Key Messages for Providers
- Measles cases are increasing in Virginia, the United States, and globally.
- Maintain a high index of suspicion for measles in patients presenting with a febrile rash and clinically compatible symptoms (cough, coryza, or conjunctivitis), especially those with recent travel, or known or suspected exposure to someone with measles.
- Immediately report suspected measles cases to your local health department. After hours, call 866-531-3068.
- Talk with your local health department about testing at the Department of Consolidated Laboratory Services (DCLS) when it is indicated.
- Follow infection control recommendations to minimize further spread.
- Ensure your patients and staff are vaccinated against measles. Vaccination is the best way to prevent measles.
Measles should be suspected in a patient who has an acute illness characterized by:
- Generalized, maculopapular rash lasting ≥3 days; and
- Temperature ≥101°F or 38.3°C; and
- Cough, coryza, or conjunctivitis.
Koplik spots may be present on the buccal mucosa. These are considered a pathognomonic sign of measles but are not present in all patients.
A measles rash may appear hyperpigmented on patients with dark skin. Be aware of measles rash presentations on different skin tones. The rash spreads from the head to the trunk to the lower extremities.
Incubation period: Symptoms may begin within 7–21 days after exposure, with an average of 10 days after exposure. The rash usually appears within 14 days of exposure.
Infectious Period: Patients are considered infectious from 4 days before through 4 days after rash appearance. Immunocompromised patients may spread the virus for the duration of their illness and may not develop the rash.
For more information:
- American Academy of Pediatrics Red Book Online Outbreaks: Measles
- CDC Clinical Overview of Measles
If you suspect measles,
- Call your local health department immediately to discuss testing, infection control, and prevention measures. Do not wait for the next business day or lab confirmation. After hours, call 866-531-3068.
- Collect specimens for PCR and serology testing.
Measles is a rapidly reportable condition in Virginia. It must be reported by physicians, directors of laboratories, and directors of medical care facilities.
Prompt testing is important to diagnose measles cases and confirm outbreaks. Providers are encouraged to use VDH’s Measles Reporting and Testing Guidance (1-page algorithm) when measles is suspected.
If a patient presents with symptoms of measles, ask if they have received MMR vaccination within the previous 21 days before deciding whether to test.
- About 5% of MMR recipients develop a rash, usually within 6-12 days after immunization. These reactions can be clinically identical to measles infection and can result in a positive lab test.
- If a recently vaccinated patient (<21 days) has fever and rash, but no history of travel or exposure, measles is unlikely and testing is not usually indicated. Consult with your local health department if you have questions.
Public health testing at Virginia’s Division of Consolidated Laboratory Services (DCLS) is available. Testing requires prior VDH approval, and requests should be routed through your local health department. DCLS performs two types of tests:
- RT-PCR to diagnose current infection
- Diagnostic testing through DCLS is available only for patients with high suspicion of measles. Factors considered for approving public health lab testing include recent travel or other relevant exposure history, age, vaccination status, and local disease trends.
- When suspicion of measles is low, measles testing through a commercial laboratory may be appropriate.
- IgM and IgG serology to assess current and past infection or immunity from vaccination
- Note that VDH does not typically recommend checking titers at a commercial laboratory after vaccination to determine immunity.
- In some cases, VDH might approve IgG testing at DCLS when measles immunity status needs to be established for contacts who have been exposed to measles but are not eligible for measles vaccine as PEP.
The estimated turnaround time for measles testing through public health is 1-2 days after specimen receipt. When collecting specimens, follow CDC’s measles infection prevention and control guidance.
Stay prepared for measles:
- Ensure that healthcare personnel have documented evidence of immunity.
- Encourage MMR vaccination for all eligible patients.
- Consider identifying and flagging the records of patients who have not received their MMR on time and offer the vaccine during encounters/admissions.
- Have screening measures in place to identify symptomatic patients, ideally before facility entry. Assess travel history of all patients with clinically compatible symptoms.
If you suspect measles, the following actions are recommended:
- Immediately provide a mask to the patient and anyone accompanying the patient and implement Standard and Airborne Precautions. Do not allow the patient to remain in waiting or common areas.
- Place the masked patient in an airborne infection isolation room (AIIR), if available, or a room with a closed door.
- AIIR prioritization: Consult the facility infection prevention and control program for guidance about patient placement as necessary.
