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id.measles.v1PRODUCTION
id.measles.v1

Measles (rubeola) — primary measles + pneumonia + ADEM + SSPE + atypical immunocompromised + immune amnesia + post-exposure prophylaxis + MMR vaccination eligibility

infectious_diseaseacutesubacutechronicadultpediatricpregnancygeriatricneonatal
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12/12 authored

Canonical 12-phase frame with authored status for this dossier.

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Frame

Detailed

Measles spectrum: primary measles (rubeola — 10-12 d incubation + 2-4 d prodrome + cephalocaudal rash + Koplik spots) + complications (pneumonia, otitis, croup, diarrhea, keratitis, ADEM) + SSPE (latent 7-10 yr, uniformly fatal) + atypical measles (immunocompromised) + immune amnesia (1-3 yr post-measles increased infection vulnerability) + post-exposure prophylaxis (MMR within 72 h immunocompetent ≥ 12 mo; IVIG within 6 d high-risk) + MMR vaccination eligibility (2-dose 12-15 mo + 4-6 yr routine; adult catch-up; 6-11 mo early-dose for travel + outbreak) (Moss Lancet 2017 PMID 28673424; Moss Lancet 2017 PMID 28673424)

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Measles phenotype framed (primary / pneumonia / ADEM / SSPE / atypical / post-exposure / vaccination eligibility) and public-health-emergency posture activated

Patient inputs (19)

Age stratifies Vitamin A dose (200,000 IU ≥ 12 mo; 100,000 IU at 6-11 mo; 50,000 IU < 6 mo per WHO + CDC), PEP eligibility (MMR ≥ 12 mo immunocompetent; IVIG < 12 mo), SSPE risk (~ 1 / 600 if primary measles < 12 mo per post-elimination cohorts), and vaccination schedule (12-15 mo + 4-6 yr routine; 6-11 mo early-dose for outbreak/travel) (Imdad Cochrane 2010 PMID 21154399; Bellini PNAS 2005)

MMR dose history + serology if needed determines susceptibility status, PEP decisions (MMR vs IVIG), and future vaccination scheduling; adults born ≥ 1957 should have documented vaccination or immunity evidence (McLean MMWR 2013 PMID 23760231; CDC ACIP)

Index case + exposure timing (within 72 h MMR PEP; within 6 d IVIG PEP; > 6 d surveillance only) + outbreak context (multiplies pre-test 10-50× for any febrile rash); secondary attack rate ~ 90% in unvaccinated susceptible household contacts (CDC ACIP; Moss Lancet 2017)

Pregnancy + susceptible exposure → IVIG within 6 d (MMR contraindicated — live attenuated); maternal mortality elevated especially with measles pneumonia; teratogenicity controversial in measles (much less established than rubella); maternal-fetal medicine consult; postpartum MMR planning (ACOG; AAP Red Book 2024)

Fever ≥ 39 °C (often 40-40.5 °C) + systemic toxicity in measles prodrome / rash phase; persistent or new fever spike post-rash = bacterial superinfection suspicion (AAP Red Book 2024)

Cephalocaudal pattern (hairline → face → trunk → extremities) + 3 C's prodrome + Koplik spots + outbreak context → near-pathognomonic clinical diagnosis (Moss Lancet 2017 PMID 28673424)

Contagious 4 d before rash to 4 d after rash onset — defines contact-tracing window (4 d back + 4 d forward) + airborne isolation duration (until 4 d after rash onset for home isolation outpatient) (CDC ACIP; AAP Red Book 2024)

IgM serology ~ 95% sensitivity at 3-30 d post-rash; LR+ very high; may be falsely negative in first 3 d of rash + in vaccine-modified disease — RT-PCR preferred in those scenarios (CDC ACIP; AAP Red Book 2024)

RT-PCR (throat / NP / urine swab) — LR+ > 100; specificity ~ 100%; sensitive in first 7-10 d after rash; preferred in outbreak setting + vaccine-modified disease + immunocompromised + early-rash scenarios where IgM may be negative (CDC ACIP)

Acute encephalopathy / seizures / focal deficits within 2 wk of rash = ADEM; subacute neurologic decline 7-10 yr post measles = SSPE; both life-threatening; empiric IV acyclovir for ADEM pending HSV PCR (AAP Red Book 2024; Tunkel IDSA encephalitis 2008; Bellini PNAS 2005)

SpO2 < 94% in measles + cough / dyspnea / new infiltrates → measles pneumonia (primary viral OR bacterial superinfection); empiric ceftriaxone + vancomycin per IDSA HAP/CAP guidance (AAP Red Book 2024; IDSA/ATS CAP 2019)

HIV (CD4 < 200), transplant (within 1 yr OR ongoing immunosuppression), chemo (cycle nadir), high-dose chronic steroid (≥ 20 mg prednisone-equivalent × ≥ 1 mo), autoimmune on biologic — all raise atypical-presentation risk (giant-cell pneumonia; persistent shedding) + high mortality; MMR contraindicated (live attenuated) so IVIG is PEP option (AAP Red Book 2024; AAP Red Book 2024)

