Measles Infection Prevention and Control Frequently Asked Questions

Complications

What is SSPE?  

Subacute sclerosing panencephalitis (SSPE) is a very rare, but fatal disease of the central nervous system which generally develops 7 - 10 years after a person has measles. Hear from a pediatrician who cared for a teen who tragically died from SSPE.  

Immunocompromised Children

Is the presentation of measles signs and symptoms different in immunocompromised children?

Immunocompromised children with measles may not present with a classic rash, so having a heightened suspicion based on history and epidemiologic exposure risk should prompt appropriate testing and timely implementation of appropriate isolation precautions.

What is the recommended home quarantine period for an immunocompromised child exposed to measles?

The home quarantine period is 21 days after the last exposure; most health departments would extend the monitoring period to 28 days if immunoglobulin (IG) is administered as post exposure prophylaxis (PEP) because IG can prolong the incubation period. Decisions on whether exposed persons who received IG as PEP appropriately (ie, within 6-day window) should return to settings such as child care, school, or work (ie, not be quarantined) should include consideration of the immune status and intensity of contacts in the setting and presence of high-risk individuals. These persons should be excluded from health care settings.

How long are immunocompromised patients with measles considered infectious?

Individuals with severe immune compromise may experience more severe measles and be infectious for longer than the typical 4 days before to 4 days after rash onset. They may also not have a typical measles rash or any rash, which can make determining date of onset challenging to guide infection control practices. They may also have more severe disease and complications from measles infection that may limit assessment of resolution of symptoms. In these cases, measles patients with immunocompromising conditions should remain in Airborne Precautions for the duration of illness. Consult with your facility's infection preventionist or health department for further guidance.

What are the recommendations for managing and protecting an immunocompromised pediatric unit or newborn nursery if there are measles cases in the community?    

MMR vaccination remains one of the most important and effective ways to prevent and control the spread of measles. Ensuring that all healthcare personnel and parents/legal guardians, siblings, and close household contacts/caregivers are up-to-date with MMR vaccination is paramount to provide cocooning protection to the child at risk who in general, is not able to receive MMR vaccine. Optimizing and limiting exposures to visitors who may have been potentially exposed to measles in the community by instituting education and processes to screen visitors at hospital entry may be helpful.  Having additional processes in place to mitigate potential measles exposures is important. These may include educating patients/families to call if exposed (rather than having exposed patients/families walk into the clinic), guidance for staff on how to triage patients after exposure calls, education of all staff on measles that clearly explains how to limit/contain individuals suspected of having measles infection and allow for timely identification, prompt isolation, testing, and reporting of suspected cases. Collaborating with and following recommendations from your local and state health department is also important, particularly as measles incidence and epidemiology changes within your community.

Infection Prevention & Control

What are pre-visit infection prevention control measures to take for a suspected case of measles?

Pre-visit telephone triage should be completed by a clinically trained person who can assess risk of exposure. The family should be instructed to arrive at a side or back entrance of the facility rather than the main entrance. Instruct the caregiver to wear a mask and to have the patient wear a mask if able and at least 2 years of age. If unable or under the age of two years the patient should be tented with a blanket or towel when entering the facility. Alternatively, the patient could be assessed in the car/parking lot.  

What is the recommended isolation for a measles patient?    

Patients with measles should isolate at home for 4 days after the development of rash (with onset of rash considered to be Day 0). 

Hospitalized patients should remain in airborne precautions for 4 days after the onset of rash.

What are best practices for measles infection prevention and control if we don’t have a negative airflow room in our office?    

Immediately provide face masks to patients 2 years of age and older and caregivers. Immediately isolate the patient and caregiver to a private room with the door closed. Standard and airborne precautions should be followed, including use of N95 mask. Only health care providers with evidence of measles immunity should provide care. The room should be shut down for two hours following a patient with suspected measles. 
Standard cleaning and disinfection procedures are adequate for measles virus environmental control. 

What is the recommended personal protective equipment (PPE) when caring for a child with measles? Is eye protection needed?

Healthcare personnel should use NIOSH-certified disposable N95 filtering facepiece respirator or higher level upon entry to the room. Staff must be medically cleared and fit-tested and trained in the proper use of respirators, safe removal and disposal and medical contraindications. Eye protection is not required for standard and airborne precautions. 

Is measles a reportable disease? To whom do we report a suspected case?    

Yes, measles is nationally notifiable, and cases should be reported to the appropriate health department. Pediatricians should immediately notify infection control (if available at your facility) and the local and/or state health department. Health departments will be able to provide guidance on specimen collection and submission and will work with pediatricians to identify who may have been exposed. 

What infection prevention steps should be taken if there is a suspected case of measles in a pediatric office?

Given the increase in global and domestic measles cases and outbreaks, healthcare providers should familiarize themselves with the clinical features of measles in order to quickly identify and minimize the spread of the virus. Measles should be considered in any patient presenting with febrile rash illness, especially if unvaccinated for measles or traveled internationally in the last 21 days. Providers should ask about recent international travel, exposure to international travelers, travel to areas with active measles or exposure to people with measles. 

It is important to follow Infection Prevention Precautions, including immediate public health notification when treating suspected measles cases.  AAP guidelines should be followed when treating measles or suspected measles cases. 

