Health Advisory

Summary

From January 1 to April 19, 2019, 626 individual cases of measles have been confirmed in 22 states.  This is the second most cases for any year since measles elimination was declared in 2000.

No confirmed cases of measles have occurred in Virginia this year.  However, three cases were identified in Maryland in the last month, increasing the risk of exposures and transmission in Northern VA.

Suggested Actions

• Assess the measles vaccination status of your patients and recommend vaccination for those who are not completely immunized.  Healthcare provider recommendations are particularly influential to parents making immunization decisions for their children.
   
• Maintain an increased index of suspicion for measles in persons with clinically compatible illness at all times but particularly if a patient presents with fever and rash, and has history of travel to an outbreak affected area (US or internationally) (https://www.cdc.gov/measles/cases-outbreaks.html).
   
• Suspected measles should be immediately reported to Public Health. Contact the Health Department’s Communicable Disease/Epidemiology Unit immediately at 703-246-2433 (normal business hours) or 703-409-8449 (evenings and weekends) to report a suspected case and for additional guidance on testing and infection control measures.  Do not wait for laboratory confirmation before making a report.
   
• For suspect measles cases, we also recommend the following actions:
  • Immediately triage the patient.  Do not allow such patients to remain in your waiting area.
  • Place a surgical mask on the patient as soon as possible.       
  • If you are aware that a suspect measles patient will be arriving at your facility, ensure that the patient is masked before entering the building.  If referring to another health care facility, notify the other facility before sending the patient so that appropriate infection control measures can be implemented at the receiving facility.   
  • Place the masked patient in a private, negative pressure room if available, or a room with a closed door.  This room should not be used for 2 hours after a suspect measles patient leaves. 
  • Use standard and airborne precautions, if possible. 
  • Only health care workers with immunity to measles should work with the patient.   
  • Collect a serum sample to test for measles IgM and IgG antibodies; and nasopharyngeal swab, oropharyngeal swabs, and urine for polymerase chain reaction (PCR) testing.
     
• Ensure that all patients, particularly those traveling internationally, are adequately vaccinated against measles. 

Additional Information

Measles is a highly infectious viral disease with an incubation period of approximately 10 days (range 7 – 21 days) from exposure to rash onset. Patients with measles are considered infectious from 4 days before to 4 days after rash onset. Transmission is primarily person-to-person via large respiratory droplets. Airborne transmission via aerosolized droplets has been known to occur within shared air space for up to 2 hours after an infectious person with measles has occupied that space.

Clinical manifestations of measles include fever, cough, coryza and conjunctivitis, followed by a maculopapular rash beginning on the face spreading caudally and centrifugally. The measles rash tends to be non-pruritic.  During the prodromal period, Koplik spots may be present. 

The laboratory criteria for measles include ANY ONE of the following:

           1) positive IgM serologic test for measles,  

           2) significant rise in measles IgG antibody,

           3) isolation of measles virus from a clinical specimen, or

           4) detection of measles-virus nucleic acid by polymerase chain reaction.

In general, persons may be presumed to be immune to measles if they have documentation of two doses of measles vaccine, laboratory evidence of immunity to measles, documentation of physician-diagnosed measles, or were born before 1957.  Persons who are not immune should be given MMR vaccine or immune globulin according to Advisory Committee on Immunization Practices (ACIP) recommendations.

Individuals who work in health care facilities in any capacity are at increased risk of exposure to measles. To ensure staff are immune to measles, they must have documentation of two doses of measles vaccine or laboratory evidence of immunity to measles.  Birth prior to 1957 is not acceptable evidence of immunity for health care providers. Susceptible personnel (unvaccinated and/or no laboratory evidence of immunity) who have been exposed to measles should not have contact with patients or be in a health care facility from the 5th through the 21st day after exposure, regardless of whether they received vaccine or immune globulin after the exposure.

Children traveling internationally can be given measles vaccine as early as 6 months of age. These children should then receive a measles vaccine at 12-15 months of age.  This second dose should be given at least 28 days after the initial dose.  Children traveling internationally who are older than 12 months of age and have already received one dose of vaccine should receive a second dose before travel.  The interval between doses should be >28 days.      

Additional information about measles and measles vaccination is available at the Centers for Disease Control and Prevention website at http://www.cdc.gov/measles/index.html.