Clinician Alert: Measles exposure Jan. 15, 2019

January 15, 2019

Please distribute widely to clinicians in your organization today.

Clark County Washington is investigating two new confirmed case of measles and eleven additional suspected cases, all in unvaccinated children. These new cases are in addition to the Clark County case reported earlier in January. Your patients may be at risk from multiple public exposures; we will share details in additional alerts as soon as they are available.

Known public exposures at this time include

  • Church of Truth, 7250 NE 41st St., Vancouver, Sunday Jan. 6. from 11 am to 4:30 pm

  • Portland International Airport, PDX Monday, Jan. 7 from 10:45 am to 3:45 pm

We expect the list of exposures to grow as more information becomes available.

Susceptible individuals exposed to these cases could develop symptoms of fever and respiratory symptoms anytime from January 13th to January 28, 2019; the famous measles rash is not usually present at the onset of fever and develops 2-4 days later. Patients are contagious BEFORE the onset of rash. If one of your patients develops compatible symptoms, take the following steps:

  1. Determine if your patient could have been exposed at the locations identified based on the most recent information. Up-to-date vaccination status makes measles much less likely.

  2. If your patient is potentially exposed and ill with a compatible syndrome including fever, cough, coryza (runny nose) and conjunctivitis then contact the local health department of the patient’s residence (numbers below)

  3. Determine by phone evaluation if the patient needs medical attention; if so, then arrange for an evaluation that minimizes spread to others by

    1. Contacting the facility where the patient will be evaluated so preparations for airborne precautions are in place

    2. Having the patient wear a mask and place immediately placed in a room

    3. Performing evaluation in a negative pressure room if possible

    4. Considering all relevant potential diagnoses; if measles is still suspected then specific testing can be facilitated by contacting the local health department

    5. Instructing the patient to isolate at home if measles is possible

  4. If the patient does not need immediate medical evaluation, then contact the local health department of the patient’s residence to obtain advice on specific testing.

Measles is a highly contagious, severe, febrile viral respiratory illness In addition to prominent respiratory symptoms and malaise, measles is characterized by a cough, conjunctivitis and an extensive rash that typically begins the 2nd to 4th day of illness. Measles frequently causes diarrhea, ear infection and pneumonia; in recent years, approximately 30% of Oregon cases required hospitalization. Less frequent but feared complications include keratitis, corneal ulceration, blindness, encephalitis, and death. Infants, the elderly, pregnant women, and compromised hosts may be at greater risk for serious complications of measles. Measles spreads easily in healthcare settings and your attention to this situation will help prevent additional cases and unnecessary prolongation of the outbreak.

Vaccination with MMR or MMRV is safe and highly effective; make sure all of your patients are up-to-date. Infants under 12 months of age are typically susceptible to measles because vaccination is usually given at 12-15 months of age.

Local Health Department Phone Numbers:

  • Clackamas: 503-655-8411
  • Clark: 360-397-8412
  • Multnomah: 503-988-3406
  • Washington: 503-846-3594

See Clark County’s Provider Alert below:

TO: Physicians and other health care providers

Clark County Public Health is investigating two additional confirmed cases of measles in unvaccinated children. These two cases are in addition to the confirmed measles case announced earlier this month. Public Health is also investigating 11 suspected measles cases.

Public Health has identified two public exposure locations for the new confirmed cases:

  • Church of Truth, 7250 NE 41st St., Vancouver,  Sunday Jan. 6. from 11 am to 4:30 pm

  • Portland International Airport, 7000 NE Airport Way, Portland. Specifically, people who spent time in Concourse D and the Delta Sky Lounge.  Monday, Jan. 7 from 10:45 am to 3:45 pm

All possible contacts are being advised to watch for symptoms of measles and seek health care for diagnosis by calling ahead in order to avoid exposing others in waiting rooms and lobbies.

Public Health will provide updates as additional information becomes available.

Clinical presentation

Please consider measles in patients who:

  • Present with febrile rash illness and the “three Cs”: cough, coryza (runny nose) or conjunctivitis (pink eye).

  • Recently traveled internationally or potentially exposed to someone with confirmed measles.

Health care providers should consider measles when evaluating patients for febrile rash illnesses, including dengue (https://www.cdc.gov/dengue/) and Kawasaki disease (https://www.cdc.gov/kawasaki/).

Infection control

If you suspect measles, immediately mask and isolate patients (in a negative-pressure room, if possible) to avoid disease transmission.

Contact your local health department to arrange for testing. Refer to the steps on the attached Suspect Measles Worksheet (www.clark.wa.gov/sites/default/files/dept/files/public-health/CD/Resources/SuspectMeaslesWorksheet.pdf).

Here are other ways to minimize exposure to others:

  • If possible and appropriate, patient may be scheduled as the last patient of the day.

  • If feasible, appropriate and patient privacy can be protected, patient can be briefly evaluated outside, at least 30 feet from others. Once mask is placed and a clear path to exam room is prepared, patient can be escorted into the building.

  • Whenever possible, patient should be escorted from a separate clinic entrance that allows them to access an exam room directly, without exposing others.

  • The number of health care workers interacting with the patient should be kept to a minimum.

  • If the patient is already in the clinic, patient should be roomed immediately, rather than allowed to wait in the lobby.

  • The exam room door should remain closed at all times, and the patient should remain masked during the entire visit.

  • All labs and clinical interventions should be done in the exam room.

  • The exam room should not be used for at least two hours after the patient has left.

Additional guidance for health care providers

CDC measles

http://www.cdc.gov/measles/hcp/index.html

CDC Provider Resources for Vaccine Conversations with Patients

https://www.cdc.gov/vaccines/hcp/conversations/index.html

Washington State Department of Health

https://www.doh.wa.gov/ForPublicHealthandHealthcareProviders/NotifiableConditions/Measles

*Presumptive evidence of measles immunity is defined as:

  1. Birth before 1957

  2. Laboratory-confirmed disease

  3. Laboratory evidence of immunity (protective antibody titers) or

  4. Documentation of age-appropriate vaccination with a live measles virus-containing vaccine:

  • Pre-school children: 1 dose

  • Children in grades K–12: 2 doses

  • Health care personnel born during or after 1957: 2 doses

  • Students at post-high-school educational institutions: 2 doses

  • International travelers ≥12 months of age: 2 doses

  • Children 6–11 months of age who plan to travel internationally: 1 dose

  • All other adults: 1 dose

Thank you for your partnership,

Clark County Public Health: (564) 397-8182

Cowlitz County Health Department: (360) 414-5599

Skamania County Community Health: (509) 427-3850

Wahkiakum County Health and Human Services: (360) 795-6207