior to the introduction of the measles vaccine in 1968, measles was a common infection in the UK with annual notifications between 160,000 and 800,000, peaks every two years, and around 100 deaths annually. Around 80% of the population developed measles in childhood.
• Infections and deaths fell gradually after the introduction of the measles vaccine, and then were substantially reduced following the introduction of the measles, mumps and rubella (MMR) vaccine in 1988, and subsequent successful campaigns to achieve coverage levels above 90%.
  • All member states of the World Health Organization (WHO) European Region have a commitment to eliminating measles and rubella. The UK achieved elimination status in 2016 and 2017 (meaning the absence of endemic measles), but transmission was re-established in 2018.
  • In England and Wales, in 2019, prior to the COVID-19 pandemic, there were around 808 confirmed cases of measles, and 5 deaths, in England and Wales. Since 2000, all reported deaths have been in unvaccinated individuals.
• Globally, measles remains a significant cause of morbidity and death, with more than 140,000 deaths in 2018, mostly in children under the age of 5. A global partnership, the Measles and Rubella Initiative, was launched in 2001 to help countries globally work towards eradication of this disease. By 2019, prior to the pandemic, measles had resurged, however, with the highest number of cases since 1996, and deaths had increased by 50% from 2016. 
• The impact of the COVID-19 pandemic has been significant, and led to a significant reduction in confirmed measles cases in 2020 and 2021, due to a combination of social distancing, changed behaviours, and reduced seeking of health care. However, there has also been a significant drop in vaccine uptake and disruption to immunisation services globally. It is feared that this, and vaccine hesitancy, could lead to an escalation in cases and deaths. 
• In 2020, there were 79 confirmed cases in England and Wales (all in the first three months of the year), and provisional data suggests there were only 2 in 2021. It is likely these figures represent the unprecedented circumstances of the time rather than a trend.

[PHE, 2019b; PHE, 2019c; WHO, 2019; M&RI, 2020; PHE, 2021; Hübschen, 2022; UKHSA, 2022a; UKHSA, 2022b]

What are the complications?

• Complications of measles occur in 10–20% of people in developed countries, but the number may be much higher in developing countries. 
• Susceptibility to opportunistic infection is increased for a period of several weeks to months, and this effect may last up to three years after the person has recovered from measles, as the measles virus suppresses the reaction of the immune system to other pathogens.
• Many organ systems may be affected, but respiratory and gastrointestinal complications are the most common. 
• Secondary infections of the respiratory tract include: 
  • Otitis media (7–9% of cases).
  • Pneumonitis.
  • Tracheobronchitis.
  • Pneumonia (1–6% of cases).
• Central nervous system complications include: 
  • Convulsions (about 1 in 200 cases).
  • Encephalitis (about 1 in 1000 cases).
  • Subacute sclerosing panencephalitis (SSPE) — a rare but serious degenerative disease of the central nervous system involving seizures and a decline in motor, cognitive, and behavioural function. It affects about 1 in 25,000 people with measles. SSPE is 16 times more common in children who contract measles at a very young age (less than 1 year). SSPE occurs a median of 7 years after exposure to the virus, although it may occur as late as three decades afterwards, and is invariably fatal.
• Diarrhoea affects about 8% of cases and may cause dehydration. Stomatitis is another complication of the digestive tract.
• Blindness can result from measles keratoconjunctivitis or other ocular complications, and occurs mainly in children with vitamin A deficiency. Measles is a leading cause of childhood blindness globally.
• Complications of measles can be more severe in: 
  • Adults, who are more likely to develop complications than children.
  • Pregnant women, where it may result in miscarriage, premature birth, and intrauterine death and stillbirth (note: there is no evidence associating measles with congenital defects). Maternal deaths may also occur.
  • Immunocompromised people, who are at particular risk of developing severe and prolonged measles and complications such as viral pneumonitis. 
  • Chronically ill or malnourished children, who can experience more frequent and severe complications. 
  • Infants, who are more likely to require hospitalisation than older children and are at higher risk of pneumonia, otitis media, SSPE and mortality due to measles. 

