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Measles

 
***Current Health Advisory: On 18 March 2024 CDC issued a Health Advisory due to a recent increase in both domestic and international measles cases.  From Jan 1- March 14, 2024, CDC has been notified of 58 confirmed cases of measles in the U.S., matching the total number of cases for all of 2023.  Most (93%) of the cases were linked to international travel, and there were 7 outbreaks where the disease was spread, largely among unvaccinated children and adolescents.  Clinicians are urged to be alert for measles cases, particularly in returning travelers.

Internationally, many countries including Austria, the Philippines, Romania and the United Kingdom are experiencing measles outbreaks.  All U.S. residents traveling internationally should be current on their MMR vaccination.  It is recommended that children ≥6 months receive a single dose of MMR prior to international travel; unimmunized children ≥12 months, adolescents and adults traveling internationally should receive 2 doses of MMR, spaced 28 days apart, prior to travel.

Full Health Advisory, including isolation, notification, testing, and management guidelines:  CDC Measles Health Advisory- 18 March 2024  ***

Measles is known as one of the most contagious diseases of humans.  It is a respiratory virus, spread person to person and through the air.  It can live in the air for up to two hours in closed areas after a person leaves the area, and infected people can spread measles to others from 4 days before to 4 days after the rash appears.  Symptoms usually start 7-14 days after becoming infected, beginning with a high fever followed by a cough, runny nose, conjunctivitis (pink eye), and a rash. The rash typically appears first on the face, along the hairline, and behind the ears, and then affects the rest of the body.

Vaccination is the cornerstone of measles prevention and is highly effective.  All children should receive 2 doses of measles vaccination as part of the routine childhood vaccine schedule, with the first dose at 12-15 months and the second at 4-6 years old. Children who live internationally in areas at increased risk for measles may be vaccinated as young as 6 months old. Unvaccinated children and adults, and those who are incompletely vaccinated (<2 doses of MMR) are most at risk for infection with measles. 

Active Duty (AD) personnel are evaluated for immunity to measles at accessions, and vaccinated if they are not already immune.  As a result, although an AD case is possible, it is likely to be mild and the threat of a measles outbreak is minimal in an operational or shipboard environment.
Measles can be serious, with about 1 in 5 infected people needing hospital admission and 1 in 1000 developing brain swelling that can be fatal. People at highest risk for severe illness from measles include infants and children less than 5 years of age, pregnant women, and people with compromised immune systems.  There is no specific antiviral agent for measles.

 

Web Resources

Center for Disease Control and Prevention (CDC):  Measles Page
Center for Disease Control and Prevention (CDC):  CDC Clinician Webpage
Advisory Committee on Immunization Practices (ACIP): MMR Vaccine Recommendations-ACIP 2022
American Academy of Pediatrics “Red Book”: Red Book Online Outbreaks: Measles | Red Book Online | American Academy of Pediatrics (aap.org)
MMWR: Prevention of Measles, Rubella, Congenital Rubella Syndrome, and Mumps, June 14, 2013/62(RR04);1-34  Recommendations of the ACIP, 2013
DHA- Immunization Healthcare Division: Immunization Information
DHA- Immunization Healthcare Division: Measles-FAQs
 

Policy

DoDI 6205.02 DoD Immunization Program
BUMEDINST 6230.15B (Immunizations and Chemoprophylaxis for the Prevention of Infectious Diseases), military accessions who are not already immune to measles are vaccinated during training, and all personnel born after 1957 are required to have received two lifetime doses of MMR vaccine or show evidence of immunity to measles.  Those born prior to 1958 are presumed immune.  Health care workers are required to show evidence of immunity or two documented doses of MMR vaccine.
 
OPNAVINST 1700.9E, children attending Navy Child Development Centers or Child Development Homes shall be immunized per recommendations from the Advisory Committee on Immunization Practices, which recommends 2 doses of MMR vaccine (at age 12–15 months and again at age 4-6 years).  Documentation of medical exemptions and waivers based on religious beliefs are required in lieu of immunization, but if a vaccine-preventable disease to which children are susceptible occurs in a facility, un-immunized children shall be excluded for the duration of possible exposure or until age-appropriate immunizations have been completed. 

 

Clinicians

Healthcare providers should consider measles in patients presenting with febrile rash illness and clinically compatible measles symptoms, especially if the person recently traveled internationally or was exposed to a person with measles. Measles in previously vaccinated people is rare, and all symptoms may be attenuated if vaccinated.

Key Measles symptoms

•  Fever, including subjective fever.  Fever typically:
  •       Precedes the rash
  •       Is high (≥ 101)
  •       Persists after the rash erupts, and peaks on day 2-3 of the rash
• Rash that typically:
  •       Starts on the head at the hairline and descends
  •        Is erythematous and maculopapular that can progress to confluence, especially on the face
  •        Initially blanches with pressure.
  •        Clears on the 3^rd to 4^th day, and doesn’t itch until the 4^th day as it’s clearing

• Usually 1 or 2 of the “3 Cs” – cough, coryza and conjunctivitis- early in the course of infection
• May have white Koplick spots in the mouth in early illness
• Children typically appear ill

CDC Clinician Fact Sheet
CDC Clinician Webpage

Diagnostic Testing
Measles RT-PCR testing of a respiratory specimen and detection of measles-specific IgM antibody serology in serum are the most common methods for confirming measles infection. Healthcare providers should obtain both a throat swab (or nasopharyngeal swab) and a serum sample and from patients suspected to have measles at first contact with them. Urine samples may also contain virus, and when feasible to do so, collecting both respiratory and urine samples for PCR can increase the likelihood of detecting measles virus.
 

