Measles: symptoms, cause and treatment (virus infection)

Measles symptoms include fever; persistent dry cough; runny or stuffy nose; a sore throat; sore eyes; painful, watery, red eyes; photophobia; headache; fatigue. Measles announces itself with these complaints. The first symptoms of measles are usually overlooked because they resemble a bad flu or a cold. The symptoms can worsen and sometimes last for weeks. Measles is most contagious in this initial phase. After a few days, red spots appear on the face and then all over the body. Measles can occur not only in children, but also in adults. Adults born between 1965 and 1975 are most susceptible to measles. They were born before measles vaccination was offered through the National Vaccination Program. Moreover, they are less exposed to measles in their youth than older people. For that reason they have not been able to produce antibodies.

  • What is measles?
  • How does measles develop?
  • How often does it happen?
  • Measles symptoms
  • First symptoms
  • Skin rash
  • Measles starts with red small bumps
  • When do the symptoms go away?
  • Measles and pregnancy
  • Immune status
  • Possibly more serious course for pregnant women
  • Measles complications
  • Examination and diagnosis
  • Physical examination
  • Differential diagnosis
  • Treatment of measles
  • Rest and drink enough
  • Treating complications
  • Sometimes fatal
  • Prevention and general advice
  • MMR vaccination
  • Other prevention measures
  • ‘Measles is not an innocent childhood disease’

Measles / Source: CDCNIPBarbara Rice, Wikimedia Commons (Public domain)

What is measles?

Measles (medical term: ‘morbilli’) is a non-itchy rash over the entire body in childhood. Adults can also be affected. Although vaccination has led to significant reductions in the number of cases, isolated outbreaks may continue to occur among population groups that do not get vaccinated. Research by Trouw based on data from the National Institute for Public Health and the Environment (RIVM) and the Central Bureau of Statistics (CBS) shows that anthroposophists are the most important refusers of vaccinations against diseases such as measles.¹ In 1976 it was included in the National vaccination programme. Initially as a separate vaccine and from 1987 as part of the MMR vaccination. The vaccine provides protection to more than 95% of vaccinated people.

How does measles develop?

Measles is caused by a highly contagious virus that resides in the nose, mouth and throat. The virus is transmitted through droplets that are spread through talking, coughing and sneezing. However, the virus can also be transmitted from one person to another via the hands, via cutlery and cups or via toys. Measles is so contagious that social distancing and hygienic measures such as washing hands do not help. Patients are most contagious from 1 to 2 days before the rash manifests until about 4 days afterward. In general, measles breaks out about ten days after infection. This is called incubation period . There is a small chance that the child will develop complications as a result of the measles. Measles is highly contagious: one sick child infects at least ten other people who have not been vaccinated against measles or have not had measles.

How often does it happen?

Measles is a highly contagious viral infection that mainly affects young children worldwide. In the Netherlands, measles is a disease that is no longer common, thanks to the measles vaccination that was included in the National Vaccination Program in 1976. According to the World Health Organization (WHO), it is estimated that around 135,000 people worldwide die each year as a result of a measles infection, especially in Africa and Southeast Asia. The highest mortality rates occur in children younger than 12 months. In the Netherlands, mortality hardly occurs (anymore). During the 2013/2014 measles epidemic, more than 180 children were hospitalized with measles and one 17-year-old died from the disease. The epidemic mainly occurred among unvaccinated, orthodox Protestant schoolchildren.

Conjunctivitis / Source: Marco Mayer, Wikimedia Commons (CC BY-SA-4.0)

Measles symptoms

First symptoms

The first symptoms and signs of measles are usually overlooked because they resemble a bad flu or cold. The symptoms can worsen and sometimes last for weeks. Measles is most contagious in this initial phase. The first symptoms are:

  • fever;
  • cough (persistent dry cough);
  • runny or stuffy nose;
  • a sore throat;
  • sore eyes;
  • painful, watery, red eyes (conjunctivitis) with light intolerance (hypersensitivity to light or photophobia) and possibly swollen eyelids;

Koplik spots, spots on the buccal mucosa that occur with measles / Source: CDC, Wikimedia Commons (Public domain)

  • fatigue, general malaise;
  • headache;
  • enlarged lymph nodes behind the ears and in the neck (swollen lymph nodes);
  • pain in the joints (arthralgia) of the hands, wrists and knees.
  • koplik spots: small red spots that are white in the center, located in the mouth and on the inside of the cheeks.

