In 2018, 140,000 people, mostly children under five, died from measles—an improvement over previous years, but still tragic for an easily preventable disease. Weak public immunization systems in some conflict-affected countries and record-high numbers of displaced people living in close quarters continue to fuel outbreaks. Since 2006, Doctors Without Borders/Médecins Sans Frontières (MSF) has vaccinated nearly 26 million children against measles.
What causes measles?
Measles is caused by a virus which is so contagious that 90 percent of non-immune people who live with an infected person will catch it. It is transmitted via droplets from the nose, mouth, or throat of infected people, by coughing, sneezing, and breathing.
Malnourished children under five years of age are more likely to get severe measles. Those without enough vitamin A in their diets, such as in areas where rice is a main food staple, or those whose immune systems are weakened by HIV/AIDS or other diseases, are also especially vulnerable.
What are the symptoms of measles?
Symptoms appear between 10 and- 14 days after exposure to the virus and include runny nose, cough, eye infection, rash and high fever. A few days after symptoms appear, tiny white spots called Koplik spots may appear inside the mouth.
In some cases, measles causes serious and even fatal complications, including severe diarrhea, ear infection, pneumonia, blindness and encephalitis.
How can measles be prevented and controlled?
Routine measles vaccination for children, combined with mass immunization campaigns in countries with high infection rates and in response to outbreaks, are the linchpin of public health strategies to reduce measles deaths globally. Full immunity requires two vaccinations, with the timing of these doses dependent on where the child lives. Infants at high risk for catching measles—for example, those living in displaced person camps, living with HIV or exposed to an outbreak— should be given their first dose as early as 6 months of age.
Although the measles vaccine is safe and affordable, coverage remains low in countries with weak or disrupted health systems. The vaccine needs to be refrigerated until use and then delivered by injection, and it requires two doses—factors that make it difficult to provide in low-resource settings with hot climates and few trained health workers. Yet preventing outbreaks requires that at least 95% of the population is immune. And babies cannot be vaccinated until they are at least six months old, so every population has vulnerable people without immunity. Most people who survive measles or are vaccinated have lifelong immunity.
How is measles diagnosed?
Clinical diagnosis of measles requires a history of fever lasting at least three days, plus at least one of the "three Cs:" cough, catarrh (build-up of mucus in the nose or throat), conjunctivitis. Clusters of tiny white spots on the inside of the mouth, known as Koplik spots, are also a sign of measles.
To declare an outbreak, laboratory confirmation of diagnosis is required. In overcrowded or closed settings such as refugee and displaced person camps or orphanages, a single confirmed case of measles is considered an outbreak since the disease spreads so easily and quickly.
How can measles be treated?
There is no specific antiviral treatment for measles. Care involves isolating patients and treating them for complications, including a lack of vitamin A, eye-related problems, stomatitis (mouth ulcers), dehydration through diarrhea, protein deficiencies, and respiratory tract infections. Most people recover within two to three weeks, but up to 30 percent of people infected with measles in low-resource settings die from one or more of these complications.
How MSF responds
Vaccination is the best protection against measles. Even after the disease has started to spread, immunizing at-risk populations can still reduce the number of infections and deaths. MSF responds to the threat of measles epidemics by conducting mass vaccination campaigns for vulnerable children (about 80 percent of our measles vaccination activity) and providing routine vaccination as part of pediatric care, both in emergency settings and in areas where government immunization systems do not function. During outbreaks we also provide supportive care for infected children, to prevent complications from becoming fatal.
Outbreak response & prevention campaigns
Once there is a single case of measles in refugee settings, an outbreak is declared, and our teams swing into action to prepare a vaccination campaign. To keep vaccines cold for up to a day, often in sweltering temperatures, logistics workers fill coolers with ice packs and load them onto trucks, along with all the supplies necessary for vaccinating thousands of children each day. While community health workers spread the word with local leaders, nurses set up vaccination stations under trees or near schools. Any children already sick will be given treatment and, if necessary, transferred to a hospital. In the past ten years, MSF has done over 30 vaccination campaigns, the majority of them in Democratic Republic of Congo, Central African Republic, Sudan, Niger, Chad, and Nigeria—many of them among populations displaced by conflict.
Starting a campaign before the first case of measles dramatically reduces the chances of an epidemic. Part of MSF’s measles response is therefore to conduct mass vaccination campaigns in areas where coverage is low and chances of an outbreak are high. Alongside countries with chronically low coverage are conflict settings like Syria, where war has destroyed a once well-functioning health systems. This has caused vaccination coverage rates to plummet and triggered several outbreaks, including measles and even diseases like polio that had become almost unknown in Syria. A vaccine coverage survey done by MSF in Kobane (northern Syria) in June 2015 showed that only 17 percent of children were fully vaccinated. For this reason we have supported both routine immunization and vaccination campaigns in Syria since we began working there after war broke out in 2011.
Though children should be fully vaccinated against measles by the time they're 12 months old, this often doesn’t happen in fragile contexts where government vaccination programs don’t reach everyone or have been disrupted. This makes “catch-up” vaccination important in many settings. For example, in refugee camps we often see that even older children get measles. In response, we may expand our vaccination activities to include children up to age 15.
During outbreaks and in our pediatric outpatient clinics and hospitals, our teams deliver medical care to children with measles, especially those who are also malnourished and therefore more likely to become severely ill. Since measles has no cure, the focus is on preventing dehydration, monitoring fever and managing complications, which include eye and ear infections and pneumonia. Children also receive vitamin A supplements, which reduce measles deaths by as much as 50 percent.
Supporting routine vaccination for children is the most effective way to prevent measles infections and epidemics. MSF has built measles vaccination into most of our programs that provide pediatric care in hospitals, primary care clinics, and malnutrition programs. For example, in camps for people displaced by Boko Haram in Maiduguri, Nigeria — where many of the children suffer from severe malnutrition — we run mobile clinics that provide medical screenings and care, as well as preventive treatments like measles vaccination and seasonal malaria chemoprevention to all the children we see.
MSF is involved in advocating for new measles vaccines that are easier to use in low-resource regions. Developing a heat-stable vaccine that doesn’t need refrigeration, or one which doesn’t require injection, will be essential in expanding immunization coverage and protecting more children from this deadly infection.
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