On a typical busy day at the Seminole Family Medical Clinic in Seminole, Texas (population, 7386), Leila Myrick, MD, PhD — who’d moved to the rural town 5 years earlier after graduating from Emory School of Medicine in Atlanta — was about to see her first real case of measles. Until then, she’d only seen it in textbooks.
“Our ER [emergency room] doctor called me about admitting a girl around 6 years old,” she recalled. “Her parents had brought her in with upper respiratory problems, but he’d noticed a rash all over her body and diagnosed measles. As soon as I hung up, I started researching what the heck is measles.”
The unvaccinated girl was among the first confirmed cases in the measles outbreak that began in late January and spread through West Texas and parts of New Mexico, Oklahoma, and Kansas. The region saw 950 cases, 111 hospitalizations, and three deaths, according to a Yale School of Public Health report. Those deaths, which included two children, marked the first US measles-related fatalities since 2015 — and the first pediatric deaths since 2003.
Myrick saw the girl’s rash and recognized it immediately. “It was exactly like what I’d seen in the textbook,” she said. “It’s a very striking rash — bold and in your face — that covers the patient from head to toe. It looks really fearsome.”
The girl survived. But what happened in Seminole has since occurred in pockets across the country and, with the holiday travel season and colder weather approaching, Myrick’s experience could become more common for physicians.
Measles was declared eliminated in the US in 2000 — a status now under threat — and many physicians have never seen a case. Here’s the best advice from Myrick and other frontline physicians for diagnosing and treating the illness and dealing with vaccine misinformation.
Identify
Three questions can help you assess your community’s risk level:
1. What’s the immunization rate in my state/region?
The national rate for two doses of the measles, mumps, and rubella (MMR) vaccine among US kindergarteners declined to 92.5% for the 2024-2025 school year, according to the CDC. You need 95% for herd immunity, and estimates show only 11 states meet that criteria, while 24 are between 90% and 95%, and 14 are below 90%.
Some state departments of health provide county-by-county school immunization rates. Check with your Department of Health for the latest numbers and sign up for alerts if offered, said Ayelet Rosenthal, MD, the medical director of infection prevention and control at Lurie Children’s Hospital in Chicago.
2. What religious and cultural groups predominate?
Past measles outbreaks have occurred in some ultra-Orthodox Jewish neighborhoods, Amish communities, and communities affiliated with the Fundamentalist Church of Jesus Christ of Latter Day Saints. The Seminole outbreak, for example, was centered in a Mennonite community. It’s important to stress that not all members of these faiths oppose vaccination. When the CDC examined 159 measles cases in 2013, it found that 82% of patients were unvaccinated and many cited philosophical or religious beliefs.
3. Are you encountering vaccine hesitancy?
When skepticism grows, vaccination rates can fall and the population becomes more susceptible.
Know the Clinical Signs
Measles symptoms appear 7-14 days after exposure to the virus. Look for:
- High fever: “It’s usually a lot higher (103-104) than other viruses or illness,” said Myrick, who has treated about 30 measles cases.
- Cough, coryza, and conjunctivitis: There’s nothing unique about the upper respiratory symptoms, but the conjunctivitis is often severe. “That’s one of the keys to diagnosing measles early,” said Myrick. “The eyes can be really bloodshot and have a lot of discharge and drainage.”
- Koplik spots: Two to three days after symptoms start, tiny white spots may appear inside the mouth.
- Maculopapular rash: Three to five days after the onset of cough, coryza, and conjunctivitis, a rash usually appears. “It begins at the nape of the neck and the face and then spreads down to the trunk and extremities,” said Rosenthal.
“Measles is sometimes missed in the period before the rash appears because the preliminary symptoms are similar to other viruses,” said Rosenthal, who managed 17 suspected or confirmed measles cases during a 1-week outbreak in Chicago in early 2024. “Doctors should have measles in the backs of their minds all the time.”
Eric Ball, MD, learned this lesson the hard way in January 2015 when children started showing up in his pediatric practice in Ladera Ranch, California, with fevers, runny noses, and flu-like symptoms. “Honestly, measles was more of a theoretical disease to me,” he said. “I assumed I’d never see it.”
The children in Ball’s waiting room were actively contagious, but that wasn’t immediately apparent. “We had one or two dozen exposures in our office that weren’t recognized until several days later,” Ball said. “It was such a public health nightmare. The last thing you want to do is expose your own patients to a potentially deadly disease in your office.”
The same thing was happening in other nearby clinics and hospitals. It marked the start of the Disneyland measles outbreak— so named because that’s where it originated — which spread to seven states, with 125 cases.
If you’re concerned about measles being missed…
Employ electronic health record systems. These can be programmed to notify clinicians and staff if a patient lives in an outbreak area or is unvaccinated. Rosenthal’s hospital developed a series of screening questions that triggered a notification on staff computers to isolate any patients with suspected measles.
Post this in your clinic/office. It’s a one-page poster provided by the Pediatric Pandemic Network about “Recognizing Measles in Your Patients.” It has photos and gives detailed instructions on how to react to suspected measles cases. It also has QR codes that can be scanned for updated national and international outbreak information.
If you’re treating a patient with measles…
According to the CDC, there is “no specific antiviral therapy that is FDA-approved for the management of measles.” “All you can do is support them,” said Ball. The following have been shown to ease symptoms:
Rest, hydrate, reduce fever. Over-the-counter acetaminophen or ibuprofen can help ease fever and discomfort.
Supplement with vitamin A. It doesn’t prevent measles and is not a substitute for vaccination, but vitamin A has been shown to reduce the severity of the infection, protect against complications (including death), and improve overall health. The CDC, American Academy of Pediatrics (AAP), World Health Organization, and National Foundation for Infectious Diseases recommend it for “all US children presenting with measles.” Precise dosing is crucial as vitamin A can be toxic at high levels and dosages vary by age.