Baseline + serial during IV acyclovir empiric (for ADEM differential pending HSV PCR) for crystalline nephropathy monitoring; dose-adjust if AKI; baseline for IVIG renal monitoring (PEP for high-risk susceptible) (FDA labels)

Procalcitonin > 0.25 ng/mL in measles + new fever spike / focal consolidation → bacterial superinfection — empiric ceftriaxone + vancomycin (IDSA/ATS CAP 2019)

LP + CSF cell count + protein + glucose + measles PCR + HSV PCR + VZV PCR + bacterial culture + Gram stain if ADEM / encephalitis; ADEM = lymphocytic pleocytosis + mildly elevated protein + normal glucose; SSPE = CSF measles IgG elevated with elevated CSF:serum IgG index (Bellini PNAS 2005; Tunkel IDSA encephalitis 2008)

CXR if respiratory features — measles pneumonia (primary viral = diffuse interstitial infiltrates; bacterial superinfection = focal consolidation); guides empiric antibiotic decision (AAP Red Book 2024; IDSA/ATS CAP 2019)

MRI for ADEM (white-matter lesions especially periventricular + subcortical) vs HSV encephalitis (temporal-lobe / limbic predilection — must distinguish, HSV is treatable medical emergency); SSPE (diffuse white-matter changes) (AAP Red Book 2024; Tunkel IDSA encephalitis 2008; Bellini PNAS 2005)

EEG burst-suppression pattern in subacute neurologic decline 7-10 yr post measles supports SSPE diagnosis (Bellini JID 2005 PMID 16235165)

CBC typically shows leukopenia + lymphopenia in primary measles; leukocytosis suggests bacterial superinfection — drives empiric antibiotic threshold (AAP Red Book 2024)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (10)

