Clinician Alert: Measles cases 2018

July 6, 2018

Two lab-confirmed cases of measles have been confirmed in Multnomah County since June 27, 2018. One is believed to have been infected during travel outside the United States and the other was a known close contact to the index case. We are asking health care providers to:

  • Be alert to measles symptoms, especially in those who are not immune (see below).
  • Immediately report any possible measles cases to the health department of the county where the patient resides.
  • Vaccinate any non-immune patient ≥ 12 months old who is susceptible to measles with MMR vaccine unless they have a medical contraindication.
  • Give a second MMR to anyone ≥ 4 years old who is eligible (≥ 4 weeks after their first MMR) to fully protect against measles.
  • Routinely vaccinate infants age 6-11 months who are planning to travel to any country outside the United States.


Individuals are considered immune to measles if ANY of the following apply:

  • Individual was born before 1957
  • Individual has had laboratory confirmed measles disease
  • Individual has been fully vaccinated for measles (1 dose for 12 months through 3 years old, 2 doses in 4 years and older)
  • Individual has laboratory evidence of immunity


About measles

Measles is a highly contagious acute febrile, respiratory illness associated with an extensive rash. Illness typically begins with fever followed by development of respiratory symptoms sometimes referred to as “the 3 C's” of cough, conjunctivitis, and coryza (nasal congestion); rash typically begins on the face around day 3 of illness and spreads to become generalized. Note that the rash may not yet be present on initial presentation.

Patients with measles may be contagious from 4 days before through 4 days after rash onset. The local county health department may exclude from school or work any non-immune individual who is exposed to a confirmed case of measles. Complications include otitis media, pneumonia, diarrhea, and encephalitis. Infants under 12 months of age who have not yet received the MMR vaccine can be particularly vulnerable to measles and its complications.


Lab testing and public health approval

For patients who are susceptible to measles AND have had known contact with a confirmed measles case AND present with compatible symptoms: Obtain approval from county public health officials and collect for measles PCR testing at the Oregon State Public Health Lab: a nasopharyngeal swab (swab the posterior of the nasal passage with a synthetic swab in 1–3 mL of viral transport medium; store specimen in refrigerator and store on ice) AND a regular urine sample.

If the patient lives in Clark County, Washington: contact Clark County Public Health for approval to send specimens to the Washington State Public Health Laboratories.

For other patients suspected of having measles based on lack of immunity and illness presentation:  Obtain serology for measles IgM and IgG (4-5 mL in red or tiger top tube) in addition to tests for any alternative diagnoses.  These patients should be instructed to remain at home and away from others until they are afebrile AND 4 days have passed since rash onset.


Office infection control:

  • Measles is highly contagious and can spread through the airborne route as well as through contact with patient secretions.
  • All health care workers who have contact with patients should have two documented MMR vaccines or laboratory evidence of immunity.
  • Medical offices should review their policies and develop a plan to evaluate patients with suspected measles.
  • Phone and front desk triage of febrile patients with fever and a new rash or conjunctivitis should include assessment of measles immunity status. The patient should wear a regular surgical mask before entering the building or as soon as symptoms compatible with measles are identified.


Ways to minimize exposure to others include:

  • 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 away from others. Once mask is placed and a clear path to exam room 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 2 hours until after the patient has left.
  • Any patient referred to an Emergency Department for evaluation should be placed immediately in a negative pressure room and seen by staff who are immune to measles and wearing a fit-tested N-95 mask or powered air purifying respirator (PAPR).


Health care providers that need additional information are encouraged to contact their health system infection control department or their local health department.

Oregon:
Multnomah County - 503-988-3406
Clackamas County - 503-655-8411
Washington County – 503-846-3594

Washington:
Clark County Public Health - 360-397-8182