Continuing professional development

Measles: symptoms, diagnosis,

management and prevention
PHC908 Gould D (2015) Measles: symptoms, diagnosis, management and prevention. Primary Health Care.
25, 1, 34-40. Date of submission: March 28 2014. Date of acceptance: April 25 2014.

Correspondence
Abstract gouldd@cardiff.ac.uk

Measles is one of the most contagious of all infectious diseases and less than 15 minutes’ exposure can result in Dinah Gould is professor
of nursing, Cardiff University,
infection for individuals who have not been fully vaccinated or who lack natural immunity. It is spread by minute Cardiff, Wales
aerosol droplets. Complications occur frequently and range from mild to life threatening. The prevention and
control of measles is taken seriously by the World Health Organization and public health authorities in the UK. Keywords
Public Health professionals should have a high level of awareness of measles and its risks, to help identify new Disease outbreaks, immunity,
measles, mumps, public health,
cases and implement measures to prevent and control spread.
public health nursing, rubella,
vaccination
MEASLES IS an acute, highly contagious infection ■ Explain to parents the side effects that can arise from
that affects mainly children, but can occur at any age. the measles, mumps and rubella (MMR) vaccination. Conflict of interest
None declared
Young people who have not been fully vaccinated and ■ Discuss infection prevention and control in
individuals who do not have natural immunity are clinical settings. This article has been subject to
at greatest risk. Immunity following infection usually Now do time out 1. double-blind peer review and
checked using antiplagiarism
lasts for life.
Throughout 2012 and early 2013, the UK saw 1 Check your knowledge software

an increase in the number of confirmed cases. Author guidelines

In preparation for reading the article,
Time out

Most of those affected were children and young adults,
who developed complications ranging from mild to
serious and life threatening. Even when recovery is
uneventful, measles can be frightening for parents as
well as distressing for the individual, disrupting
family life and resulting in time away from school
and other activities.
Public Health England (PHE) recommends that health
professionals have a high level of awareness of measles
and its risks to ensure public health measures can be
implemented swiftly to prevent spread.
Aims and intended learning outcomes
The aim of this article is to provide an overview of
measles: signs and symptoms, diagnosis, risk of
complications, strategies for prevention and control,
and assessment and management of patients in
community and hospital settings.
After reading this article you should be able to:
■ State the signs and symptoms of measles.
■ List the complications that can result.
■ Discuss the public health measures that can be
taken to prevent and control the spread of measles.
rcnpublishing.com/r/
go online to check your understanding of the phc-author-guidelines
following terms: antibody, antigen, autism,
herd immunity, bacteria, encephalitis,
epidemic, immunoglobulin, incidence, otitis
media, outbreak, pneumonia, prodrome,
pyrexia, RNA, vaccination, virus.
The measles virus
Morbillivirus, which is a single-stranded, enveloped
ribonucleic acid (RNA) virus belonging to the
paramyxovirus family, is the cause of measles.
In old textbooks, it is sometimes called morbilli.
Dissemination
Measles is one of the most contagious infectious
diseases. The virus is spread in minute aerosol
droplets 1-5 µm in size, released by coughing, sneezing
and spluttered conversation. The small droplets can
remain suspended in air long after they have been shed
and transmission is by droplet inhalation. The virus is
so contagious that physical contact is unnecessary for
infection to occur: it can be spread through contact

