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    Measles (Rubeola)

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    Dec.02.2022

    Measles (Rubeola)

    Synopsis

    Key Points

    • Measles (rubeola) is a highly contagious viral disease, which is characterized by a prodrome of fever, coryza, conjunctivitis, and cough, followed by a diffuse exanthem that evolves in head-to-toe order
    • Illness may be severe; fevers tend to be quite high, precipitating febrile seizures in very young children
    • There is no known antiviral treatment, but vitamin A is recommended for young children to mitigate disease and prevent complications
    • Most common complications are otitis media, viral or bacterial pneumonia, encephalitis, and keratoconjunctivitis
    • In developing countries, measles remains a common cause of death in children, usually due to dehydration, pneumonia, or encephalitis
    • Measles vaccine is highly effective in preventing infection among vaccinated people, but a 95% uptake rate is required to provide herd immunity and to prevent measles from becoming endemic in a population r1

    Urgent Action

    • Postexposure prophylaxis is recommended for exposed susceptible people; administer vaccine within 72 hours or immunoglobulin within 6 days of exposure r2r3
    • In the hospital setting, infected patient is placed in a single patient airborne infection isolation room; caretakers must use N95 or similar respirator

    Pitfalls

    • Patients are highly contagious before eruption of rash, potentially exposing susceptible people before diagnosis is clinically evident
    • In developed countries, measles has become uncommon and many physicians have never seen a case. It is important to have a high index of suspicion and to ascertain potential for exposure (eg, recent international travel, attendance at mass gathering) to facilitate timely and accurate diagnosis

    Terminology

    Clinical Clarification

    • Measles—or rubeola—is a highly contagious viral disease transmitted via the respiratory route. Measles is most common in nonimmunized children
    • Typically, manifestations begin with a nonspecific prodrome (eg, fever, cough, coryza, conjunctivitis) followed by a morbilliform rash that descends from head to toe

    Classification

    • Measles virus is classified as a Morbillivirus of the Paramyxoviridae family r2

    Diagnosis

    Clinical Presentation

    History

    • Exposure history and evidence of immunity
      • Most cases in the United States result from international importation of measles virus r2c1
      • Majority of cases occur in nonimmunized or underimmunized people r2c2
      • Evidence of immunity to measles includes any of the following: r4
        • Documentation of age-appropriate vaccination with live measles-containing vaccine
          • 1 dose in preschool-aged children
          • 2 doses in school-aged children
        • Laboratory evidence of immunity
        • Laboratory confirmation of disease (active or previous)
        • Birth before 1957
    • Prodrome
      • Onset of illness is marked by an influenzalike prodrome
      • Characteristic symptoms include fever, coryza, cough, conjunctival irritation, and photophobia c3c4c5c6c7
    • Fever
      • May be as high as 40.5 °C and may precipitate febrile seizures in very young children r1c8
      • Defervescence often occurs several days after appearance of rash r2
        • Persistent fever may indicate secondary bacterial infection complicating course of illness
    • Rash r4c9c10
      • Onset of rash occurs 3 to 4 days into illness
      • Begins on head and neck
      • Travels downward over the course of 1 or 2 days
      • Begins to fade after several days in the same descending pattern
      • Of note, characteristic rash may be absent in immunocompromised hosts
    • Less prevalent symptoms r4
      • Some patients experience diarrhea c11
      • Some younger patients experience crouplike symptoms (eg, barky cough, raspy voice) or bronchiolitis (eg, difficulty breathing) c12c13c14

    Physical examination

    • Patients often appear quite ill c15
    • Conjunctival injection may be present
    • Cervical lymphadenopathy may be present c16
    • Koplik spots c17
      • Pathognomonic for measles
      • Often visible before rash eruption
      • Lesions are small and white with a blue-gray center on an erythematous base
      • Typically located adjacent to the molars on buccal mucosa; may be observed elsewhere on oropharyngeal mucosa
    • Rash
      • Often morbilliform early in its evolution c18
      • May become confluent, especially on head and neck c19
      • Palms and soles are often involved c20
      • Becomes more brown than red over course of several days before fading c21
      • Areas of desquamation may develop c22
    • Less prevalent respiratory signs in young children r4
      • Stridor associated with crouplike presentation c23
      • Scattered, coarse wheezing; tachypnea; and retractions associated with bronchiolitislike presentation c24c25c26c27