[Mina, 2015; Bester, 2016; Rota et al, 2016; Gershon, 2019; PHE, 2019a; PHE, 2019b; CDC, 2020; Hübschen, 2022; Kondamudi, 2022; OVG, 2022]

What is the prognosis?

• Most people with measles make a full recovery with symptomatic management after around seven days of symptoms. 
• Death from measles is rare in developed countries, but there were more than 140,000 deaths from measles worldwide in 2018.
• In England and Wales there was one or no deaths per year from 2000-2017, increasing to 3 in 2018 and 5 in 2019, and one in 2020. All deaths since 2000 have been in individuals who were not vaccinated against measles.
• The case fatality ratio estimates globally for measles varies from 0.02% to 3%, or more, depending on the person's age, nutritional status, vaccine coverage, and healthcare availability. More than 95% of measles deaths occur in countries with low per capita income and limited healthcare infrastructure.

[Rota et al, 2016; Portnoy, 2019; WHO, 2019; OVG, 2022; UKHSA, 2022b]

Is measles preventable?

• Measles vaccination has had a significant effect on reducing measles cases and deaths, resulting in a 73% drop in measles deaths worldwide between 2000 and 2018.
• In the UK, there was an overall reduction in measles cases following introduction of the measles vaccine in 1968, but the most significant drop occurred after the measles, mumps, and rubella (MMR) vaccine was introduced in 1988. Since, coverage levels of more than 90% have been achieved and notifications of measles have since been at very low levels.
• All deaths in England and Wales since 2000 have been in unvaccinated individuals. 
• Two doses of the MMR provides optimal protection, although intravenous or intramuscular immunoglobin may be an option for some vulnerable individuals who have been exposed to measles [PHE, 2019d].

For more information on measles vaccination, see the CKS topic on Immunizations - childhood.

[PHE, 2019d; PHE, 2019b; WHO, 2019; UKHSA, 2022b]

How should I diagnose measles?

• Consider a diagnosis of measles in people presenting with a rash, fever, and other symptoms suggestive of measles.
  • Check the person's immunization history and whether they have previously had measles.
    • Measles is more likely in people who have not been fully immunized and have no history of measles infection.
    • The group most at risk are young adults.
  • Determine whether the person has had significant contact with a possible case of measles (that is, being in the same room for 15 minutes or more, or face-to-face contact, although in immunosuppressed individuals ANY level of contact should be assumed significant).
    • Consider contacting the local Health Protection Team (HPT) to understand if there are any local measles outbreaks.
    • Enquire if the person has recently travelled within the UK or to a country where measles is endemic.
    • Remember that measles is highly contagious from the onset of symptoms, which is usually some days before the rash appears. See the section on Definition for more information about spread.
  • Ask about and look for the presence of typical features of measles. Clinically typical measles presents with fever, usually of 39ºC or more without antipyretics, maculopapular rash, and at least one (and usually all three) of cough, coryzal symptoms, and conjunctivitis.
    • The prodromal phase occurs 10–12 days after contracting the infection and lasts for 2–4 days before the rash becomes apparent. Symptoms include increasing fever, malaise, cough, rhinorrhoea, and conjunctivitis. This latter symptom may help differentiate measles from other flu-like illnesses.
    • Fever increases during the prodromal phase to around 39ºC at about the time the rash appears, and then gradually decreases.
    • Koplik's spots may appear on the buccal mucosa at the end of the prodromal phase, a day or so before, or around the same time as the rash, and disappear over the next 2-3 days. These consist of 2–3 mm red spots with white or blue-white centres. These are pathognomonic for measles but can easily be confused with other mouth lesions.
    • The rash is erythematous and maculopapular and may become confluent as it progresses. It appears on the face and behind the ears first (when other symptoms tend to be at their most severe), before descending down the body to the trunk and limbs, and forming on the hands and feet last, over the course of about 3–4 days. The rash fades after it has been present on an area for about 5 days, with the total duration of rash being up to 1 week, after which time the person should feel better. There are images on the DermNet New Zealand website of the typical rash associated with measles.
    • Note that people with immunosuppression may not necessarily have a rash.
    • Timing as well as nature of symptoms may help in differentiating from other illnesses causing a rash.
  • Consider a different cause for the rash if the person is likely to have immunity to measles, clinical features are atypical, there is no history of contact with measles or travel to measles-endemic countries, and there are no local outbreaks.
  • In cases of measles in those who have been vaccinated or previously been infected (breakthrough or modified measles), sypmtoms may be mild and have a shorter duration, and there may not be the typical rash. Cases of breakthrough measles are relatively rare, and have lower infectivity.
  • If there is any suspicion of measles infection, immediately notify the local HPT. Measles is a notifiable disease.
    • Clinical diagnosis alone is unreliable and it is the repsonibility of the clinician that infection be confirmed by laboratory investigation (but notification should not await laboratory confirmation). 
    • Contact the HPT, who will send an oral fluid testing kit to the affected person for IgM/IgG and/or viral RNA testing. In England, the Colindale Virus Reference Department supplies each HPT with testing kits, reporting results to the person's GP and local HPT.
      • Note: the HPT oral fluid kit is for surveillance purposes only, not for clinical testing and diagnosis.
    • The requirement for notification is a statutory duty for surveillance purposes, so that post-exposure prophylaxis of vulnerable contacts (immunosuppressed, young, or pregnant) can be considered. Healthy contacts who have not been immunised do not usually benefit from post-exposure vaccination (other than for future exposure) but if they have been in contact with vulnerable individuals, this may need assessment by the HPT.
  • How to contact your local health protection team (HPT) in the UK: 
    • In England, you can find your local HPT contact details here.
    • In Northern Ireland, you can phone 0300 555 0114, or use the Public Health Agency contact information here. 
    • In Scotland, you can find your local HPT contact details from Public Health Scotland here.
    • In Wales, you can phone 0300 00 300 32 or find further information about the health protection team from Public Health Wales here.

