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Measles

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Mode of transmission

  • The measles virus is most commonly acquired by inhaling microscopic droplets that contain viral particles ("airborne" transmission). 
  • Less frequently, Measles is acquired by direct contact with body fluids (e.g. nasal, throat secretions) of infected patients.

Exposure

Exposed persons are defined as those who enter the same room or work-space as a person who has Measles infection or who enter the room or work-space within two hours of the infected person leaving (the "two hour" rule does not apply to negative pressure rooms)

This definition does not apply in either of the following circumstances:

  • The person with Measles is no longer infectious (> 4 days after onset of rash - see "period of infectivity") 
  • The exposed individual was wearing appropriate personal protective equipment (i.e. N-95 mask, plus gown and gloves if handling body fluids)

Non-immune persons

  • Persons born after 1st January 1969 who do not have documentation of having received two previous doses of a measles containing vaccine** or previous Measles infection
  • Severely immunocompromised patients irrespective of vaccination history or previous Measles infection
  • Premature infants <28 weeks gestation

**where the first dose was received on or after the first birthday and second dose no earlier than one month after the first dose.

High risk patients

Persons at high risk of developing Measles complications:

  • Pregnant women
  • Infants
  • Immunocompromised patients of all ages

Incubation time

  • Typically there are 8-12 days between exposure and onset of symptoms (ie first prodromal symptoms such as fever, coryza, conjunctivitis and cough). 
  • The time between exposure and onset of symptoms can vary from 7-18 days.
  • The average interval between exposure and rash is 14 days.

Period of infectivity

  • Patients are infectious from 5 days prior to onset of rash until 4 days after onset of rash (approximately 9 days). 
  • Immunocompromised patients may be infectious for the entire duration of the illness. 

Clinical Case definition

Use in conjunction with current epidemiology below

  1. Fever ≥ 38° C
  2. Maculopapular rash (starts behind ears and neck - pink macules that become faintly palpable)
  3. And one or more of the following
    - Cough
    - Coryza
    - Conjunctivitis
    - Koplik's spots on buccal mucosa

Epidemiologic Factors

  • Current community or national outbreak of measles, or
  • History of contact with known or suspected measles case, or
  • Travel to measles endemic country or a country/region with a recent outbreak, or
  • Residing in an area with a large unvaccinated community.

Laboratory confirmed Measles infection

Laboratory confirmation of Measles infection requires either Measles virus detection by PCR or detection of Measles IgM by serological testing. Both samples may be taken in a suspected case to ensure best possible chance of diagnosis.

Nasopharyngeal or Throat swab sample for Measles PCR

  • Throat swabs are the preferred specimens for measles PCR diagnosis. Nasopharyngeal swabs or aspirates may also be used.
  • This test is most useful in the first few days of illness when serology may be negative (When requesting Measles PCR, the duration of illness / rash must be included on the request form). 
  • The test is also useful as a test for Measles infection in severely immunocompromised patients where antibody response is unreliable (Clinical details must be included on the request form)
  • Standard (red) viral swabs should be used (COPAN flocked swabs, broken off into viral transport medium). For requests after midday on weekdays or anytime on weekends please discuss with on-call microbiologist as may need urgent processing to confirm case and potential outbreak investigation/contact tracing.

Serology

  • Requests for Measles IgM are tested for both IgM and IgG
  • IgM confirms acute Measles (IgM remains positive for up to 30-60 days).
    • IgM may be negative in the first few days after rash onset.
  • If the patient is IgG positive and IgM negative, acute Measles is unlikely
  • If IgM is negative but clinical suspicion of Measles remains high, do PCR if circumstances warrant and/or repeat serology 7 days after the onset of rash.
  • If Measles immune status needs to be determined (for example, in the setting of contact tracing), samples will be tested for measles IgG. A positive result in this setting implies immunity. For weekend urgent serology please contact the on call microbiologist to ensure it is processed.

Infection Control Measures

All suspected cases of measles should be discussed with the Infection Control service (Infectious Diseases or on call clinical microbiologist after hours) to ensure laboratory diagnosis is confirmed, correct isolation and tracing of contacts is initiated. Measles is a notifiable disease to the public health service in your region.

Managing patients with Measles
Patients with laboratory confirmed Measles and patients meeting the clinical case definition for Measles should be managed with Airborne Precautions during the "period of infectivity" (see above). If the patient is immunocompromised (including pregnant women), Airborne Precautions should continue for the entire duration of illness.

