Measles on call
Suzanne Meredith
Specialty Registrar in Public Health
Measles on call
• Clinical Features
• Epidemiology
• Prevention and Control
• Diagnosis
• Example of On call case /
action
Measles
Measles is one of the most highly infectious
diseases known.
Agent: Systemic viral infection caused by a
paramyxovirus
Reservoir: Humans
Transmission: spread person to person by direct
contact with nose and throat secretions or respiratory
droplets,
Incubation period: 7-18 days, av 10 days
Infectious period: 4 days before – 4 days after rash.
Laboratory confirmation: PCR testing of oral fluid ,
urine, CSF or tissue or serology (single raised IgM or
rise in IgG).
Clinical Features
• Prodromal illness – high fever, coryzal respiratory
infection
• Cough, Conjunctivitis, runny nose
• Koplik’s spots – early part of illness, look like grains of
salt on a red inflamed background in the mouth
• Rash starts day 3 or 4, red, blotchy, maculopapular, not
itchy, begins on face and behind ears, then generalised
• Complications: debilitation, pneumonitis, acute otitis
media, pneumonia, encephalitis.
• Measles can be particularly severe in susceptible
infants, pregnant women, and immunocompromised
individuals.
Surveillance
 Suspected
 Suspected by clinician or person with fever and maculopapular rash
and one of: cough, coryza or conjunctivitis
 Confirmed
 Measles IgM positive in blood or oral fluid
 Epidemiologically linked
 Person with signs and symptoms of measles in contact with a lab
confirmed case 7-18 days before onset of symptoms
Confirmed Measles Cases 2007-2012
Confirmed measles cases in
travellers, 2012 (n=210)
Level 3 outbreak declared week 29
Measles cases in travellers reported in HPZone
2012Region
(up to Sep 2012)
Confirmed (by
Not
Colindale) confirmed
EM
EM
EoE
London
NE
NW
NW
NW
SE
SE
SW
WM
WM
WM
Y&H
Y&H
Y&H
East Midlands North
East Midlands South
Bedfordshire and
Hertfordshire
South West London
North East
Cumbria and Lancashire
Cheshire and Merseyside
Greater Manchester
Sussex and Surrey
Thames Valley
South West (North)
West Midlands East
West Midlands North
West Midlands West
South Yorkshire
North Yorkshire and
Humber
West Yorkshire
Grand Total
Not yet Grand
tested
total
8 (8)
9 (9)
1
3
3
8
12
20
4 (4)
0
4 (4)
30 (29)
13 (13)
9 (9)
4 (4)
2 (4)
1 (1)
15 (15)
6 (6)
10 (10)
2 (1)
0
0
0
2
1
0
1
0
0
0
0
0
0
0
2
11
13
6
3
3
3
1
7
8
5
2
4
2
15
45
20
12
8
5
2
22
14
15
4
10 (10)
1 (1)
128 (126)
1
0
9
7
0
82
18
1
219
Prevention and Control
• Measles
Vaccination
introduced in
1968
• MMR 1988
• 2 doses required
• Late 1990s- early
2000s
controversy links
with autism and
Crohns disease
• WHO target 95%
MMR Percentage of children
immunised by their 2nd birthday,
2011-12 by PCT
England
%
91.2
East Midlands
Bassetlaw PCT
Derby City PCT
Derbyshire County PCT
Leicester City PCT
Leicestershire County & Rutland PCT
Lincolnshire Teaching PCT
Northamptonshire Teaching PCT
Nottingham City PCT
Nottinghamshire County Teaching PCT
92.9
90.1
93.4
94.5
93.0
94.6
91.8
93.9
88.8
92.0
On call 28th – 29th September
2012
23:52 28th September (Friday night)
Paediatric Registrar notification of suspected
measles in a traveller 15 year old girl.
On Call action
Obtain history of immunisation
Contact with suspected or confirmed cases and travel
Is diagnosis likely?
