Measles

Measles is a virus that infects the lungs and breathing passages like the nose, mouth, and throat, and spreads throughout the body.

Anyone who is not already immune can contract measles, but it most commonly affects children. Certain groups are most at risk for serious measles complications, including:

• Children ages five and under
• Adults ages 20 and over
• Pregnant people
• People with health conditions that affect their immune system

Measles symptoms can include:

• High fevers
• Coughing
• Runny nose or congestion
• Red inflamed eyes (conjunctivitis)
• Eye and ear infections
• A flat red spotty rash that appears first on the face at the hairline then spreads downward to the neck, trunk, arms, legs, and feet. Rash usually appears 3-5 days after fever.
• Tiny bluish white spots in the mouth (Koplik Spots)
• Severe symptoms include hearing loss and death

For pictures of measles rash or Koplik spots, visit: Photos of Measles.

Measles is highly contagious. An infected individual can spread the disease to others before noticing any symptoms, especially in the four days before and after a rash develops. Measles virus is exhaled by the infected person and can remain suspended in the air for 2 hours, even after the infected person leaves the room.

Data show that unvaccinated people have a 90% likelihood of contracting measles if exposed. Unvaccinated children who have not previously been infected are more likely to get infected.

There is no treatment for measles, but you can take actions to feel better and prevent complications. If you or your child has measles or believe you have been exposed, isolate yourself away from others and call a healthcare provider immediately. Hydration, rest, avoiding harsh light, and taking a fever reducer or pain reliever can also help relieve symptoms.

Exposed individuals can prevent measles if action is taken quickly post exposure. Those who do not have evidence of immunity and have had a known exposure to measles should call their doctor immediately. They may give you post-exposure prophylaxis (medical treatment that prevents or reduces severity of disease).

There are two possible options for post-exposure prophylaxis (remember, timing is important):

1. One dose of measles, mumps, and rubella (MMR) vaccine, administered within 72 hours of exposure.
2. Immunoglobulin, administered within 6 days of exposure. 

A doctor should be notified of any exposure so that they can assess susceptibility and potential for post exposure prophylaxis based on the time frame.

After an exposure, it can take anywhere from 7 to 21 days for the symptoms of measles to appear. Most commonly, symptoms appear 10 to 14 days after exposure. The first symptom is usually fever. The measles rash typically begins 2 to 4 days after the fever begins.

If you are susceptible—unvaccinated or under vaccinated for measles AND have travelled internationally or to places in the United States with known outbreaks—monitor your health for 21 days after returning home. It is 90% likely that a susceptible person will get measles after being exposed.

If you develop signs or symptoms of measles, call your doctor immediately and inform them that you were in a location where measles was transmitting. Your doctor will provide instructions on how to come into the clinic or hospital to be evaluated safely without exposing other people.

Information regarding known outbreaks:

• United States Outbreaks
• Global Measles Outbreaks

Vaccination is the most effective way to avoid contracting measles. CDC data show the measles-mumps-rubella (MMR) vaccine is highly effective and safe. Individuals with a history of prior infection or vaccination who have received the full two-dose series of MMR vaccines are 97% protected and are unlikely to contract measles. One dose is 93% effective at preventing measles.

It only takes a few days for antibodies to develop in response to the MMR vaccine. Within two to three weeks of vaccination, the immune system is ready to protect against measles.

Yes. It is safe for most people. However, a vaccine, like other medicines, can cause side effects in some people. The MMR vaccine can cause fever, mild rash, temporary pain or stiffness of the joints. More severe problems, such as seizures, bleeding problems or allergic reactions are very rare. Getting MMR vaccine is much safer than getting measles, and most people do not have any problems with the vaccine.

This depends on a variety of factors including age, health, vaccination status, and risk level. It is a decision that should be made with the guidance of trusted healthcare professionals. Anyone who questions their vaccination status should talk to their doctor about whether to pursue an MMR vaccine.

General guidance includes the following:

• Anyone born prior to 1957: It is presumed that everyone in this group either had the measles and therefore gained immunity or were exposed to the measles and developed immunity without becoming symptomatic. This is aptly called “presumptive immunity” and applies to those who did not receive vaccination. It is important to note, however, that healthcare workers born before 1957 are asked to provide evidence of immunity, rather than presuming they are immune, out of an abundance of caution for patients in their care.
• Anyone born after 1957 and vaccinated prior to 1968 should get one dose of MMR vaccine.
  • An inactivated measles vaccine was distributed between 1963 and 1967.  It was found to induce a less robust immune response and was replaced in 1968 by the live attenuated version in use today. Therefore, people who were vaccinated prior to 1968 with either inactivated measles vaccine or measles vaccine of unknown type should be revaccinated with at least one dose of MMR vaccine.
  • Not many people fall into this group; the inactivated measles vaccine was given to fewer than 1 million people before being replaced by the currently used measles vaccine. Anyone who is unsure about whether they received the less effective inactivated measles vaccine, should first try to find their vaccination records or documentation of measles immunity. If written documentation of measles immunity is not accessible, MMR vaccination is recommended. There is no harm in getting an additional dose of MMR vaccine if immunity is already present either from infection or vaccination. Another option is to pursue a blood test to determine immunity, although this is generally not recommended.
• Anyone born between 1968 and the present should follow the US Immunization Schedule.

