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Health Alert: Measles

Posted: May 27, 2008
To: Health Care Providers
Cc: All Medical Staff
From: Leigh Hall, MD, Deputy Health Officer
Disease Control Unit - Sonoma County Department of Health Services
707-565-4566

This alert is to advise you of recently diagnosed cases of measles in California and to advise you of precautions to take when evaluating cases of rash illness. The first case was identified in January 2008 in San Diego County. This case was a 7-year-old unvaccinated child returning from a trip to Switzerland. Subsequent exposures to this child in the pediatrician's office and in a school setting resulted in 11 additional confirmed measles cases. More recently, an adult traveler returning from India in April 2008 developed measles after returning to San Francisco. Because measles is extremely contagious and can be life threatening to susceptible individuals we are alerting clinicians and Infection Control Professionals and requesting they follow these recommendations.

Actions requested of all clinicians:

1. Be alert for cases of measles. Consider measles in any patient with fever and rash with recent international travel or with exposure to a visitor from abroad or a US resident who has recently returned from international travel.
2. Implement airborne precautions immediately for all patients with fever and morbilliform and/or vesicular rash: identify, isolate and provide a face mask for the patient to wear.
3. Report suspect cases to the Disease Control at 707-565-4566; in addition, if the case is or was in the hospital, report to your hospital Infection Control Professional (ICP).
4. Coordinate diagnostic testing with the Sonoma County Disease Control.
5. Work with your Infection Control Professional (ICP) (if in a hospital) or Disease Control (if in other settings) to identify exposed susceptible contacts and assess them for post-exposure prophylaxis and the need for exclusion from work or quarantine.

Description of measles:

Due to a successful vaccination program, measles is rare in the US. However in recent months there has been a significant rise in cases due to outbreaks in several states. Imported international cases initiated outbreaks that subsequently involved mostly unvaccinated persons. The imported cases originated from many countries. Most were from Europe. Clinicians should suspect measles in patients presenting with fever and rash and should ask patients about recent travel and other possible exposures.

Measles is a highly infectious, acute viral disease characterized by a prodrome of fever (which can be as high as 103-105 ºF), malaise, cough, coryza and conjunctivitis, which usually occurs 10-12 (range 7 to 18) days after exposure. After 1-4 days of prodrome an erythematous maculopapular rash develops that usually begins on the face and upper neck and then progresses downward and outward. Pathognomonic enanthem (Koplik spots) may occur. People who have received vaccinations against measles can have a more mild clinical presentation (modified measles) and people who have received antibodies (e.g. newborns receiving maternal Ab and people who have received IG) can have an atypical presentation (rash progresses in opposite fashion). Complications of measles include bronchitis, pneumonia, encephalitis and death.

Infection Control:

Measles is transmitted person-to-person via large respiratory droplets and via aerosolized droplet nuclei. People with measles are infectious from 4 days before rash onset to 4 days after rash onset. Airborne precautions should be used immediately with all suspect cases. Patients should be given a surgical mask to wear at all times. Patients should be placed into a private negative air pressure room. If an airborne isolation room is not available, the patient should be placed in a private room with the door closed. Anybody entering the patient's room should wear respiratory protection (N95 respirator). Patient movement should be minimized. Patients should not go to other areas of the facility for blood draws or other tests. These airborne precautions should be used for any patient with fever and a morbilliform and/or vesicular rash. Contact Disease Control for guidance on re-use of the isolation room. Please strongly consider educating triage staff to identify and request assistance for patients with fever and a rash.

Notifications and responsibilities:

Report all suspect cases to the Sonoma County Department of Health, Disease Control at 707-565-4566. In addition, if the case is or was in the hospital, report to your hospital Infection Control Professional (ICP). Do not wait for laboratory results before notifications. Disease Control will arrange for testing by the Public Health Laboratory system, which will provide more rapid results than most commercial labs. In the hospital setting, the Infection Control Professional will coordinate implementation of infection control measures, identification of exposed susceptible contacts, provision of post-exposure prophylaxis, symptom surveillance and, if necessary, restriction from work or quarantine of exposed susceptible health care workers. In other medical settings, Disease Control will work with the designated manager of the facility. In non-medical settings, Disease Control will manage these disease control interventions.

Before having contact with patients suspected to have measles, health care workers should be protected by vaccination or documented to have immunity. To protect healthcare workers from future exposures, please ensure now that they are vaccinated or have immunity to measles.

Diagnosis:

Testing via the Public Health Laboratory system should be pursued as soon as possible for all suspect cases. Disease Control will facilitate testing. Do not delay diagnosis by sending specimens to commercial laboratories. Measles can be diagnosed by serology (a positive IgM [collected 2-28 days after rash] or a significant rise in IgG), and by isolation from nasopharyngeal or urine specimens. Please obtain all specimens (serum in a red top tube, a nasopharyngeal swab on a Dacron tip swab placed in viral transport media and a urine sample in a sterile cup). Specimens should be sent after consultation with Disease Control to the Sonoma County Public Health Lab (565-4711).

Identification of exposed persons (contacts):

All contacts of suspect measles cases should be identified, their susceptibility determined and reported to Disease Control.

A person is considered a contact if during the infectious period they:

• lived with the case,
• shared air space, including for up to two hours after the case was present, and they were not masked.

Identification of susceptibility or immunity:

A person is considered susceptible if they answer "No" to ALL the questions below. A person is considered immune if they answer "Yes" to any of these questions.

• Were you born before 1957?
• Do you have documentation of 2 doses of measles vaccine?
• Do you have a history of measles with a physician's documentation of the infection?
• Do you have laboratory evidence of measles immunity?

Restriction of Exposed, Susceptible Health Care Workers:

Exposed, susceptible health care workers should be removed from all patient contact and excluded from the facility from the 5th day after first exposure until 21 days after the last exposure (28 days if immune globulin was given).

Post-exposure prophylaxis:

If additional cases occur and are promptly recognized, PEP should be pursued for exposed susceptible contacts:

• Immune globulin (IG) can prevent or modify measles in a non-immune person if given within 6 days of exposure. IG is indicated for susceptible contacts at high risk for developing severe measles, including some infants < 12 months old, pregnant women, immunocompromised persons and others for whom the vaccine is contra-indicated. Severely immunocompromised patients, including other symptomatic HIV-infected patients, exposed to measles should receive IG, regardless of vaccination status because they may not be protected by the vaccine. Infants < 6 months old are usually immune because of passively acquired maternal antibodies. However, if measles is diagnosed in a mother, unvaccinated children in the household who lack evidence of measles immunity should receive IG.
• Measles containing vaccine (MCV) is recommended as PEP for most susceptible persons aged > 12 months. Administration of MCV is preferable to using IG, except as noted above. If administered within 72 hours of initial exposure, MCV may provide some protection. MCV is available in monovalent (measles only) formulation and in combination formulations, such as measles-rubella (MR) and measles-mumps-rubella (MMR) vaccines.

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