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Box 1 Signs and symptoms of measles
■ Rhinitis, sneezing.
■ Conjunctivitis.
■ Mild sensitivity to light, with swelling of eyelids.
■ Mild to severe pyrexia.
■ Koplik’s spots: small grey-white spots appearing on
the mucus membranes lining the mouth and throat.
■ Fatigue, irritability.
■ Myalgia: generalised aches and pains.
■ Poor appetite.
■ Harsh, non-productive cough.
■ Rash.
■ Diarrhoea and vomiting (occasional).
Box 2 Common mild complications of measles
■ Conjunctivitis.
■ Laryngitis.
■ Ear infection/earache.
■ Bronchitis.
■ Croup.
with oral and nasal secretions and it can survive for
up to two hours on objects such as door handles and
light switches.
People become infectious in the four-day prodromal
period before the appearance of the rash, when the
cause of the illness is usually unsuspected, increasing
risk of transmission. They remain infectious until the rash
resolves. Immunity following infection or full vaccination
usually lasts for life.
Epidemiology
Measles was once endemic in the UK (Hawker et al
2012). The number of cases depended on factors that
allowed the virus to multiply and the susceptibility
of the population. Before the introduction of MMR
vaccination, outbreaks occurred cyclically every few
years, once the community had sufficiently large cohorts
of children lacking immunity. Between outbreaks, cases
remained sporadic until there was a new cohort of
susceptible children.
Initially, the introduction of the MMR vaccine
prevented outbreaks of measles, however, in the
1990s and 2000s, public concern about the safety of
the combined vaccine resulted in poor uptake. This is
considered the reason for the increase in infections
reported in 2012 and early 2013.
Signs and symptoms
Box 1 lists the typical signs and symptoms. The incubation
period is seven to 18 days, most commonly 10-12.
The initial symptoms appear about ten days after
exposure to the virus. The rash usually appears after
four days and most people are ill for about 14 days.
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Prodrome The prodromal period lasts about four days.
During this time, the individual develops a cough,
runny nose and conjunctivitis, and may have
diarrhoea and vomiting.
Koplik’s spots These are small red spots, each with a
bluish-white speck in the centre. They develop over the
mucous membranes lining the mouth and throat, and
are most clearly seen opposite the molar teeth; they are
detected in 60-70% of people affected (NHS Choices
2013a). Koplik’s spots persist for two to three days,
usually until after the rash disappears.
Pyrexia Some individuals experience only mild pyrexia,
but for others temperature can peak as high as 40.6°C
and remain at this level for several days (NHS Choices
2013a). Temperature often falls in the early stages of
measles, rising again when the rash appears.
Rash The measles rash is still sometimes described as
morbiliform, reflecting the traditional name of the infection.
It is a red, itchy, maculopapular rash fading to brown
before it resolves (Figure 1). It first appears behind the
ears, spreading to other areas around the head and neck,
then down the trunk and legs. It appears within 2-4 days
of infection, continues to develop over 3-4 more days and
gradually assumes a blotchy appearance as the individual
spots coalesce (NHS Choices 2013a). The skin sometimes
desquamates (peels) as the rash disappears.
Complications
Most people recover uneventfully. About 10% develop
complications, which are mostly mild. However, severe,
life-threatening side effects can occur, and it is estimated
that one in 5,000 cases is fatal (NHS Choices 2013b).
Mild complications Those most commonly associated
with measles are listed in Box 2. Although they can
Figure 1 Measles rash
Science Photo Library
February 2015 | Volume 25 | Number 1 35
 Continuing professional development
be distressing, they are not usually serious and
resolve spontaneously.
Febrile convulsions (fits) are estimated to occur in
0.5% of cases. Although they are alarming for parents,
they do not usually cause lasting health problems. At one
time, it was thought there was an association between
a child having febrile convulsions and developing epilepsy,
however there is no evidence that this is the case.
Children who have had measles can develop a squint if
the virus particles affect the nerves or muscles serving
the eye. There is also a risk of otitis media through
secondary bacterial infection.
Complications are more likely for individuals who
experience severe infection, but occasionally previously
healthy people can develop either a severe infection
or life-threatening complications. Pregnant women,
babies younger than 12 months and people who are
immunocompromised, such as those with HIV/AIDS or
those undergoing chemotherapy, are at particular risk.
Fatality is highest for those younger than 12 months,
lowest for children aged between one and nine years,
increasing again for older children and young adults.
Severe complications These tend to involve the
neurological and respiratory systems.
Encephalitis Acute demyelinating encephalitis
(inflammation of the brain) is a rare and serious
complication of measles developing within 7-10 days
of the appearance of the rash (NHS Choices 2013b).
It is estimated to occur in 0.1% of cases and is thought
to be an allergic reaction to the virus.
The child becomes irritable and increasingly drowsy,
may complain of headaches, may vomit and eventually
lapse into unconsciousness. Mortality rate is 10-15%
and, of those who survive, 25% sustain severe brain
damage (NHS Choices 2013b). There is no treatment
other than supportive care.
Pneumonia Bronchopneumonia develops in 5% of cases,
giving rise to serious respiratory problems; it accounts
for 56-86% of the mortality associated with measles
(NHS Choices 2013b). It usually occurs as a result of
secondary infection caused by Staphylococcus aureus or
secondary viral infection (herpes simplex or adenovirus).