What else may cause a measles-like rash?

• Other causes of rash are much more likely in people who have previously had measles or who have been fully immunized.
• Differential diagnoses include:
  • Parvovirus B19, the virus that causes fifth disease (erythema infectiosum, also known as slapped cheek syndrome). This is a mild self-limiting illness that, in addition to a bright red rash on the cheeks, may cause a red, lacy rash on the rest of the body which can be mistaken for measles, however, there are no Koplik's spots. Arthralgia and arthritis may occur in adults.
  • Streptococcal infection (for example scarlet fever) — can cause a maculopapular rash which appears on the abdomen and spreads to the back and limbs 12–48 hours following symptom onset. Sore throat is usually a prominent symptom, although a cough is generally not a feature. 'Strawberry tongue' (a white coating) may be visible.
  • Herpes virus type 6 (roseola infantum) — a mild illness which may be asymptomatic. Fever can last for 3–5 days after which a maculopapular rash appears (when clinical improvement has occurred).
  • Rubella — typically mild and presents with a rash which may be non-specific or maculopapular but not confluent. The rash usually starts behind the ears and on the face, and then spreads down the body (similar to measles). However, the infection is generally mild, and if fever is present it rarely occurs after the first day of the rash. There may be post-auricular and sub-occipital lymphadenopathy. Koplik's spots are not visible. 
  • Early meningococcal disease — may present with a maculopapular rash, but becomes purpuric in later stages, and does not fade when a glass is pressed against it. 
  • Infectious mononucleosis (glandular fever) — typically presents with a sore throat, malaise and fever. Rash is less common, affecting around 10%, although a maculopapular rash may occur in those treated with antibiotics for the sore throat.
  • Kawasaki disease — usually presents with a high fever, along with a widespread rash, bilateral dry conjunctivitis, inflammation of the lips and mouth (there may be a 'strawberry tongue'), red and swollen hands and feet, leading to peeling skin, and cervical lymphadenopathy. The rash usually starts non specifically on the extremities before spreading to involve the trunk.
• Other infectious differential diagnoses to consider, in people with a relevant history of travel, include Zika, Dengue, and Chikungunya.
• Drug reactions may also cause a rash which can appear similar to the rash associated with measles. 

Scenario: Management of measles

From birth onwards.

Search strategy

Scope of search

A literature search was conducted for guidelines, systematic reviews and randomized controlled trials on primary care management of acute measles.

Search dates

July 2017 - October 2022

Key search terms

Various combinations of searches were carried out. The terms listed below are the core search terms that were used for Medline.

