January 2015
Measles Cases in California Continue to Rise:
What Should You Know and What Can You Do?
On January 26, the California Department of Public Health
(CDPH) reported six more cases of measles have been
confirmed in California following an outbreak at Disneyland
that began in December 2014, increasing to 74 the total
number of people in the state who have been infected.
Previously, 68 people in California had been confirmed to
have the measles, along with 14 others elsewhere: five in
Arizona, three in Utah, two in Washington state, one each in
Oregon, Colorado and Nevada, and one in Mexico. The latest
tally includes 73 cases documented by the California
Department of Public Health and one additional patient
reported by the Ventura County Health Care Agency.
According to report from the Centers for Disease Control
(CDC, www.cdc.gov), 68 people, from 11 states were
reported to have measles between January 1-23. On January
23, 2015, the CDC issued a Health Advisory to notify public
health departments and health care facilities about this
multi-state outbreak and to provide guidance for health care
providers nationwide.
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Contagious? You Bet!
According to the CDC, measles is one
of the most contagious diseases
known.
 For every person infected with
measles who enters a completely
susceptible, unimmunized
population, 12 to 18 people are
infected.
 For severe acute respiratory
syndrome, or SARS, the number is
2 to 4.
 Ebola in West Africa? About 1.5 to
2.5.
Measles spreads through the
respiratory droplets that become
airborne during a cough or sneeze.
“You can catch measles just by being
in a room where a person with
measles has been — even if the
person is gone,” the CDC says.
The majority of the people who got measles are
unvaccinated.
Measles is still common in many parts of the world including some countries in Europe, Asia, the
Pacific, and Africa.
Travelers with measles continue to bring the disease into the U.S.
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Measles can spread when it reaches a community in the U.S. where groups of people are
unvaccinated.
Clinical Features:
Measles is an acute viral respiratory illness. It is characterized by a prodrome of
fever (as high as 105°F) and malaise, cough, coryza, and conjunctivitis -the three “C”s -, a pathognomonic
enanthema (Koplik spots) followed by a maculopapular rash. The rash usually appears about 14 days after
a person is exposed; however, the incubation period ranges from 7 to 21 days. The rash spreads from the
head to the trunk to the lower extremities. Patients are considered to be contagious from 4 days before
to 4 days after the rash appears. Of note, sometimes immune-compromised patients do not develop the
rash.
CDC’s Dr. Jane Seward describes measles clinical features and what to do if a healthcare provider suspects
measles, in this 5-minute video.
The Virus: Measles is caused by a single-stranded, enveloped RNA virus with 1 serotype. It is classified
as a member of the genus Morbillivirus in the Paramyxoviridae family. Humans are the only natural hosts
of measles virus.
Background:
In the decade before the live measles vaccine was licensed in 1963, an average of
549,000 measles cases and 495 measles deaths were reported annually in the United States. However, it
is likely that, on average, 3 to 4 million people were infected with measles annually; most cases were not
reported. Of the reported cases, approximately 48,000 people were hospitalized from measles and 1,000
people developed chronic disability from acute encephalitis caused by measles annually.
Complications:
Common complications from measles include otitis media, bronchopneumonia,
laryngotracheobronchitis, and diarrhea.
Even in previously healthy children, measles can cause serious illness requiring hospitalization.
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One out of every 1,000 measles cases will develop acute encephalitis, which often results in
permanent brain damage.
One or two out of every 1,000 children who become infected with measles will die from
respiratory and neurologic complications.
Subacute sclerosing panencephalitis (SSPE) is a rare, but fatal degenerative disease of the central
nervous system characterized by behavioral and intellectual deterioration and seizures that
generally develop 7 to 10 years after measles infection.
People at High Risk for Complications:
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Infants and children aged <5 years
Adults aged >20 years
Pregnant women
People with compromised immune systems, such as from leukemia and HIV infection
Transmission:
Measles is one of the most contagious of all infectious diseases; approximately 9 out
of 10 susceptible persons with close contact to a measles patient 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 on surfaces and in the air for up to two
hours after an infected person leaves an area.