10 need judgement
  • informationallife_threateningmeasles_pneumonia_severe
    Measles pneumonia with respiratory distress (SpO2 < 94% OR new bilateral infiltrates OR mechanical ventilation requirement) — life-threatening; admit (ICU if respiratory failure); supportive O2 ± ventilation; empiric ceftriaxone + vancomycin for bacterial superinfection (especially MRSA, S. aureus, S. pneumoniae, S. pyogenes, H influenzae) per cross-route to pulm.cap.core.v1; continue Vitamin A pediatric (AAP Red Book 2024; IDSA/ATS CAP 2019; IDSA HAP/VAP 2016)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningmeasles_encephalitis
    Measles ADEM / acute postinfectious encephalitis (altered mental status, seizures, focal deficits within 2 wk of rash) — life-threatening; admit ICU; LP + CSF studies + MRI brain + EEG; empiric IV acyclovir 10 mg/kg q8h (adult) or 60 mg/kg/d divided q8h (neonate) pending HSV PCR (HSV is the major treatable mimic; do NOT delay); steroids controversial (high-dose IV methylprednisolone considered per neurology, evidence weak); ribavirin NOT effective for measles ADEM; ID + neuro consult; ~ 15% mortality + ~ 25% permanent neuro sequelae per CDC (AAP Red Book 2024; Tunkel IDSA encephalitis 2008)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningmeasles_in_immunocompromised
    Immunocompromised patient (HIV CD4 < 200, transplant within 1 yr OR ongoing immunosuppression, chemo nadir, chronic high-dose steroid, primary immunodeficiency) with measles — life-threatening; atypical presentation possible (atypical rash patterns + giant-cell pneumonia + persistent shedding); high mortality (~ 10-30%); admit + ID consult + supportive + bacterial co-empirics + ribavirin off-label considered per ID (data weak — case-series only; NO FDA-approved antiviral for measles); MMR CONTRAINDICATED in severe immunocompromise (live attenuated) so IVIG is PEP option (AAP Red Book 2024; AAP Red Book 2024; IDSA)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningsspe_features_subacute_neurologic_decline
    Subacute neurologic decline 7-10 yr post primary measles — cognitive decline + behavioral change + myoclonic jerks + ataxia + seizures + eventual vegetative state → SSPE (subacute sclerosing panencephalitis); life-threatening / uniformly fatal within 1-3 yr; diagnosis = clinical + EEG burst-suppression + elevated CSF measles IgG with elevated CSF:serum IgG index + MRI white-matter changes; NO curative therapy (intraventricular interferon-α + isoprinosine + ribavirin combinations explored — at best slow progression); palliative care + family education + neurology + ID consult; ~ 1 / 10,000-100,000 measles cases overall (~ 1 / 600 in primary measles < 12 mo per post-elimination cohorts); most powerful argument for universal MMR vaccination — SSPE 100% preventable by vaccination (Bellini JID 2005 PMID 16235165; Bellini JID 2005 PMID 16235165; AAP Red Book 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveremeasles_diagnosis_immediate_public_health_notification
    ANY suspected/confirmed measles case → IMMEDIATE notification of state/local public health (do NOT wait for laboratory confirmation) + airborne isolation (negative-pressure room with N95 PPE) + outbreak investigation + contact tracing (4 d before rash + forward 4 d after rash); every measles case is a notifiable disease per CDC + state law (CDC ACIP; state notifiable-disease law)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveremeasles_in_pregnancy_susceptible
    Susceptible pregnant patient (any trimester) exposed to measles within 6 d — IVIG 0.5 g/kg IV (max 15 g); if active disease, treat per phenotype (supportive + bacterial co-empirics if pneumonia + maternal-fetal medicine consult); MMR CONTRAINDICATED in pregnancy (live attenuated); maternal mortality elevated especially with measles pneumonia; teratogenicity controversial but less established than rubella; postpartum MMR planning (ACOG; CDC ACIP; AAP Red Book 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveremeasles_in_infant_under_12mo
    Infant < 12 mo with measles exposure OR active disease — severe; IVIG 0.5 g/kg IV (max 15 g) within 6 d of exposure (MMR not routinely given < 12 mo; early-dose MMR at 6-11 mo for international travel + outbreak, counts as dose 0); if active disease → admit + Vitamin A age-adjusted (50,000 IU < 6 mo, 100,000 IU at 6-11 mo) + supportive + bacterial co-empirics if pneumonia features; admit threshold low; SSPE risk sharply higher in primary measles < 12 mo (~ 1 / 600 per post-elimination cohorts per Bellini JID 2005 PMID 16235165) (CDC ACIP; AAP Red Book 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateimmune_amnesia_post_measles
    ALL measles survivors → 1-3 yr increased infection vulnerability per Mina Science 2019 PMID 31672891 (measles infection wipes out 11-73% of pre-existing antibody repertoire to other pathogens) → catch-up vaccination of all previously-incomplete routine vaccinations + close monitoring + lower threshold for empiric antibiotics in febrile illness in measles survivors (Mina Science 2019)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmildpost_exposure_prophylaxis_susceptible_contact
    Susceptible contact (no documented vaccination + no documented immunity + no prior measles disease) with measles exposure → PEP decision; within 72 h → MMR 0.5 mL SC for susceptible immunocompetent ≥ 12 mo (NOT pregnant, NOT severely immunocompromised); within 6 d → IVIG 0.5 g/kg IV (max 15 g) for susceptible high-risk (immunocompromised, pregnant, infant < 12 mo); > 6 d → surveillance only (CDC ACIP; AAP Red Book 2024; ACOG)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmildvitamin_a_indicated_all_pediatric_measles_cases
    ALL pediatric measles cases (any age < 18 yo, especially < 5 yo where mortality reduction is largest) regardless of nutritional status → Vitamin A 200,000 IU PO day 1 + day 2 (≥ 12 mo); 100,000 IU at 6-11 mo; 50,000 IU < 6 mo; third dose 2-4 wk later in clinical vitamin-A deficiency or severe protein-energy malnutrition; reduces mortality ~ 30-50% + complications (pneumonia, croup, diarrhea, corneal ulceration) per WHO + multiple Cochrane meta-analyses (Imdad Cochrane 2010 PMID 21154399; D'Souza Cochrane 2002 PMID 21154399; WHO 2024; AAP Red Book 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

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Recommended regimen

Measles supportive care + universal Vitamin A pediatric + empiric bacterial co-therapy for superinfection + empiric IV acyclovir for ADEM differential + ribavirin off-label for immunocompromised atypical measles
axis: measles_supportive_and_vitamin_a_and_empiric_co_therapystep vitamin_a_universal_pediatric - Vitamin A universal for ALL pediatric measles cases regardless of nutritional status (WHO + CDC)
Selected step "Vitamin A universal for ALL pediatric measles cases regardless of nutritional status (WHO + CDC)" — Pediatric measles case (any age < 18 yo; especially < 5 yo where mortality reduction is largest); regardless of nutritional status
  • vitamin_a_retinol
    first line
    fat_soluble_vitamin
    200,000 IU PO day 1 + day 2 (≥ 12 mo); 100,000 IU PO day 1 + day 2 (6-11 mo); 50,000 IU PO day 1 + day 2 (< 6 mo); third dose 2-4 wk later in clinical vitamin-A deficiency or severe protein-energy malnutrition • PO • day 1 + day 2
    triggers: pediatric_measles_any_age
    Reduces measles mortality ~ 30-50% in pediatric cohorts regardless of nutritional status (Imdad Cochrane 2010 PMID 21154399; D'Souza Cochrane 2002 PMID 21154399; WHO 2024; AAP Red Book 2024)
    rxcui 11246

outpatient playbook — drug actions (8)