Lobar pneumonia usually develops through secondary
infection caused by Streptococcus pneumoniae.
Diagnosis
It is usually possible to diagnose measles from clinical
presentation, especially the typical rash and the
presence of Koplik’s spots. However, laboratory testing is
undertaken for surveillance. Diagnosis is confirmed by the
presence of antibodies specific to measles in a sample of
saliva. Testing is most accurate if it takes place as soon
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as the rash appears. Accuracy declines after two weeks
and the test is not reliable six weeks after onset.
Public health measures
Because the virus is so contagious, public health
measures to prevent and control the spread of measles
are important, even in countries where the incidence
of the infection is low. The key measures are:
■ MMR vaccination.
■ Surveillance and notification of cases.
■ Control of established outbreaks.
■ Isolation of infectious cases and suspected cases.
Now do time out 2.
2 Public health management
Access the Public Health England (2014)
Time out
website and look at the information provided
about the public health management of
measles. From your reading, explain from
the perspective of public health to a junior
colleague why early detection of one or more
cases of measles is important.
Early detection enables public health authorities
to launch a vaccination campaign promptly and
identify others at risk who would benefit from
post-exposure prophylaxis (administration of human
natural immunoglobulin (HNIG) or vaccination).
Those at risk include anybody who has not been fully
vaccinated or who does not have natural immunity and,
as mentioned earlier, some groups are at particularly
high risk. For these, follow up and treatment are
particularly important.
Advice in specific cases is available from public
health bodies. Awareness of local cases of measles
also provides an opportunity for the immune status of
healthcare workers to be checked so they can be offered
vaccination if necessary.
Measles, mumps and rubella vaccine Vaccination for
measles as a single dose was introduced in the UK in
1968. Uptake remained low until the combined MMR
vaccine was introduced in 1988. The current MMR
vaccine is a freeze-dried preparation containing live
attenuated (weakened) viruses of all three. It is estimated
to provide protection from measles for 90% of recipients
and protection from mumps and rubella for 95% (PHE
2013a). The vaccine is thus highly effective, offering
a high level of herd immunity that can be maintained
through effective vaccination campaigns.
European countries have set targets for the
elimination of measles in line with recommendations
from the World Health Organization (WHO) (2010),
with intensive surveillance designed to detect, investigate
PRIMARY HEALTH CARE
and confirm suspected cases. The original target date set
for elimination in 2010 has not been met and has been
rescheduled for this year (NHS Choices 2013c).
Immunisation schedule In the UK, immunisation to
prevent measles is administered routinely as part of the
two-dose MMR vaccine. The first dose is given when the
child is aged between 12 and 13 months. Occasionally,
vaccination is recommended before 12 months if the
family lives in or is planning to visit a locality where the
incidence of measles is known to be high. The second
dose is given between the ages of three years and
four months and five years. This is recommended before
the child starts school, at the same time other vaccinations
are given. Although a single dose of vaccine for measles is
still available in the UK, it is not recommended.
Health workers in direct contact with patients should
receive the MMR vaccine when they start work, unless
they are already immune.
MMR controversy In 1998, Andrew Wakefield,
a gastroenterologist working at the Royal Free Hospital
in London, claimed that administration of the combined
vaccine could trigger inflammatory bowel disease through
an adverse effect on the immune system and might also
be responsible for children developing autistic spectrum
disorder. The controversy continued until 2010, when it
emerged Wakefield’s paper had been based on observations
undertaken with only 12 children. His later claims were
also subsequently discredited and further, rigorous research
failed to establish any link between MMR vaccination,
bowel disorders or autism (Demicheli et al 2012).
However, his claims were widely publicised and
exaggerated fears about the vaccine’s safety resulted
in poor uptake. In 2005, only 85% of children were fully
vaccinated in England, compared with the previous norm
of 100% (PHE 2013a). Wakefield has since been found
guilty of manipulating evidence, conflict of interests and
unethical conduct, and his name has been removed from
the medical register.
Box 3 Contraindications for MMR vaccination
■ Severe local or generalised reaction to a previous
dose of the measles, mumps and rubella vaccine.
In cases of doubt, the opinion of a specialist
paediatrician should be sought.
■ Allergy to neomycin or gelatine.
■ Untreated malignant disease.
■ Immunosuppression either through illness or
steroid therapy.
■ Within six months of chemotherapy or radiotherapy.
■ Within three months of receiving blood products
such as immunoglobulin.
■ Pregnancy.
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Vaccination side effects Parents can be reassured that
most children remain well after receiving the MMR
vaccine, although occasionally there are mild side
effects. These are more likely to appear after the second
dose. Children sometimes develop mild pyrexia and
a faint rash seven to ten days later. Symptoms persist for
a few days and are not a cause for concern.
Children occasionally develop mild pyrexia
accompanied by a sore throat and joint pains up to
three weeks after vaccination, but these symptoms
resolve spontaneously.
In about 1% of cases, children develop swollen
salivary glands. This reaction occurs in response to the