• exp Measles/, exp Measles virus/, measles.tw

Sources of guidelines

• National Institute for Health and Care Excellence (NICE)
• Scottish Intercollegiate Guidelines Network (SIGN)
• Royal College of Physicians
• Royal College of General Practitioners
• Royal College of Nursing
• NICE Evidence
• World Health Organization
• Guidelines International Network
• TRIP database
• Agency for Healthcare Research and Quality
• National Health and Medical Research Council (Australia)
• Royal Australian College of General Practitioners
• British Columbia Medical Association
• Canadian Medical Association
• Alberta Medical Association
• Michigan Quality Improvement Consortium
• Singapore Ministry of Health
• National Resource for Infection Control
• RefHELP NHS Lothian Referral Guidelines
• Medline (with guideline filter)
• Driver and Vehicle Licensing Agency
• NHS Health at Work (occupational health practice)

Sources of systematic reviews and meta-analyses

• The Cochrane Library:
  • Systematic reviews
  • Protocols
  • Database of Abstracts of Reviews of Effects
• Medline (with systematic review filter)
• EMBASE (with systematic review filter)

Sources of health technology assessments and economic appraisals

• NIHR Health Technology Assessment programme
• The Cochrane Library:
  • NHS Economic Evaluations
  • Health Technology Assessments
• Canadian Agency for Drugs and Technologies in Health
• International Network of Agencies for Health Technology Assessment

Sources of randomized controlled trials

• The Cochrane Library:
  • Central Register of Controlled Trials
• Medline (with randomized controlled trial filter)
• EMBASE (with randomized controlled trial filter)

Sources of evidence based reviews and evidence summaries

• Drug and Therapeutics Bulletin
• TRIP database
• Central Services Agency COMPASS Therapeutic Notes

Sources of national policy

• Department of Health
• Health Management Information Consortium (HMIC)

Patient experiences

• Healthtalk
• BMJ - Patient Journeys

Sources of medicines information

The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.

• British National Formulary (BNF)
• electronic Medicines Compendium (eMC)
• European Medicines Agency (EMEA)
• Medicines and Healthcare products Regulatory Agency (MHRA)
• REPROTOX
• Scottish Medicines Consortium
• Stockley's Drug Interactions
• TERIS
• TOXBASE
• Micromedex
• UK Medicines Information

Stakeholder engagement

Our policy

The external review process is an essential part of CKS topic development. Consultation with a wide range of stakeholders provides quality assurance of the topic in terms of:

• Clinical accuracy.
• Consistency with other providers of clinical knowledge for primary care.
• Accuracy of implementation of national guidance (in particular NICE guidelines).
• Usability.

Principles of the consultation process

• The process is inclusive and any individual may participate.
• To participate, an individual must declare whether they have any competing interests or not. If they do not declare whether or not they have competing interests, their comments will not be considered.
• Comments received after the deadline will be considered, but they may not be acted upon before the clinical topic is issued onto the website.
• Comments are accepted in any format that is convenient to the reviewer, although an electronic format is encouraged.
• External reviewers are not paid for commenting on the draft topics.
• Discussion with an individual or an organization about the CKS response to their comments is only undertaken in exceptional circumstances (at the discretion of the Clinical Editor or Editorial Steering Group).
• All reviewers are thanked and offered a letter acknowledging their contribution for the purposes of appraisal/revalidation.
• All reviewers are invited to be acknowledged on the website. All reviewers are given the opportunity to feedback about the external review process, enabling improvements to be made where appropriate.

Stakeholders

• Key stakeholders identified by the CKS team are invited to comment on draft CKS topics. Individuals and organizations can also register an interest to feedback on a specific topic, or topics in a particular clinical area, through the Getting involved section of the Clarity Informatics website.
• Stakeholders identified from the following groups are invited to review draft topics:
  • Experts in the topic area.
  • Professional organizations and societies (for example, Royal Colleges).
  • Patient organizations, Clarity has established close links with groups such as Age UK and the Alzheimer’s Society specifically for their input into new topic development, review of current topic content and advice on relevant areas of expert knowledge.
  • Guideline development groups where the topic is an implementation of a guideline.
  • The British National Formulary team.
  • The editorial team that develop MeReC Publications.
• Reviewers are provided with clear instructions about what to review, what comments are particularly helpful, how to submit comments, and declaring interests.