  1. 1. Vitamin A (pediatric universal)
    200,000 IU PO day 1 + day 2 (≥ 12 mo); 100,000 IU at 6-11 mo; 50,000 IU < 6 mo • PO • day 1 + day 2
    trigger: Pediatric measles case
    Universal per WHO + CDC regardless of nutritional status
  2. 2. acetaminophen (fever / pain)
    Pediatric 10-15 mg/kg/dose q4-6h PRN (max 75 mg/kg/d); adult 500-1000 mg q6h PRN (max 4 g/d) • PO • q4-6h PRN
    trigger: Fever or pain
    AVOID aspirin (Reye syndrome risk like varicella per AAP)
  3. 3. MMR vaccine (PEP susceptible immunocompetent ≥ 12 mo within 72 h)
    0.5 mL SC • SC • single dose within 72 h of exposure
    trigger: Susceptible immunocompetent contact ≥ 12 mo within 72 h of exposure; NOT pregnant; NOT severely immunocompromised
    CDC ACIP; AAP Red Book 2024 — may modify or prevent disease
  4. 4. IVIG (PEP susceptible high-risk within 6 d)
    0.5 g/kg IV (max 15 g) • IV • single dose within 6 d of exposure
    trigger: Susceptible high-risk contact (immunocompromised, pregnant, infant < 12 mo) within 6 d of exposure
    CDC ACIP; AAP Red Book 2024; ACOG
  5. 5. MMR vaccine (routine pediatric 2-dose schedule)
    0.5 mL SC × 2 doses • SC • Dose 1 at 12-15 mo; dose 2 at 4-6 yr
    trigger: Routine pediatric immunization
    McLean MMWR 2013 PMID 23760231; 97% efficacy after 2 doses; 93% after 1 dose
  6. 6. MMR vaccine (early-dose 6-11 mo travel/outbreak)
    0.5 mL SC × 1 dose • SC • Single early dose at 6-11 mo for international travel or outbreak response — counts as dose 0; standard 2-dose schedule continues at 12-15 mo + 4-6 yr
    trigger: International travel or outbreak response at age 6-11 mo
    CDC ACIP — early-dose modifies / prevents disease in travel + outbreak context; does NOT count toward standard 2-dose schedule
  7. 7. MMR vaccine (adult catch-up)
    0.5 mL SC × 1 or 2 doses • SC • Adults born ≥ 1957 without documented vaccination or immunity → 1 dose; high-risk (HCW, students, international travelers, outbreak contacts) → 2 doses 4-8 wk apart
    trigger: Adult catch-up + high-risk indication
    McLean MMWR 2013 + CDC ACIP — CONTRAINDICATED in pregnancy + severe immunocompromise (live attenuated)
  8. 8. catch-up immunizations for measles survivors (immune amnesia)
    Per ACIP / institutional schedule • per vaccine • 1-3 yr post-measles
    trigger: Measles survivor — catch-up vaccination of all previously-incomplete routine vaccinations (pediatric or adult)
    Mina Science 2019 PMID 31672891 — immune amnesia 1-3 yr post-measles; catch-up vaccination of all previously-incomplete routine vaccinations + close monitoring + lower threshold for empiric antibiotics in febrile illness

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Prodrome 2-4 d: cough + coryza + conjunctivitis (the 3 C's) + fever ≥ 39 °C (often 40-40.5 °C) + malaise — measles prodrome (Moss Lancet 2017 PMID 28673424; AAP Red Book 2024); Koplik spots — clustered grayish-white papules on red base on buccal mucosa opposite molars (pathognomonic; transient 12-72 h before rash; easily missed) (Moss Lancet 2017; AAP Red Book 2024); Maculopapular rash beginning at hairline / behind ears / face → caudal spread (cephalocaudal) over 3 d → confluent → desquamates with hyperpigmentation (Moss Lancet 2017; AAP Red Book 2024).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Measles (rubeola) — primary measles + pneumonia + ADEM + SSPE + atypical immunocompromised + immune amnesia + post-exposure prophylaxis + MMR vaccination eligibility** (id.measles.v1).
Phenotype framing: Primary measles vs rubella (separate togavirus; milder + lymphadenopathy + TORCH-teratogenic in pregnancy — distinguished by serology), scarlet fever (sandpaper rash + strawberry tongue + recent strep — distinguished by rapid strep), roseola (fever then rash AFTER defervescence; HHV-6/7), drug eruption (no Koplik, no prodrome, recent drug exposure), Kawasaki disease (5+ d fever + extremity changes + coronary aneurysm risk), dengue (retro-orbital + thrombocytopenia + geographic exposure), erythema infectiosum (parvovirus B19 — slapped cheek + lace pattern), enteroviral exanthem, mononucleosis (EBV) with ampicillin-induced rash. Measles ADEM vs HSV encephalitis (HSV temporal-lobe predilection + HSV PCR positive; empiric IV acyclovir for both pending PCR). SSPE vs other progressive neurodegenerative disorders in young (history of early-life primary measles + EEG burst suppression + CSF measles IgG with elevated CSF:serum IgG index). Atypical measles (vaccine-modified or immunocompromised) vs other viral exanthem (PCR + IgM serology; outbreak context) (Moss Lancet 2017; AAP Red Book 2024)
Scope: Measles spectrum: primary measles (rubeola — 10-12 d incubation + 2-4 d prodrome + cephalocaudal rash + Koplik spots) + complications (pneumonia, otitis, croup, diarrhea, keratitis, ADEM) + SSPE (latent 7-10 yr, uniformly fatal) + atypical measles (immunocompromised) + immune amnesia (1-3 yr post-measles increased infection vulnerability) + post-exposure prophylaxis (MMR within 72 h immunocompetent ≥ 12 mo; IVIG within 6 d high-risk) + MMR vaccination eligibility (2-dose 12-15 mo + 4-6 yr routine; adult catch-up; 6-11 mo early-dose for travel + outbreak) (Moss Lancet 2017 PMID 28673424; Moss Lancet 2017 PMID 28673424)

