Incubation period is 8-14 days. Starts with a prodrome of cough, coryza, conjunctivitis and fever lasting 2-6 days. Then the rash appears: brick red, maculopapular, starts behind ears, spreads from face on to trunk and then everywhere including palms/soles. Discrete spots may then coalesce. With time the rash may darken (“stain”) and may desquamate. The child is typically irritable – compare other common childhood rashes.

Koplik’s spots are pathognomic but easily missed as they appear early in the illness, disappearing within a few days of the rash starting. They are grey or white spots on the buccal mucosa opposite the 2nd molars.

Case definition is rash 3+ days, fever, cough, conjunctivitis or coryza plus diagnostic lab result. Diagnosis is by throat swab (or urine) for PCR. Send blood for IgG/M too.


  • Check vulnerable contacts eg unvaccinated, immunosuppressed but also infants and pregnant women. There is not an explicit definition for close contact. Ideally vaccination should be offered within 3 days.
    • Pregnant vaccinated women should be fine, if in doubt do rapid antibody levels, give HNIG (Human Normal Immunoglobulin, NOT MMR) if necessary, repeat serology at 3/52.
    • Infants under 6/12 should get HNIG, unless mother has had natural measles (or born before 1970!). Else MMR, unless 6-8/12 old and a household contact or high risk.
  • Respiratory protective equipment should be worn when caring for confirmed or suspected cases viz FFP3 respirator.

[HPN Scottish Guidance Dec 2013]


Measles now endemic again in England and many European countries, with cases increasing year on year with only a slight reversal during lockdown. Before vaccines, pretty much inevitable part of childhood.

Andrew Wakefield in 1998 didn’t help – no immediate problem with his false paper (due to herd immunity), first death not until 2006, at which point rate 13x higher than pre-Wakefield. Vaccine hesitancy continues to be one of the biggest global health challenges of our time.

Measles after MMR occurs 7-14 days post-vaccination. Very rare after booster. Tends to be mild fever, rash and conjunctivitis.

Porto Outbreak

March-April 2018, 96 confirmed cases in a hospital in Porto, Portugal. Mostly vaccinated Health care workers!!!

Atypical presentations – mac-pap rash only, low fever.

Chances of an “escape variant” not covered by vaccine almost zero.