Alaska Public Health Advisory
Measles – Situational Awareness
Distributed via AK PHAN
June 5th, 2014
While Alaska has not had a known measles case in 14 years, over 300 cases have been reported in 18 U.S. states (including CA, OR, and WA) thus far in 2014. Most of the recent U.S. outbreaks were initiated through contact with imported cases, and most locally-acquired U.S. cases have been in unimmunized persons. Almost half of the directly-imported cases in the United States have been associated with travel to the Philippines, which has been experiencing a large measles outbreak since October 2013. With the high frequency of domestic and international travel, and the existence of considerable numbers of un- and under-immunized persons in Alaska, we strongly urge all Alaskans to make sure that they and their children are up-to-date on their measles vaccination.
Since the keys to preventing and controlling measles transmission include on-time vaccination, early recognition of disease, and isolation of measles patients while they are infectious, we provide the following recommendations for health care providers:
- Make every effort to ensure that all of your patients are up-to-date on their measles vaccinations.
- Un- or under-vaccinated Alaskans who are traveling to countries where measles is circulating should receive MMR vaccine before they go. Infants traveling to these countries can be vaccinated as early as six months of age (note: they should still also receive the two standard doses of MMR vaccine starting on or after their first birthday).
- Consider measles in patients of any age who have a fever AND a rash, regardless of their travel history. The fever can spike as high as 105°F. Measles rashes are red, blotchy, and maculopapular; they typically start on the hairline and face and then spread downward to the rest of the body.
- In some cases this year, measles was initially misdiagnosed as Kawasaki disease, dengue fever, or scarlet fever.
- Obtain a thorough history on patients presenting with a rash and fever, including:
- any known contacts with similar febrile rash illness;
- travel outside of North or South America or contact in the U.S. with international travelers (including transit through an international airport and or other international tourist attractions) in the prior three weeks; and
- prior vaccination for measles. Please note that although documentation of receipt of two doses of MMR vaccine or a prior positive measles IgG test result makes the diagnosis of measles less likely, measles can still occur in such persons.
If measles is suspected:
- Mask the patient(s) immediately. If a surgical mask cannot be tolerated, other practical means of source containment should be implemented (e.g., place a blanket loosely over the heads of infants and young children suspected to have measles when they are in the waiting room or other common areas).
- Isolate the patient(s) immediately in an airborne infection isolation room, if one is available. If such a room is not available, place patient in a private room with the door closed.
- Do not allow suspect measles patients to remain in the waiting area or other common areas.
- Depending on the number of air changes per hour (see information in link above), do not use the examination room for up to one hour after the possibly infectious patient leaves.
- If possible, schedule to see suspect measles patients at the end of the day.
- For additional infection control information, please see the CDC “Guideline for Isolation Precautions” at: http://www.cdc.gov/hicpac/2007IP/2007isolationPrecautions.html
- Implement airborne precautions
- Regardless of immune status, all health care personnel entering the patient room should use respiratory protection at least as effective as an N95 respirator.
- If possible, allow only health care personnel with documentation of two doses of live measles vaccine or laboratory evidence of immunity (measles IgG positive) to enter the patient’s room. Do not allow susceptible visitors in the patient room.
- Contact the Alaska Section of Epidemiology immediately by calling 907-269-8000 during work hours or 800-478-0084 after hours. The risk of a measles outbreak can be reduced if public health control measures are implemented immediately.
- Inform any facility where the patient is being referred for additional clinical evaluation or laboratory testing about the patient’s suspect measles status and do not refer suspect measles patients to other locations unless appropriate infection control measures can be implemented at those locations.
- Suspect measles patients and exposed persons should inform all health care providers of the possibility of measles prior to entering a healthcare facility so that appropriate infection control precautions can be implemented.
- Collect clinical specimens for measles testing
- Obtain a throat or nasopharyngeal swab; use a viral culturette and place into viral transport media (other media types can inhibit viral growth).
- Draw 7-10 ml of blood in a red-top or serum separator tube; spin down serum if possible. NOTE: capillary blood (approximately 3 capillary tubes to yield 100 μl of serum) may be collected in situations where venipuncture is not preferred (e.g., in children aged <1 year).
- Collect 50-100 ml of urine in a sterile centrifuge tube or urine specimen container.
- Contact the Section of Epidemiology to facilitate testing.
- Document all persons who were exposed to the patient while he/she was in the facility and for one hour after the suspect measles patient left. If measles is confirmed in the suspect measles patient, exposed people will need to be assessed for measles immunity.
- Consider post-exposure prophylaxis for contacts within 72 hours of exposure (MMR vaccine) or up to 6 days after exposure (Immune globulin – intramuscular or intravenous). Consult with the Section of Epidemiology regarding appropriate administration.
- Read CDC’s complete measles infection control guidance at: http://www.cdc.gov/measles
- Post flyers in your clinic
- Visiting another Country Flyer English http://eziz.org/assets/docs/IMM-1046.pdf
- Visiting another Country Flyer Tagalog http://www.health.state.mn.us/divs/idepc/diseases/measles/thinkmeasles/thkmeastag.pdf
- Links to flyers in several other languages http://www.health.state.mn.us/divs/idepc/diseases/measles/thinkmeasles/index.html
- Attention: You Could Have Measles poster http://www.cdph.ca.gov/HealthInfo/discond/Documents/MeaslesPatientIllnessAlert.pdf