Health Advisory
MEASLES TESTING AND VACCINATION RECOMMENDATIONS

The Delaware Division of Public Health (DPH) is issuing this health advisory to update health care providers on the measles outbreak occurring in the United States. Although Delaware has not yet seen any confirmed cases of measles in 2019, all three bordering states — Pennsylvania, New Jersey, and Maryland — have had confirmed cases of measles this calendar year.

Summary

From January 1 to May 3, 2019, 764 individual cases of measles have been confirmed in 23 states. This is an increase of 60 cases from the previous week. This is the greatest number of cases reported in the U.S. since 1994 and since measles was declared eliminated in 2000. The states that have reported cases to CDC are Arizona, California, Colorado, Connecticut, Florida, Georgia, Illinois, Indiana, Iowa, Kentucky, Maryland, Massachusetts, Michigan, Missouri, Nevada, New Hampshire, New Jersey, New York, Oregon, Pennsylvania, Texas, Tennessee, and Washington. Measles outbreaks are ongoing in New York, New Jersey, Michigan, California, and many other countries in Europe, Asia, Africa, South America, and Oceania.

Background

Measles is a viral disease that spreads from person to person through airborne droplets when someone with the virus coughs or sneezes. It can also be spread by direct contact with nose or throat mucus secretions of someone with measles. Measles can be dangerous, especially for babies and young children. One in every four people with measles will need to go to the hospital. One in every three will have problems, such as diarrhea, ear infection, lung infection and in rare cases, swelling of the brain. For every 1,000 children with measles, one to two will die.

Symptoms of measles generally appear 7 to 14 days (ranges from7 to 21 days) after a person is infected. Measles is characterized by a prodromal phase with a temperature of 101 degrees F (38.3 degrees C) or higher, malaise, and the three “C”s: cough, coryza and conjunctivitis. Two to three days after symptoms begin, Koplik spots appear inside the mouth. Around three to five days after symptoms begin, a flat red rash appears on the head and face and descends to the neck, trunk, and extremities. Small, red bumps may appear on top of the flat spots. Immunocompromised individuals may not exhibit rash or may exhibit an atypical rash.

Most people are not at risk because they have been vaccinated or have developed immunity due to a previous measles infection. Individuals that are susceptible to becoming infected with measles include:

•  Anyone born in or after 1957, who has not received at least one dose of live measles-containing vaccine (MMR);
•  Infants too young to be vaccinated;
•  People who were vaccinated with an inactivated vaccine that was used from 1963 to 1967, and have not been re-vaccinated;
•  Individuals of any age who refused vaccination;
•  People whose immune systems are compromised due to disease or medication.

Recommendations

Vaccination is recommended for any patient who has not been previously vaccinated.

•  Children up to the age of 17 should receive two doses of the measles vaccine. The first dose of measles vaccine should be given at 12 to 15 months of age. The second dose at age 4 to 6 (or no earlier than 28 days apart).
•  Adults, born in or after 1957, should receive at least one dose of vaccine unless they have proof of vaccination or have a blood test that shows immunity.
•  Adults at high risk, including college students, individuals with HIV who do not have current evidence of severe immunosuppression, and international travelers who have only received a single dose of the MMR vaccine should receive a second dose (as long as it is 28 days after the initial dose).
•  Healthcare workers and individuals who provide care for immunocompromised persons should receive two doses of the measles vaccine at least 28 days apart.

If a person cannot remember if they were vaccinated for measles there is no harm in giving the vaccine to a person who may already be immune to measles and should be immunized. There is also no indication to provide a third dose of the vaccine routinely.

Post Exposure Prophylaxis for Those with Known Exposure to a Measles Case:

•  MMR given to nonimmune individuals within 72 hours of exposure can prevent measles disease
•  MMR is recommended for adults and children without contraindications who have not previously received two doses of MMR, if at least one month has elapsed since the most recent dose
•  For infants between 6 and 11 months of age, a dose of MMR can be given but will not count as part of the primary series

Testing

Providers should obtain the following specimens from patients who are suspected of having measles and provide the onset date of patient’s symptoms. The Delaware Public Health Laboratory conducts Measles PCR testing. Providers must first contact the Office of infectious Disease Epidemiology to obtain approval.

•  Throat or nasopharyngeal swab for rRT-PCR testing
  •  Send specimen in viral or universal transport media (VTM/UTM)
  •  Ship on cold packs
•  Urine for rRT-PCR testing
  •  Collect minimum of 50 mL in sterile container
  •  Ship on cold packs in leak-proof container
•  Serum for measles IgM and IgG testing
  •  Acute phase serum as soon as possible and convalescent serum two to three weeks later
  •  Collect minimum of 5 mL of blood in a red-top or serum-separator tube (SST)

Reporting

Measles is a reportable disease in Delaware. All Delaware physicians, laboratories, and other health care providers are required by regulations to report patients with the indicated conditions to the Office of Infectious Disease Epidemiology. Both lab-confirmed and clinical diagnoses are reportable within the time interval specified below. Reporting enables appropriate public health follow-up for your patients, helps identify outbreaks, and provides a better understanding of disease trends in Delaware. Follow this link to find out more information about Meaningful Use in Delaware: https://dhss.delaware.gov/dhss/dph/meaningfuluse.html.

How to Report

•  Immediately notify the Office of Infectious Disease Epidemiology of any suspected or confirmed measles case. To report or to obtain approval for testing, call 302-744-4490 during business hours (8am to 4:30pm) and 1-888-295-5156 after hours. You may also use this phone number if you have further questions.
•  Complete a Notifiable Disease Report PDF Form at https://dhss.delaware.gov/dhss/dph/epi/files/morbiditycard.pdf. When you open the report form, you can enter the information online and use the Tab key to move from field to field. When the form is complete, print out both pages. If you have a fax machine, you can fax the Disease Report Form page to DPH Office of Infectious Disease Epidemiology at 302-223-1540.

What to Report

•  Date
•  Patient information
  •  Name
  •  Race/Ethnicity
  •  Sex
  •  Phone
  •  Birth date
•  Address and zip code
•  School or Type and Place of Employment
•  Condition or Disease
  •  Date of Onset
  •  Laboratory data
  •  Recent domestic or international travel
  •  Exposure to measles in the community
  •  Physician’s name, phone and address
  •  Hospital
  •  Any additional information

Additional Information

•  Frequently asked questions:
  https://dhss.delaware.gov/dhss/dph/files/measlesfaq.pdf
•  CDC: https://www.cdc.gov/measles/index.html
•  CDC: https://www.cdc.gov/measles/cases-outbreaks.html
•  Pennsylvania Department of Health:
  https://www.health.pa.gov/topics/Documents/HAN/2019-PAHAN--446-05-08-ADV-Measles%20Testing%20Guidance.pdf

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