A case of measles has been confirmed in an infant who is an Orange County resident who recently returned from international travel. The OC Health Care Agency’s, Communicable Disease Control Division (CDCD) is reaching out to identified contacts.

Providers should ask patients their travel plans, and ensure that all patients are up to date with their measles vaccination prior to international travel. In particular, infants 6 months to 12 months of age are recommended to receive a dose of measles vaccine (MMR) prior to travel. While this dose does not count towards completion of the routine series it is recommended for those at high-risk for exposure, specifically international travelers. Those who have only received one-dose of MMR vaccine should receive a second dose prior to travel, which may be administered as soon as 28 days after the first dose of MMR. Providers should consider following the recommendations for international travel for patients traveling domestically to places with measles transmission.

Measles is an acute viral illness typically presenting with fever, cough, coryza, and conjunctivitis, followed 3-5 days later by a rash. The maculopapular rash typically begins on the face and spreads down the torso and out to the extremities. The incubation period for measles ranges from 7-21 days after exposure, and individuals are infectious from 4 days prior to rash onset until 4 days after rash onset. Measles is highly contagious and spreads via airborne transmission.

People who are not immune to measles can benefit from post-exposure prophylaxis (PEP) when administered within 6 days of exposure, see below from recommendations on measles PEP. Non-immune individuals who do not receive PEP or receive PEP after 6 days from exposure, should isolate for 21 days and monitor for symptoms.

Management of Suspect Cases

• Providers seeing a suspect case of measles should contact CDCD immediately at 714-834-8180 (staffed 24 hours per day).
• Suspect cases of measles should be placed immediately in standard and airborne isolation and evaluated wearing personal protective equipment, including N95 respirator, eye protection, gown, and gloves.
• Settings without respiratory isolation rooms should consider deferring having the patient seen until the end of the day. If a suspect case is seen in a non-respiratory isolation room, the room should be left empty for at least one hour

Testing

• The recommended test is detection of measles virus RNA by PCR of throat (preferred) or nasopharyngeal swab specimens. Urine specimens can also be collected and may be more sensitive later in the illness.
• It is strongly recommended that specimens for measles virus testing be submitted to the Orange County Public Health Laboratory (OC PHL), as testing can be completed more quickly than commercial laboratories, thereby speeding up control activities. CDCD can arrange pick up of appropriate specimens for rapid test turnaround by contacting us at 714-834-8180. Specimens require CDCD approval prior to submission.
• Appropriate PCR specimen collection is performed by swabbing of the throat or nasopharynx using a synthetic swab (not cotton or with wood) placed in a screw capped container with viral transport media (VTM) or universal transport media (UTM). Specimens should be maintained at 2-8^◦C and transported within 72 hours. 

Post-exposure Prophylaxis (PEP)

• Measles-Mumps-Rubella (MMR) and immune globulin (IG) are effective as post-exposure prophylaxis (PEP) when administered within the appropriate interval from exposure.
• Susceptible persons > 6 months of age with 1 or no documented doses of MMR may receive MMR vaccine to decrease their risk of developing severe disease if not contraindicated. 
• Children 6-11 months of age may receive either MMR vaccine within 72 hours of exposure or IG within 6 days of exposure to decrease their risk of severe disease.
• Individuals with a contraindication to MMR vaccine may receive IG < 6 days after date of last exposure to prevent disease. However, only IG administered < 6 days after first exposure to measles is considered adequate PEP for public health contact management. Persons who receive IG > 6 days after the first exposure to the case, while the case is infectious, should be placed in isolation and quarantine.

Isolation and Quarantine

• Exposed individuals who do not have documented immunity to measles, had a known exposure to measles, and have not received PEP (MMR vaccine < 72 hours of first exposure) or (IG < 6 days of first exposure) should isolate for a period of 21 days from last exposure.

Prevention

• Unexposed but not immune individuals should be vaccinated unless there is a contraindication.
• Travelers should ensure that they are up to date with their measles vaccination prior to travel. Infants 6 months up to one year of age, who are traveling internationally, are recommended to receive a dose of MMR vaccine prior to travel (Plan for Travel | Measles (Rubeola) | CDC).

OC Health Care Agency/Communicable Disease Control - Measles

California Department of Public Health - Measles

Centers for Disease Control and Prevention - Measles

For questions or concerns, please contact the Communicable Disease Control Division at 714-834-8180.