|Publication: 11/07/2019 --|
|Last review: 01/01/1900|
|Next review: 31/03/2022|
|Approved By: Trust Clinical Guidelines Group|
|Copyright© Leeds Teaching Hospitals NHS Trust 2019|
This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
Management of contacts
Appendix 1 - Complications
Appendix 2 - Patients who have come into contact with a suspected/confirmed case of measles
Appendix 3 - Staff who have come into contact with a suspected /confirmed case of measles
Measles is a highly contagious viral illness that is spread through coughing and sneezing. It can be severe in immunosuppressed individuals and young infants. It is also more severe in pregnancy and can lead to foetal loss.
The most effective way to control measles is achieving a high uptake of two doses of measles, mumps, rubella (MMR) vaccine. The vaccine effectiveness of a single dose of MMR is around 90% and approximately 95% for two doses.
Measles is a notifiable disease under the Health Protection Legislation (England) Guidance 2010 and should be notified on clinical suspicion.
Clinicians are required to notify all suspected measles cases as soon as possible to their local Health Protection Team (HPT), both as part of surveillance and so that timely public health management can be undertaken.
Risk assessment should consist of a combination of clinical and epidemiological factors such as clinical presentation, vaccination history, travel history, age of the patient and epidemiological links e.g. local outbreaks or contact with a confirmed case.
Management should not be delayed whilst waiting for a laboratory confirmed result.
- A high temperature, may reach 40C
- Coryzal symptoms - runny or blocked nose and sneezing
- Inflamed buccal mucosa
- Small greyish-white spots in the mouth (before rash appears) known as Koplik spots
- Aches and pains
- Loss of appetite, tiredness, irritability
- Rash: 2 - 4 days from onset of above symptoms a rash may appear which generally starts on the face and behind the ears. The rash can spread over 2-3 days from first appearance to trunk and can be generalised. The rash is red, blotchy, maculopapular (i.e. non-vesicular), not itchy and lasts between 3 -7 days.
Reinfection. In these cases, the symptoms are generally mild and shorter in duration. In some cases, the rash is not typical. It is usually seen in individuals who have received one or two doses of measles containing vaccination. The infectivity of these cases is low.
Laboratory confirmation of clinically suspected cases can be made by collecting a Buccal swab
This will be tested for measles RNA, and can therefore::
- reliably exclude measles diagnosis, as well as confirm it;
- genotype, if positive, can differentiate wild and vaccine strain.
On ICE, request ‘Measles PCR (buccal swab)’
How to obtain a buccal swab.
- Use a PINK topped microbiology e-swab
- Rub on the inside of cheek for 20 seconds
- Snap swab into virology specimen tube
- Label clearly as ‘Measles PCR- send directly to the laboratory’
- A throat swab will be required if other tests are required (such as adenovirus) and can also be used for measles diagnosis (as an alternative to the buccal swab).
- For older children over 10 years and adults we would also recommend a serum sample for measles IgG and IgM, this is particularly useful where measles re-infection is suspected (i.e. measles following one or more measles vaccines).
Management of the suspected/confirmed case
The Infection Prevention and Control Team (IPCT) should be informed of all suspected measles so that they can undertake a risk assessment and provide appropriate advice.
Individuals with measles infection are infectious from approximately 4 days before rash onset until 4 full days after the onset of the rash.
The incubation period is typically around 10-12 days from exposure to onset of symptoms, but can vary from 7 to 21 days.
The transmission route of measles is mostly airborne by droplet spread or direct contact with nasal or throat secretions of infected persons. Much less commonly, measles may be transmitted by articles freshly soiled with nose and throat secretions, or through airborne transmission with no known face to-face contact.
- Admission of patients with measles should be avoided where possible.
- If admission is essential the patient must be isolated immediately in a single room, and doors must be kept closed. Source isolation to be maintained until 4 full days after the onset of the rash.
- Isolation rooms with negative pressure ventilation used where available. Negative pressure rooms are located on J20 at SJUH, L06 at LGI and L47 for paediatric cases.