Patient engagement

Clarity Informatics has enlisted the support and involvement of patients and lay persons at all stages in the process of creating the content which include:

• Topic selection
• Scoping of topic
• Selection of clinical scenarios
• First draft internal review
• Second draft internal review
• External review
• Final draft and pre-publication

Our lay and patient involvement includes membership on the editorial steering group, contacting expert patient groups, organizations and individuals.

Evidence exclusion criteria

Our policy

Scoping a literature search, and reviewing the evidence for CKS is a methodical and systematic process that is carried out by the lead clinical author for each topic. Relevant evidence is gathered in order that the clinical author can make fully informed decisions and recommendations. It is important to note that some evidence may be excluded for a variety of reasons. These reasons may be applied across all CKS topics or may be specific to a given topic.

Studies identified during literature searches are reviewed to identify the most appropriate information to author a CKS topic, ensuring any recommendations are based on the best evidence. We use the principles of the GRADE and PICOT approaches to assess the quality of published research. We use the principles of AGREE II to assess the quality of published guidelines.

Standard exclusions for scoping literature:

• Animal studies
• Original research is not written in English

Possible exclusions for reviewed literature:

• Sample size too small or study underpowered
• Bias evident or promotional literature
• Population not relevant
• Intervention/treatment not relevant
• Outcomes not relevant
• Outcomes have no clear evidence of clinical effectiveness
• Setting not relevant
• Not relevant to UK
• Incorrect study type
• Review article
• Duplicate reference

Organizational, behavioural and financial barriers

Our policy

The CKS literature searches take into consideration the following concepts, which are discussed at the initial scoping of the topic.

• Feasibility
  • Studies are selected depending on whether the intervention under investigation is available in the NHS and can be practically and safely undertaken in primary care.
• Organizational and Financial Impact Analysis
• Studies are selected and evaluated on whether the intervention under investigations may have an impact on local clinical service provision or national impact on cost for the NHS. The principles of clinical budget impact analysis are adhered to, evaluated and recorded by the author. The following factors are considered when making this assessment and analysis.
  • Eligible population
  • Current interventions
  • Likely uptake of new intervention or recommendation
  • Cost of the current or new intervention mix
  • Impact on other costs
  • Condition-related costs
  • In-direct costs and service impacts
  • Time dependencies
• Cost-effectiveness or cost-benefit analysis studies are identified where available. 

We also evaluate and include evidence from NICE accredited sources which provide economic evaluations of recommendations, such as NICE guidelines. When a recommended action may not be possible because of resource constraints, this is explicitly indicated to healthcare professionals by the wording of the CKS recommendation.

Declarations of interest

Our policy

Clarity Informatics requests that all those involved in the writing and reviewing of topics, and those involved in the external review process to declare any competing interests. Signed copies are securely held by Clarity Informatics and are available on request with the permission of the individual. A copy of the declaration of interest form which participants are asked to complete annually is also available on request. A brief outline of the declarations of interest policy is described here and full details of the policy is available on the Clarity Informatics website. Declarations of interests of the authors are not routinely published, however competing interests of all those involved in the topic update or development are listed below. Competing interests include:

• Personal financial interests
• Personal family interest
• Personal non-financial interest
• Non-personal financial gain or benefit

Although particular attention is given to interests that could result in financial gains or losses for the individual, competing interests may also arise from academic competition or for political, personal, religious, and reputational reasons. An individual is not obliged to seek out knowledge of work done for, or on behalf of, the healthcare industry within the departments for which they are responsible if they would not normally expect to be informed.

Who should declare competing interests?

Any individual (or organization) involved in developing, reviewing, or commenting on clinical content, particularly the recommendations should declare competing interests. This includes the authoring team members, expert advisers, external reviewers of draft topics, individuals providing feedback on published topics, and Editorial Steering Group members. Declarations of interest are completed annually for authoring team and editorial steering group members, and are completed at the start of the topic update and development process for external stakeholders.

Competing interests declared for this topic:

None.