Health Update
UPDATE OF MEASLES SITUATION IN THE US

Summary

The Delaware Division of Public Health (DPH) is issuing this Health Alert to inform the medical community that the United States is currently experiencing a record number of measles cases, the highest number reported since measles elimination was documented in the U.S. in 2000.

Measles is preventable with the measles containing measles-mumps-rubella (MMR) vaccine. The vaccine is routinely recommended for all children, even when home-schooled, and is required for children attending any public or private school in Delaware. Adolescents, adults, and especially persons such as health care workers who are at risk of exposing high-risk persons to measles, and persons traveling to other parts of the world, are urged to be vaccinated against measles if they don’t have proof of measles immunity (record of previous vaccination or positive measles serological test results). Unvaccinated, immunocompromised persons and others at high risk of complications from measles can be protected from measles, if exposed to a measles case, by post-exposure prophylaxis with Immune Globulin if it can be given within 6 days of exposure.

Background

From January 1 - to June 13, 2014, there have been 477 confirmed measles cases reported to the Centers for Disease Control and Prevention (CDC), by 20 states. Ohio has reported the highest numbers to date (311).

The Philippines is currently experiencing a large and ongoing outbreak with 40,000 cases and 40 deaths and most of the US cases have been associated with imports from that country, though importation from other countries has also been documented. The majority of cases were in individuals who were unvaccinated or of unknown vaccination status. A smaller group was of individuals too young to have been vaccinated. The Ohio outbreak is affecting mostly their Amish community after the disease was brought back by travelers returning from the Philippines.

Measles is one of the most contagious of all infectious diseases; approximately 90% of susceptible persons with close contact to a measles patient will develop measles. The virus is transmitted by direct contact with infectious droplets or by airborne spread when an infected person breathes, coughs, or sneezes. Measles virus can remain infectious on surfaces and in the air for up to two hours.

Measles is characterized by a prodrome of fever (as high as 105°F) and malaise, cough, coryza, and conjunctivitis, a pathognomonic enanthema (Koplik spots) followed by a maculopapular rash. The rash usually appears about 14 days after a person is exposed; however, the incubation period ranges from 7 to 21 days. The rash spreads from the head to the trunk to the lower extremities. Patients are considered to be contagious from 4 days before to 4 days after the rash appears. Of note, immunocompromised patients may not develop the rash.

Recommendations

Delaware has not experienced an increase in reported measles cases. However, DPH is being proactive by recommending that providers take the following action:

• Consider measles in patients presenting with febrile rash illness and clinically compatible measles symptoms, especially if the person recently traveled internationally, was exposed to a person with febrile rash illness or had contact with international visitors.
• Institute respiratory and airborne precautions immediately for all patients with febrile rash or suspect measles.
• Obtain specimens for confirmation of the diagnosis.
• IMMEDIATELY report any suspect measles cases in Delaware to DPH’s Office of Infectious Disease Epidemiology at 1(888) 295-5156 or (302) 744-1033. Do NOT wait for laboratory confirmation before reporting a suspected case.
• Strongly advise all citizens considering international travel to ensure they are up-to-date with their vaccinations. Though the Philippines may appear to be the main origin for the current outbreak in Ohio, measles is fairly widespread outside the US.
• Ensure all patients’ vaccinations (including measles) are up-to date.

Additional Information

Suspect measles cases needing medical attention should not be allowed in patient waiting areas. They should be masked and placed immediately in an examination room, with the door closed. The examination room in which a patient with suspected or confirmed measles was examined should cleaned and not be used again for at least two hours. With hospitalized patients, respiratory isolation is recommended for 4 days after the onset of rash.

Listings of all exposed patients and staff will be required by DPH from any medical facility treating a case of measles.

Collecting Specimens

Blood specimens for both measles IgM and IgG antibodies should be obtained at the time of clinical presentation. Oropharyngeal or nasopharyngeal swabs are the preferred samples for virus isolation or detection of measles RNA by RT–PCR. Synthetic swabs are recommended. Urine samples may also contain virus and collection of both samples can increase the likelihood of detecting the virus. The sample should be collected at the first contact with a suspected case when the serum sample for diagnosis is drawn.

Though detection of measles RNA and measles virus isolation are most successful when samples are collected on day 1 through day 3 following onset of rash, virus may still be recovered by cell culture through day 10 following rash onset. Detection of measles RNA by RT–PCR may be successful as late as 10–14 days post rash onset.

For information on measles or to report a suspected case call the DPH Office of Infectious Disease Epidemiology at 302-744-1033 or visit: http://www.cdc.gov/measles.

For information on measles vaccine call the Delaware Immunization Program at 302-744-1060.

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