- Gloves, apron and fluid repellent mask (FFP3) must be worn as part of PPE.
- Remove PPE and wash hands before leaving room. (Source Isolation Policy)
- Pregnant staff or staff who have a compromised immune system avoid contact with measles.
NB Any patient with a maculopapular rash should be isolated even if measles is unlikely (as there are other virus causes such as parvovirus or enterovirus which are contagious) unless a non-infectious cause is found (such as allergy).
There’s no specific treatment or antiviral therapy for uncomplicated measles. Most patients with uncomplicated measles will recover with rest and supportive treatment (such as hydration and antipyretics).
Secondary bacterial infections should be treated with antibiotics.
Measles is a serious illness that can be unpleasant and lead to complications especially in vulnerable immunocompromised or pregnant patients.
Immunosuppressed individuals are at higher risk of developing prolonged and severe measles, particularly pneumonitis and may not present with a rash.
Measles can be particularly debilitating in very young infants, who are more likely to develop complications and require hospitalisation. Measles can be severe in pregnant women and leads to an increased risk of prematurity and foetal loss. Young infants are at high risk of complications such as pneumonia, otitis media, Subacute Sclerosing Panencephalitis SSPE and of a fatal outcome.
See Appendix 1 for further information on Complications.
It is the responsibility of the ward manager to ensure that the details of any contacts (patient, staff, relative or visitor) are obtained.
Management of Patient Contacts – see Appendix 2 for patient contact details to be collected and forwarded to Infection Prevention and Control.
IPCT will help to assess the exposure of patients. Contact with suspected/confirmed case is defined as being in the same room for cumulative 15 minutes; with particular attention to identifying and managing immunosuppressed and vulnerable contacts.
Post exposure prophylaxis (measles immunoglobulin) is effective for reducing the effects of or preventing measles if given soon enough to vulnerable contacts. This requires identification of contacts in the following order of priority:
1. Immunosuppressed contacts
2. Pregnant women.
3. Infants < 12 months
Information about the classification of immunosuppressed individuals is provided in PHE Measles Guidance August 2017.
All contact should be identified as vaccine can be offered to non-immune healthy individuals and restriction may be placed on their working or other activities (such as attending school)
Post-exposure Prophylaxis for LTHT patients
In order to inform the decision to recommend post exposure prophylaxis, a local risk assessment should be undertaken to determine the likelihood of measles in the index case and the level of potential exposure of the vulnerable contacts.
If the index case is laboratory confirmed, epidemiologically confirmed or considered likely to be measles by the local Health Protection Team (HPT), then the need for post exposure prophylaxis (PEP) should be urgently addressed.
Detailed information on the level and nature of exposure can be found in the PHE National Measles Guidelines. For each identified contact, the decision to offer PEP is based on the level and timing of exposure and susceptibility to measles.
Please refer to Guidance for Measles post-exposure prophylaxis published by PHE in 2017.
Patient contacts who remain an in-patient following exposure to be source isolated in a single room from 5-21 days post exposure.
Management of Staff Contacts - see Appendix 3
- For staff who have had any face to face contact.
- Been in the same room for 15 minutes.
PLEASE COMPLETE ALL DETAILS - If staff details are not complete it may prevent appropriate follow up and contact screening.
In areas that are most likely to be the first port of call for suspected measles managers to have this information ready.
Once complete send an electronic copy of Health care workers only to: email@example.com
OCCUPATIONAL HEALTH ROLE
Occupational health will follow up all staff contacts.
All healthcare workers should have satisfactory evidence of protection against measles to protect both themselves and their patients.
- Satisfactory evidence of protection includes documentation of having received two or more doses of measles containing vaccine and/or a positive measles IgG antibody.
Health Care Workers (HCWs) who are exposed to a confirmed or likely case and do not have satisfactory evidence of protection should be excluded from work from the 5th day after the first exposure to 21 days after the final exposure.
If HCWs are tested rapidly after exposure, they can continue to work if found to be measles IgG positive (confirms immunity).