No severity triggers fired against current inputs.

Plan

Regimen axis: **Measles supportive care + universal Vitamin A pediatric + empiric bacterial co-therapy for superinfection + empiric IV acyclovir for ADEM differential + ribavirin off-label for immunocompromised atypical measles** — step "Vitamin A universal for ALL pediatric measles cases regardless of nutritional status (WHO + CDC)".
1. vitamin_a_retinol 200,000 IU PO day 1 + day 2 (≥ 12 mo); 100,000 IU PO day 1 + day 2 (6-11 mo); 50,000 IU PO day 1 + day 2 (< 6 mo); third dose 2-4 wk later in clinical vitamin-A deficiency or severe protein-energy malnutrition PO day 1 + day 2 (fat_soluble_vitamin, first line) — Reduces measles mortality ~ 30-50% in pediatric cohorts regardless of nutritional status (Imdad Cochrane 2010 PMID 21154399; D'Souza Cochrane 2002 PMID 21154399; WHO 2024; AAP Red Book 2024)

Setting playbook (outpatient) — Manage uncomplicated immunocompetent measles in child / adult on supportive care + Vitamin A pediatric + airborne isolation at home until 4 d after rash onset; PEP for susceptible contacts (MMR within 72 h immunocompetent ≥ 12 mo; IVIG within 6 d high-risk); vaccination reconciliation (routine pediatric 12-15 mo + 4-6 yr; adult catch-up; early-dose 6-11 mo travel/outbreak); immune-amnesia post-measles surveillance for 1-3 yr (catch-up vaccination + close monitoring + lower threshold for empiric antibiotics in febrile illness) (CDC ACIP; AAP Red Book 2024; Mina Science 2019)
2. Vitamin A (pediatric universal) 200,000 IU PO day 1 + day 2 (≥ 12 mo); 100,000 IU at 6-11 mo; 50,000 IU < 6 mo PO day 1 + day 2 — Pediatric measles case (Universal per WHO + CDC regardless of nutritional status)
3. acetaminophen (fever / pain) Pediatric 10-15 mg/kg/dose q4-6h PRN (max 75 mg/kg/d); adult 500-1000 mg q6h PRN (max 4 g/d) PO q4-6h PRN — Fever or pain (AVOID aspirin (Reye syndrome risk like varicella per AAP))
4. MMR vaccine (PEP susceptible immunocompetent ≥ 12 mo within 72 h) 0.5 mL SC SC single dose within 72 h of exposure — Susceptible immunocompetent contact ≥ 12 mo within 72 h of exposure; NOT pregnant; NOT severely immunocompromised (CDC ACIP; AAP Red Book 2024 — may modify or prevent disease)
5. IVIG (PEP susceptible high-risk within 6 d) 0.5 g/kg IV (max 15 g) IV single dose within 6 d of exposure — Susceptible high-risk contact (immunocompromised, pregnant, infant < 12 mo) within 6 d of exposure (CDC ACIP; AAP Red Book 2024; ACOG)
6. MMR vaccine (routine pediatric 2-dose schedule) 0.5 mL SC × 2 doses SC Dose 1 at 12-15 mo; dose 2 at 4-6 yr — Routine pediatric immunization (McLean MMWR 2013 PMID 23760231; 97% efficacy after 2 doses; 93% after 1 dose)
7. MMR vaccine (early-dose 6-11 mo travel/outbreak) 0.5 mL SC × 1 dose SC Single early dose at 6-11 mo for international travel or outbreak response — counts as dose 0; standard 2-dose schedule continues at 12-15 mo + 4-6 yr — International travel or outbreak response at age 6-11 mo (CDC ACIP — early-dose modifies / prevents disease in travel + outbreak context; does NOT count toward standard 2-dose schedule)
8. MMR vaccine (adult catch-up) 0.5 mL SC × 1 or 2 doses SC Adults born ≥ 1957 without documented vaccination or immunity → 1 dose; high-risk (HCW, students, international travelers, outbreak contacts) → 2 doses 4-8 wk apart — Adult catch-up + high-risk indication (McLean MMWR 2013 + CDC ACIP — CONTRAINDICATED in pregnancy + severe immunocompromise (live attenuated))
9. catch-up immunizations for measles survivors (immune amnesia) Per ACIP / institutional schedule per vaccine 1-3 yr post-measles — Measles survivor — catch-up vaccination of all previously-incomplete routine vaccinations (pediatric or adult) (Mina Science 2019 PMID 31672891 — immune amnesia 1-3 yr post-measles; catch-up vaccination of all previously-incomplete routine vaccinations + close monitoring + lower threshold for empiric antibiotics in febrile illness)

