Office preparedness

The information below is provided for informational purposes only and is not an AAD guideline. Please refer to your local, state, or national guidelines for infection control regulations.

1. How can I prepare my practice for a patient with suspected measles?

If your office does not have an airborne infection isolation room (AIIR), refer/transfer the patient to a facility where an AIIR is available. During the pending transfer, the patient should wear a mask and be isolated in a room with the door closed.¹ Notify the facility and accepting physician of any incoming measles patient.

Pre-Visit Telephone Triage:^2,3

If there are cases of measles in your community, consider screening patients with a pre-visit telephone triage completed by a clinically trained staff member. Ask whether the patient has had any of the following symptoms within the last week:

• High fever

• Cough

• Coryza (runny nose)

• Conjunctivitis (red, watery eyes)

• Maculopapular rash

For patients who report one or more measles symptoms, assess the risk of exposure by asking the following questions:

• Are measles cases present in your community?

  • Did the patient spend time out of the country or in a high-risk area in the 21 days before symptom onset?

  • Has the patient ever received the MMR vaccine?

If possible, offer measles testing outside of the office to avoid transmission in healthcare settings.

Office Visit^1,4

If the patient will be seen in the office, provide face masks to patients and family prior to or as soon as possible after entry into the facility.

Do not allow patients with suspected measles to remain in the waiting room or other common areas of a health care facility. Isolate patients with suspected measles immediately, ideally in an AIIR if available, or in a private room with a closed door until an AIIR is available.

Only health care personnel (HCP) with immunity to measles should evaluate suspected cases. HCP should adhere to standard and airborne precautions when evaluating suspect cases, regardless of their vaccination status. HCP without evidence of immunity should be excluded from work from day 5 after the first exposure until day 21 following their last exposure.

For patients referred to hospitals for a higher level of care, call the facility and accepting physician ahead of time to ensure immediate isolation.

Public Health Notification¹

Immediately notify state, tribal, local, or territorial health departments about any suspected case of measles to ensure rapid testing and investigation. States report measles cases to the CDC.

Testing^1,5

Two types of tests are available for measles: serology testing and real-time RT-PCR.

Serology testing detects specific IgM antibodies in serum specimens collected within the first few days of rash onset. It can provide presumptive evidence of a current or recent measles virus infection.⁵

Real-time RT-PCR has the greatest diagnostic sensitivity, especially in immunocompromised patients. Specimens should be collected immediately when a patient is potentially exposed to measles or develops clinical features suggestive of measles. Real-time RT-PCR uses nasopharyngeal or throat swabs and urine specimens, and it is available at many state public health laboratories and AOHL/CDC Vaccine Preventable Disease Reference Centers.⁵

Specimen collection

The CDC recommends that either a nasopharyngeal swab, throat swab, or urine specimen, as well as a blood specimen, be collected from all patients with clinical features compatible with measles.⁵ Nasopharyngeal or throat swabs are preferred over urine specimens.⁵

Given potential shortages of IgM test kits, clinicians should be vigilant in contacting their state or local health department for guidance on testing.

Local health department directory, test instructions, and laboratory contact information

• 24-hour Epi On Call Contact List

• CDC Test Directory

• You must contact your state or local health department first to determine where to submit specimens and how to ship them

• Handout with testing recommendations for clinicians (PDF)

Management^1,6

In coordination with the local or state health department, provide appropriate measles post-exposure prophylaxis (PEP) as soon as possible after exposure to close contact and lack presumptive evidence of immunity. The choice of PEP is based on the elapsed time from exposure, either with MMR (within 72 hours) or immunoglobulin (within 6 days).

Close contact: Exposure to measles in health care settings includes spending any time while unprotected (i.e. not wearing recommended respiratory protection).

Presumptive evidence of immunity: Presumptive evidence of immunity [At least one]: 1) Written documentation of vaccination with 2 doses of measles virus-containing vaccine (the first dose administered at age ≥ 12 months; the second dose no earlier than 28 days after the first dose. 2) Laboratory evidence of immunity (measles immunoglobulin G IgG in serum; equivocal results are considered negative.) 3) laboratory confirmation of disease. 4) Birth before 1957.