• *Negative RT-PCR results do not rule out measles because it can be affected by the timing of specimen collection and the quality and handling of the clinical specimen. Virus isolation and RNA detection are more likely to be successful when the specimens are collected early (ideally within three days of rash onset, but up to ten days post rash may be successful).

 

• * IgM Unvaccinated persons. Following measles virus infection in an unvaccinated individual, measles IgM antibodies appear within the first few days (1–4 days) of rash onset, peak within the first week post rash onset and are rarely detected after 6–8 weeks. If a negative result is obtained from serum collected within 72 hours after rash onset, a second serum should be collected ≥72 hours after rash onset.

 

• * IgM Vaccinated persons may not have an IgM response, or it may be attenuated. A negative IgM test in vaccinated person suspected of having measles should not be used to rule out the case; RT-PCR testing may be the best method to confirm such cases.

CDC MMRV Testing for Clinicians

Patient Isolation and Infection Control
It is critical to rapidly identify and appropriately isolate measles cases within a healthcare facility.  Transmission within healthcare settings is not uncommon, especially from patient waiting areas.

Mask the patient immediately upon identification if the patient can wear a surgical mask.

Bypass the waiting room if possible, and separate suspected measles cases from other patients. Immediately place patient in airborne infection isolation room if available, or a private room with a door if not.

Allow only healthcare personnel with documentation of two doses of live measles vaccine or laboratory evidence of immunity (measles Immunoglobulin G positive) to enter the patient’s room, if possible.

For more information, please reference:  CDC Interim Measles Infection Control Guidelines

Confirmed measles cases should be isolated at home from non-household and unimmunized people during their infectious period, from 4 days before rash onset through 4 days after rash onset. Suspected cases should also isolate until measles has either been ruled out or their presumed infectious period is over.

Post-Exposure Management
Public Health should be contacted immediately when a measles case is suspected to initiate contact tracing and control measures. Infectious Disease specialist should be contacted for assistance with Immune Globulin administration when indicated.

VDH Postexposure Prophylaxis Recommendation Table

Reporting

Measles is a nationally notifiable disease.  Navy policies BUMEDINST 6220.12C and NMCPHC-TM-PM 6220.12 require that all cases of measles must be reported within 24 hours, following the procedures outlined in NMCPHC-TM-PM 6220.12.  If you suspect a case, immediately notify your cognizant Navy Environmental and Preventive Medicine Unit (NEPMU) and local/state health department.
Case Classification per Armed Forces Medical Reportable Events Guide: 

Probable:
In the absence of a more likely diagnosis, a case with a generalized, maculopapular rash lasting ≥ 3 days and temperature ≥ 101F or 38.3 C and cough or coryza or conjunctivitis where lab results are not available and there is no epidemiologic link to a laboratory-confirmed case.
Confirmed:
Any acute febrile rash illness with any of the following:

• Measles virus identified by culture from any clinical specimen or
• Measles virus nucleic acid (RNA) detected (example: PCR, sequencing, NAAT) from any clinical specimen or
• Seroconversion from a negative measles IgG followed by a positive measles IgG in convalescent sera or
• Significant rise of measles IgG titer between 2 serum samples or
• Measles positive IgM antibody from serum or
• Epidemiologically linked to a laboratory-confirmed case

 
Critical reporting elements are travel/deployment history during the incubation period, exposure to measles cases and immunization history.

 

Public Health

While endemic measles was declared “eliminated” in 2000, measles is often brought into the U.S. by travelers or people from other countries. Due to its extreme contagiousness, each imported measles case could start an outbreak, especially if under-vaccinated groups are exposed. Surveillance and prompt investigation of cases and contacts help to stop the spread of disease.

Measles vaccine is highly effective with durable immunity.  Because Active Duty personnel are universally evaluated for immunity to measles at accessions and vaccinated if they are not already immune, measles poses minimal operational risk to forces.

CDC reports that 90.8% of children have at least one dose of MMR by age 24 months, and 91.9% of adolescents aged 13-17 are fully vaccinated with MMR (2020-2021 statistics), although there are known pockets of significant under vaccination. While the Active Duty and Health Care Worker populations should be fully vaccinated, there remains potential vulnerability within the wider MHS beneficiary population.  A 2022 MSMR report suggested that overall pediatric immunization rates within the MHS are similar to their civilian counterparts, although MMR was not directly assessed.  https://www.health.mil/News/Articles/2022/11/01/Brief-Report-MSMR 

NMCFHPC Measles Case/Outbreak Investigation Guide-May2024 *NEW*

CDC Manual for the Surveillance of Vaccine Preventable Diseases-Measles
CDC Webpage for Public Health Professionals
VDH Postexposure Prophylaxis Recommendation Table
CDC Measles Investigation Worksheet
CDC Surveillance Worksheet
 

 

Epidemiology and Publications

 
NMCFHPC- EpiData Center *CAC-required*:   EDC Case Finding Algorithm
AFHSD MSMR Report-2019: Measles, Mumps, Rubella, and Varicella in MHS, 2016-2019
CDC Morb Mortal Wkly Rep (MMWR) 2020;69:722–723 Measles Outbreak on an Army Post and a Neighboring Community-El Paso, TX 2019
Center for Disease Control and Prevention (CDC): National Epidemiology