Non-pharmacologic actions:
- Home airborne isolation until 4 d after rash onset (CDC contagious window: 4 d before to 4 d after rash)
- STAT public health notification (state/local public health department) on clinical suspicion — outbreak investigation + contact tracing
- Family + household exposure assessment + PEP for susceptible contacts (MMR within 72 h immunocompetent ≥ 12 mo; IVIG within 6 d high-risk)
- School / workplace exclusion until 4 d after rash onset
- Hydration counseling + return precautions for dehydration, new respiratory symptoms, new neuro features
- Immune-amnesia surveillance plan for 1-3 yr post-measles — close monitoring + lower threshold for empiric antibiotics in febrile illness + catch-up vaccination of all previously-incomplete routine vaccinations
- Vaccination reconciliation at every visit until 2-dose MMR series complete + adult catch-up complete + high-risk catch-up complete
- Outpatient ophthalmology follow-up if keratitis suspected (Vitamin A-responsive corneal ulceration)
- Outpatient neurology + neuropsychology + rehabilitation if post-ADEM (~ 15% mortality + ~ 25% permanent neuro sequelae)
- Outpatient palliative + neurology + ID if SSPE
- Public health reporting through outbreak resolution; cross-state coordination if travel-associated case

AVOID / contraindication checks:
- Mmr contraindicated pregnancy live attenuated (CDC ACIP; AAP Red Book 2024)
- Mmr contraindicated severe immunocompromise live attenuated (CDC ACIP; AAP Red Book 2024)
- Mmr febrile seizure 1 in 1500 to 3000 doses benign counsel (CDC; FDA label)
- Mmr itp 1 in 30000 to 40000 doses usually self limited counsel (CDC; FDA label)
- Mmr egg allergy NOT a contraindication revised acip 2010 (CDC ACIP)
- Ivig renal failure warning monitor creatinine (FDA label)
- Ivig hemolytic anemia warning monitor CBC (FDA label)
- Ivig thromboembolic events warning especially in elderly and immobilized (FDA label)
- Ivig anaphylaxis iga deficiency screen first dose monitor (FDA label)
- Vitamin a cumulative toxicity 200000iu single dose below toxic threshold but monitor cumulative exposure (WHO 2024; FDA label)
- Vitamin a teratogenicity pregnancy DO NOT use high dose in pregnant (WHO 2024; FDA label)
- Acyclovir iv hydration prevent crystalline nephropathy 1.5 to 2x maintenance (FDA label)
- Acyclovir dose adjust aki Cr x 1.5 2 q12h Cr x 2 3 q24h (FDA label)
- Airborne isolation negative pressure room N95 PPE for all suspected measles (CDC)
- Home isolation until 4d after rash onset contagious window 4d before to 4d after (CDC)
- Immediate public health notification on clinical suspicion do not wait for labs (CDC; state notifiable disease law)
- Avoid aspirin in pediatric measles reye syndrome risk (AAP Red Book 2024; FDA label)
- Ribavirin off label only id consult driven data weak not routine (AAP Red Book 2024; AAP Red Book 2024)
- Ribavirin teratogenicity category x contraindicated pregnancy (FDA label)
- Ribavirin hemolytic anemia monitor cbc (FDA label)
- Steroids controversial in measles adem high dose iv methylprednisolone considered per neurology evidence weak (AAP Red Book 2024)
- Ceftriaxone vancomycin empiric for bacterial superinfection cross route pulm cap core v1 (IDSA/ATS CAP 2019)
- Vancomycin AUC target not trough (IDSA 2020 vancomycin consensus — AUC/MIC 400 600)
- Vitamin a corneal ulceration third dose 2 4wk later if clinical deficiency (WHO 2024)