Post-visit infection control guidelines

Standard cleaning and disinfection procedures (e.g., using cleaners and water to pre-clean surfaces prior to applying EPA-registered disinfectants) are adequate for measles virus environmental control.¹ Used PPE and other patient care items should be disposed of as regulated medical waste according to federal and local regulations.¹

The room occupied by the patient should remain vacant for 2 hours after a patient with suspected measles leaves the room. The measles virus can remain infectious in the air for up to two hours after an infected person leaves an area, whether or not they were masked.^1,7

2. What are the next steps if someone in my practice is diagnosed with measles?

Immediately notify state, tribal, local, or territorial health departments about any suspected case of measles to ensure rapid testing and investigation. States will report measles cases to the CDC. Notify the state even if measles is suspected, and do not wait for laboratory confirmation. Contact tracing measures may be necessary; call the state health department for the procedure as this may vary from state to state.

• 24-hour Epi On Call Contact List

3. How long is a patient infectious?

A patient with measles can spread the virus to others for about 8 days, from 4 days before to 4 days after the onset of rash.⁸ Thus, patients with measles should remain in airborne precautions for 4 days after the onset of rash. However, immunocompromised patients with measles should remain in airborne precautions for the entire duration that they are symptomatic due to prolonged virus shedding.^1,9

4. What personal protective equipment (PPE) does my staff need?¹

Health care personnel (HCP) without acceptable presumptive evidence of measles immunity should not enter a known or suspected measles patient’s room.

For HCP with presumptive evidence of immunity are available:

• HCP should use respiratory protection (a respirator) that is at least as protective as a fit-tested, NIOSH-certified disposable N95 filtering facepiece respirator, regardless of presumptive evidence of immunity, upon entry to the room or care area of a patient with known or suspected measles.

• Respirator use must be in the context of a complete respiratory protection program in accordance with Occupational Safety and Health Administration (OSHA).

• HCP should be medically cleared and fit-tested if using respirators with tight-fitting facepieces (e.g., a NIOSH-certified disposable N95) and trained in the proper use of respirators, safe removal and disposal, and medical contraindications to respirator use.

For more details please see the following:

• Guideline for Isolation Precautions: Precautions to prevent transmission of infectious agents

• Respiratory Protection Standard 29 CFR 1910.134

5. What PPE does a patient with suspected measles need?¹

If transport is necessary within the facility:

• The patient should wear a face mask if tolerated. If masks are not tolerated, the patient should be “tented” with a blanket or towel when entering and exiting the facility.

• Use a transportation route and process that includes minimal contact with persons not essential for the patient’s care.

• Notify HCP in the receiving area of the impending arrival of the patient and of the precautions necessary to prevent transmission.

If transport is necessary outside the facility:

• Inform the receiving facility and the transport vehicle HCP in advance about airborne precautions being used.

6. What are the guidelines if someone in my staff was exposed to measles?¹⁰

Please always refer to your local state and hospital guidelines for further details.

HCP with presumptive evidence of immunity to measles:

1. Post-exposure prophylaxis (PEP) is not necessary.

2. Work restrictions are not necessary.

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

HCP without presumptive evidence of immunity to measles:

1. Administer PEP in accordance with CDC and Advisory Committee on Immunization Practices (ACIP) recommendations.

2. Work restrictions should be implemented from day 5 after their first exposure through day 21 after their last exposure, regardless of receipt of PEP.

3. Work restrictions are not necessary for HCP who received the first dose of MMR vaccine prior to exposure:

   1. They should receive their second dose of MMR vaccine as soon as possible (at least 28 days after their first dose).

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

For HCP with known or suspected measles, exclude them from work for 4 days after the rash appears.

Immunocompromised HCP with known or suspected measles should be excluded from work for the duration of their illness.

During a measles outbreak, administer measles vaccine to HCP in accordance with CDC and ACIP recommendations.