References
1. Orenstein WA, Samuel KL, Hinman
AR. Summary and Conclusions: Measles
Elimination Meeting, 16–17 March
2000. The Journal of Infectious Diseases,
2004; 189: 43–47.
2. CDC. Measles Cases and Outbreaks
in 2018. www.cdc.gov/measles/casesoutbreaks.
html. Accessed Nov 5, 2018.
3. Bester JC. Measles and Measles
Vaccination. JAMA Pediatrics. 2016;
170(12): 1209–1215.
4. Adams DA, Thomas KR, Jajosky RA,
et al. Summary of Notifiable Infectious
Diseases and Conditions — United States,
2015. MMWR Morb Mortal Wkly Rep
2017; 64:1–143.
5. Hall V, Banerjee E, Kenyon C, et al.
Measles Outbreak — Minnesota April–
May 2017. MMWR Morb Mortal Wkly
Rep 2017; 66:713–717.
6. Moss WJ. Measles. Lancet. 2017; 390
(10111): 2490–2502.
7. Clemmons NS, Gastanaduy PA,
Fiebelkorn AP, et al. Measles — United
States, Jan 4–April 2, 2015. MMWR Morb
Mortal Wkly Rep 2015; 64:373–376.
8. Fiebelkorn AP, Redd SB, Gallagher K,
et al. Measles in the United States during
the Postelimination Era. The Journal of
Infectious Diseases, 2010; 202: 1520–
1528.
9. Arciuolo RJ, Jablonski RR, Zucker
JR, Rosen JB. Effectiveness of Measles
Vaccination and Immune Globulin Post-
Exposure Prophylaxis in an Outbreak
Setting— New York City, 2013. Clinical
Infectious Diseases. 2017; 65(11): 1843–
1847.
10. World Health Organization. Weekly
Epidemiological Record. 2009; 84: 349–
360. www.who.int/wer/2009/wer8435.pdf.
11. Sudfeld CR, Navar AM, Halsey
NA. Effectiveness of Measles Vaccination
and Vitamin A Treatment. International
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12. Measles Epidemiology and Control
and the Role of Novel Vaccination
Strategies. Viruses. 2017; 9 (11).
13. McLean HQ, Fiebelkorn
AP, Temte JL, et al. Prevention of
Measles, Rubella, Congenital Rubella
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MMWR Morb Mortal Wkly Rep 2013;
62:1–34.
Management of measles and post-exposure prophylaxis
Airborne isolation precautions should be implemented in suspected measles cases until the
diagnosis is ruled out. Suspected cases should be quickly triaged from any waiting areas.
If measles is suspected, these control measures can help reduce the risk of subsequent
transmission.9 All healthcare personnel should have documented evidence of immunity to
measles on record at their workplace.
Supportive care, treatment of complications and prevention of further transmission are
the main objectives of measles management. Although no specific antiviral treatment for
measles is available, WHO and the American Academy of Pediatrics recommend Vitamin
A for treatment of children with measles.10,11 A systematic review by Sudfeld, et. al,
indicated two doses of Vitamin A (200,000 IU for children 1 year or older and 100,000
IU for infants) was associated with a 62% reduction in mortality from measles.11
Contacts of an individual with measles who have unknown immune status can be
offered postexposure prophylaxis (PEP). The MMR vaccine is an acceptable form of PEP
when administered within 72 hours of initial measles exposure, while immune globulin
can be given up to six days after exposure.9,12 Although these options may provide some
protection for susceptible persons, those who receive either form of PEP should be advised
to watch for signs and symptoms until 21 days after their exposure. If exposed contacts are
unable to receive either PEP within the allotted timeframe, it is recommended that they
either show evidence of immunity prior to returning to their daily routine (school, work,
daycare, hospital) or self-exclude for the entire 21-day incubation period.9
Immunization recommendations for adults
and for international travel
Many US measles cases have professed unknown measles vaccination history or immune
status.7 CDC recommends that all adults without evidence of immunity against measles
receive at least one dose of the MMR vaccine, while adults in high-risk settings should
receive two doses. High-risk groups are considered to be healthcare workers, college
students or international travelers.13 If an adult patient is suspected to have measles or has
been a close contact of a known case, it is important to identify their immune status. A
measles IgG titer should be collected in patients who have been close contacts of a measles
case but do not have documentation of prior infection or vaccination.12
Although it is recommended that children receive their first MMR vaccine between
12–15 months, children ages 6–11 months should receive one dose of the MMR vaccine
prior to international travel to endemic countries.7 Typically, adults born before 1957 are
considered to have presumptive evidence of immunity because of the likelihood of having
contracted measles due to the prevalence of the disease before 1957. However, prior to
traveling internationally, adults born before 1957 should receive two doses of MMR, at
least one month apart.9
For adults and international travelers, MMR vaccines are available at the Immunization
Clinic at the Dallas County Health and Human Services Department. The fee schedules
for these services can be found at www.dallascounty.org/department/hhs/foreigntravel.
Summary
Any suspected measles cases should be reported immediately to Dallas County Health
and Human Services at 214-819-2004. To facilitate testing and follow-up of potential
exposures, clinicians are asked to contact DCHHS while a patient with possible measles
is still present in the clinical setting. Healthcare providers can advise a patient who is
concerned about having measles to call before arriving at the healthcare facility or schedule
such outpatients at the end of the day. To avoid exposing other patients in waiting rooms
and treatment areas, a separate entrance ideally should be used, and the patient should be
masked and quickly triaged from waiting areas.
Measles will continue to be a potential diagnosis that physicians in our area may
encounter. Indeed, one of the three measles patients mentioned in DFW news reports
this year was diagnosed with the infection by an area hospital emergency room and had
a history of recent international travel. The expert diagnostic acumen of clinicians and
prompt reporting to local health departments can make a critical difference in stopping
the spread of this highly contagious disease in our communities. DMJ
December 2018 Dallas Medical Journal 13