- If an AIIR is not available, transfer the patient as soon as possible to a facility where an AIIR is available. Notify the facility before transfer.
- Instruct healthcare personnel to wear respiratory protection (i.e., fit-tested N95 respirator), regardless of presumptive immunity status. Respiratory protection should be single use, not extended use.
- Permit only healthcare personnel with measles immunity and wearing respiratory protection (i.e., respirator) to attend to the patient.
- Report suspected cases immediately to your infection prevention and control program and local health department (after hours call 866-531-3068).
- Maintain Airborne Precautions for 4 days after rash onset (rash onset is considered Day 0). Immunocompromised patients with measles should remain in Airborne Precautions for the duration of illness due to prolonged virus shedding.
- Limit visitors to those who are immune and necessary for the patient’s well-being and care. Non-immune visitors should not enter the facility while the patient is still infectious.
- For management of exposed visitors, see Post-Exposure Prophylaxis (PEP) section.
- Limit transport of patients with known or suspected measles to essential purposes only.
- Notify transferring teams (e.g., emergency medical services, transporters) and receiving departments or facilities before transfer.
- Mask the patient during transport, if tolerated.
- Close rooms that were in use by a patient with suspect or confirmed measles to allow for sufficient removal of air contaminants.
- To determine how long the room should remain closed, follow the estimated time for 99.9% removal efficiency of airborne contaminants in the CDC guidance.
- If air exchanges are unknown, keep the room vacant for 2 hours.
- Implement environmental infection control.
- Perform standard cleaning and disinfection procedures using an EPA-registered disinfectant for healthcare settings, per manufacturer’s instructions.
- Manage used, disposable PPE and other patient care items for measles patients as regulated medical waste according to federal and local regulations.
- Manage exposed healthcare personnel according to the Infection Control in Healthcare Personnel: Epidemiology and Control of Selected Infections Transmitted Among Healthcare Personnel and Patients (2024).
- Patients exposed to measles who do not have evidence of measles immunity:
- Might be eligible for Post-Exposure Prophylaxis (PEP).
- Should watch for symptoms for 21 days after the exposure. Extend to 28 days after exposure if immunoglobulin (IG) was given.
- Require Airborne Precautions from the 5th day after their exposure until the end of the exposure period (i.e., 21 or 28 days after exposure).
- Patients exposed to measles who have evidence of immunity do not require Airborne Precautions unless they have measles symptoms.
- If appropriate, healthcare providers might consider different scheduling options for patients who have been exposed to measles and do not have evidence of immunity. These could include telehealth visits, scheduling a visit at the end of the day when susceptible patients are not present, or postponing the visit until the monitoring period is over.
- CDC Interim Infection Prevention and Control Recommendations for Measles in Healthcare Settings
- Assessment Tool for Healthcare Personnel Exposed to Measles
- APIC Measles Resources and Tools
- CDC Project Firstline Measles Micro-Learn
- CDC Measles Assessment Tool (MAT) for Infection Control in Healthcare Settings: Measles Preparedness and Response During Community Outbreaks
Vaccinations play a critical role in protecting the health of children, families, and communities. Vaccination is the best way to prevent measles because it is safe, effective, and provides long-lasting protection.
Healthcare providers are the most trusted sources for vaccine information. Tools to help with talking with your patients about vaccines include:
- American Academy of Pediatrics’ Vaccine Confidence Campaign
- Let’s Get Real About Vaccines
- North Carolina Department of Health and Human Services’ Talking with Parents and Caregivers About Vaccines website
- Immunize.org’s Measles: Questions and Answers
Measles vaccine is available combined with mumps and rubella vaccines as MMR, or MMR combined with varicella vaccine as MMRV. The MMR and MMRV vaccines are live-attenuated (weakened) vaccines that produce a mild, non-infectious response. A single-antigen measles vaccine is not available in the United States.
MMR and MMRV vaccines are about 93% effective at preventing measles after 1 dose and about 97% effective after 2 doses.
- The second dose is administered to provide a second chance to respond to vaccination.
- Very few people who get 2 doses of measles vaccine will get measles if exposed to the virus.
Healthcare providers can access the Virginia Immunization Information System to verify patient vaccination history. Patients may also request their records from VDH.
Infants: If traveling internationally, or to an outbreak setting, infants 6 through 11 months old should receive 1 dose of MMR vaccine before departure.