mumps component of the vaccine. The swelling resolves
spontaneously. Febrile convulsions have been reported for
0.1% of cases (NHS Choices 2013a, 2013b, 2013c).
Now do time out 3.
3 Vaccination risk
Reflecting on earlier sections of this article,
Time out
what advice would you give to parents
concerning the risk of febrile convulsions
following MMR vaccination?
The risk of a child having a febrile convulsion in response
to infection with the measles virus is estimated at 0.5%
of cases (PHE 2013a), which is higher than the risk of
having a febrile convulsion as the result of vaccination,
so parents can be reassured about the safety of
vaccination. Nevertheless, parents can be influenced
by the opinions of friends and family or the media,
sources that are not always accurate.
Anxious parents should be advised that the following
are not contraindications for MMR vaccination:
■ Family history of adverse reactions following MMR.
■ Previous infection with measles, mumps or rubella.
■ Asthma, eczema, hay fever or rhinitis.
■ Antibiotic treatment.
■ Treatment with topical or inhaled steroids.
■ Being breastfed.
■ Being older than the age recommended in the
vaccination schedule.
■ Allergy to eggs.
Parents can be reassured that minor illness without fever
– such as otitis media, upper respiratory tract infection,
mild diarrhoea and vomiting – are not reasons for deferring
vaccination. If a child has an acute illness with pyrexia,
vaccination should be deferred until the child is well.
Contraindications The MMR vaccine is not recommended
for a minority of individuals (Box 3). Special consideration
is necessary for children younger than six months who are
exposed to the risk of measles. If the mother had measles
February 2015 | Volume 25 | Number 1 37
 Continuing professional development
before the child was born, the child is usually immune
because of protection by maternal antibodies in utero.
If the mother has not had measles, the child can be
protected by receiving an injection of HNIG that contains
antibodies. Protection is immediate, but short-term only.
Surveillance Monitoring infection rates can detect
changes in the baseline rate to identify trends and
permit rapid action to be undertaken to control
outbreaks (Thacker and Berkelman 1988). Enhanced
surveillance for measles was introduced in the UK in
1994, organised through the Centre for Infections,
which is responsible for reporting cases every month.
The reports are shared with the WHO and the European
Surveillance Network.
Because of the high contagiousness of measles,
medical practitioners in the UK are required to notify
the relevant public health authorities of all suspected
and actual cases by telephone. Written confirmation is
required within three days. Standard letters from the
public health bodies are available to be sent to schools
and nurseries attended by children who have measles.
National catch-up programme This initiative was
announced by the PHE in April 2013 (NHS Choices
2013c). The aim was to offer MMR vaccination to as many
previously unvaccinated 10-16 year olds as possible before
the next school year to reduce the increasing number of
confirmed cases despite high vaccine uptake. In 2012,
94% of five year olds had received the initial vaccine
dose and 90% had received their second dose, yet there
were 2,000 confirmed cases of measles that year;
by the end of March 2013, there were 587 confirmed
cases (PHE 2013a). Of these, 20% were admitted to
hospital and 15 developed severe complications, mainly
pneumonia or meningitis (PHE 2013b).
A similar campaign was launched in Wales (Public
Health Wales 2014) in response to a measles epidemic
in the Swansea area between November 2012 and May
2013. There were 1,219 confirmed cases, 88 hospital
admissions, and a man aged 25 years died from
pneumonia. Drop-in sessions were held in primary care
centres, schools and hospitals, and the MMR vaccine
was offered to 75,868 people. The outbreak was
declared over in July 2013.
However, Public Health Wales has estimated that there
are still 30,000 ten to 18 year olds in Wales who have
not been fully vaccinated and are at considerable risk.
Control of established cases and outbreaks When a case
of measles occurs, it is necessary to check the vaccination
history of all those who have been in contact with the
index (first) case. Contacts are asked to provide their
immunisation history or indicate whether they have natural
immunity. However, such accounts are not always reliable.
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Measles is one of a range of infectious conditions that can
result in pyrexia and general malaise, accompanied by
a rash. Individuals may be genuinely mistaken about the
nature of a previous infection, especially one that occurred
years ago when they were very young, and may assume
that they have had measles when they have not.
A salivary test can be undertaken to identify the
presence of measles-specific antibodies. If it is negative
after exposure to a case of measles, post-exposure
prophylaxis can be offered.
If an outbreak occurs, it is managed by a specially
convened outbreak control team. Members will include
specialists in health protection, education representatives
from the local authority, members of the school nursing
service and GPs. Representatives from the local NHS
acute trust are likely to include a microbiologist, infection
control nurse and paediatrician.
Isolation of infectious cases PHE (2013a) has developed
guidelines for managing people with measles and
suspected infection in primary care and other settings.
These emphasise that staff employed in reception areas
should be aware that patients complaining of a rash
or pyrexia should be given appointments at the end of
clinic sessions so they encounter as few other patients
as possible, and they should be asked to wait in rooms
away from the main reception areas.
Patients with measles should be excluded from
childcare settings, schools and workplaces for the first
five days after the appearance of the rash, when they