    Causes and Risk Factors

    Causes

    • Infection with measles virus c28
    • Transmission
      • Respiratory transmission via direct contact with respiratory secretions or airborne contact with respiratory droplets c29c30
      • Virus remains infective in droplet form in air for several hours r2
    • Communicability r2
      • Highly communicable, infecting the majority (more than 90%)r5 of susceptible exposed hosts, according to experts c31
      • Contagious from several days before to several days after rash onset
      • Most infectious during late prodrome at peak of cough and coryza
    • Incubation
      • Approximately 8 to 12 days from exposure to onset of symptoms r4
    • Immunity
      • Lifelong immunity develops after primary infection r2
      • Most people develop lifelong immunity after appropriate vaccination r2

    Risk factors and/or associations

    Age
    • In developing countries with low immunization rates: r1
      • Measles is primarily a disease of childhood c32c33
      • Most children acquire the infection at some point; therefore, disease in adults is relatively uncommon
    • In developed countries with high immunization rates: r6
      • Outbreaks may include nonimmune people of any age c34c35c36
      • Very young children, who have not been fully vaccinated yet, are affected most often
    Other risk factors/associations
    • In temperate climates, occurs most often in winter c37
    • Outbreaks in developed countries can be attributed to: r7
      • Lack of or incomplete vaccination
      • Clusters of intentionally unvaccinated children
      • Measles imported from international travel
      • Immunocompromise

    Diagnostic Procedures

    Primary diagnostic tools

    • Diagnosis in endemic area c38
      • Base diagnosis on typical presentation in developing countries with low rates of immunization
        • WHO clinical case definition includes either of the following: r8
          • Any person a clinician suspects of having measles
          • Any person with fever; maculopapular rash; and cough, coryza, and conjunctivitis
    • Diagnosis in nonendemic area
      • Report any suspected cases to public health authorities to assist in determining specific diagnostic approach r4
      • Suspect diagnosis in nonendemic areas with high immunization rate based on clinical presentation r1
        • Assess for possible exposures r1
          • International travel or contact with someone who has recently traveled internationally
          • Recent attendance at events or in venues with large crowds that might have included international travelers
          • Consult public health authorities to determine if there are known cases in the community
        • Ascertain reliable vaccination status r1
          • Appropriate immunization renders diagnosis much less likely; however, it does not exclude possibility of measles infection
      • Confirm diagnosis with laboratory studies; options include detection of the following: r1
        • Measles-specific IgM in serum
        • Polymerase chain reaction for measles virus RNA in oropharyngeal or nasopharyngeal secretions or in urine; collecting both respiratory and urine samples can increase the likelihood of detecting the virus
        • Isolation of virus by culture is possible but is not routine in clinical setting
      • Confirmation of diagnosis requires both serologic and virologic evidence of disease in populations with high vaccine coverage r4
    • Other studies performed during evaluation of febrile illness may show nonspecific abnormalities, including the following:
      • Leukopenia and lymphopenia
      • Elevated liver enzymes

    Laboratory

    • Measles-specific IgM r1r9c39
      • Performed on a single sample; use ELISA testr2c40
      • Results are typically positive 3 days (more than 72 hours) after rash onset
        • Measles IgM may persist up to 1 month in nonimmunized people
        • Measles IgM may be absent or only transiently present in people who have had 1 or 2 vaccine doses; therefore, do not use measles IgM to exclude diagnosis in immunized patients r4
      • False-positive results may occur in nonendemic settings
        • Public health authorities will guide further confirmatory testing via viral culture, IgG avidity testing, or plaque reduction neutralization tests
      • False-negative results
        • May occur early in illness
          • Antibody response may take some time to develop; test result may be false-negative within the first 72 hours after rash appearance r1
          • When measles is strongly suspected, repeat test at least 72 hours after rash appearance r1
        • May occur in immunized people r4
          • Measles-specific IgM cannot exclude disease in immunized patients r4
    • Reverse transcription polymerase chain reaction test r10c41
      • Perform test on nasopharyngeal swab, oropharyngeal swab, or urine
      • Highest rates of detection are within 3 days of rash onset, but results may be positive for up to 2 weeks r10
    • A significant (4-fold or higher) rise in measles IgG antibody in paired acute and convalescent serum specimens also confirms diagnosis, but it is not helpful acutely r11

    Imaging

    • Chest radiograph r2c42c43
      • Not routinely recommended
      • Indicated if pulmonary complications (eg, secondary bacterial pneumonia) are suspected
      • Of note, abnormal chest radiograph findings are common during acute measles even in absence of clinical signs of pneumonia