- Infants who receive a dose of MMR vaccine before their first birthday should receive 2 more doses of MMR vaccine at the recommended ages and at least 28 days apart.
Children: Children should receive 2 doses of MMR vaccine with the first dose at 12 through 15 months of age and the second dose at 4 through 6 years of age.
- Giving the second dose of the vaccine earlier is allowed as long as it is at least 28 days after the first dose.
Students, travelers, and healthcare personnel: Unless they have evidence of measles immunity, college and other students, healthcare personnel, and international travelers need 2 doses that have been given on or after age 1 and at least 28 days apart.
Adults: All other adults born in or after 1957 should have documentation of at least 1 dose of MMR or other evidence of measles immunity.
Persons receiving postexposure prophylaxis immune globulin (IG): Refer to VDH’s Postexposure Prophylaxis (PEP) Guidance for Measles Exposures for details about postexposure prophylaxis. MMR vaccine should be administered no earlier than 6 months after IGIM administration or 8 months after IGIV administration. Once the time interval has passed, follow age-appropriate dosing recommendations.
Patients who are severely immunocompromised for any reason should not be given MMR vaccine. HIV-infected individuals may receive MMR vaccination if they are not severely immunosuppressed.
- HIV-infected children may receive MMR vaccine if CD4+ T-lymphocyte count is >15 percent.
- HIV-infected adults may receive MMR vaccine if they are not severely immunocompromised (i.e., CD4 count is 200 cells/µL or greater).
Persons known to be pregnant should not receive the measles vaccine. Pregnancy should be avoided for 4 weeks following MMR vaccine.
Persons receiving large daily doses of corticosteroids (>2 mg/kg per day or >20 mg per day of prednisone) for 14 days or more should not receive MMR vaccine because it can lead to complications. Avoid MMR vaccination for at least one month after stopping high dose steroid therapy.
Administration of blood products and immune globulin require waiting a certain period before administering measles vaccine.
For more information:
- Breastfeeding is not a contraindication to vaccination of either the woman or the breastfeeding child.
- Persons receiving low dose or short course (<14 days) corticosteroid therapy, alternate-day treatment, maintenance physiologic doses, or topical, aerosol, intra-articular, bursal, or tendon injections may be vaccinated.
- Patients with leukemia in remission who have not received chemotherapy for at least 3 months may receive MMR or its component vaccines.
For more information:
There are two post-exposure prophylaxis (PEP) options for measles:
- MMR vaccine if within 72 hours of exposure
- Immunoglobulin (IG) if within six days of exposure
When possible, MMR vaccine is given as PEP. IG should be prioritized for people who are at risk of severe disease or complications and cannot be vaccinated.
- Administer intramuscular immunoglobulin (IMIG) to those <6 months of age
- Administer intravenous immunoglobulin (IVIG) to immunocompromised persons
- Perform serologic testing (IgG) of pregnant persons and administer IVIG if they test negative
Refer to VDH’s Postexposure Prophylaxis (PEP) Guidance for Measles Exposures for details about PEP for persons exposed to the measles virus.
Healthcare providers may contact their local health department to acquire IG.
The recommended dose of IMIG is 0.5 mL/kg of body weight (maximum dose = 15 mL) and the recommended dose of IVIG is 400 mg/kg.
Note: Infants <6 months do not need serologic testing because they are known to be unvaccinated, and immunocompromised patients do not need serologic testing because IVIG is recommended regardless of immune status.
No patient should receive both vaccine and immunoglobulin. If possible, vaccine or IG should be administered as close together as possible to family members so that their period of quarantine is the same or similar.
- VDH Postexposure Prophylaxis (PEP) Guidance for Measles Exposures
- VDH Assessment Tool for Healthcare Personnel Exposed to Measles
- CDC’s Interim Infection Prevention and Control Recommendations for Measles in Healthcare Settings
- CDC Steps for Responding to Measles Exposures in Healthcare Settings
- CDC Factsheet: Immune globulin for Measles Post-Exposure Prophylaxis
- American Academy of Pediatrics Red Book Online Outbreaks: Measles
- American College of Obstetricians and Gynecologists (ACOG)’s Management of Pregnant and Reproductive Aged Women during a Measles Outbreak
- CDC Measles Preparedness and Response in Healthcare Settings
- CDC Pink Book Chapter 13: Measles