Measles Information for Providers

Measles can be prevented with measles-containing vaccine, which is primarily administered as the combination measles-mumps-rubella (MMR) vaccine.

• One dose of MMR vaccine is approximately 93% effective at preventing measles; two doses are approximately 97% effective.
• Protection does not wane over time.
• The second dose may be given any time at least four weeks after the first dose.
• The second dose is not a booster dose; it is intended to induce immunity in the 2-5% of people who do not respond to the first dose.
• Common side effects include sore arm, fever, mild rash, temporary pain and stiffness in the joints. This occurs mostly in teenage or adult women who did not already have immunity to the rubella component of the vaccine.
• Severe events rarely occur.

• History of anaphylactic reactions to neomycin
• History of severe allergic reaction to any component of the vaccine
• Pregnancy* (pregnancy should be avoided for four weeks following MMR vaccine)
• Immunosuppression
• Moderate or severe acute illness
• Recent blood product
• Personal or family (i.e., sibling or parent) history of seizures of any etiology (measles, mumps, rubella, and varicella vaccine only)

For more detailed information on contraindications and precautions, see the Pink Book.

*Close contact with a pregnant woman is not a contraindication to MMR vaccination. Breastfeeding is not a contraindication to vaccination of either the mother or the breastfeeding child.

Children are at the highest risk for measles.

Recommended schedule:

• First dose at age 12-15 months
• Second dose at age 4-6 years, before entry to kindergarten

If traveling internationally, infants age 6-11 months:

• One dose before departure
• Will need to revaccinate with two doses, the first dose beginning at 12-15 months. The second dose can be given as early as four weeks later.

Consider the patient’s age:

• Those born before 1957 are considered protected. No MMR vaccine is indicated.
• For those born in 1957 or later, one dose of MMR vaccine usually gives adequate protection from measles.
  • If the patient has laboratory evidence of immunity or having had measles, the MMR vaccine is not indicated.

Recommendations for High-risk Adults

Definition of high-risk:

• Health care personnel
  • Anyone who works in health care settings, including nurses, technicians, receptionists and support staff
  • For more, read pages 10-14 of the MMWR, “Immunization of Health-Care Personnel”.
• International travelers
• Students at post-high school education institutions

Recommendation:

• Two-dose MMR series at least four weeks apart or
• Laboratory evidence of immunity or
• Laboratory confirmation of disease

For unvaccinated health care personnel born before 1957 who lack laboratory evidence of measles immunity or laboratory confirmation of disease:

• Consider vaccinating with two doses of MMR vaccine at the appropriate interval for measles.
• During an outbreak of measles: recommend two doses of MMR vaccine.

Source: Epidemiology and Prevention of Vaccine-Preventable Diseases, Chapter 13

Vaccines for Children (VFC) and Vaccines for Adults (VFA) vaccine may be used in accordance with ACIP guidelines, even if the indication is for international travel. If using MMR vaccine for adults, please order MMR with a VFA intention in VIMS. If you’ve submitted an inventory reconciliation within one week, you can go into VIMS and order MMR without reconciling. If more than one week, e-mail ahs.vdhimmunizationprogram@vermont.gov

Visit the Vaccination Coverage page to get MMR immunization coverage data for schools, child care programs and colleges and universities in Vermont.

Measles is one of the most contagious of all infectious diseases; up to nine out of 10 susceptible people with close contact to someone with the disease will develop measles. The virus is transmitted by direct contact with infectious droplets or by airborne spread when an infected person breathes, coughs or sneezes. Measles virus can remain infectious in the air for up to two hours after an infected person leaves an area.

Measles is an acute viral respiratory illness. It is characterized by a prodrome of fever (often as high as 105°F), malaise, cough, coryza (runny nose) and conjunctivitis, followed by a maculopapular rash.

• The prodrome lasts 2-4 days and begins with a gradually increasing fever followed by cough, coryza and conjunctivitis (“the three Cs”).
• Koplik spots, small spots with white centers on the mucus membrane of the mouth, appear around the time of rash onset.
• The rash usually appears about 14 days after a person is exposed. It spreads down and out from the hairline, to the face, torso and lower extremities. The rash fades in order of appearance. Note: sometimes immunocompromised patients do not develop the rash.

Incubation period

• From exposure to prodrome symptoms averages 10-12 days
• From exposure to rash onset averages 14 days (range 7-21 days)

Communicability

• From four days before through four days after rash onset for a total of 9 days
• Immunocompromised patients may be infectious longer 

Usually, the illness is mild to moderately severe; most people feel sick enough to seek medical care. Measles can result in complications such as pneumonia, and rarely, encephalitis or death.

People at high risk for severe illness and complications from measles include:

• infants and children less than 5 years old
• adults older than 20 years old
• pregnant women
• people with compromised immune systems, such as from leukemia and HIV infection

Visit the CDC page, Photos of Measles and People with Measles.

Prompt recognition, reporting and investigation is important because the spread of measles can be limited with early case identification and vaccination of susceptible contacts. If you have a suspect measles case, immediately call the Health Department at 802-863-7240 (option 2). Someone is available 24/7 to assist.