are most likely to be infectious. If hospital admission is
necessary, the infection control team should be contacted
in advance because full source isolation will be required.
Now do time out 4.
4 Prevention
Design a care plan to prevent the spread
Time out
of measles in the clinical setting where you
work. You could refer to Gould (2009).
The chain of infection can be broken by admitting
patients to single rooms and keeping the door shut.
Personal protective clothing should always form part
of the standard infection, prevention and control
precautions for any patient. It is particularly important
when delivering care to patients with confirmed or
suspected measles, because the virus is present in oral
and nasal secretions and can survive for up to two hours
in the environment. Hand hygiene should be performed
before and after patient contact (Gould 2009).
Surgical masks do not provide effective protection
against airborne infections because they are designed
PRIMARY HEALTH CARE
to reduce risks from respiratory droplets, not the much
smaller droplet nuclei that carry the measles virus that
are more likely to reach the lower respiratory passages
(Fennelly and Nardell 1998). Filter masks are a better
alternative, although evidence of their effectiveness
is lacking (Adal et al 1994). Patients should be
encouraged to cover their noses and mouths when
coughing or sneezing, and to expectorate into special
disposable containers.
Other infection prevention and control precautions
should include the following disposal and
decontamination measures:
■ Dealing with excreta.
■ Laundry.
■ Clinical and other equipment.
■ Crockery and cutlery.
■ Cleaning.
■ Providing information for patients, visitors and
other staff. They should wear personal protective
clothing and should wash and dry their hands
carefully, before and after contact with patients.
Management
There is no cure for measles. However, recovery is
usually spontaneous once the immune system has
cleared the body of infection. Most patients can be
managed safely at home and measures can be used to
relieve symptoms, promote rest and reduce the distress
associated with febrile illness. Parents are advised to
seek help if they suspect that their child has measles
because the case should be notified to the public
health authorities. Advice on websites designed for
parents (NHS Choices 2013d) suggests that, once it
has been established that their child has measles,
they should seek help if:
■ Symptoms become worse.
■ The child’s temperature rises above 38°C or remains
high once the rash has disappeared.
There are additional signs of illness, such as earache,
drowsiness or irritability, indicating the possibility of
complications.
Parents should be advised to keep children cool but
not cold, and prevent dehydration by encouraging them
Box 4 Safety net for assessing preschool children
One or more of the following should be offered:
■ Verbal and/or written information for parents/
carers on warning symptoms and how to access
further health care.
■ Follow-up appointment at a specific time and venue.
■ Liaison with other health professionals to ensure
the parent/carer has direct access to further
assessment, including out-of-hours provision.
(Adapted from National Institute for Health and Care Excellence 2013)
PRIMARY HEALTH CARE
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Copyright © 2015 RCN Publishing Ltd. All rights reserved.
to drink cool drinks and eat ice lollies. If parents are
aware that their child has not been fully vaccinated and
has been in contact with a case of measles, they are
likely to be aware of the risks and be vigilant for
symptoms. Education about the purpose of antibiotic
treatment may be necessary: antibiotics are ineffective
against viral infections and should be prescribed only if
a secondary bacterial infection, such as a bacterial ear
infection or bacterial pneumonia, has developed.
Fever in very young children
This is one of the most common reasons for parents
to take children to see a GP and the second most common
reason for hospital admission (National Institute for
Health and Care Excellence (NICE) 2013). Nurses who
work in primary care settings are likely to encounter
children under five years who have developed pyrexia.
The updated NICE (2013) guidelines are particularly
helpful in assessing and managing such children.
These incorporate a traffic-light table to help health
professionals identify serious illness so children can
receive the best care in the most appropriate settings.
Now do time out 5.
5 Up-to-date guidance
Access the updated guidelines on assessing
Time out
and managing fever in young children from
the National Institute for Health and Care
Excellence (2013). How do these apply in the
setting where you work?
The NICE guidelines provide an invaluable resource for
any health professional whose work is likely to bring
them in contact with preschool children face-to-face
or remotely – for example, a helpline or telephone
triage. The guidelines apply to children aged between
four weeks and five years. Patient-centred care is
emphasised to encourage attention to the individual
needs of children, parents and other carers, as is the
importance of good communication to enable shared
decision making.
Routine assessment should include recording
temperatures (electronic temperature in the axilla,
chemical dot thermometer in the axilla or infrared
tympanic thermometer), heart rates and respiratory
rates. The presence and absence of other symptoms
are then assessed according to protocol, with a safety
net for the parent/carer (Box 4).
Today, parents are likely to be aware that severe,
life-threatening infections can occur in childhood
(Purssell 2009). However, this is rare and in most
cases children will be rated as ‘green’ on the traffic
light system, meaning that they do not need hospital
admission, or ‘amber’, meaning that it is safe for them
February 2015 | Volume 25 | Number 1 39
 Continuing professional development