Identify vulnerable contacts and assess susceptibility
(Hawker and Begg)
Clinical History
6 day history of headache, sore throat, sore eyes,
cough, runny nose
Seen by GP previous day ?viral tonsillitis Had 1 day of
antibiotics
Today onset of maculopapular rash- started on face,
behind ears, spread to include chest and back
1 white spot in mouth - ?Koplik Spot
Information from Registrar
obtained from mother
Not had MMR
Lives on a traveller site
No known cases on site but attends a church where
measles has been reported
Lives in a caravan with mother, father and brother,
aged 4
A number of other children on the site are
unvaccinated
Diagnosis
 The positive predictive value of a clinical diagnosis of
measles is generally poor when cases are sporadic and
outside of an outbreak situation but in recent months HPU
reported more ad-hoc cases.
 In the absence of laboratory results, the diagnosis of
measles will depend upon a combination of epidemiological
and clinical factors
 Management will normally have to precede the results of
laboratory testing (even where requested urgently)
Is measles likely/unlikely?
• Assessment by experienced member of HPU
• Source?
 Contact with another case?
 Traveller community?
 Recent travel to endemic country?
• Vaccination status?
• Clinical History
Assessment of Contacts
1.Immunocompromised
2.Pregnant women, infants
3.Health Care Workers
4.Healthy contacts
Has there been a significant exposure?
4 days before – 4 days after rash appears
• Less than 15 minutes exposure to a case can lead to disease in a
susceptible person.
•
Is the exposed individual likely to be susceptible?
• Infants, pregnant women and immunosuppressed individuals
should be assessed for susceptibility according to the HPA Post
Exposure Prophylaxis for Measles guidelines.
Contact information given by Paediatric
Registrar 00:34 on Saturday morning
Contact information given by Mother 9am on
Saturday morning
Actions:
• Pregnant lady asked to go to QMC for IGG test
• Phoned QMC to arrange
• 2 other babies to attend local hospitals for HNIG
• Details obtained and provided to 2nd on call to arrange with
Birmingham
• HPA advised unless confirmed epi link to a confirmed case not to
issue HNIG until case tested IgM +ve.
• New swab and blood test taken and sent for urgent testing
• Grandmother – not immunocompromised- no further action
• MMR for other children – now dispersed- advised to attend GP on
Monday
Post on-call outcome
•2nd on call spoke again to 2 mothers re HNIG for babies and risks
Monday:
•PCT’s alerted to probable measles case
•01/10/12
Measles confirmed +ve IgM PCR nasal swab and blood
•Practice Nurse contacted to arrange MMRs @ caravan site – majority from site
attended the practice for MMR
•HNIG organised for babies – 1 had it, 1 refused
•The mother who refused HNIG for baby attended practice to get 2nd child MMR
•Staff reiterated the importance of HNIG and the risks of measles
•Pregnant woman tested IgG +ve – no HNIG required
•Visit to site by HPA – only 2 caravans left – most moved away- revisited again
to take swabs 4 days later
Secondary cases
MMR 
HNIG
MMR 
HNIG
Key points:
• Communication issues – no phones/ did not answer
• Moved away – difficult to contact / spread of infection
to other sites
• Lots of young children – all with no MMR
• Large amounts of communication and work between
HPA/ GP and PCT re immunisation
• Several secondary cases
References:
1- Hawker & Begg, Communicable Disease Control and Health Protection
Handbook, Wiley-Blackwell, 3rd Edition, 2012.
2. Health Protection Agency National Measles Guidelines
http://www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1274088429847
3. Health Protection Agency Measles Surveillance Information
http://www.hpa.org.uk/web/HPAweb&HPAwebStandard/HPAweb_C/12230
19390211?printable=true
4. Department of Health, The Green Book
https://www.wp.dh.gov.uk/immunisation/files/2012/07/Chap-21dh_122643.pdf
5. Health Protection Agency. Post Exposure Prophylaxis for Measles
guidelines.
http://www.hpa.org.uk/web/HPAwebFile/HPAweb_C/1238565307587
6. The NHS Information Centre , NHS Immunisation Statistics, England
2011-12 https://catalogue.ic.nhs.uk/publications/publichealth/immunisation/nhs-immu-stat-eng-2011-2012/nhs-immu-stat-eng2011-12-rep.pdf
Acknowledgements
Jane Freeman, East Midlands HPU (North)
Vanessa Macgregor, East Midlands HPU (North)