There has been a recent increase in measles activity internationally and in the United States. Healthcare providers should be on alert for patients who have: (1) febrile rash illness and symptoms consistent with measles (e.g., cough, coryza, or conjunctivitis), and (2) have recently traveled abroad, especially to countries with ongoing measles outbreaks. Infected people are contagious from 4 days before the rash starts through 4 days afterwards. The average incubation period of measles (from contact with a case until onset of rash) is 14 days, with a range of 7–21 days.
Measles cases often originate from unvaccinated or under vaccinated U.S. residents who travel internationally and then transmit the disease to people who are not vaccinated against measles. The increased number of measles importations seen in recent weeks is reflective of a rise in global measles cases and a growing global threat from the disease.
Recommendations for Healthcare Providers
1. Consider measles in patients who present with a febrile rash illness. Have a high index of suspicion in patients who present with a morbilliform rash with fever still present at the time of rash onset AND cough, coryza, or conjunctivitis.
The characteristic measles rash is classically described as a generalized, maculopapular, erythematous rash that begins several days after the fever starts. It starts on the head and neck before spreading to cover most of the body, often causing itching. The measles rash appears two to four days after the initial symptoms (fever/cough) and lasts for up to eight days. The rash is said to "stain", changing color from red to dark brown, before disappearing. Koplik's spots seen inside the mouth are pathognomonic (diagnostic) but are not often seen because they are transient and may disappear within a day of arising.
2. Isolate: Do not allow patients with suspected measles to remain in the waiting room or other common areas of the healthcare facility; isolate patients with suspected measles immediately, ideally in a single-patient airborne infection isolation room (AIIR) if available, or in a private room with a closed door until an AIIR is available. Healthcare providers should be adequately protected against measles and should adhere to standard and airborne precautions when evaluating suspect cases regardless of their vaccination status.
If a patient needs to be sent to hospital for evaluation, give them a mask to wear and telephone ahead and let the Emergency Department or Ambulance staff (if applicable) know that you are referring a case of suspected measles.
3. Notify: Immediately notify the Connecticut Department of Public Health (CT DPH) Immunization Program about any suspected case of measles to ensure rapid testing and investigation. Measles is a category 1 reportable disease in Connecticut, which means providers must call immediately upon suspicion.
Call 860-509-7929 during normal business hours (M-F 8:30am to 4:30 pm). To report a suspected case after hours or on weekends/holidays, call 860-509-8000.
4. Test: Follow CT DPH's testing recommendations and collect either a nasopharyngeal swab or throat swab for reverse transcription polymerase chain reaction (RT-PCR), as well as a blood specimen for serology from all patients with clinical features compatible with measles. RT-PCR is the gold standard test for measles diagnosis and is available at the CT DPH Laboratory (DPHL) for the fastest turnaround time. Testing performed at DPHL must be coordinated through the CT DPH Immunization Program.
5. Manage: In coordination with CT DPH staff, provide appropriate measles post-exposure prophylaxis (PEP) to close contacts without evidence of immunity, either measles, mumps, and rubella vaccine (MMR) or immunoglobulin. The choice of PEP is based on elapsed time from exposure or medical contraindications to vaccination."
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If you suspect a patient has measles, DPH will discuss recommendations regarding public health measures after evaluating available clinical and risk-factor information.
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If you have questions about managing an asymptomatic patient who reports a measles exposure, please contact the Immunization Program.
6. Vaccinate: Make sure all your patients are up to date on measles vaccine, especially before international travel. People 6 months of age or older who will be traveling internationally should be protected against measles.
Check vaccination records for:
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Your staff - All staff born during or since 1957 should have documentation of two doses of measles containing vaccine.
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Your patients - Ideally all patients born during or since 1966 should have received two doses of a measles-containing vaccine. Currently MMR vaccine is routinely recommended at 12–15 months and 4–6 years of age.
Resources
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For Healthcare Professionals – Diagnosing and Treating Measles | CDC
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Interim Infection Prevention and Control Recommendations for Measles in Healthcare Settings | CDC
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Rashes: What You Should Know (Children’s Hospital of Philadelphia)Measles (CDC)
Advisories