Skin rash

After this phase, the characteristic and clear symptoms of measles will manifest themselves. The characteristic rash in measles develops within two to four days after the appearance of the above symptoms. A red, non-itchy rash appears that starts on the face and ears and gradually spreads to the rest of the body, with the spots blending into each other.

Measles starts with red small bumps

The measles rash initially appears as small red bumps of a few millimeters, but later grow larger. The fever can rise to 40 degrees Celsius for a number of days. The rash is usually not itchy. Symptoms tend to be more severe as the patient ages.

When do the symptoms go away?

After about a week, the rash will gradually start to disappear. The rash generally leaves no visible marks. The patient is contagious from four days before symptoms appear until four days after the onset of the characteristic skin rash (or spots in the mouth).

Pregnancy and measles / Source: Zerocool, Pixabay

Measles and pregnancy

Immune status

Is it bad if a pregnant woman has had contact with a child with measles? According to the National Institute for Public Health and the Environment (RIVM), this depends on the immune status of the pregnant woman:

  • If the pregnant woman has been vaccinated or has had the infection, there is no risk.
  • If it concerns a non- (or incompletely) vaccinated pregnant woman, immunoglobulin (antibodies) may be considered within 1 week of infection.

Possibly more serious course for pregnant women

According to the RIVM, there are indications that pregnant women have an increased risk of a serious course of measles. However, having measles during pregnancy is not associated with an increased risk of birth defects in the child. In rare cases, contracting measles during pregnancy can lead to spontaneous abortion or premature birth.

Measles complications

In some cases, measles can lead to serious to very serious complications. These include:

  • Ear infection (otitis media): This can happen to 1 in 10 children.
  • Brain inflammation or encephalitis: an inflammation of the brain tissue. This occurs in approximately 1 in 1,000 patients.
  • Subacute sclerosing panencephalitis (SSPE), also called Dawson’s disease, Dawson’s encephalitis or measles encephalitis: a very rare chronic and progressive brain inflammation caused by a mutated measles virus. This serious condition occurs in 1 in 100,000 cases of measles. Often a measles infection occurs before the age of 2 years, followed by about 6-15 asymptomatic years, after which gradual and progressive neurological deterioration occurs.
  • Myocarditis, an inflammation of the myocardium, or heart muscle.
  • Pneumonia: this affects approximately 1 in 15 cases.
  • Diarrhea and vomiting.
  • Bronchitis and laryngitis: laryngitis is an inflammation of the larynx or upper trachea. Bronchitis is an inflammation of the mucous membrane in the airways.
  • Thrombocytopenia: a decrease in the number of platelets, sometimes causing small subcutaneous bleeding.
  • Pregnancy problems: Pregnant women who become infected with measles have an increased risk of miscarriage, premature birth and low birth weight of the baby.

GP examines child / Source:

Examination and diagnosis

Physical examination

Measles is usually diagnosed based on the visible symptoms. The doctor mainly bases this on the classic symptoms: coughing, a runny nose, conjunctivitis, Koplik’s spots and the rash. If necessary, a blood test or saliva test can be performed to confirm the diagnosis.

Differential diagnosis

The following conditions may be very similar to measles:

  • acute conjunctivitis (conjunctivitis);
  • side effects of medication (skin rash);
  • enteroviral infections;
  • erythema infectiosum or fifth disease;
  • meningitis (with headache, fever and stiff neck);
  • skin complications of viral hemorrhagic fever (fever caused by a virus);
  • glandular fever or glandular fever;
  • dengue fever;

Child with scarlet fever / Source: Badobadop, Wikimedia Commons (CC BY-SA-3.0)

  • Rocky Mountain spotted fever (caused by Rickettsia rickettsii, a bacterium in the Rickettsiaceae family);
  • scarlet fever;
  • roseola infantum, or sixth disease;
  • rubella or rubella;
  • sepsis (blood poisoning);
  • syphilis;
  • systemic lupus erythematosus (autoimmune disorder); and
  • Kawasaki disease or mucocutaneous lymph node syndrome (MCLS).