Below is a quick summary of recommended infection prevention and control practices:

• Provide face masks for patients (2 years of age and older) and family before they enter the facility. Patients unable to wear a mask should be “tented” with a blanket or towel when entering the facility.
• Immediately move patient and family to an isolated location, ideally an airborne infection isolation room (AIIR) if available. If unavailable, use a private room with the door closed.
• No other children should accompany a child with suspected measles.
• Patients (2 years of age and older) and family should leave face masks on if feasible.
• Standard and airborne precautions should be followed, including use of N95 mask.
• Only health care providers with evidence of measles immunity should provide care.

Post-Exposure Prophylaxis

What is the recommendation for healthcare personnel exposed to a measles patient?   

For asymptomatic healthcare staff with presumptive evidence of immunity: 

• Postexposure prophylaxis is not necessary.
• Work restrictions are not necessary.
• Implement daily monitoring for signs and symptoms of measles from the 5th day after their first exposure through the 21st day after their last exposure. 

For asymptomatic healthcare staff without presumptive evidence of immunity:

• Administer postexposure prophylaxis.
• Exclude from work from the 5th day after their first exposure through the 21st day after their last exposure, regardless of receipt of postexposure prophylaxis.
• Work restrictions are not necessary for healthcare staff who received the first dose of MMR vaccine prior to exposure:
  • They should receive their second dose of MMR vaccine as soon as possible (at least 28 days after their first dose).

Implement daily monitoring for signs and symptoms of measles from the 5th day after their first exposure through the 21st day after their last exposure.  

What are the recommendations for post exposure prophylaxis?    

See Table 3.32 of the Red Book Measles Chapter for guidance on Postexposure Prophylaxis (PEP) for People Exposed to Measles Who Are NOT Pregnant or Immunocompromised and Table 3.33 Postexposure Prophylaxis (PEP) for People Exposed to Measles Who ARE Pregnant or Immunocompromised. 

Prevention for Adults and Healthcare Personnel

Should healthcare personnel (HCP) receive the MMR vaccine?

Testing

What is the protocol for measles testing?

What supplies should I stock in my practice to ensure I can collect the proper specimens for measles testing? Suspected cases should be confirmed with laboratory testing involving local or state public health laboratories or CDC laboratories. Usually, the tests that are conducted are measles RNA detection by RT-PCR from a throat or nasopharyngeal sample and the detection of measles-specific IgM antibody in serum. Which tests are available may vary by location. Pediatricians can contact their local public health departments for guidance on what specimens they would request for measles testing, as well as related supplies that would be needed. 

Treatment

What options are available for measles treatment?    

There is no specific antiviral therapy for measles. Medical care is supportive and to help relieve symptoms and address complications such as bacterial infections.

If a rash occurs after receiving the MMR vaccine, does that indicate that the person has measles?

Transient rashes have been reported in approximately 5% of vaccine recipients, usually between 5 and 12 days after receipt of MMR vaccine. Recipients who develop rash and/or fever are not considered contagious. However, if the vaccine was administered as part of an outbreak response, it is important to ensure rapid differentiation of vaccine reaction from infections with wild-type virus. Local public health authorities can assist with this. 

Vaccination Timing

Have there been any reports of MMR vaccine shortages?  

AAP has been in communication with the vaccine manufacturers and at this time there are no reported shortages.

I'm concerned about delaying MMR for 11 months after high dose IVIG. The recomendations were at a time with low measles exposure. Is there any change in recomendations with new case rates?

There are no current changes to the 11 month wait time from 2 gm/kg IVIG to MMR. Please refer to the footnote of Table 1.11 of The Red Book for situations when measles is circulating in the community:These intervals should provide sufficient time for decreases in passive antibodies that would allow for an adequate immune response to measles vaccine. Physicians should not assume that children are protected fully against measles during these intervals, and if measles virus is circulating in the community or if the child is traveling to an area where measles may be circulating, a measles-containing vaccine should be administered but not counted as a valid dose (measles vaccine should be readministered after the appropriate interval has passed from the receipt of blood product in accordance with the routine immunization schedule). If a blood product must be given within 14 days after administration of a measles- or varicella-containing vaccine, these vaccine doses are considered invalid and the vaccines should be readministered after the appropriate interval.

Vitamin A

Does Vitamin A prevent measles? 

Vitamin A does not prevent measles; only the MMR vaccine can prevent measles. Vitamin A should not be used to try to prevent measles, nor should it be used in high dosages as it can lead to toxicity (eg. nausea, vomiting, headache, fatigue, joint and bone pain, blurry vision, skin/hair problems, increased intracranial pressure, liver damage, confusion, coma, etc)

Vitamin A is recommended for those infected with measles, regardless of hospitalization status, under the supervision of a health care professional. It is recommended for administration once daily for 2 days (ie, immediately on diagnosis and repeated the next day), at the following doses:

• 200 000 IU (60 000 μg retinol activity equivalent [RAE]) for children 12 months or older;
• 100 000 IU (30 000 μg RAE) for infants 6 through 11 months of age; and
• 50 000 IU (15 000 μg RAE) for infants younger than 6 months.
• An additional (ie, a third) age-specific dose of vitamin A should be given 2 through 6 weeks later to children with clinical signs and symptoms of vitamin A deficiency.

Vitamin A is usually administered orally in capsule or liquid form. Additional information can be found in the Measles Chapter of Red Book Online. Information to share with families can be found on here.