If you have a patient who’s been exposed to measles but can’t readily show evidence of immunity…
Consider giving the MMR vaccine. Consider this if it’s within 72 hours of exposure. According to the CDC, this may provide some protection or modify the disease course. If that 72-hour window has closed or vaccination is not possible…
Consider immune globulin (IG). This antibody treatment — given via intramuscular or intravenous injection — can prevent or modify the disease if administered within 6 days of exposure, according to the CDC. It can be given to unvaccinated infants, pregnant women, and immunocompromised patients.
Complications
According to the CDC, 1 in 5 unvaccinated people in the US who catch measles are hospitalized. Pneumonia (1 in 20 children) and encephalitis (1 in every 1000) are usual reasons.
“One of the children I took care of developed a secondary bacterial pneumonia and required admission to the ICU,” recalled Rosenthal. “Seeing the complications of a disease that I once thought I’d never see was very humbling.”
An estimated one to three kids per 1000 who become infected with measles will die from respiratory and neurologic complications.
Isolate
The truly frightening thing about measles is how contagious it is. Its infective period is 4 days prior to and 4 days after the rash appears. According to the CDC, measles spreads by contact and through the air when an infected person coughs or sneezes. The droplets can stay in a room up to 2 hours after that person leaves it. If there are 10 people in that room, up to nine will be infected if they are not protected. Thus, assume any suspected case is a confirmed case and do the following:
Minimize exposure to other patients. When parents call, have office personnel do telephone triage, asking about measles symptoms, exposure, and vaccination status. If you expect a visit from a patient with suspected measles, require everyone to wear masks. When they arrive, immediately direct them to an airborne isolation room or, if your clinic doesn’t have one, a private screening room.
Consider car-side examinations or telehealth. Ball started examining children with telltale symptoms in their cars. If that’s not an option, use telehealth apps for preliminary and follow-up visits.
Protect yourself and your staff. If measles is confirmed and the patient is in a private screening room, keep the door shut and arrange to transfer the patient to a facility with an airborne isolation room as quickly as possible. Minimize access to the room and make sure any staff who enters has immunity for measles and wears an N95 mask, plus gown, gloves, and eye protection.
Decontaminate the room. After the patient leaves, immediately close off and decontaminate the screening room with an environmental protection agency-registered disinfectant. The same ones used against HIV and Hepatitis B and C are effective against measles. You can find a list here.
Follow the 4-day rule. Patients and parents should isolate for 4 days after the rash appears. (Rash onset is day zero.) Stay home, avoid public places, and limit close contact with others, especially babies, pregnant women, and those with weakened immune systems.
Myrick faced a challenging situation with her initial case. That little girl had six siblings at home, and her parents were taking turns visiting the hospital. Although the parents said they were vaccinated, Myrick suspected the kids at home were not and worried the family would further spread the disease. She encouraged them to isolate.
Protect your family. Myrick and Rosenthal both had young children at home during their outbreaks. Although everyone was fully vaccinated, Myrick took the extra precaution of giving her two kids (and herself and her staff) an extra dose of the MMR vaccine. She also gave her children a measles antibody titer, which measures the level of immunoglobulin G antibodies to determine measles immunity.
Report. Notify your local or state health department of every suspected or confirmed measles case. It will likely conduct contact tracing to identify others in the community who may have been exposed and work to prevent a larger outbreak.
Rosenthal opened an incident command center at her hospital. It drafted standards of care for personnel in immediate care areas, and quickly educated them about identifying, isolating, and treating patients. “We provided daily updates to personnel, hospital leaders, and stakeholders,” she said.
Inform
Two MMR doses provide 97% protection from measles, but some parents still resist vaccination. Here’s how frontline doctors are handling it.
Listen to their concerns. “I’m often surprised that it’s not the same concern every time,” said Myrick. “Opinions range from ‘I heard it was bad’ to ‘we don’t put anything unnatural in our bodies’ to ‘I’m worried about autism’ to ‘I just don’t know.’” Hear parents out and respect their opinions.
Be patient and nonjudgmental. “I make sure to use a nonjudgmental tone and words to address their concerns,” said Rosenthal. “I use clear factual information about the vaccines, including their safety and effectiveness. I provide information about the disease and the possible complications from the disease, and if they say they need to think about it, then I invite them to reach out to me with further questions. I make sure they understand we have an open line of communication.”
Consider a ‘Refusal to Immunize’ form. Myrick doesn’t just let parents say no. If they still refuse after she addresses their concerns, she asks them (“in a kind and gentle manner”) to sign a Refusal to Immunize form, available on the AAP website. This often gives them pause and may reinforce the seriousness of the decision.
Reassure those who can’t vaccinate. “The most important protection for them is making sure the people around them are immune and avoiding measles exposure,” said Rosenthal. “We advise that if they’re ever exposed, let us know immediately because there are postexposure prophylaxis options, such as IG.”
Fight fear with facts. This two-page “Measles FAQ” from the Pediatric Pandemic Network clearly and succinctly presents pertinent info. Consider handing it out to your patients.
Stay up to date. Check the Vaccine Education Center at the Children’s Hospital of Philadelphia, Philadelphia, for the latest information and resources. Rosenthal also recommends the AAP’s Red Book (which includes a chapter on measles) and the Journal of Pediatrics, which has many recent scientific articles on measles.
Impress upon parents the potential for suffering. “What struck me the most, because I’d never seen a kid with measles prior to 2015, was how sick they were,” said Ball. “There was one little girl lying in the backseat of the car with this weird, angry-looking rash. It was like someone had dumped red paint on her head and it was dripping down her body. These kids just looked miserable.”
