Quality and Population Health

Measles Outbreak Clinical Quick Guide

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Key Points

  • Ensure all health care personnel (HCP) have documented evidence of immunity on file at their work location
  • Encourage symptomatic patients to call BEFORE visiting a health care facility. Call ahead if referring a patient to another health care facility. Post signage directing staff and/or patients to identify anyone presenting with fever and rash
  • Mask (if tolerated) and place all patients with suspected measles in airborne isolation immediately. All staff should wear a fit-tested respirator (e.g. N95) when caring for patients with suspected/confirmed measles
  • Ask about risk factors (including recent travel internationally or to communities with current measles outbreaks) in patients with febrile rash illness consistent with measles
  • Ensure all patients, including travelers, are up-to-date with their MMR vaccines

Clinical Presentation

Always consider measles when evaluating patients with fever and rash. Measles symptoms include:

  • High fever (>101)
  • Cough, coryza, and/or conjunctivitis
  • Generalized maculopapular rash which usually begins at the hairline and spreads downwards to the neck, trunk, arms, legs and feet

Laboratory Testing

If measles is suspected, order the following blood tests (adult 2 yellow top tubes, pediatrics one red top tube):

  • Blood specimen for IgM (acute infection)
    • Epic order: Measles IgM Ab 304LAB180
  • Blood specimen for IgG (immunity)
    • Epic order: Measles Antibody Screen (IgG) 304LAB178

Expected turnaround time is 48-72 hours.

If patient is immunocompromised, requires hospitalization, or there is a high clinical suspicion for measles also send the following PCR testing (NOTE NJDOH AUTHORIZATION REQUIRED):

  • Nasopharyngeal/throat swab for measles PCR testing
    • Call CPD at X 3430 to obtain a Nasopharyngeal VCM Swab Set
    • Collect the specimen and place swab in the Green Cap VCM Medium
    • Epic order: Miscellaneous Test-Measles PCR to NJ State Lab
  • Urine collection
    • 10-50 ml of urine in a sterile container
    • Epic order: Miscellaneous Test-Measles PCR to NJ State Lab

NJDOH authorization process for swab and urine PCR testing:

  • Provider must call the local health department where the patient lives during normal business hours. On evenings, nights, or weekends call the NJDOH at (609) 392-2020 to obtain approval.
  • The department of health will fax the NJDOH SRD-1 Form to the provider.
  • The provider must send the completed NJDOH SRD-1 Form to the lab. The NJDOH will not process the urine and nasopharyngeal specimens until the completed document is received.

Post-Exposure Prophylaxis (PEP)

  •  Non-immune individuals ≥6 months should receive MMR as PEP within 72 hours from first exposure, unless contraindicated
  • Persons ≥ 1 year of age with 1 dose of MMR before exposure should receive a 2nd dose (if at least 28 days since previous dose)
  •  Immune globulin (IG) should be given to non-immune individuals who are exposed to measles and at high risk for complications including: infants ˂6 months, infants 6-12 months who didn’t receive MMR within 72 hours of exposure, non-immune pregnant women, and severely immunocompromised persons

Outbreak Vaccine Recommendations

HCP treating patients who live in/travel to outbreak communities should:

  • Consider offering MMR vaccine to all infants 6-11 months of age without contraindications
  • Offer MMR vaccine at the earliest opportunity to all unvaccinated eligible patients ≥ 1 year of age
  • Offer a second dose of MMR vaccine to eligible patients ≥1 year who have previously received one dose of vaccine, separated by at least 28 days
  • Offer teenagers and adults without documented evidence of immunity against measles two doses of MMR vaccine separated by at least 28 days. Extra doses of MMR are not harmful.

If the patient was born before 1957: the patient is considered immune.

If the patient was born between 1957 and 1989:

  • and the patient is unsure of vaccination status, you can order measles IgG test to assess for immunity and offer MMR series if not immune.
  • Alternatively, you can also just offer MMR series if no contraindication as there is no harm in booster.

Offer the patient a second MMR for those who received only one dose, if the patient is:

  • a likely exposure to measles in endemic areas (parts of Rockland County, Brooklyn, and Ocean County NJ)
  • traveled to counties where the rates of measles are high (Philippines, India, Ukraine)
  • Health care personnel

Reporting

Report all suspect measles cases (febrile illness accompanied by generalized maculopapular rash) immediately (DO NOT WAIT FOR LABORATORY CONFIRMATION) to the local health department. If unable to reach the local health department, notify the NJDOH during regular business hours at (609) 826-5964. After business hours, or on the weekend, call NJDOH at (609) 392-2020.

Sources: Adapted from NJDOH materials; EH Infection Prevention and Control. May 2019.