Box 5 Advice on looking after a preschool child
with fever
■ Paracetamol or ibuprofen can be given to reduce
distress. These should be discontinued as soon as
the child is no longer distressed.
■ If the medication used does not help reduce
distress, another can be tried; more than one type
of medication should not be given simultaneously.
■ Avoid giving antipyretic agents solely to reduce
temperature: these may adversely affect the
long-term outcomes of illness.
(Adapted from National Institute for Health and Care Excellence 2013)
to go home. Box 5 outlines advice for parents caring for
a preschool child with fever at home.
Health staff and vaccination
The MMR vaccination is offered routinely to health
professionals whose work is likely to bring them in direct
mild to life threatening. Recent upsurges in
confirmed cases, attributed to low levels of vaccine
uptake throughout the 1990s and early 2000s in
response to public concern about the safety of the
MMR vaccine, has imposed a burden on UK health
services and resulted in considerable morbidity
and at least one death.
Nurses in primary care have an important role
in the early identification of measles cases and the
implementation of public health measures required
to prevent and control the spread of the infection.
Those in other settings may encounter children or young
adults with suspected or confirmed measles, and they
need to be familiar with the precautions necessary
to prevent spread.
Now do time out 6.
6 Reflective account
Now that you have finished the article,
Time out

contact with patients, but who have not previously been

you might want to consider writing
fully vaccinated and who do not have natural immunity.
a reflective account of 750-1,000 words.
If necessary, the vaccine should be administered before
Go to the Primary Health Care website at
the commencement of employment.
rcnpublishing.com/r/phc-reflective-account
to find out how to make a submission.
Measles in developing countries
Measles is a major health threat in developing countries,
where malnourishment places children at high risk of
developing complications through secondary infection, Find out more
and the mortality rate is high. Those suffering from
vitamin A deficiency are at risk of becoming blind. Resources suitable for patients and members
of the public:
Conclusion ■ NHS Choices, tinyurl.com/nhs-choices-measles
Measles is not a harmless childhood infection. ■ Patient.co.uk, tinyurl.com/patient-measles
Complications occur frequently and range from

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40 February 2015 | Volume 25 | Number 1 PRIMARY HEALTH CARE

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