Measles Is Back: A Wake-Up Call

Medscape

07-05-2025

Many still believe that measles is a harmless disease and that vaccinations are more harmful, citing autism as a potential side effect, a claim debunked by numerous studies, including a notable 2015 cohort study in the United States.
Vaccine expert Peter Jay Hotez, MD, PhD, director of the Center for Vaccine Development at Texas Children's Hospital, Houston, recently highlighted in an interview that outdated beliefs also extend to those endorsing measles parties, budesonide, vitamin A, and clarithromycin as viable treatments. Despite the known complications and availability of effective vaccines, measles continues to pose a significant global health threat.
Vaccination Shortfall
The World Health Organization (WHO) and the United Nations Children's Fund (UNICEF) reported that measles cases in the European Region reached 127,350 in 2024, doubling the figures from 2023 and marking the highest number since 1997. Over 40% of these cases affected children aged under 5 years, with more than half requiring hospitalisation. Preliminary data up to 6 March 2025 recorded 38 deaths.
After the COVID-19 pandemic, vaccination rates declined, leading to a sharp increase in the number of measles cases in 2023 and 2024. Many countries have yet to restore their vaccination rates to pre-pandemic levels, heightening the risk for further outbreaks.
Despite the vaccination mandate introduced in March 2020 under the Measles Protection Act, Germany still faces challenges in controlling measles. The WHO reported 79 measles cases in 2023. The vaccination coverage for the second dose was 93%, which is still below the 95% threshold required to effectively curb the spread of the disease.
Case Histories
The severity of measles is underscored not only by epidemiologic data and fatalities among the unvaccinated during a recent outbreak in Texas but also by individual case studies. One such case, reported by physicians in the journal Cureus , involved a 24-year-old man who presented myoclonic jerks and sensory symptoms for 3 days, followed by generalised weakness for a day. He also suffered a generalised tonic-clonic seizure, prompting the initiation of anticonvulsant therapy.
Key clinical findings at presentation:
Vital signs were stable.
Myoclonic jerks persisted despite anticonvulsant treatment.
Blood and cerebrospinal fluid analyses were unremarkable.
The EEG indicated generalised slowing with theta waves.
Brain MRI revealed effacement of the sulcal spaces in the bilateral parietal, temporal, and occipital regions with subtle leptomeningeal enhancement, suggestive of meningitis.
The results of autoimmune encephalitis tests were negative.
During his hospital stay, he experienced multiple brief bouts of abrupt generalised weakness and loss of postural stability. A neurologic examination after 2 weeks found that the paralysis had become flaccid.
An elevated titre of 625 immunoglobulin G anti-measles antibodies in the cerebrospinal fluid was detected by enzyme immunoassay, raising suspicion of subacute sclerosing panencephalitis (SSPE).
Disease Progression and Aetiology
SSPE, a rare but fatal complication, typically manifests 4-10 years post-infection, with some cases reported sooner or as late as 27 years. A study published in PLOS One indicates that the risk of developing fatal SSPE may be significantly higher than previously believed. While earlier estimates placed the risk between 1 in 100,000 and 1 in 10,000, the authors reported that for children under 5 years of age, the risk could be as high as 1 in 3300. The disease progresses through four stages, from personality changes and academic decline to myoclonus, seizures, and dementia. In the third stage, rigidity, extrapyramidal symptoms, and apathy develop. In the fourth stage, it progresses to coma, a vegetative state, or akinetic mutism. The time from the onset of symptoms to death was within 1-3 years of symptom onset. The pathogenesis of SSPE is unclear, but its cause is certain: Only wild-type measles virus, never the vaccine strain, has been found in all cases of SSPE.
Another recent case illustrating that measles can be severe was reported in Clinical Medicine and involved a 44-year-old man. The patient presented at the emergency department with a week-long history of malaise, myalgia, dry cough, and diarrhoea, followed by a day of fever and extensive rash. He had been in contact with his grandchildren, who had measles 2 weeks prior. He had not travelled abroad recently and had received all the recommended childhood vaccinations in the UK, including the measles vaccination. The following are the findings:
Erythematous maculopapular rash
Hypoxia and tachypnoea
No Koplik spots
Elevated inflammatory markers (C-reactive protein, 36 mg/L; normal, < 5 mg/L)
Lymphopenia (lymphocytes, 0.69 × 10 9 /L; normal, 1-4 × 10 9 /L)
/L; normal, 1-4 × 10 /L) Serum liver function tests showed a raised aspartate aminotransferase at 147 U/L (normal, 10-50 U/L) and gamma-glutamyl transferase at 148 U/L (normal, 1-55 U/L) with normal alkaline phosphatase and bilirubin levels
Mild thrombocytopenia (platelets, 143 × 10 9 /L; normal, 150-450 × 10 9 /L) but otherwise normal complete blood cell count, coagulation, fibrinogen, and renal function tests
/L; normal, 150-450 × 10 /L) but otherwise normal complete blood cell count, coagulation, fibrinogen, and renal function tests HIV serology test result was negative
Chest x-ray demonstrated multifocal nodular opacities within both lower zones and right hilar adenopathy, suggesting infective/inflammatory aetiology
A mouth swab tested positive for measles virus RNA
CT angiogram confirmed no pulmonary embolism but confirmed x-ray findings
The patient was diagnosed with measles pneumonitis. After treatment with ribavirin and antibiotics, the patient fully recovered.
A few years ago, a measles infection had a fatal outcome for a woman during an outbreak in Hildesheim, Germany. The patient, a mother of five children aged between 4 and 16 years, contracted the disease from her school-aged children. Due to a shortage of vaccine supply, the woman's vaccination was delayed. She developed measles-like symptoms 3 days post-vaccination and was found dead on the eighth day.
Molecular characterisation of the virus confirmed that the samples taken at the time of her death and during the autopsy contained the wild-type measles virus variant responsible for the outbreak in Hildesheim, which circulated in Germany from 2018 to 2020. The vaccine virus was not detected.
Viral Persistence
'An increase in measles cases is a clear sign of a breakdown in immunisation coverage. As cases of measles continue to surge, we need urgent government action to both strengthen health systems and implement effective public health measures to secure protection for all children from this dangerous but preventable disease,' warned Regina De Dominicis, UNICEF's regional director for Europe and Central Asia.
'Measles is back, and it's a wake-up call. Without high vaccination rates, there is no health security. As we shape our new regional health strategy for Europe and Central Asia, we cannot afford to lose ground. Every country must step up efforts to reach under-vaccinated communities,' said Hans Henri P. Kluge, the WHO regional director for Europe. 'The measles virus never rests — and neither can we.'