Search tips
Search criteria 


Logo of idermojHomeCurrent issueInstructionsSubmit article
Indian Dermatol Online J. 2014 Apr-Jun; 5(2): 144–147.
PMCID: PMC4030339

A burst in the incidence of viral exanthems



Vaccines have a major role in eradication programs of viral diseases. Vaccines against measles, rubella, and varicella are included in the vaccination schedules for children in most countries.


A comparative analysis between 2011 and 2012 was performed to investigate if the number of patients with viral exanthemas reported to our clinic in 2012 was increased.

Materials and Methods:

Patients were grouped in four categories: rubella, measles, varicella and other viral exanthemas.


Between January and April 2011, there were registered 37 cases with viral exanthemas: 69.5% presented with varicella and 30.5% with other viral exanthemas. Between January and April 2012, there were 178 cases registered with viral eruption, of which 37% were of other viral exanthemas, 35.4% rubella, 19.7% measles and 7.9% varicella. The highest incidence was seen in patients aged between 20 and 29 years (52.2%), with 21% having measles, 32.2% rubella, 9% varicella and 37.6% having other exanthemas. In 2012, the number of cases of viral exanthemas increased 5 times, with important outbreaks of new cases of measles and rubella.


Although vaccines against measles and rubella were being used since 1979 and 1998 respectively, it was only in 2004, that these vaccines became part of the mandatory vaccination schedule. Although persons under 32 years should be protected against measles infection if they are previously vaccinated, more than 90% of the registered cases of measles occurred in such patients. The patients registered between January and April 2011 were mostly pediatric. Adults also were much more affected with measles, rubella, or varicella viruses in 2012 than in 2011.

Keywords: Measles, Romania, rubella, vaccination, viral exanthemas


Viral exanthem is a widespread nonspecific rash usually characterized by a generalized eruption of erythematous papules and macules.[1] In most of the cases, they are correlated with self-limited disease. However, in some cases, diagnosis of an exanthema may be crucial to preventing further spread of the disease.[2]

Certain exanthemas have distinct patterns of rashes and prodromal (prerash) symptoms which aid in incriminatingthe causative virus. In many cases, however, an accurate diagnosis cannot be made on the basis of clinical aspect alone. History may be helpful when evaluating these patients, specifically their disease contacts, immunization record, previous exanthematous illnesses and associated prodromal symptoms.[2]

Some illnesses are seasonal, and this knowledge may be useful, too. Manifestation and morbidity of infections differ between the sexes and among different ages.[3]

Measles or rubeola is a highly infectious disease with a worldwide distribution caused by an RNA paramyxovirus[4] with a basic reproductive number of 15-20[5] (e.g. one case of measles will result in at least 15 new cases infection when introduced in a fully susceptible population).

Measles remains one of the leading causes of childhood mortality with more than 530,000 children worldwide dying from measles each year.[6]

Vashishtha et al. show that in India, the median case fatality ratio of measles is 1.63% and cites a recent study that estimates that 80,000 Indian children die each year due to measles with it's complications amounting to 4% of under-five deaths.[7]

Measles vaccine was used for the 1st time in 1963, in United States. First dose is administrated between 12 and 15 months, followed by the booster shot at the age of 7 years (first grade).[8,9]

Live, attenuated measles vaccine are available either as monovalent vaccine or as measles-containing vaccine (MCV) in combination with rubella or mumps vaccines.

In 1985 a routine MCV (MCV 1) was introduced in India's Expanded Program on Immunization, with a recommended age for vaccination of 9-12 months. A second dose of measles vaccine (MCV 2) was recommended in the Indian states with ≥80% evaluated coverage for MCV 1. The MCV 2 was administered at the time of the DPT booster dose (at 16-24 months of age). For the Indian states with <80% evaluated coverage for MCV 1 a catch-up measles vaccination campaign was implemented for children aged 9 months to 10 years.[7]

Rubella, also called the German measles or 3 days measles, is an epidemic disease caused by an enveloped RNA togavirus.[4] The mechanism of infection is similar to measles.

Rubella vaccine was first introduced in 1969. At the moment, administration of the vaccine is the same as for measles vaccine as they are given in combination.

Varicella is caused by the varicella-zoster virus.[10] Varicella vaccine was developed in 1970, in Japan and started to be routinely used in Japan, Korea and afterwards, starting with 1995, in the United States. A tetravalent combination with measles, mumps, rubella (MMR) and varicella is available from 2005. First dose of the vaccine should be administrated between 12 and 15 months and the second dose between 4 and 6 years old, before kindergarten or first grade.

Adults and older children who have not had varicella can also be vaccinated, and the vaccine doses should be 4-8 weeks apart.

