LAC DPH Health Alert: Measles Exposure in LA County August 22, 2018 Public Health 815 This message is intended for primary care, urgent care, emergency, pediatric, and internal medicine, infectious disease, and laboratory providers. Please distribute as appropriate. Key Messages A patient with infectious measles visited Santa Monica from August 8-10, 2018. Health care providers should consider the diagnosis of measles among persons presenting with a febrile rash illness and institute immediate airborne precautions for patients with fever and rash to prevent nosocomial exposures. Suspect cases should be immediately reported to the LAC DPH even before laboratory confirmation. Situation The Los Angeles County Department of Public Health is investigating possible exposure to a confirmed measles case in Santa Monica, August 8-10. The case patient visited six venues, a hotel and five restaurants in Santa Monica: Sea Blue Hotel, Urth Café, Chez Jay Restaurant, Cora's Coffee Shoppe, and Ivy at the Shore restaurant. To date no secondary cases have been identified though contact investigations are ongoing. Actions Requested of Providers Consider measles when evaluating any patient who has an acute rash illness with fever. IMMEDIATELY institute airborne precautions for all persons with a measles like rash and fever. Reduce exposures: schedule suspect cases for end of the day and have them enter via a separate entrance. Do not send to the Emergency Department (ED) unless they require hospitalization and if so, contact the ED first. Place visible signs instructing patients with fever and rash to immediately notify staff. Obtain specimens for confirmation of diagnosis: blood for serology, and urine +/- nasopharyngeal (NP)/throat swabs for PCR. IMMEDIATELY report suspect cases to the Morbidity Central Reporting Unit at 888-397-3993 (after 5 pm or on weekends, call: 213-974-1234). Do not wait for laboratory confirmation. For Long Beach or Pasadena cases see reporting section below. Provide a list of all exposed staff and patients to the public health department. Measles Clinical Presentation Measles symptoms usually begin 10-12 days (up to 21 days) after exposure with a prodrome of fever (up to 105 F), malaise, cough, coryza, and conjunctivitis. Two to four days later, a maculopapular rash develops around the hairline or ears and spreads downward to the face, trunk, and extremities. Severe illness can occur including pneumonia, encephalitis, and death. Specimen Collection At presentation, collect blood for both measles IgM and IgG antibodies. Draw 8-10 mL of blood in a red top or serum separator tube; spin down serum if possible. NOTE: With prior notification and consent of the testing laboratory, capillary blood may be collected if venipuncture is not preferred. In addition to blood specimen: If within 14 days of rash onset, collect a throat swab and a urine specimen for culture/PCR. Swabs are to be collected using a viral culturette and placed into viral transport media. Collect 10-50 mL of urine in a sterile centrifuge tube or urine specimen container. Keep specimens on wet ice and send to the Public Health Lab as soon as possible. Transmission and Infection Control Measles is highly infectious and is transmitted by airborne spread of respiratory droplets. Typically, measles patients are contagious from 4 days before to 4 days after rash onset. Suspect measles cases should not be allowed in patient waiting areas. If airborne isolations rooms are not available, patients should be masked and placed immediately in an examination room, with the door closed. Clinics, emergency departments and urgent care centers should ensure that front desk staff and registration and triage personnel ask every patient about generalized rash and fever. Patients with suspect measles should be seen at the end of the day and use a separate entrance. The examination room should not be used for two hours after the patient visit. Prevention Routine vaccination with two doses of measles-containing vaccine is the safest and most effective way to prevent disease. It is routinely recommended for all children and is a requirement for school attendance. Non-immune immunocompromised persons, infants ≤ 12 months, and others at high risk of complications from measles can be protected with immune globulin ≤ 6 days after exposure. Clinicians may consider administering immune globulin to any suspected contact in accordance withCDPH recommendations. Non-immune immunocompetent individuals can receive the MMR vaccine ≤72 hours after exposure as an immediate prevention measure. After 72 hours, MMR may be offered to anyone for future prevention. High population-level immunity can help limit transmission of measles during any outbreak. MMR vaccine is 90% to 95% effective in preventing measles. The best way to protect your patients from measles is to ensure that children receive their first dose of MMR routinely at age 12 months and their second dose at age 4 to 6 years. Adult patients without documentation of prior measles vaccination or immunity to measles, can have measles IgG titers drawn, or they can be vaccinated without obtaining serology. There is no harm from administering additional doses of MMR vaccine. Reporting Measles cases must be reported by telephone immediately to the local health department (Title 17, California Code of Regulations, § 2500).Reporting suspect cases in Los Angeles County: Weekdays 8:00 am-5:00 pm: call 888-397-3993. After hours: call 213-974-1234. Reporting suspect cases in the City of Long Beach, contact Long Beach Health and Human Services: Weekdays 8:00 am to 5:00 pm: call 562-570-4302. After hours: 562-500-5537, ask for the Duty Officer.Reporting suspect cases in the City of Pasadena, contact the Pasadena Health Department: Weekdays 8:00 am to 5:00 pm (closed every other Friday): call 626-744-6089. After hours call: 626-744-6043. Additional Resources Technical assistance: LAC DPH Vaccine Preventable Disease Control Program Surveillance Unit at 213 351-7800. Information for parents and FAQs for patients http://publichealth.lacounty.gov/media/measles/index.htm CDPH Measles Factsheet https://www.cdph.ca.gov/Programs/CID/DCDC/CDPH%20Document%20Library/Immunization/Measles-Quicksheet.pdf This Health Alert was sent by Dr. Franklin Pratt, Medical Director, Vaccine Preventable Disease Control Program, Los Angeles County Department of Public Health