Measles Health Alert/Advisory - Feb. 5, 2019

Dear Colleague:

Details of the situation:

Five measles cases, four between the ages of 12 to 21 months, have been reported in three different counties within the Department of State Health Services Region 6/5 South (Southeast Texas).

Vaccination remains the most effective method for preventing measles. Two of the cases had their immunizations administered only 1 - 3 weeks before developing symptoms. Genotyping has revealed the cases were B3 strain, the most common strain currently circulating in Mexico and the second most common strain seen in Canada and the United States. The current vaccine, which contains strain A, is effective against B3 and has demonstrated a high protection rate (95-98% seroconversion with the first dose and 99% with the second dose). One of the cases was an adult linked to one of the infant cases.

Measles is highly contagious and early identification remains a critical public health measure to reduce the spread of the disease. We are working with local health departments regarding the reported cases. Please consider measles as a part of your differential diagnosis if you see patients with the clinical signs and symptoms described below.

Clinical information:

Measles (rubeola) is a highly contagious febrile rash illness caused by a paramyxovirus transmitted via the respiratory route. The incubation period averages 10-12 days from exposure to prodrome and 14 days from exposure to rash onset (range 7 -18 days). The prodrome generally lasts 2-4 days and is characterized by fever, increasing in a stepwise fashion and often peaking at 103°-105°F.

Fever is followed by the onset of cough, coryza, and/or conjunctivitis. Koplik spots, while not always present, are considered to be pathognomonic for measles and appear as punctate blue-white spots on the bright red background of the buccal mucosa, occurring 1-2 days before the rash to 1-2 days afterward. The measles rash is a maculopapular eruption that begins at the hairline and gradually proceeds to face and upper neck and from there downward and outward. The maculopapular lesions are generally discrete but may become confluent. Other symptoms of measles include anorexia, diarrhea (especially in infants), and generalized lymphadenopathy. Complications can include otitis media, pneumonia, encephalitis, seizures, and death.

While it is rare that vaccinated individuals develop measles, it can happen. Vaccinated individuals may have an atypical clinical presentation—typically shorter rash duration or atypical rash presentation, and possible lack of fever, cough, coryza, or conjunctivitis.

Disease Reporting Requirements/Statute:

Several Texas laws (Health & Safety Code, Chapters 81, 84, and 87) require specific information regarding notifiable conditions to be provided to the health department. Healthcare providers, hospitals, laboratories, schools, childcare facilities, and others are required to report patients who are suspected of having measles (Chapter 97, Title 25, Texas Administrative Code).

In Texas, suspicion of measles is required to be reported immediately.
Do not wait for laboratory confirmation to report measles.
Measles reports should be made to the local health department or
800-705-8868.

Infection Control:

Patients are contagious from 4 days before the onset of the rash to 4 days after the appearance of the rash (the day of rash onset is day 0). If a patient presents with these symptoms, isolate the patient with airborne isolation precautions, if possible.

All healthcare facilities should ensure that they have updated documentation of measles immunity status for all staff—not just healthcare providers. Documentation of immunity includes a written record of receipt of two MMRs, positive serological titers, or birth before 1957 (although healthcare facilities should consider vaccinating unvaccinated personnel born before 1957 who do not have laboratory evidence of measles immunity). During an outbreak of measles, unvaccinated healthcare workers regardless of the birth year who lack laboratory evidence of immunity should receive 2 doses of MMR vaccine. Exclude healthcare personnel without evidence of immunity from duty from day 5-21 after the last exposure, regardless of post-exposure prophylaxis.

People suspected of having measles should be advised to stay home from work, school, daycare, and any public outings (e.g., church, grocery store) until four days after the rash onset has passed. People that have been exposed to measles and are not immune and did not receive PEP should be advised to stay home from day 5-21 after exposure.

