February 13, 2015

Dear Colleague:

Thanks to your efforts, Virginians are weathering a challenging flu and norovirus season.  Today, I am writing about an additional infectious disease threat, measles, in an effort to assure we are all doing as much as possible to minimize the impact on all people in Virginia.  Fortunately, to date, there have been no cases of measles reported in Virginia in 2015.  However, from January 1 to February 6, 2015, 121 people from 17 states and Washington, D.C., have been reported as having measles.  Most of these cases (103 people) are part of a large, ongoing outbreak linked to an amusement park in California. This outbreak, combined with the highest number of cases reported nationally in 2014 (644, including 2 in Virginia) have heightened public awareness about the seriousness of measles and the importance of adequate immunization.

My goal with this letter is to assist you by providing Virginia-specific information concerning:

• Measles vaccination.
• Management of a patient who presents with measles-like symptoms.
• Key issues summary

Vaccination is the best prevention

Measles is highly infectious, but it is also highly preventable through vaccination.  In Virginia, 88.6 percent of children have received the measles vaccine by their second birthday, and 93.1 percent are fully vaccinated against measles when they begin school. The Virginia Department of Health urges persons who are not vaccinated or whose children have not been vaccinated to receive the vaccine as soon as possible. Virginia Code allows for exemption from required immunizations for religious and/or medical reasons; however, exemption rates remain low at 0.19 percent for medical and 0.84 percent for religious reasons.

A health care provider’s recommendation encouraging vaccine has been shown to be one of the most influential components of a parent’s decision making about vaccinating their children.  Please continue to encourage routine vaccinations to your patients. 

Measles related vaccination recommendations include the following:

• Children should receive two doses of MMR vaccine – the first dose at 12 through 15 months of age and the second dose 4 through 6 years of age. Giving the second dose earlier is acceptable as long as it is at least 28 days after the first dose.
• Children 6 through 11 months of age who are traveling internationally should receive one dose of vaccine prior to departure. Upon return, the child should receive two additional doses of vaccine as above.
• Birth before 1957 is considered acceptable evidence of immunity for adults other than health care workers, college and other students, and international travelers, who should receive two appropriately spaced doses.
• Adults born after 1957 who are not in a high risk group described above need one dose.
• People who received two doses of MMR vaccine as children according to the U.S. vaccination schedule do not ever need a booster dose.

Management of Patients with Illness Clinically Compatible with Measles

Measles is a highly infectious viral disease spread through coughing, sneezing, and contact with secretions from the nose, mouth, and throat of an infected person. Typically, it is characterized by fever >101°F, cough, coryza, and conjunctivitis.  After 3-7 days of illness, this stage progresses to a maculopapular rash that begins on the face and generalizes to the rest of the body.  Persons with measles are contagious from 4 days prior to rash onset through 4 days after rash onset.

In patients who are symptomatic and you suspect measles, the following actions are recommended:

• Notify your local health department (After hours call 866-531-3068).
• Do not allow such patients to remain in your waiting area.
• Immediately provide a surgical mask to the patient and place the masked person in a private negative pressure room, if available, or a room with a closed door. This room should not be used for 2 hours after a suspect measles patient leaves.
• Use standard and airborne precautio
• Permit only health care workers with measles immunity to attend to the
• For patients being transmitted through EMS service, EMS and the receiving hospital should be notified prior to arrival so the masked patient may be directed immediately to an appropriate exam room.
• Collect serum, a nasopharyngeal swab, throat swab, and urine (if possible) and coordinate with the local health department to test for measles IgM and IgG antibodies and viral detection by PCR and isolation.

Patients who are asymptomatic may present to you because they believe they have been exposed or worried they may be susceptible.  For those who are not immune, provide vaccination as appropriate.

People who work in health care facilities in any capacity are at increased risk of exposure to measles.  To ensure health care workers, from direct care to administrative staff, are immune to measles, they must have documentation of two doses of measles vaccine or laboratory evidence of immunity to measles.  Recommendations from the Centers for Disease Control and Prevention (CDC) regarding the vaccines recommended for health care workers can be found here: http://www.cdc.gov/vaccines/adults/rec-vac/hcw.html.  Susceptible personnel who have been exposed to measles should not have contact with patients or be in a health care facility from the 5th to the 21st day after exposure, regardless of whether they received vaccine or immune globulin after the exposure.

In summary:

• Maintain a high index of suspicion in your patients who present with measles-like symptoms.
• Ensure all eligible patients are adequately vaccinated against
• Encourage staff in your health care facility to receive the vaccines recommended for health care personnel.
• Contact your local health department immediately to report a suspected case and for additional guidance on testing and control After hours call 1-866-531-3068.
• Seek additional clinical information about measles at http://www.cdc.gov/measles/index.html.

Please contact either your local health department or the Virginia Department of Health at 804-864-8055 if you have any questions about this guidance.

Sincerely,

Marissa J. Levine, MD, MPH, FAAFP

State Health Commissioner