If you cannot find your vaccine records, you should get vaccinated.  The MMR vaccine is safe to receive even if you already have immunity to measles, mumps, or rubella.

• People who have serious allergies to gelatin, the drug neomycin or a previous dose of the vaccine.
• Pregnant women or women who are trying to get pregnant within 4 weeks should not get MMR vaccine until after they deliver their babies.
• People with a severe immunodeficiency (e.g., from hematologic and solid tumors, receipt of chemotherapy, congenital immunodeficiency, or long-term immunosuppressive therapy or patients with human immunodeficiency virus [HIV] infection who are severely immunocompromised) should check with their doctor or nurse before getting vaccinated.
• People who have recently had a transfusion or were given other blood products should check with their doctor or nurse before getting vaccinated.
• People with high fevers should not be vaccinated until after the fever and other symptoms are gone.

No. Persons with evidence of presumptive immunity do not need any further vaccines. No “booster” doses of MMR vaccine are recommended for either adults or children. There are no recommendations for a 3rd dose of MMR vaccine to improve protection against measles. People are considered to have life-long immunity once they have received the recommended number of MMR vaccine doses or have other evidence of immunity.

Because measles is more common in other parts of the world, people who travel to other countries should make sure that they are protected before traveling.

• All travelers 12 months of age and older should have 2 doses of MMR given at least 28 days apart or a blood test showing immunity.
• Children 6 through 11 months of age should receive 1 dose of MMR before traveling. These children will still need to get their 2 routine doses of MMR at 12-15 months and 4-6 years of age.

Talk to your doctor if you have questions about measles, mumps, and rubella (MMR) vaccine. Many pediatricians, doctor’s offices, and pharmacies offer measles vaccines. In addition to those locations, you can call and schedule an MMR vaccine with:

• Barnstable County Public Health Nurses. Appointments are available on Tuesdays and Thursdays 8:30 AM to 4:00 PM. To schedule an appointment, call (508) 375-6617.
• Cape Cod Visiting Nurse Assocation (VNA): For a full listing of current immunization clinics, including locations, dates and times, please contact the Public Health and Wellness Department of the VNA at 800-631-3900.

READ THE MA DPH CLINICAL ADVISORY. AVAILABLE HERE

• SUSPECT: Consider measles as a diagnosis in anyone with fever (≥101°F or 38.3°C) and a generalized maculopapular rash with cough, coryza, or conjunctivitis who has recently been abroad, especially in countries with ongoing outbreaks, or with travel to US locations where outbreaks are occurring.
• When considering measles, then:
  • ISOLATE: Do not allow patients with suspected measles to remain in the waiting room or other common areas of a 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. Offer testing outside of facilities to avoid transmission in healthcare settings. Call ahead to ensure immediate isolation for patients referred to hospitals for a higher level of care.
  • NOTIFY: Immediately call the MDPH 24/7 Epi line: 617-983-6800 to report any suspected case of measles to ensure rapid testing and investigation. States report measles cases to CDC and share information about suspected cases with local boards of health.
  • TEST: Collect either a nasopharyngeal swab (preferred) or throat swab for reverse transcription polymerase chain reaction (RT-PCR) and a blood specimen for serology from all patients with clinical features compatible with measles. Urine may be submitted as a back-up specimen. RT-PCR is available at the Massachusetts State Public Health Laboratory. The turnaround time is typically 24-48 hours after the specimens are received. Turnaround time for serologic testing is usually longer. Given potential shortages in IgM test kits, providers should be vigilant in contacting their state or local health department for guidance on testing.
  • MANAGE: In coordination with local or state health departments, provide appropriate measles post-exposure prophylaxis (PEP) as soon as possible after exposure to close contacts without evidence of immunity, either with MMR (within 72 hours) or immunoglobulin (within 6 days). The choice of PEP is based on elapsed time from exposure or medical contraindications to vaccination.
  • REVIEW VACCINATION RECORDS: The best time to review vaccination records of staff and patients is before exposures occur. Exposed healthcare providers without presumptive evidence of immunity to measles will be excluded from work and other public activities from day 5 after the first exposure until day 21 following their last exposure. Exclusion parameters for non-healthcare workers exposed to measles are similar, resulting in missed days of school, daycare, work, vacation and so on.
  • WATCH FOR SYMPTOMS AFTER TRAVEL: After domestic travel to an area with an ongoing outbreak or international travel, patients should be advised to watch for signs and symptoms of measles for 3 weeks after return. Patients developing fever and rash during this period should call their healthcare provider and tell them about the recent travel and symptoms so the provider can arrange to evaluate the patient without exposing others.

