• Seldom seen in infants less than five months of age (due to passively transferred protective maternal antibodies).
• High fever and toxic looking.
• Cough, Coryza and Conjunctivitis (the 3 C’s).
• Koplik’s spots appear during the febrile phase. These are 1 - 2 mm diameter whitish-grey spots surrounded by erythematous rings at the buccal mucosa opposite the molar teeth.
• The rash appears on the fourth or fifth day - first behind the ears, or over the eyelids, then spreading to the rest of the face and upper neck and then the rest of the body (centrifugal, top down).
• When the rash appears, the fever becomes higher and the child appears more ill. The fever lasts for another 3 - 4 days. The Koplik’s spots disappear by the second day of appearance of the rash.
• The rash fades after about five days but there is staining of the skin for days to weeks.
• Differential diagnoses of the rash can include :
  • Roseola infantum
  • Rubella
  • Other viral exanthem (ECHO, coxsackievirus, parvovirus B19, etc)
  • Kawasaki disease
  • Drug rash.

• Laboratory confirmation of measles MUST be attempted for all cases, preferably by serologic tests. A fourfold or greater increase in measles antibody titre in acute and convalescent serum specimens is diagnostic of measles.
• Immunofluorescence (IF) of cells from nasal exudates is useful for a rapid diagnosis (false positive results have been reported).
• Detection of specific IgM antibody is useful for the diagnosis of acute measles on one serum sample.
• Measles PCR available on research basis. This is rapid, diagnostic, specific (and sensitive if done within the 1st 4 days of rash onset) but costly.
• A chest X-ray should be done if respiratory symptoms and signs indicate pneumonitis, or a secondary bacterial pneumonia.

A legally notifiable disease in Singapore. Notify Ministry of Health (Form MD 131 or electronically via CD-LENS) not later than 72 hours from the time of diagnosis.

• Symptomatic measures: anti-pyretics, tepid sponging, cough suppressants and anti-histamines.
• Hospitalisation for treatment of complications.
• Oxygen should be provided for all individuals with measles who develop respiratory distress.
• Antibiotics (especially against Staphylococcus) are used when there is evidence of secondary bacterial infection e.g. raised total white counts.
• Intravenous immunoglobulin (polyclonal or measles-specific) and intravenous and/ or nebulised ribavirin have been used with success in some immunocompromised patients.
• Two doses of 200,000 IU (megadose) vitamin A given over 2 days to children with measles (especially hospitalised children) in areas with high case-fatality rates can reduce measles-related overall and pneumonia-specific mortality by 64-83%. This is not routine in Singapore.

• All pre-school children should be immunised against measles. Combined Measles/Mumps/Rubella (MMR) vaccine is given to all children between 12 and 15 months of age as part of the childhood immunisation programme in Singapore (see Appendix 2). Proof of vaccination is required for admissions to crèches, kindergartens and primary schools.
• The second dose of MMR vaccine is now given to all primary I school entrants at around 6 years of age. Infected children should stay away from school for one week after onset of rash. All unimmunised children at the nursery or kindergarten where the infection occurred should be immunised as soon as possible.
  (See section on post-exposure prophylaxis for management of measles exposure in Appendix 1.)
• All childhood vaccinations should be notified to the National Immunisation Registry, Health Promotion Board, and post-vaccination adverse reactions to the Pharmacovigilance Branch, Health Sciences Authority.