Monitoring

Regimen monitoring:
- STAT public health notification + airborne isolation + outbreak investigation (contact tracing 4 d before rash + 4 d after rash) — TIME-CRITICAL, do NOT wait for lab confirmation
- Daily reassessment of respiratory + neuro + dehydration + skin status
- IgM serology + RT-PCR confirmation (PCR preferred in vaccine-modified + immunocompromised + early-rash scenarios)
- Serial creatinine + UOP during IV acyclovir empiric (for ADEM differential pending HSV PCR) — crystalline nephropathy prevention
- Serial creatinine + CBC + electrolytes during IVIG PEP — renal + hemolytic + thromboembolic surveillance per FDA label
- Procalcitonin trend if antibiotics started — bacterial superinfection differential
- CSF reassessment if ADEM not improving — consider HSV / VZV / bacterial differential; routine repeat LP not typical but per neurology if concern
- EEG + MRI surveillance in SSPE — progression monitoring; family + neurology + ID
- Immune-amnesia surveillance 1-3 yr post-measles — catch-up vaccination of all previously-incomplete routine vaccinations + close monitoring + lower threshold for empiric antibiotics in febrile illness (Mina Science 2019)
- Vaccination tracking: routine pediatric 2-dose schedule audit (12-15 mo + 4-6 yr); adult catch-up tracked to completion; early-dose MMR (6-11 mo) does not count toward standard 2-dose schedule
- Airborne isolation expiry: 4 d after rash onset for home isolation outpatient; hospital airborne isolation duration per institutional policy
- Family + caregiver education on return precautions + immune-amnesia surveillance + catch-up vaccination + 2-dose MMR schedule
- School / workplace exclusion until 4 d after rash onset; reporting to school health authorities if institutional cluster
- Public health follow-up through outbreak resolution; cross-state coordination if travel-associated case

Setting (outpatient) monitoring:
- Rash resolution + desquamation 7-10 d
- Fever resolution 48-72 h after rash onset
- Immune-amnesia surveillance 1-3 yr
- Vaccination tracking: MMR dose 2 at 4-6 yr (pediatric routine) OR 4-8 wk after dose 1 (adult catch-up)
- Post-ADEM: neurology + functional assessment + serial imaging
- Post-SSPE: palliative care + family education + neurology + ID; progression to vegetative state + death within 1-3 yr

Follow-up plan: Post-measles: immune-amnesia surveillance for 1-3 yr — catch-up vaccination of all previously-incomplete routine vaccinations + close monitoring + lower threshold for empiric antibiotics in febrile illness in measles survivors (Mina Science 2019 PMID 31672891); routine pediatric vaccinations re-administered if pre-measles immunity is impaired. Post-pneumonia: respiratory recovery + lung function; ID follow-up if immunocompromised. Post-ADEM: neurology + neuropsychology + rehabilitation; ~ 15% mortality + ~ 25% permanent neuro sequelae; serial imaging + functional assessment. Post-SSPE: palliative care + family education + neurology + ID; progression to vegetative state + death within 1-3 yr. Vaccination reconciliation: MMR 2-dose pediatric schedule audit; adult catch-up; early-dose MMR for travel + outbreak; high-risk catch-up (HCW, students, international travelers, outbreak contacts). Family education + contact tracing if institutional outbreak; public health reporting through resolution.
- Close-out criterion: Follow-up + immune-amnesia surveillance + vaccination plan + family education delivered

Monitoring phase: Outpatient: rash resolution 7-10 d (cephalocaudal pattern desquamates with hyperpigmentation); fever should resolve 48-72 h after rash onset; return precautions for new respiratory / neuro / dehydration features; isolation until 4 d after rash onset; immune-amnesia surveillance 1-3 yr (catch-up vaccination + close monitoring + lower threshold for empiric antibiotics in febrile illness). Inpatient / ICU: daily reassessment of respiratory + neuro status; serial creatinine + UOP for IV acyclovir + IVIG monitoring; procalcitonin trend if antibiotics started; CSF reassessment if ADEM not improving (consider HSV / VZV / bacterial differential). SSPE: palliative + family + neurology + ID; progression monitoring (EEG, MRI, functional assessment). Vaccination tracking: routine pediatric 2-dose schedule audit (12-15 mo + 4-6 yr); adult catch-up tracked to completion; early-dose MMR (6-11 mo) does not count toward standard 2-dose schedule which continues at 12-15 mo + 4-6 yr.

Disposition

Current setting: outpatient — Manage uncomplicated immunocompetent measles in child / adult on supportive care + Vitamin A pediatric + airborne isolation at home until 4 d after rash onset; PEP for susceptible contacts (MMR within 72 h immunocompetent ≥ 12 mo; IVIG within 6 d high-risk); vaccination reconciliation (routine pediatric 12-15 mo + 4-6 yr; adult catch-up; early-dose 6-11 mo travel/outbreak); immune-amnesia post-measles surveillance for 1-3 yr (catch-up vaccination + close monitoring + lower threshold for empiric antibiotics in febrile illness) (CDC ACIP; AAP Red Book 2024; Mina Science 2019)

Disposition criteria:
- Sustained recovery — rash resolved + airborne isolation expired (4 d after rash onset) + vaccination plan in progress + family education delivered + immune-amnesia surveillance plan + outpatient follow-up scheduled with sub-specialty as indicated

Escalation triggers (move to higher acuity):
- New respiratory distress / SpO2 < 94% → urgent ED + CXR + IV acyclovir empiric + IV antibiotics if bacterial superinfection features
- New neuro signs / seizures → urgent ED + MRI + LP + IV acyclovir empiric (HSV differential)
- Dehydration with inability to maintain oral intake → urgent ED + IV fluids
- Persistent fever > 48-72 h after rash onset → suspect bacterial superinfection → re-evaluate
- Subacute neurologic decline 7-10 yr post-measles → neurology + ID + SSPE evaluation (EEG + MRI + CSF measles IgG with intrathecal antibody index)
- Immune-amnesia surveillance: febrile illness in measles survivor 1-3 yr post-measles → lower threshold for empiric antibiotics + work-up other infections