Acceptable evidence of presumptive immunity against measles includes at least one of the following:

• written documentation of adequate vaccination:
  • one or more doses of live-virus measles containing vaccine administered on or after the first birthday for preschool-age children and adults not at high risk
  • two doses of  live-virus measles containing vaccine for school-age children, adolescents, and adults at high risk, including college students, healthcare personnel, and international travelers
• laboratory evidence of immunity
• laboratory confirmation of measles (verbal history of measles does not count)
• birth before 1957

Although birth before 1957 is considered acceptable evidence of measles immunity, healthcare facilities should consider vaccinating unvaccinated personnel born before 1957 who do not have other evidence of immunity with 2 doses of MMR vaccine (minimum interval 28 days).

Prior to hiring, healthcare facilities should require 2 doses of MMR vaccine at the appropriate interval for unvaccinated healthcare personnel regardless of birth year if they lack laboratory evidence of measles immunity.

Persons without evidence of presumptive immunity and no contraindications to MMR vaccine can be vaccinated without testing. Persons without evidence of presumptive immunity might be considered for testing for measles-specific IgG antibody, but testing is not needed prior to vaccination, and insurance coverage for it varies.

ACIP does not recommend measles antibody testing after MMR vaccination to verify the patient’s immune response to vaccination.

Two documented doses of MMR vaccine given on or after the first birthday and separated by at least 28 days is considered evidence of presumptive immunity, according to ACIP. Documentation of appropriate vaccination supersedes the results of serologic testing for measles, mumps, rubella, and varicella.

First, make sure all your patients are fully vaccinated according to the U.S. immunization schedule.

In certain circumstances, MMR vaccine is recommended for infants aged 6 through 11 months. Give infants this age a dose of MMR vaccine before international travel, or travel to areas of the US with a current outbreak. Do not count any dose of MMR vaccine as part of the 2-dose series if it is administered more than 4 days before a child’s first birthday. Instead, repeat the dose when the child is 12 months.

If a young child is travelling internationally or to an area in the US with an outbreak, you might consider vaccinating children age 12 months and older at the minimum age (12 months, instead of 12 through 15 months) and giving the second dose 4 weeks later (at the minimum interval) instead of waiting until age 4 through 6 years.

Finally, remember that infants too young for routine vaccination and people with medical conditions that prevent them from being immunized for measles,  depend on high MMR vaccination coverage among those around them for protection. Be sure to encourage all your patients and their family members to get vaccinated if they are not immune.

MMR can be given to children as young as 6 months of age who are at high risk of exposure such as during international travel or a community outbreak. However, doses given BEFORE 12 months of age cannot be counted toward the 2-dose series for MMR vaccination.

Yes. Healthcare personnel (HCP) with 2 documented doses of MMR vaccine are considered to be immune regardless of the results of a subsequent serologic test for measles, mumps, or rubella. Documented age-appropriate vaccination supersedes the results of subsequent serologic testing. In contrast, HCP who do not have documentation of MMR vaccination and whose serologic test is interpreted as “indeterminate” or “equivocal” should be considered not immune and should receive 2 doses of MMR vaccine (minimum interval 28 days). ACIP does not recommend serologic testing after vaccination. For more information, see ACIP’s recommendations on the use of MMR vaccine at www.cdc.gov/mmwr/pdf/rr/rr6204.pdf, page 22.

People with medical conditions that contraindicate measles immunization depend on high MMR vaccination coverage among those around them to protect them. To help prevent the spread of measles virus, make sure all your staff and patients who can be vaccinated are fully vaccinated according to the U.S. immunization schedule. Also, encourage patients to remind their family members and other close contacts to get vaccinated if they are not immune.

If patients who cannot get MMR vaccine are exposed to measles, CDC has guidelines for immune globulin for post-exposure prophylaxis which can be found at www.cdc.gov/mmwr/pdf/rr/rr6204.pdf

MMR vaccine given to susceptible individuals within 72 hours of initial measles exposure can reduce the risk of getting sick or reduce the severity of symptoms.

Another option for exposed, measles-susceptible individuals at high risk of complications who cannot be vaccinated is to give immunoglobulin (IG) within 6 days of exposure. Do not administer MMR vaccine and IG simultaneously, as the IG invalidates the vaccine.

More information on post-exposure prophylaxis for measles can be found in the 2013 ACIP guidance at www.cdc.gov/mmwr/pdf/rr/rr6204.pdf, page 24.