The effectiveness of the vaccine is 100% in prevention of moderate and severe disease and 85-90% in preventing varicella in general. The vaccine gives protection for at least 20 years. However, breakthrough infections can occur even in those who have been vaccinated.[11]


At the beginning of 2012, an increased number of patients with viral exanthemas reported to our outpatient clinic; therefore, a comparative analysis between 2011 and 2012 was performed. The interval chosen was January to April, due to the higher incidence of the viral diseases during this period of the year. The search was made for all of the diagnosis of viral exanthemas. Patients were grouped in four categories: Rubella, measles, varicella, and viral exanthemas. The diagnosis for varicella, rubella and measles was made based on the presence of their clinical signs and evolution of the disease [Annex 1].[2,4,7,8,10,15] A clue for the diagnosis was the patient's history of exposure to an infected contact. The generic name of viral exanthemas was used for all the other viral eruptions.

Annex 1
Rubella, measles and varicella at a glance


In 2011, between January and April, from the 3723 patient attending our clinic, 37 cases were registered with viral exanthems (1%). Among them, 69.5% presented with varicella (26 cases) and 30.5% with miscellaneous types of viral exanthemas (11 cases). There were no cases of rubella or measles registered during this period. The patients were between 6 months and 64 years old, with an average age of 25.2 years. The patients suffering from varicella had an average age of 30.8 years (the youngest was 14 years old, and the oldest was 64 years old). Most of the varicella cases registered were aged between 10 and 19 years old (14 cases). For the other age groups, the distribution was even. Viral exanthemas patients were younger, having an average age of 12.5 years old [Figure 1a]. Viral exanthemas affected only patients aged between 6 months and 23 years old, each decade having an even distribution. Women outnumbered men in a ratio of 3:1. There were no significant difference between the rural and the urban area.

Figure 1
Number of cases registered between January and April 2011 (a) and 2012 (b) divided by age groups

Between January and April 2012, of the 3402 patients who addressed our clinic, 178 were registered with viral eruption, of which 35.4% were diagnosed with rubella (63 cases), 19.7% with measles (35 cases), 7.9% with varicella (14 cases) and 37% being other types viral exanthemas (66 cases). Patients were aged between 4 months and 51 years old, with a mean age of 24.2 years, with no significant difference between the groups [Figure 1b]. The highest percentage of patients wereaged between 20 and 29 years (52.2%). Of these, 21% were suffering from measles (20 cases), 32.2% from rubella (30 cases), 37.6% from other types of viral exanthemas (35 cases) and only 9% from varicella (eight cases). Other incidence peaks for rubella were registered between 10-19 years and 30-39 years: 13 and 17 cases therefore summing 40% and 42% of all the cases registered on those age groups. Men were more affected then women in a ratio of 2.5:1. The majority of the patients were coming from an urban area (82.7%).


Compared to 2011, in 2012, the number of cases of viral exanthemas was 5 times higher, especially due to the outbreak of new cases of measles and rubella.

In Romania, in 1979 anti-measles vaccination was first introduced, followed by the anti-rubella vaccination in 1998 (bivalent measles-rubella) that was administrated only to teenage girls. In 2004, anti-MMR vaccine was introduced in the mandatory vaccination schedule.[12] Today, in Romania, children younger than 9 years should benefit from the immunization given by the vaccination against rubella. This aspect is reflected in the figures obtained; in 2012, wherein none of our patients affected by rubella infection was younger than 9 years. A potential risk of congenital rubella syndrome can occur if the infection affects pregnant women. In 2012, only a small number of women of childbearing age were registered (15 cases), with a male: female ratio of 3:1.[13] The most recent rubella outbreak reported in Romania was at the end of 2011 in Salaj, in North-Western part of the country, with 1840 cases being registered. Among these, 98% were never vaccinated against rubella. The highest incidence was recorded in teenagers.[13]

Even if the vaccine against measles was first introduced in 1979, sporadic cases and minor epidemics still occur. Although persons under 32 years should be protected against measles infection due to the vaccination, more than 90% of the registered cases of measles occurred in patients that should have been immunized. This situation might have been caused by failure of parents to immunize their children and the failure of childhood immunization to protect some teenagers and adults.[13,14]

In addition, the introduction of measles vaccination in Europe in 1960s and 1970s fundamentally changed the epidemiology of the disease. The proportion of the population which must be immune in order for transmission to be stopped, called “critical proportion,” is not achieved because the vaccination coverage is low. As a consequence, population from countries where there is a sub-optimal vaccine uptake will experience outbreaks until, through catch-up vaccination campaigns; the number of immune people is kept above the “critical proportion.”[5,13]

Surveillance data report of measles monitoring in Europe, in 2011, mention Romania among the countries with the highest number of cases, next to Italy, German, Spain and France. In these five countries, more than 90% of all cases of measles from Europe were accounted for. In 2011, In 2011, Romania reported more than 4000 cases of measles.[15]

In Romania, like in most of the European countries, varicella vaccine is not on the mandatory vaccination list.