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Measles pneumonia with respiratory distress (SpO2 < 94% OR new bilateral infiltrates OR mechanical ventilation requirement) — life-threatening; admit (ICU if respiratory failure); supportive O2 ± ventilation; empiric ceftriaxone + vancomycin for bacterial superinfection (especially MRSA, S. aureus, S. pneumoniae, S. pyogenes, H influenzae) per cross-route to pulm.cap.core.v1; continue Vitamin A pediatric (AAP Red Book 2024; IDSA/ATS CAP 2019; IDSA HAP/VAP 2016)
- [LIFE_THREATENING] Measles ADEM / acute postinfectious encephalitis (altered mental status, seizures, focal deficits within 2 wk of rash) — life-threatening; admit ICU; LP + CSF studies + MRI brain + EEG; empiric IV acyclovir 10 mg/kg q8h (adult) or 60 mg/kg/d divided q8h (neonate) pending HSV PCR (HSV is the major treatable mimic; do NOT delay); steroids controversial (high-dose IV methylprednisolone considered per neurology, evidence weak); ribavirin NOT effective for measles ADEM; ID + neuro consult; ~ 15% mortality + ~ 25% permanent neuro sequelae per CDC (AAP Red Book 2024; Tunkel IDSA encephalitis 2008)
- [LIFE_THREATENING] Immunocompromised patient (HIV CD4 < 200, transplant within 1 yr OR ongoing immunosuppression, chemo nadir, chronic high-dose steroid, primary immunodeficiency) with measles — life-threatening; atypical presentation possible (atypical rash patterns + giant-cell pneumonia + persistent shedding); high mortality (~ 10-30%); admit + ID consult + supportive + bacterial co-empirics + ribavirin off-label considered per ID (data weak — case-series only; NO FDA-approved antiviral for measles); MMR CONTRAINDICATED in severe immunocompromise (live attenuated) so IVIG is PEP option (AAP Red Book 2024; AAP Red Book 2024; IDSA)

Citations

- CDC ACIP — MMR Vaccination + Measles Surveillance (current 2024-2025) + CDC Measles Outbreak Response (current 2024-2025) + AAP Red Book current edition (2024 + 2026 floor) Measles chapter + WHO Measles Guidelines 2024 (universal Vitamin A regardless of nutritional status) + Moss Lancet 2017 measles review (PMID 28673424) + Mina Science 2019 immune amnesia (PMID 31672891) + Bellini J Infect Dis 2005 SSPE incidence (PMID 16235165) + McLean MMWR 2013 ACIP MMR/rubella/mumps (PMID 23760231) + Imdad Cochrane 2010 Vitamin A supplementation 6mo-5yr (PMID 21154399) + Tunkel IDSA encephalitis 2008 empiric IV acyclovir + IDSA/ATS CAP 2019 bacterial superinfection + ACOG Practice Advisory Measles in Pregnancy [PMID:31672891](https://pubmed.ncbi.nlm.nih.gov/31672891/)
- Cited evidence (PMID 28673424) [PMID:28673424](https://pubmed.ncbi.nlm.nih.gov/28673424/)
- Cited evidence (PMID 16235165) [PMID:16235165](https://pubmed.ncbi.nlm.nih.gov/16235165/)
- Cited evidence (PMID 23760231) [PMID:23760231](https://pubmed.ncbi.nlm.nih.gov/23760231/)
- Cited evidence (PMID 21154399) [PMID:21154399](https://pubmed.ncbi.nlm.nih.gov/21154399/)

Last reconciled with current guidelines: 2026-05-22.
References
  • CDC ACIP — MMR Vaccination + Measles Surveillance (current 2024-2025) + CDC Measles Outbreak Response (current 2024-2025) + AAP Red Book current edition (2024 + 2026 floor) Measles chapter + WHO Measles Guidelines 2024 (universal Vitamin A regardless of nutritional status) + Moss Lancet 2017 measles review (PMID 28673424) + Mina Science 2019 immune amnesia (PMID 31672891) + Bellini J Infect Dis 2005 SSPE incidence (PMID 16235165) + McLean MMWR 2013 ACIP MMR/rubella/mumps (PMID 23760231) + Imdad Cochrane 2010 Vitamin A supplementation 6mo-5yr (PMID 21154399) + Tunkel IDSA encephalitis 2008 empiric IV acyclovir + IDSA/ATS CAP 2019 bacterial superinfection + ACOG Practice Advisory Measles in Pregnancy — PMID:31672891
  • Cited evidence (PMID 28673424) — PMID:28673424
  • Cited evidence (PMID 16235165) — PMID:16235165
  • Cited evidence (PMID 23760231) — PMID:23760231
  • Cited evidence (PMID 21154399) — PMID:21154399