Treatment of measles

Rest and drink enough

Sufficient rest is important for a full recovery. Drink plenty of water to prevent dehydration. Be careful if fever still occurs or returns three days after the onset of the spots, as this may be a complication. In that case, consult your doctor. Without complications, the complaints usually disappear within a week.

Treating complications

Complications such as otitis media (middle ear infection) and pneumonia (pneumonia) should be treated with antibiotics. Such a pneumonia or ear infection is then caused by the measles virus itself, sometimes accompanied by a bacterial (super) infection. An ear infection can lead to permanent deafness. Another (feared) complication of measles is meningitis, which occurs in approximately 1 in 1,000 cases of the disease. If rare serious complications such as encephalitis or myocarditis are suspected, hospitalization will follow.

Sometimes fatal

1 to 2 per 1,000 cases of measles are fatal . Only rarely does SSPE (subacute sclerosing panencephalitis) occur. SSPE is a progressive and usually fatal condition that occurs months or years later after an apparently normal measles virus infection and causes mental deterioration, increasing behavioral abnormalities, muscle twitching and seizures. The patient usually dies within three years.

Prevention and general advice

MMR vaccination

There is a vaccine against measles that is included in the standard vaccination program. It is offered free of charge in the Netherlands, together with the vaccine against mumps and rubella (MMR). Children receive two MMR vaccinations. When they are 14 months and 9 years old.

Other prevention measures

You can also take the following preventive measures:

  • Use a paper tissue when coughing and sneezing. Throw it away immediately after use.
  • You can also cough and sneeze in the bend of your elbow.
  • Wash your hands thoroughly with soap regularly, especially after a heavy coughing or sneezing fit.
  • Teach children how to cough and sneeze properly.
  • Frequently disinfect surfaces that are frequently touched, such as toys, doorknobs, telephones, tables, counters, etc.

‘Measles is not an innocent childhood disease’

The danger of measles should not be underestimated. Measles is one of the most contagious human diseases and a leading cause of death in children worldwide. Every year, more than 100,000 people (mainly children) die from measles disease worldwide, despite the availability of a safe and effective measles vaccine. The virus erases part of the immune system’s memory, making infected people susceptible to infections with other pathogens. This is evident from research by Erasmus MC, where Rory de Vries received his PhD. The researcher looked at how measles is transmitted and how the virus makes people sick.²

Sick child / Source:

How is the virus transmitted?
Measles is characterized by high fever, red spots and a weakening of the immune system. According to the researcher, it is not a harmless childhood disease, although many people think so. Wrongly so. The researcher looked at how exactly the virus is transmitted. He has shown which cells are important when the virus enters the body. Via these so-called dendritic cells and alveolar macrophages, the virus ends up in a certain type of white blood cells, the lymphocytes. From there, the virus spreads further to some organs, the respiratory tract and the skin.

Death due to weakened immune system
Measles mainly causes death because the virus weakens the immune system. De Vries has shown how that process works. Normally, people build up defenses against a virus after being infected with it. Cells that have been involved in the defense against this virus remain present in the blood and can recognize the virus as soon as it wants to enter the body again. The body then already knows how to eliminate the virus. “Measles, however, causes these immunological memory cells to largely disappear after infection, so that the immunological memory is partly ‘erased’. This leads to an increased susceptibility to opportunistic infections with other pathogens, just like with the disease AIDS,” says De Freeze. De Vries’ thesis is a stepping stone for follow-up studies, which will focus on the development of new and more efficient methods of administering the measles vaccine.

In the Netherlands, hardly any people have died from measles since the vaccination. An epidemic does occur once every 5 to 7 years. These mainly occur locally, among people who have not been vaccinated.


  1. Fidelity. Anthroposophists in particular do not vaccinate children. August 3, 2013
  2. Erasmus MC Press release. ‘Measles is not a harmless childhood disease’. Measles virus on the rise in Europe. February 7, 2013.

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