This supplementary information is presented as submitted by the corresponding author. It has not been copy-edited by NTvG.
Since vaccination of Dutch children against measles through the National Immunisation Programme started in 1976, the incidence of measles greatly decreased. Local epidemics, however, still occur. Since May 2013, a local epidemic of measles is developing in The Netherlands, predominantly in unvaccinated groups where the highly contagious virus can easily spread. We describe two patients with measles and discuss the diagnosis, complications, and measures to reduce the impact of the epidemic.
Patient A, an unvaccinated 10 year old boy, suddenly fell ill with high, fever, conjunctivitis, and a generalized maculopapular rash. His buccal mucosa showed the so-called koplik spots. A PCR test on saliva confirmed the clinical diagnosis of measles. After a couple of days, the rash subsided and the patient recovered fully.
Patient B, an unvaccinated 9 year old boy, was admitted with increasing drowsiness. Five days earlier, he had developed the first signs and symptoms of measles. When admitted to the hospital, the patient was apathetic with an EMV score of 10 (E3M5V2). There were no focal neurological abnormalities and a lumbar puncture revealed clear liquor with mild pleiocytosis and a slightly raised protein content although a negative PCR for measles. Serologic analysis and PCR on pharyngeal swab supported the diagnosis measles encephalitis. During the night, his condition deteriorated, resulting in a decreased EMV score (E2M3V1) and he developed a hypotonic hemiplegia. Four weeks after admission, the patient is still unconscious.
In The Netherlands, measles epidemics are largely confined to orthodox protestant minority groups with religious objections to vaccination. From the moment of waning of maternal antibodies until the first regular vaccination and in absence of herd immunity, children are at risk for measles. Therefore, an extra (at age < 12 months) or early (12-14 months) vaccination is offered to all children at the age from 6 to 14 months who live in areas with low (<90%) vaccination rates. As long as social geographic clusters of unvaccinated persons exist, the disease will continue to strike in the future.