Measles: A Public Health Victory and a Renewed Population Health Challenge

Jason Fisher, MSN, APRN, FNP-BC, NI-BC, CPHQ

Measles, a highly contagious viral illness that can cause severe complications and death. Before widespread vaccination, measles was endemic in the United States (US). In 2000, the US declared measles eliminated, meaning that there was no continuous year-round transmission within the country (Mathis et al., 2024). However, elimination does not mean zero cases of measles, as imported measles can and still does occur and trigger outbreaks. 

Prior to the existence of the measles vaccine, it was estimated that up to 500 people died and 48,000 were hospitalized each year in the US (Centers for Disease Control and Prevention [CDC], 2025). Since 2000, vaccination rates have fallen while measles cases and outbreaks have climbed across the country and in Ohio in pockets of under vaccination, increasing the risk of outbreaks and a return to sustained transmission.

Who Remains at Risk and Why

While vaccination is highly effective at preventing measles, two groups remain vulnerable: (1) people who cannot be vaccinated for medical reasons and (2) people who decline vaccination.  

• Medical contraindications can include profound immunosuppression or chronic immune thrombocytopenic purpura (Papaevangelou, 2021); these individuals rely heavily on herd immunity for protection.
• Vaccine hesitancy and refusal is often driven by fear and misinformation, which can be influenced by information sources and trust in health systems (Ashkenazi et al., 2020). 
• Concern about febrile seizures is common, though febrile seizures have been reported only in one out of every 3,000 to 4,000 cases and are not associated with an increased risk for recurrent seizures or epilepsy (Papaevangelou, 2021). 

Epidemiological Definitions

• Incidence is the rate of new cases of symptomatic measles infections (Porche, 2023). The numerator is the number of new cases, and the denominator is all individuals in the population during the time period (Porche, 2023). 
• Prevalence is the rate of new and existing cases of measles infections (Porche, 2023). The numerator is the number of cases of measles present, and the denominator is all individuals in the population during the time period (Porche, 2023). Prevalence is considered a factor of the incidence and the duration of the disease (Porche, 2023). 
• A case is defined by a case definition that includes the components of person, place and time along with clinical signs, symptoms, laboratory data, and exposure information (Porche, 2023). Exclusion criteria may also be used (CDC, 2024).
• An outbreak is defined by the CDC (2024) as when there are more cases than expected within a given time, within a specified geographic location, or target population. 
• Endemic disease is defined as the persistent presence of an infectious agent within a population or geographic area (CDC, 2024).
• Herd immunity refers to the protection that occurs when a certain number of people in a region are immune to an infectious disease (Harvard Health Publishing, n.d.). 

Measles Essentials

• Measles (rubeola) is one of the most contagious infectious diseases, with an estimated ~90% secondary infection rate (Chen, 2025).
• Humans are the only natural host; there are no known animal reservoirs.
• Transmission: respiratory droplets and direct contact with respiratory secretions (e.g., coughing/sneezing).
• Higher-risk groups include children with immunodeficiencies, people traveling to areas with higher measles rates, and infants who lose passive maternal antibodies before routine immunization (Chen, 2025).
• Typical clinical course:
• Early symptoms: the “3 C’s” — cough, coryza, conjunctivitis (upper-respiratory infection-like)
• Then: fever, followed by a maculopapular rash 2–4 days after fever onset (Misin et al., 2020)
• Rash pattern: starts on the face → spreads to trunk and extremities over 3–5 days → resolves within about 7 days
• Koplik spots: small white-blue spots on buccal mucosa 1–2 days before rash; pathognomonic
• Complications: otitis media, pneumonia, encephalitis, and death.
• Management: primarily supportive care (hydration, prevention/management of secondary bacterial infection); vaccination is the best prevention (Misin et al., 2020).

Measles Vaccination Summary

• In the US, measles protection is provided through the measles, mumps, and rubella (MMR) vaccine, and a combined MMR vaccine with varicella (MMRV) is an option for some children.
• Two doses are recommended, the first at 12-15 months and the second at 4-6 years before school entry (CDC, 2021). Effectiveness is approximately 93% after the first dose and 97% after the second dose (Misin et al., 2020; Quach et al., 2022).
• The first U.S. measles vaccine was licensed in 1963; measles was declared eliminated in the U.S. in 2000 (Quach et al., 2022).

Incidence and Outbreaks

• Globally reported measles cases increased sharply from 2022 to 2023, with incidence rising from 28 to 91 cases per one million population and the number of large or disruptive outbreaks also increased (Minta et al., 2024). 
• In the US, CDC surveillance reported 800 confirmed measles cases across 25 states as of April 17, 2025 (CDC, 2025). 
• In Ohio, 32 cases were reported across six counties as of April 16, 2205 (DataOhio, 2025). 

Possible Implications of Seroprevalence (Antibody Titers)

Because measles is usually short in duration, prevalence estimates are less commonly reported than vaccination coverage and seropositive studies. Seroprevalence studies measure immunoglobulin G (IgG) titers to estimate population immunity:

• In a large German adult sample, seroprevalence of anti-measles IgG exceeded 97% among adults born before 1965 but was below 90% in adults born later (Friedrich et al, 2021). 
• In a highly MMR-vaccinated population sample in Minnesota, only 53% had positive titers, raising questions about waning immunity and the importance of maintaining high coverage and community-level protection (Quach et al., 2022). 