Where MMR vaccine is given post-exposure, it is unlikely to prevent the development of measles but if the HCW remains symptom-free for at least 14 days after MMR was given, they can return at that stage.
HCWs with satisfactory evidence of protection can continue to work normally but should be advised to report to Occupational Health (OH) if they develop symptoms between 7 days after the first exposure and 21 days after the last exposure.
Exposed HCWs that develop fever or rash should be excluded from all work until 4 full days after onset of the rash.
Those HCWs should be treated as an epidemiologically confirmed case and laboratory confirmation and notification should be sought in the usual way.
Other Contacts (relatives / visitors) - Public Health England will require their contact information
All contacts should be identified as vaccine can be offered to non-immune healthy individuals and restrictions may be placed on their working or other activities.
|Target patient group:||Patients with measles and patient and staff contacts.|
|Target professional group(s):||Pharmacists
Secondary Care Doctors
Secondary Care Nurses
PHE national measles guidelines (August 2017) Authors Gayatri Amirthalingam, Kevin Brown, Olivier le Polain, Mary Ramsay Reviewed by Members of the Vaccine Scientific Steering Group and HPT immunisation leads Version 1 Date of Issue August 2017.
PHE Guidelines on Post-Exposure Prophylaxis for measles (August 2017)
PHE publications gateway number: 2017250
and Evidence levels:
A. Meta-analyses, randomised controlled trials/systematic reviews of RCTs
B. Robust experimental or observational studies
C. Expert consensus.
D. Leeds consensus. (where no national guidance exists or there is wide disagreement with a level C recommendation or where national guidance documents contradict each other)
Trust Clinical Guidelines Group
LHP version 1.0
Conflicts of Interests
– no conflicts of interest
The most frequent complications include viral pneumonitis and otitis media, as well as diarrhoea.
Measles infection often leads to a temporary reduction in immune responses in the few weeks following infection, which may increase the risk of severe secondary bacterial and viral infections.
Tracheobronchitis (‘measles croup’) and pneumonia due to secondary bacterial infection are frequent complications of measles.
Encephalitis occurs more rarely, in about 0.05% to 0.1% of measles case.
Subacute sclerosing panencephalitis (SSPE) is a very rare but very severe complication, occurring in about 0.01% of cases. Cases of SSPE present a few years after measles infection with progressive neuro-cognitive symptoms which in most cases lead to coma and death. The risk of SSPE is increased in children who acquire measles before the age of 1 year.
Immunosuppressed individuals are at higher risk than immunocompetent individuals of developing prolonged and severe measles, and of suffering complications.
Viral pneumonitis is the most frequent severe complication, which generally develops within two weeks of symptom onset. It is also the most common cause of death in immunosuppressed individuals. Patients at highest risk include those who have severely impaired cell-mediated immunity, such as patients who have recently undergone bone marrow transplantation, patients with primary T-cell dysfunction, AIDS patients and patients with acute lymphoblastic leukaemia. The risk of severe disease also remains high for patients with other forms of immunosuppression, such as those with other forms of malignancy, and those receiving high doses of steroids or other types of immunosuppressive drugs.
Further information about the classification of immunosuppressed individuals is provided in the Guidance for Measles post-exposure prophylaxis published by PHE in 2017.
In order to inform the decision to recommend post exposure prophylaxis, a local risk assessment should be undertaken to determine the likelihood of measles in the index case and the level of potential exposure of the vulnerable contacts. If the index case is laboratory confirmed, epidemiologically confirmed or considered likely to be measles by the local Health Protection Team (HPT), then the need for post exposure prophylaxis should be urgently addressed. Detailed information on the level and nature of exposure can be found in the PHE National Measles Guidelines. For each identified contact, the decision to offer PEP is based on the level and timing of exposure and susceptibility to measles.
Equity and Diversity
The Leeds Teaching Hospitals NHS Trust is committed to ensuring that the way that we provide services and the way we recruit and treat staff reflects individual needs, promotes equality and does not discriminate unfairly against any particular individual or group.