Measles: A Reemerging Threat to Women’s Health

Measles, or rubeola, is a highly contagious viral infection caused by a single-stranded RNA virus of the family Paramyxoviridae. The clinical disease due to this virus was described over a millennium ago. It is one of the most contagious diseases known to man, and it is known to remain contagious for 2 hours after an infected person has evacuated the area. Through the efforts of Drs. Maurice Hillerman, Ruth Kirschstein, and many other dedicated scientists, a safe and effective measles vaccine became available in the 1960s. In 1972, the live attenuated measles vaccine became a part of the measles-mumps- and -rubella, or “MMR” vaccine. Endemic measles was declared eliminated in the United States in 2000 and in the Americas in 2015. ¹

Dr. Marohl and colleagues at the University of Kansas have analyzed the serostatus of their patients in a publication in this edition of the Journal of Women’s Health. ² They found that 16.4% of their cohort was seronegative to measles, although immune to rubella. And vice versa, 5.3% were seronegative for rubella and immune to measles. Their population was women seeking care for infertility at a single clinical site. Most of their patients gave a history of prior vaccination. The authors conclude that seropositivity for rubella does not conclusively prove that these women are concurrently seropositive for measles. There was “poor agreement beyond chance that rubella immunity confers rubeola immunity.”

Measles has considerable morbidity and mortality in pregnant people. There were measles outbreaks in the late 1980s and early 1990s in the United States, and there were multiple publications about pregnancy and measles during that time frame. In one case series, there was 3% maternal mortality. ³ Measles infection during pregnancy is also associated with preterm delivery and other adverse fetal and neonatal outcomes, such as stillbirth. Measles has reemerged in multiple locations, including western Kansas, the population of this study. While we were writing this editorial, a second pediatric measles death was reported in Texas. Previously, no child in the United States had died from measles in the past two decades.

It is likely that measles will become endemic again in the United States and possibly in Canada. We would recommend that women’s health care providers and all other providers who care for the pregnant population review clinical protocols to prevent the detrimental effects of measles in their communities. The Centers for Disease Control and Prevention and the American College of Obstetricians and Gynecologists have online resources about measles and pregnancy. ^4,5 Two doses of the measles-mumps-rubella vaccine are recommended during childhood, one at 12–15 months and a second one at ages 4–6. A history of vaccination should be documented during clinical encounters with reproductive-age women, pregnant and nonpregnant. Linkages to state immunization registries should be established with existing electronic medical records systems to improve the accuracy of vaccination records. Additionally, practitioners should empower their patients to access and retain their own copies of vaccination records. Unvaccinated, nonpregnant people should receive the MMR vaccine. Given that the MMR vaccine is a live attenuated vaccine, it is contraindicated during pregnancy. Therefore, it is important to discuss and administer this vaccine as indicated during the preconception or postpartum period.

Clinicians and other health care staff should also be familiar with infection control protocols for suspected measles cases. Given that measles is spread through contact with infectious respiratory droplets and can become airborne, isolation and proper personal protective equipment are cornerstones to stop nosocomial spread. Nurses, midwives, and physicians should be familiar with diagnostic testing for measles and protocols for reporting cases to local public health officials. There are clinical guidelines for post-exposure prophylaxis, including the special circumstances for susceptible pregnant people and exposed newborns. ⁶

The reemergence of measles is an immediate threat to the health of women and their families. The work by Dr. Marohl et al. shows that a substantial portion of our patients may be at risk for the deleterious effects of this pathogen.