It is unlikely to be measles if:

• No rash on face/head/neck
• Rash starts on trunk or legs
• No concurrent fever with rash
• Child feels well

Most childhood febrile rashes are not measles. Consider the presence or absence of prodromal symptoms, especially fever and rash presentation, when considering a measles diagnosis.

Get a printable PDF with this information

These are initial recommendations from the Health Department in the event of a suspect case. We will work closely with you and your facility to provide assistance.

What you can do before you even see a suspect case:

• Ensure appropriate documentation of immunity is readily available at your facility for all health care personnel.

When you have a suspect case:

• Isolate patient and institute respiratory and airborne precautions.
• Report suspect cases immediately to the Health Department at 802-863-7240.
• Obtain specimens for confirmation of diagnosis.
• Call ahead to ensure appropriate precautions if transport to hospital is necessary.
• Collect list of all exposed patients and staff along with immune status.

The following guidance applies to the Health Department Lab measles testing:

• Contact the Health Department at 802-863-7240, option 2, for assistance with submitting specimens to the Health Department Laboratory for testing. Testing will be performed at no charge. Instructions for Collecting and Shipping Measles PCR Specimens to the Health Department Laboratory 
• Obtain specimens for both measles PCR and serology at first contact with a patient suspected to have measles.
• Collect a throat or nasopharyngeal swab for measles PCR as soon as possible after rash onset. Swabs should be synthetic (non-cotton) in viral transport media. Respiratory samples are preferred early in the course of illness because that test is more sensitive in that timeframe, and samples can be tested at the Health Department Laboratory.
• Measles IgM testing must be sent out-of-state by the Health Department Laboratory. Providers may wish to send serology samples directly to reference laboratories for more rapid IgM turnaround time.
  If sending through the Health Department Laboratory, collect 0.7mL of blood in a red-top or serum separator (tiger top) tube for measles IgM. Allow the blood to clot thoroughly and then centrifuge the tube to remove serum from the clot. Gel separation tubes should be centrifuged within two hours of collection. Measles IgM results from blood specimens collected within the first 72 hours after rash onset may be falsely negative and may need to be repeated before rule-out.
• Refrigerate all specimens after collection and transport them on ice packs within 24 hours of collection.
   

Swab

• Refrigerate in the viral transport medium tube at 2-8°C for up to 72 hours. After 72 hours, specimens should be frozen at -20°C or lower.
• Must be received within 24 hours of collection.
• If specimen will not reach lab within 24 hours, store at -70°C or colder and transport using dry ice.

Serum (out-of-state testing)

• Store at 4°C.
• Should be received within two days of collection.

A Clinical Test Request Form must be filled out for all specimens.

• Refrigerate all specimens after collection and transport them on icepacks within 24 hours of collection.
• Use your regular courier for transport of specimens to the Health Department Lab.

• If you are alerted prior to the patient’s arrival, try to schedule them as the last appointment of the day to avoid exposure to other patients and meet them outside the facility with a face mask when they arrive.
• Bypass the waiting area if possible and do not allow the patient to remain in the waiting room or any common areas.
• Immediately place the patient in an airborne infection isolation room. If such a room is not available, place the patient in a private room with the door closed and keep the patient masked.

• Allow only health care personnel with documentation of 2 doses of MMR vaccine or laboratory evidence of immunity (measles IgG positive) to enter the patient’s room.
• All health care personnel entering the room of a suspect measles patient should use an N95 respirator or a respirator with similar effectiveness in preventing airborne transmission. If N95 or other airborne respirators are not available, health care staff should use a general face mask.

• Close and do not use the examination room for at least 2 hours after the suspect measles case has left.
• Make note of all staff and patients who were in the area during the time the suspect measles patient was in the facility and for 2 hours after they left. If measles is confirmed in the suspect patient, exposed people will need to be assessed for measles immunity.

People with measles can spread the virus to others from four days before the rash starts through four days after. As soon as measles is suspected, it is important to take steps to prevent the spread of the disease.

Stay away from others.

Until we know whether or not you have measles, it is important to reduce the risk of getting anyone else sick. Stay at home and away from other people as much as possible until results come back. Providers can offer a letter to schools or workplaces if needed. Your provider will be in touch as soon as test results are in, and someone from the Vermont Department of Health will also reach out to help with next steps.

Know who in your household is immune to measles.

Have people in your household check their immunization history to find out if they are immune. If tests confirm that this is measles, that will help the Health Department know who may need to be vaccinated and who is already immune.

Most people are immune if they:

• Were born before 1957 or
• Have laboratory-confirmed evidence of immunity to measles or
• Have documentation of measles vaccination.

Get a printable PDF with this information for your patients

The Health Department will work collaboratively with any provider reporting a patient suspected to have measles and facilities where measles exposures may have occurred. Priority activities include:

• Identify and notify contacts.
• Determine susceptibility of contacts.
• Provide postexposure vaccine, including a second dose, if appropriate.
• Recommend and provide postexposure IG for susceptible high-risk people.
• Initiate active surveillance.
• Enforce exclusions while contagious.
• Recommend self-isolation and monitor for measles signs and symptoms in susceptible contacts as needed.
• Communicate with partner agencies, healthcare providers and the public.