Diagnosis and Laboratory Testing: Health care providers should consider measles in patients presenting
with febrile rash illness and clinically compatible measles symptoms, especially if the person recently
traveled internationally or was exposed to a person with febrile rash illness. Health care providers should
report suspected measles cases to their local health department within 24 hours.
Laboratory confirmation is essential for all sporadic measles cases and all outbreaks. Detection of
measles-specific IgM antibody and measles RNA by real-time polymerase chain reaction (RT-PCR) are the
most common methods for confirming measles infection. Healthcare providers should obtain both a
serum sample and a throat swab (or nasopharyngeal swab) from patients suspected to have measles at
first contact with them. Urine samples may also contain virus, and when feasible to do so, collecting both
respiratory and urine samples can increase the likelihood of detecting measles virus. For more
information, see Measles Lab Tools.
Evidence of Immunity:
Acceptable presumptive evidence of immunity against measles includes
at least one of the following:
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written documentation of adequate vaccination:
o one or more doses of a measles-containing vaccine administered on or after the first
birthday for preschool-age children and adults not at high risk
o two doses of measles-containing vaccine for school-age children and adults at high risk,
including college students, healthcare personnel, and international travelers
laboratory evidence of immunity
laboratory confirmation of measles
birth in the United States before 1957
Health care providers should not accept verbal reports of vaccination without written documentation as
presumptive evidence of immunity. For additional details about evidence of immunity criteria, see Table 3
in Prevention of Measles, Rubella, Congenital Rubella Syndrome, and Mumps, 2013: Summary
Recommendations of the Advisory Committee on Immunization Practices (ACIP).
Vaccination:
Measles can be prevented with measles-containing vaccine, which is primarily
administered as the combination measles-mumps-rubella (MMR) vaccine. The combination measlesmumps-rubella-varicella (MMRV) vaccine can be used for children aged 12 months through 12 years for
protection against measles, mumps, rubella and varicella. Single-antigen measles vaccine is not available.
One dose of MMR vaccine is approximately 93% effective at preventing measles; two doses are
approximately 97% effective. Almost everyone who does not respond to the measles component of the
first dose of MMR vaccine at age 12 months or older will respond to the second dose. Therefore, the
second dose of MMR is administered to address primary vaccine failure [1]
Vaccine Recommendations
[For more information: http://www.cdc.gov/vaccines/vpd-vac/measles/default.htm#recs]
Children
Students at posthigh school
educational
institutions
Adults
International
Travelers
CDC recommends routine childhood immunization for MMR vaccine starting with the
first dose at 12 through 15 months of age, and the second dose at 4 through 6 years of
age or at least 28 days following the first dose.
Students at post-high school educational institutions without evidence of measles
immunity need two doses of MMR vaccine, with the second dose administered no
earlier than 28 days after the first dose.
People who are born during or after 1957 who do not have evidence of immunity
against measles should get at least one dose of MMR vaccine.
People 6 months of age or older who will be traveling internationally should be
protected against measles. Before travelling internationally,
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Health care
personnel (Yes,
you and your
team!)
Infants 6 through 11 months of age should receive one dose of MMR vaccine.
Children 12 months of age or older should have documentation of two doses of
MMR vaccine (the first dose of MMR vaccine should be administered at age 12
months or older; the second dose no earlier than 28 days after the first dose).
Teenagers and adults born during or after 1957 without evidence of immunity
against measles should have documentation of two doses of MMR vaccine,
with the second dose administered no earlier than 28 days after the first dose.
Health care personnel should have documented evidence of immunity against measles,
according to the recommendations of the Advisory Committee on Immunization
Practices [48 pages].
Footnote
1. CDC. Prevention of Measles, Rubella, Congenital Rubella Syndrome, and Mumps, 2013: Summary
Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 2013;62(RR04);1-34.