In this case-based module, Dr Toni Hazell discusses the diagnosis, treatment and prevention of measles and whooping cough, including how to identify and manage suspected cases, what appropriate treatment should be given in primary care and how to support improved uptake of vaccination against these serious infectious diseases.
Learning objectives
With the concerns about ongoing outbreaks of measles and whooping cough, it’s important for nurses in general practice to be alert to potential cases and opportunities to encourage preventive measures. Working through the cases will enhance your knowledge of the prevention and management of measles and whooping cough in primary care, in particular:
- The characteristic presenting symptoms of measles and whooping cough in children and adults, and how to distinguish them from other potential infectious diseases
- How cases should be diagnosed and managed in primary care, including appropriate treatment for suspected or confirmed cases
- Appropriate public health measures to take if suspected cases of measles or whooping cough present to you, including infection and prevention control measures and how to notify appropriate bodies
- Prevention of measles and whooping cough through vaccination; why and when vaccinations are recommended and how to advise patients who have missed their vaccinations
Note all cases in this module are hypothetical scenarios developed for illustrative purposes only
Case 1. Child presenting with temperature and rash, who has not had MMR vaccinations
You are the triage nurse for same-day appointments at your practice and get a phone call from a parent who is concerned that her child has a temperature and a rash. You notice that the child has not had the measles, mumps and rubella (MMR) vaccination, and wonder if this might be measles, as you have just had an alert that there are lots of cases locally.
1. How does measles present?
Measles starts with 2-4 days of illness (the ‘prodromal phase’) which typically involves coryzal symptoms, similar to a cold, although notably there is usually a high temperature (≥39°C) and also conjunctivitis, which might make you consider measles rather than another respiratory infection.
The rash usually starts on the face and behind the ears, at the same time as the other symptoms are most severe. It then spreads down the body and covers the whole skin with no gaps, taking about 3-4 days to reach the hands and feet (see image 1 below).
Image 1. Child with measles rash on face, arms and trunk.
Koplik spots might appear on the palate or inside of the cheek – they are a few mm wide and are red with a white centre (see image 2). They are pathognomic, ie, someone with Koplik spots definitely has measles. Symptoms may be less (or not present at all) if the patient is immunocompromised.
Image 2. Koplik’s spots on inside of cheek in young adult woman with measles
2. What is the primary care management of measles?
Measles is a notifiable condition, which means that doctors have a legal responsibility to inform public health when it is suspected – nurses don’t have this legal responsibility, but it is still good practice to do so. You can find the details of your local public health team here for England, Scotland, Wales or Northern Ireland.1-4
In this scenario, if you suspect measles from a phone call but still need to see the patient, think about how you are going to do that without putting your other patients in the waiting room at risk – measles is exceptionally infectious. Perhaps they could come in through a back or side door and wait on their own in an empty clinical room. The public health team will arrange testing, and for positive cases any necessary contact tracing and post-exposure prophylactic treatment. Primary care management for anyone with suspected measles is symptomatic, involving rest, fluids and paracetamol. Those who are systemically unwell will need to be considered for hospital admission; any patient who is immunosuppressed should be discussed with their specialist consultant.
To complete the full module featuring four cases visit the Nursing in Practice 365 website.
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Dr Toni Hazell is a portfolio GP in London