Implications for Healthcare Quality Professionals

Healthcare quality professionals can plan an important enabling role by supporting reliable vaccination workflows, early identification, and safe management of suspected cases. Quality teams are well positioned to translate public health guidance into practical clinical processes:

• Support vaccination as a core safety and population health strategy (e.g., improve reminders/recall, reduce missed opportunities, and monitor coverage by clinic, school or neighborhood). 
• Partner with clinicians to address hesitancy through consistent messaging and trust-building, and by proactively correcting common myths (e.g., febrile seizure risk) (Ashkenazi et al., 2020, Papaevangelou, 2021; Tuckerman et al., 2022). 
• Ensure triage and infection prevention processes align with current CDC guidance for suspected measles (CDC, 2024). 
• Use multilingual signage and educational materials in combination with culturally competent care to support patients and families to promote vaccination and reduce delays in identification of infection (CDC, 2024). 

References

Ashkenazi, S., Livni, G., Klein, A., Kremer, N., Havlin, A., & Berkowitz, O. (2020). The relationship between parental source of information and knowledge about measles/measles vaccine and vaccine hesitancy. Vaccine, 38(46), 7292–7298. https://doi.org/10.1016/j.vaccine.2020.09.044

Centers for Disease Control and Prevention. (2024). Outbreaks and case definitions. https://www.cdc.gov/urdo/php/surveillance/outbreak-case-definitions.html

Centers for Disease Control and Prevention. (2024). Interim infection prevention and control recommendations for measles in healthcare settings. https://www.cdc.gov/infection-control/hcp/measles/index.html

Centers for Disease Control and Prevention. (2025). Measles cases and outbreaks. https://www.cdc.gov/measles/data-research/index.html#cdc_data_surveillance_section_2-what-to-know-about-measles

Chen, S. (2025, Apr 15). Measles. Medscape. https://emedicine.medscape.com/article/966220-overview#a3

DataOhio. (2025). Summary of infectious diseases in Ohio. https://data.ohio.gov/wps/portal/gov/data/view/summary-of-infectious-diseases-in-ohio?visualize=true

Freidrich, N., Poethko-Müller, C., Kuhnert, R., Matysiak-Klose, D., Koch, J., Wichmann, O., Santibanez, S., & Mankertz, A. (2021). Seroprevalence of measles-, mumps-, and rubella-specific antibodies in the German adult population – cross-sectional analysis of the German health Interview and Examination Survey for Adults (DEGS1). The Lancet Regional Health - Europe, 7. https://doi.org/10.1016/j.lanepe.2021.100128

Harvard Health Publishing. (n.d.). D through I. Harvard Medical School. https://www.health.harvard.edu/d-through-i#E-terms

Mathis, A.D., Raines, K., Masters, N.B., Filardo, T.D., Kim, G., Crooke, S.N., Bankamp, B., Rota, P.A., & Sugerman, D.E. (2024). Measles – United States, January 1, 2020-March 28, 2024. Morbidity and Mortality Weekly Report, 73(14), 295-300. http://dx.doi.org/10.15585/mmwr.mm7314a1

Minta, A.A., Ferrari, M., Antoni, S., Lambert, B., Sayi, T.S., Hsu, C.H., Steulet, C., Gacic-Dobo, M., Rota, P.A., Mulders, M.N., Wimmer, A., Bose, A.S., O’Connor, P., & Crowcroft, N.S. (2024). Progress toward measles elimination – Worldwide, 2000-2023. Morbidity and Mortality Weekly Report, 73(45), 1036-1042. http://dx.doi.org/10.15585/mmwr.mm7345a4

Misin, A., Antonello, R.M., Di Bella, S., Campisciano, G., Zanotta, N., Giacobbe, D.R., Comar, M., & Luzzati, R. (2020). Measles: An overview of a re-emerging disease in children and immunocompromised patients. Microorganisms, 8(2), 276. https://doi.org/10.3390/microorganisms8020276

Papaevangelou, V. (2021). Measles vaccination of special risk groups. Human Vaccines & Immunotherapeutics, 17(12), 5384–5387. https://doi.org/10.1080/21645515.2021.1997034

Porche, D. J. (2023). Epidemiology for the advanced practice nurse: A population health approach. Springer Publishing. doi: 10.1891/9780826185143

Quach, H.Q., Ovsyannikova, I.G., Grill, D.E., Warner, N.D., Poland, G.A., & Kennedy, R.B. (2022). Seroprevalence of measles antibodies in a highly MMR-vaccinated population. Vaccines, 10(11), 1859. doi: https://doi.org/10.3390/vaccines10111859

Tuckerman, J., Kaufman, J. & Danchin, M. (2022). Effective approaches to combat vaccine hesitancy. Pediatric Infectious Diseases Journal, 41(5), e243-e245. doi: 10.1097/INF.0000000000003499