Measles

Aim

The guide Emergency Department staff with the assessment and management of measles. 

Transmission and Epidemiology¹

• Measles is highly infectious.
• Spread by small respiratory particles (aerosols) or direct contact with secretions.
• The virus may be suspended in the air for up to an hour after an infected person leaves the room or waiting area.
• Patients are infectious for 3-4 days prior to the rash developing and a further 4-6 days from onset of rash.
• After exposure to measles, it is usually about 10 days (range 7-18 days) to the onset of fever and about 14 days until the onset of rash.

Assessment

Place the patient in a negative pressure isolation room (NPIR) or single room with door closed with contact + airborne precautions as soon as measles is suspected.

Examination¹

• The child appears miserable, febrile and unwell
• The 3 C's
  • Cough
  • Coryza
  • Conjunctivitis
• Coarse blotchy maculopapular rash (Morbilliform). The rash starts on the face for 1 to 2 days and spreads down to the body. The rash will last for 4 to 7 days.
• Koplik spots appear 1-4 days before the rash appears – white spots on the bright red buccal mucosa of the cheek opposite the premolar.
• Other symptoms can include anorexia, diarrhoea (especially infants) and generalised lymphadenopathy.

People who have received one or two doses of a measles-containing vaccine may develop an attenuated infection with mild symptoms and signs.

Investigations

At PCH: Contact the on-call Clinical Microbiologist to discuss test selection & prioritisation of sample processing.

Measles PCR can be performed on the following sample types:

• Nasopharyngeal swab – for measles and respiratory virus PCR
• Urine
• EDTA blood

Measles serology may also be used for diagnosis of acute infection or demonstrating immunity:

• Request Measles serology (IgM and IgG).
  • Measles IgG only is required if screening for immunity
  • Measles IgM generally appears by day 3 after the appearance of the rash and may persist for 1 month

Management

Clinical Management

• There is no specific antiviral treatment for measles infection
• Management of measles is supportive

Public Health Management⁵

• Upon suspicion of measles, isolate the patient in a negative pressure isolation room (NPIR) or single room with door closed with contact + airborne precautions in place.
  • Refer to Standard and Transmission Based Precautions – Infection Prevention and Control Manual (internal WA Health only)
  • Refer to the Transmissible Diseases Index – CAHS Infection Control Policies – (internal WA Health only)
  • Refer to Rash Management – ED Guidelines
• A clinical notification for all suspected Measles cases must be made urgently by phone to the Communicable Disease Control Directorate on (08) 9222 0255 (during business hours) or (08) 9328 0553 (after hours). Refer to Statutory Notification Alert: Measles (health.wa.gov.au)
• Take a contact history (include age of individuals exposed, immunisation and pregnancy status)
• Non-immune contacts ≥ 6 months age should receive a measles mumps rubella (MMR) vaccine (or MMRV (measles mumps rubella varicella) in some circumstances) within 72 hours of the exposure
  • Children > 12 months age who have received one dose of measles-containing vaccine may receive their second dose early if at least 4 weeks have passed since their first dose
• Normal human immunoglobulin (NHIG) may be indicated for post-exposure prophylaxis for immunocompromised or pregnant contacts and infants less than 6 months age.Refer to the Australian Immunisation Handbook table for ‘Post-exposure prophylaxis needed within 72 hours of 1^st exposure for people exposed to measles’, for further details on post-exposure prophylaxis.⁵
• For possible measles cases discharged from ED, advise isolation at home until results become available. If positive, the exclusion time is 6 days from the onset of the rash.

Complications

• Pneumonia - is the most common cause of death in measles and may progress onto bronchiolitis obliterans
• Acute otitis media
• Acute encephalitis (affects 1 per 1000 cases)
• SSPE (Sub Acute Scelerosing Pan Encephalitis) – a rare late complication

Bibliography

1. Communicable Diseases Network Australia (CDNA). CDNA National Guidelines for Public Health Units: Measles (2019). Available from: CDNA Series of National Guidelines (SoNGs) | Australian Government Department of Health and Aged Care
2. Dowse G. (2010) Epidemiology of vaccine preventable diseases in Western Australia. Australia. Department of Health
3. Dowse G. (2010) Public health management of 200 key vaccine preventable diseases. Australia. Department of Health
4. NSW Health. (2008) Measles response protocol for NSW public health units. NSW Australia
5. Post-exposure prophylaxis needed within 72 hours of 1st exposure for people exposed to measles | The Australian Immunisation Handbook (health.gov.au). [Last Updated 27 September 2022 Cited: 11 January 2023] Available from: Table. Post-exposure prophylaxis needed within 72 hours of 1st exposure for people exposed to measles | The Australian Immunisation Handbook (health.gov.au)
6. Nelson Textbook of Pediatrics: 20th Edition Robert M. Kliegman, Bonita M.D. Stanton, Joseph St. Geme, Nina F Schor Publisher: Elsevier

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