The patients affected by viral exanthemas between January and April 2011 are mostly pediatric patients. Most common causes of an erythematous viral exanthema in children are nonpolio Enteroviruses (coxsackie viruses, echo viruses, Enteroviruses), respiratory viruses (adenoviruses, rhinoviruses, parainfluenza viruses, respiratory syncytial virus, influenza viruses), acute Epstein-Barr virus, human herpes viruses 6 and 7 and parvovirus B19.

In 2012, adults were more affected by exenthematous viral infections. Measles, rubella or varicella viruses were involved in 63% of the cases. In 37% of the cases, infective agents as parvovirus B19, Epstein-Barr virus, cytomegalovirus could be considered.

Measles and rubella elimination is a priority to World Health Organization/Europe. It is important that member states take appropriate action by sustaining high immunization coverage among children and to reduce susceptibility among older age groups. The regional goal is to eliminate measles and rubella by 2015.[16]


Source of Support: Nil

Conflict of Interest: None declared


1. Sarkar R, Mishra K, Garg VK. Fever with rash in a child in India. Indian J Dermatol Venereol Leprol. 2012;78:251–62. [PubMed]
2. Scott LA, Stone MS. Viral exanthems. Dermatol Online J. 2003;9:4. [PubMed]
3. Eshima N, Tokumaru O, Hara S, Bacal K, Korematsu S, Karukaya S, et al. Age-specific sex-related differences in infections: A statistical analysis of national surveillance data in Japan. PLoS One. 2012;7:e42261. [PMC free article] [PubMed]
4. Belazarian LT, Lorenzo ME, Pearson AL, Sweeney SM, Wiss K. Chapter 192: Exanthematous Viral Diseases. In: Goldsmith LA, Katz SI, Gilchrest BA, Paller AS, Leffell DJ, Wolff K, editors. Fitzpatrick's Dermatology in General Medicine. 8th ed. Vol. 2. The McGraw Hill Co; 2012. pp. 2337–66.
5. European Centre for Disease Prevention and Control. European monthly measles monitoring (EMMO). Surveillance Report. Issue 8: 21 February. 2012. [Last accessed on 2012 Dec 05]. Available from: .
6. Berggren KL, Tharp M, Boyer KM. Vaccine-associated “wild-type” measles. Pediatr Dermatol. 2005;22:130–2. [PubMed]
7. Vashishtha VM, Choudhury P, Bansal CP, Gupta SG. Measles control strategies in India: Position paper of Indian Academy of Pediatrics. Indian Pediatr. 2013;50:561–4. [PubMed]
8. Battegay R, Itin C, Itin P. Dermatological signs and symptoms of measles: A prospective case series and comparison with the literature. Dermatology. 2012;224:1–4. [PubMed]
9. National Network of Immunization Information. Measles, Mumps, Rubella (MMR) 2012. [Last accessed on 2012 Dec 05]. Available from: .
10. Schmader KE, Oxman MN. Chapter 194: Varicella and Herpes Zoster. In: Goldsmith LA, Katz SI, Gilchrest BA, Paller AS, Leffell DJ, Wolff K, editors. Fitzpatrick's Dermatology in General Medicine. 8th ed. Vol. 2. The McGraw Hill Co; 2012. pp. 2383–401.
11. National Network of Immunization Information-Varicella. 2012. [Last accessed on 2012 Dec 05]. Available from: .
12. Matei D. Vaccination program in Romania 2009. Rev Medicala Rom. 2009;56:303–8.
13. Janta D, Stanescu A, Lupulescu E, Molnar G, Pistol A. Ongoing rubella outbreak among adolescents in Salaj, Romania, September 2011–January 2012. [Last accessed on 2014 Feb 22];Euro Surveill. 2012 17(7):pii=20089. Available online: . [PubMed]
14. Derrough T, Bacci S, Lopalco PL. Letter to the editor: Commitment needed for the prevention of congenital rubella syndrome in Europe. [Last accessed on 2014 Feb 22];Euro Surveill. 2012 17(10):pii=20106. Available online: . [PubMed]
15. World Health Organization Regional Office for Europe. Eliminating measles and rubella and preventing congenital rubella infection. 2012. [Last accessed on 2012 Dec 05]. Available from: .
16. Dhillon S, Curran MP. Live attenuated measles, mumps, rubella, and varicella zoster virus vaccine (Priorix-Tetra) Paediatr Drugs. 2008;10:337–47. [PubMed]

Articles from Indian Dermatology Online Journal are provided here courtesy of Medknow Publications