Lab Confirmation Tests:

• Testing for measles should be done in patients meeting clinical case definition: (1) a generalized rash lasting >3 days, (2) fever >101F (38.3C), and (3) cough, coryza, or conjunctivitis.
• A blood specimen for serology and a throat swab for viral culture or PCR should be collected at the first contact with a suspected measles case. Currently, PCR is only available through public health laboratories. Work with the local health department to coordinate PCR testing.
• For serological testing performed, please provide both IgM and IgG test results to your local health department.
• Testing should also be considered in persons who have been exposed or traveled to an area where measles is endemic and who have a rash-fever illness.

Post Exposure Prophylaxis (PEP) Recommendations:

MMR vaccine is recommended for the following potentially exposed groups:

• Exposed persons (6 months and older and not otherwise contraindicated) without evidence of immunity to measles –administer MMR within 3 days of exposure. If a child <12 months old is vaccinated for potential exposure, he should be revaccinated with 2 additional doses of MMR according to schedule.

Immune globulin
IGIM 0.5 mL/kg of body weight (maximum dose = 15 mL) is recommended for the following potentially exposed groups:

• Infants 0-6 months within 6 days of exposure
• Any susceptible, immunocompetent, exposed individual (except pregnant women), if the window for MMR PEP has passed and it is still within 6 days of exposure
• Priority for IG should be given to infants, household contacts, anyone at risk for complications, and anyone with prolonged, close contact.

IGIV 400 mg/kg is recommended for the following potentially exposed groups within 6 days of exposure:

• Severely immunocompromised persons
• Pregnant women without evidence of measles immunity

Any nonimmune person exposed to measles who received IG should subsequently receive MMR vaccine, which should be administered no earlier than 6 months after IGIM administration or 8 months after IGIV administration provided the person is then aged ≥12 months and the vaccine is not otherwise contraindicated.

Routine Vaccination:

All patients should be kept current with measles vaccination. Check the vaccination history of all patients and offer the vaccine to anyone that is not up to date with the vaccine schedule. Maintaining high two-dose MMR vaccination coverage in communities remains the most effective way to prevent outbreaks.

If you have further questions or need to report measles case(s), please contact your local health department:

Brazoria County Health Department
Telephone: 979-864-2168
Fax: 979-864-3694
After hours: 800-511-1632
Website: Brazoria County Health Department

Fort Bend County Health & Human Services
Telephone: 281-342-6414
Fax: 281-342-7371
After hours: 281-434-6494
Website: Fort Bend County Health & Human Services

City of Beaumont Health Department
Telephone: 409-832-4000
Fax: 409-835-2545
After hours: 409-839-4208
Website: City of Beaumont Health Department

Galveston County Health District
Telephone: 409-938-2322
Fax: 409-938-2399
After hours: 888-241-0442
Website: Galveston County Health District

City of Port Arthur Health Department
Telephone: 409-983-8848
Fax: 409-982-5616
After hours: 409-981-9901
Website: City of Port Arthur Health Department

Hardin County Health Department
Telephone: (409) 246-5188
Fax: 409-246-4373
After hours: 409-659-7759
Website: Hardin County Health Department

Chambers County Health Department
Telephone: 409-267-2731
Fax: 409-267-4276
After hours: 409-267-9862
Website: Chambers County Health Department

Harris County Public Health
Telephone: 713-439-6000
Fax: 713-439-6306
After hours: 713-755-5000
Website: Harris County Public Health

Houston Health Department
Telephone: 832-393-5080
Fax: 832-393-5232
After hours: 832-393-5080
Website: Houston Health Department

Orange County Health Department
Telephone: 409-246-5188
Fax: 409-246-4373
After hours: 409-659-7759
Website: Orange County Health Department

Montgomery County Public Health District
Telephone: 936-523-5026
Fax: 936-539-9272
After hours: 888-825-9754
Website: Montgomery County Public Health District

If you are not in one of the above jurisdictions, contact our office:

Department of State Health Services, Region 6/5 South
Telephone: 713-767-3000
Fax: 713-767-3006
After hours: 800-270-3128
Website: Region 6/5 South6-5

Best Regards,

Carlos Plasencia, MD, MSPH
Regional Medical Director
Public Health Region 6/5S
Texas Department of State Health Services
5425 Polk Street, MC 1906
Houston, TX 77023