  • Airborne infection isolation room (negative pressure room)
  • Fitted N-95 masks should be worn by all non-immune healthcare workers and visitors who enter the room
  • Single use gown and gloves should be worn by staff if there is a possibility of contact with body fluids and secretions
  • Until placed in a negative pressure room, the patient should wear a surgical mask
  • Non-immune healthcare workers and visitors without evidence of immunity (i.e. born after 1968, without documentation of adequate vaccination or physician diagnosed measles) should not be permitted to enter the rooms of patients with Measles
  • If a negative pressure room is temporarily unavailable, the patient should be managed in a single room with the door closed.
    • The patient should wear a surgical mask.
    • The room should not be used for at least 2 hours after being vacated by the infectious patient and should be cleaned prior to being reoccupied.
    • Single use gown and gloves should be worn by staff if there is a possibility of contact with body fluids and secretions

Managing Staff

  • The immune status of all staff (clinical and nonclinical) in a work area should be determined prior to exposure
    • All staff born during or before 1969 are considered immune
    • All staff born after 1st January 1969 are considered immune if they have documentation of having received two doses of a measles containing vaccine, have had laboratory confirmed measles or documented laboratory evidence of immunity
    • All clinical staff will have had pre-employment screening for immunity to measles and if they are not aware of their status they should check with Occupational Health
    • If after checking with Occupational Health, immune status is still uncertain, staff should submit a blood sample (forms arranged through Occupational Health and Safety) to the virology lab (use plain tube) to determine immune status
  • All non-immune staff should be vaccinated with MMR unless contra-indicated (eg pregnancy)
  • If a patient with measles is admitted to a unit then all non-immune staff should be redeployed to other work areas until they have documented evidence of having received at least one dose of MMR vaccine
  • Exposed non-immune staff should be offered post-exposure prophylaxis as appropriate (see below)
  • Exposed non-immune staff should be relieved of direct patient contact from day 5 to day 21 post exposure regardless of whether they have received vaccination or immunoglobulin

Managing non-immune exposed patients

  • Non-immune exposed patients should be managed with Airborne Precautions until 21 days post exposure or 4 days after development of rash regardless of whether they have received vaccination or immunoglobulin
  • Immunocompromised patients who have been exposed should be managed with Airborne Precautions until 21 days post exposure or for the duration of illness regardless of whether the patient received immunoglobulin

Post-exposure prophylaxis

See guidelines around dosing of Human Normal Immunoglobulin (NHIG) and intravenous immunoglobulin (IVIG) and a flow chart summary of approach to post-exposure prophylaxis

  1. Immunocompetent patients and staff
    Non-immune, immunocompetent, non-pregnant adults should be offered MMR within 72 hours of exposure.
    Non-immune immunocompetent children >1 year should be offered MMR within 72 hours of exposure.
    The second dose should be given one month after the first. A third dose is required if the first dose was given aged < 1 year.
    Immunocompetent children and adults who are non-immune and exposed greater than 72 hours prior and less than 6 days may be offered immunoglobulin to help containment (that is to prevent further measles cases and contain evolving outbreak). If they are not offered immunoglobulin, all non-immune individuals should be offered MMR and followed to ensure 2 doses are given (or 3 doses total if the first dose is given aged less than 1 year).
  2. Immunocompromised patients (see below)
    Measles immune status of "Group A" immunocompromised inpatients (see below for definition) should be determined prior to exposure.
    Non-immune immunocompromised patients >12 months of age should be considered for use of immunoglobulin if within 6 days of exposure.
    Discuss with the clinical team caring for that patient
    Patients with severe defects of cell-mediated immunity >12 months of age should be considered for use of immunoglobulin if within 6 days of exposure irrespective of whether IgG can be detected
  3. Pregnant patients / staff
    The Measles immune status of pregnant patients should ideally be determined prior to admission to hospital.
    Non-immune pregnant patients or staff should be considered for use of immunoglobulin if within 6 days of exposure.
    Discuss with the clinical team caring for that patient.
    Pregnant patients or pregnant staff who have had at least one previous dose of MMR do not require immunoglobulin.
  4. Infants
    Exposed infants 6-12 months of age
    If immunocompetent give MMR0* if within 72 hours of exposure.
    If between days 3 and 6 after exposure and there are concerns regarding immunosuppression or containment is needed - then discuss use of immunoglobulin with paediatrician.
    *MMR0 indicates a dose of MMR given to an infant aged <1 year. In such cases the infant would need 2 future doses (MMR1 and MMR2) aged over 1 year for measles protection.
    Exposed infants <6 months of age
    If the Mother is non-immune and exposure occurred less than 6 days earlier, discuss use of immunoglobulin with the team caring for the woman. If mother's immunity cannot be checked in time to give IVIG within 6 days of first exposure then give IVIG.
    Premature infants <28 weeks gestation should be considered non-immune irrespective of maternal immune status.

NHIG dosing for Measles post-exposure prophylaxis

According to the New Zealand Blood Service, the level of measles-specific antibody in NHIG is lower than recommended (between 14-16 IU/ml). This is lower than the concentration recommended by the British Pharmacopoeia (50IU/ml). The current MedSafe-approved datasheet for NHIG recommends a dose of 0.2mL/kg for measles post exposure prophylaxis. However, because of the low concentrations of Measles-specific antibody in NHIG at the present time, new doses of NHIG are recommended below. These doses are likely to be amended following further testing of the level of measles-specific antibody in NHIG.

