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Posted on: November 20, 2018

Health Advisory: Measles Outbreaks in Israel, New York City and Surrounding Areas — Nov. 20, 2018

Health Advisory: Measles Outbreaks in Israel,
New York City and Surrounding Areas — Nov. 20, 2018

Key Messages:

  • There is an ongoing outbreak of measles in Israel and New York City, as well as several surrounding communities in New York and New Jersey.
  • Consider the diagnosis of measles among persons presenting with a febrile rash illness, particularly if there has been recent travel to Israel or exposure to other communities where there is an outbreak.
  • Report all patients with suspected measles immediately to the Snohomish Health District. Do not wait for laboratory confirmation. See “Actions Requested” below.
  • Screen for rash with fever at the point of entry to a healthcare facility and immediately institute airborne precautions to prevent healthcare-associated exposures.

Situation:
Currently there is an outbreak of measles in Israel with over 1,500 cases diagnosed. Outbreaks of measles are now occurring in Orthodox Jewish communities in New York City and several surrounding communities in New York and New Jersey. Some of these cases had recent travel to Israel. There are no confirmed cases in Snohomish County presently.  Providers should suspect measles in any patient with fever and rash, especially if they had recent travel to Israel, New York City, or any surrounding communities in New York or New Jersey.

Action requested: 

  • Screen for acute rash illness with fever at entry to any clinic or healthcare facility.
  • If you suspect measles:
    • IMMEDIATELY institute respiratory and airborne precautions for all persons with a measles like rash and fever.
    • IMMEDIATELY report to Snohomish Health District at (425) 339-5278. Do not wait for laboratory confirmation.
  • Reduce exposures: schedule patients for end of the day and have them enter via a separate entrance if possible. Do not send suspect measles cases to the Emergency Department (ED) unless they require hospitalization. Be sure to notify the ED first.
  • Obtain specimens for confirmation of diagnosis: blood for serology, nasopharyngeal/throat swabs for viral culture (NP swab preferred) and urine for PCR. Do not send suspect measles cases to a commercial laboratory for specimen collection. All specimens should be sent to the Public Health Laboratory after consultation with the Snohomish Health District.
  • Susceptible contacts with respiratory symptoms or fever should stay home and call the Snohomish Health District at (425) 339-5278.
  • If a contact goes a healthcare provider for evaluation of possible measles, then call ahead to ensure that facility personnel are aware of the specific reason for referral so that special arrangements can be made to keep them out of areas used by other patients.
  • Persons with possible measles should avoid contact with others until the diagnosis is known.

Measles Clinical Presentation:
Measles symptoms usually begin 10-12 days (up to 21 days) after exposure with a prodrome of fever (up to 105ºF) for 2-4 days followed by cough, conjunctivitis, or runny nose, and a maculopapular rash typically moving from the hairline down to cover the entire body. The rash lasts 5-6 days or longer. Severe illness can occur including pneumonia, encephalitis, and death.

Specimen Collection: 

  • Contact the Snohomish Health District for approvals and instructions prior to collecting specimens.
  • Collect serum for both measles IgM and IgG antibodies. Provide at least 1 cc of serum.
  • NOTE - measles serology results collected earlier than 72 hours after rash onset may result in a false negative result so may need to be repeated.
  • In addition, if within 14 days of rash onset:
    • Nasopharyngeal or throat swab: To collect the nasopharyngeal swab (preferred respiratory specimen), swab the posterior nasal passage with a Dacron™ or rayon swab with a non-wooden shaft and place the swab in 2–3 ml of viral transport medium. Store specimen in refrigerator and transport on ice to arrive at PHL within 72 hours of collection, and
    • Collect a urine specimen. Collect at least 50 ml of clean voided urine in a sterile urine cup for PCR (urine specimens do not have not be processed by the submitting lab).
  • Store all specimens in the refrigerator at 4-8ºC and transport on cold pack(s) to PHL
  • For additional information regarding collection, storage and shipping of specimens for viral isolation, see: https://www.cdc.gov/vaccines/pubs/surv-manual/chpt22-lab-support.pdf.
  • All specimens sent to PHL must be accompanied by a completed PHL virology form: https://www.doh.wa.gov/Portals/1/Documents/5230/302-017-SerVirHIV.pdf. Along with the patient and submitter names, besure to include the date of collection, date of rash onset, and immunization
    history (if known) on the form.

Transmission and InfectionControl:
Virus is spread directly from
person to person by inhalation of suspended respiratory droplet nuclei or wheninfectious nasopharyngeal secretions come into contact with the mucous
membranes of a susceptible person. Measles virus is sensitive to strong lightand drying, but remains infectious in aerosol form in air for approximately 2
hours. 

Measles is one of the mostcontagious of all infectious diseases, with >90% attack rates among
susceptible close contacts. Suspect measles cases should not be allowed inpatient waiting areas. They should be masked and placed immediately in an
examination room, with the door closed. Patients with suspect measles should beseen at the end of the day and use a separate entrance if possible. The
examination room should not be used for at least two hours after the patienthas left.

Suspected measles patients should not be referred to commercial labs or other departments/facilities for testing or other services. Coordinate specimen collection with the Snohomish Health District if appropriate media is not available or additional guidance is needed.

Prevention:
Routine vaccination with two
doses of measles-containing vaccine is the safest and most effective way toprevent disease. MMR vaccine is 90% to 95% effective in preventing measles. The
best way to protect patients from measles and to meet school immunizationrequirements is to ensure that children receive their first dose of MMR
routinely at age 12 months and their second dose at age 4 to 6 years. Ask abouttravel plans. Infants traveling internationally should be protected against
measles by receiving a first dose between age 6 to 11 months, but will requiretwo additional doses at 1 year and between 4 to 6 years. 

Exposed non-immune
immunocompetent individuals
should receive the MMR vaccine ≤72 hours after first exposure as an immediate prevention measure (PEP). If MMR vaccine is not administered within 72 hours of exposure it should still be offered to provide protection from future exposures.

Exposednon-immune immunocompromised persons, infants ≤ 12 months, and others at high
risk of complications from measles
can be protected with immune globulin ≤ 6 days after exposure. Clinicians may consider administering immune globulin to any suspected contact in accordance with Washington State Department of Health Guidelines.

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