The new recommended doses of NHIG are:

  1. Immunocompetent infants (under 12 months) should receive 0.6mL/kg with a maximum volume of 5mL
  2. Pregnant women, immunocompromised adults and immune compromised or deficient children should receive 0.6mL/kg with a maximum dose of 15mL (recommended in three 5 mL injections).

IVIG Dosing for Measles post-exposure prophylaxis

IVIG (Intragam®P) can be considered for immune suppressed measles contacts (who may for example have a central venous catheter) or in patients due to the number and volume of intramuscular injections IVIG may be recommended subject to clinical agreement and resourcing.

The recommended dose of intravenous immunoglobulin is 0.15g/Kg.

If there are further queries can be directed to the New Zealand Blood Service medical team via the district health board blood bank.

Management of CONTACTS of Measles

**Note this algorithm may be different depending on containment as outlined above.

NOTE - If patient is immunocompromised, see information below.

Immunocompromised patients

The following is adapted from [1] UK guidelines updated May 2009

All immunocompromised patients are at risk of severe measles and should be considered for post-exposure prophylaxis with NHIG or IVIG following exposure to measles. However some patients with immunosuppression will have immunity due to past infection or vaccination and measurable levels of measles-specific serum IgG. For patients with severe defects of cell mediated immunity passive immunoglobulin may be indicated even in the presence of measurable antibody.

Group A: These patients may have developed an adequate response to vaccination or measles during childhood therefore their measles status needs to be established prior to exposure (for example at the next out-patient appointment) so that post-exposure prophylaxis can be informed.

This group includes most patients with immunosuppression and is listed below:

  • Adults with malignant disease until at least 6 months after completion of immunosuppressive chemotherapy and radiotherapy (unless part of group B)
  • Adult patients who have received a solid organ transplant and are currently on immunosuppressive treatment
  • Patients receiving systemic high-dose steroids, until at least three months after treatment has stopped (for example children on prednisone at a daily dose of 2mg/kg/day for at least one week, or 1mg/kg/day for one month and adults on 40mg of prednisone for >1 week).
  • Adult patients with immunosuppression due to HIV without a diagnosis of AIDS
  • Patients receiving other types of immunosuppressive drugs (e.g. azathioprine, cyclosporin, methotrexate, cyclophosphamide, leflunomide, anti-TNF alpha and the newer cytokine inhibitors) alone or in combination with steroids, until at least six months after terminating such treatment.

For those with unknown status at the time of exposure, management is on the basis of vaccine history and where possible, rapid antibody testing. If measles IgG is negative or unknown Group A should receive immunoprophylaxis with NHIG or IVIG as outlined earlier.

Group B: This group includes patients who are unlikely to have developed or to maintain adequate antibody levels from past exposure or vaccination. This group would include:

  • Children with malignant disease until at least 6 months after completion of immunosuppressive chemotherapy or total body irradiation
  • Patients on treatment for ALL until at least six months after completion of immunosuppressive chemotherapy
  • Patients with severe primary immunodeficiency
  • Patients who have received a bone marrow transplant until at least 12 months after finishing all immunosuppressive treatment, or longer where the patient has developed graft-versus-host disease
  • Adult patients with AIDS and children with HIV or AIDS

It is recommended that, unless already on replacement immunoglobulin therapy, Group B patients should receive immunoglobulin

Use of vitamin A in children with acute measles infection

The Ministry of Health recommends vitamin A for all infants and children hospitalised with measles.

Vitamin A for treatment of measles is administered once daily for 2 days at the following doses:

  • 200 000 IU for children ≥ 12 months of age
  • 100 000 IU for infants 6-11 months of age
  • 50 000 IU for infants younger than 6 months of age

In cases with clinical Vitamin A deficiency a third dose should be given 4-6 weeks later.

If a child with measles is managed in the community and has risk factors such as a condition causing fat malabsorption (cystic fibrosis, short bowel syndrome and cholestasis), an immunodeficiency or malnutrition (including adolescents with eating disorders) or recent arrival from a developing country, then the case should be discussed with a paediatrician and Vitamin A considered.

Pharmacy input is needed to ensure the correct formulations are sourced and made available both in hospital and community cases if indicated.

Information for Families

See the Kidshealth factsheet on Measles and Measles Immunisation

Auckland Regional Public Health Service Measles Information

See the information from ARPHS on the measles situation, with information for health professionals and families, schools and primary care resources developed by the Ministry of Health

Acknowledgements

The following infection control definitions and guidelines are derived from documents and guidelines produced by the Health Protection Agency in the UK, the Centers for Disease Control and Prevention in the USA, the American Academy of Paediatrics, the New Zealand Immunisation Handbook 2014, New Zealand Blood Services and the Auckland Regional Public Health Service. See also the ADHB policies and guidelines library for 'Measles Infection Prevention & Control Policy' (internal staff only)

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Document Control

  • Date last published: 21 December 2015
  • Document type: Clinical Guideline
  • Services responsible: Paediatric Infectious Diseases, Clinical Microbiology
  • Author(s): Emma Best, Lesley Voss, Josh Freeman, Sally Roberts
  • Editor: Greg Williams
  • Review frequency: 2 years

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