    Differential Diagnosis

    Most common

    • Influenza c44d1
      • A viral infection that, like the prodrome of measles, is characterized by coryza, cough, and fever (often high), and occurs predominantly in winter months in temperate climates
      • Unlike measles, rash does not develop
      • Differentiated by absence of rash and by laboratory testing (ie, rapid antigen detection test, polymerase chain reaction test)
    • Rubella c45d2
      • Viral infection that presents in a manner similar to measles, with fever, conjunctival irritation, and eye pain, followed by a rash that begins on face and spreads downward
      • Unlike measles, lymphadenopathy is a prominent feature, most commonly involving posterior auricular and suboccipital nodes
      • Diagnosis is confirmed and distinguished from measles by detection of rubella-specific IgM antibodies
    • Scarlet fever c46
      • Manifestation of group A streptococcal infection (most often pharyngitis) due to a toxin-producing strain
      • Characterized by a diffuse erythematous rash beginning on chest and spreading to neck and extremities
      • Unlike measles, rash begins early in course of illness, often spares parts of the face (circumoral pallor), features deeper reddening of skin folds, and evolves to a palpable texture described as sandpaper; there may be evidence of pharyngitis and a so-called strawberry tongue
      • Demonstration of group A streptococci by rapid antigen test or culture supports diagnosis
    • Erythema infectiosum (also known as fifth disease) c47d3
      • Caused by Parvovirus B19 r12
      • Begins like measles with a prodrome of fever and coryza, sometimes accompanied by mild gastrointestinal symptoms, followed a few days later by an erythematous eruption beginning on face and traveling downward
      • Slapped cheek appearance of facial rash is characteristic; adults often experience arthropathy
      • Clinically difficult to distinguish from measles; some clues to diagnosis include the following:
        • Widespread community outbreak of erythema infectiosum suggests diagnosis
        • Infected children are, in general, much less ill-appearing than those with measles
        • Slapped cheek rash is characteristic, and generalized rash is often much less impressive than rash associated with measles
      • Diagnosis is most often established based on clinical assessment in conjunction with mild, self-limited clinical course
      • Diagnosis can be confirmed (usually only occasionally necessary in immunocompromised hosts) by detecting viral particles during the first few days of illness, or serologically (ie, virus specific IgM or 4-fold change in virus-specific IgG) thereafter
    • Exanthem subitum (also known as roseola) c48
      • Caused by human herpesvirus 6B or human herpesvirus 7 r12
      • Begins with high fever (which may result in febrile seizures in very young children), followed several days later by an erythematous rash
      • Like measles, there may be associated conjunctivitis, cough, and diarrhea
      • Unlike measles, onset of rash coincides with defervescence
      • Diagnosis is most often established based on clinical assessment alone; exanthem subitum has a self-limited clinical course
      • Diagnosis can be confirmed (usually only occasionally necessary in immunocompromised hosts) in 1 of the following ways:
        • By demonstrating viral DNA early in the illness
        • Serologically (ie, virus-specific IgM or 4-fold change in virus-specific IgG; there is some cross-reactivity between human herpesviruses 6 and 7)
    • Kawasaki disease c49d4
      • Childhood disease of unknown cause
      • Like measles, characterized by fever (which may be high), conjunctival injection, and erythematous rash
      • Distinguishing clinical features may be present, including fissured lips, strawberry tongue, edema of hands and feet, and periungual desquamation
      • Diagnosis is clinical, based on established criteria
        • Demonstration of hallmark coronary artery abnormalities in context of consistent physical findings secures diagnosis and clearly distinguishes it from clinically similar entities

    Treatment

    Goals

    • Provide supportive and symptomatic care
    • Prevent complications

    Disposition

    Admission criteria

    Complications requiring close vigilance or intervention (eg, pneumonia due to measles virus or secondary bacterial infection)

    Criteria for ICU admission
    • Pneumonia requiring mechanical ventilation

    Recommendations for specialist referral

    • Measles is a nationally notifiable disease in the United States. Report probable and confirmed cases to state health department within 24 hours r13
    • Refer to infectious disease specialist if diagnosis is in doubt or if secondary bacterial pneumonia is suspected
    • Refer to neurologist if there is evidence of encephalitis

    Treatment Options

    Patient management primarily involves supportive therapy; no specific antiviral therapy is available for treatment r14

    No antiviral agents are approved for use against measles

    • Ribavirin has been used to treat severe infection, but it is of unknown benefit

    Vitamin A

    • May decrease severity of illness, particularly in vitamin A–deficient patients
    • Some data indicate that administration of vitamin A reduces mortality and blindness; however, conclusive evidence is lacking r15
    • Developing countries
      • Vitamin A deficiency is more common
      • Vitamin A is recommended for all children with measles r9
    • Developed countries
      • Vitamin A supplementation is recommended for children with severe measles r9
      • Consider routinely administering to immunodeficient and malnourished patients and to those who have malabsorption r2
    • Administer orally at diagnosis and repeat dose the following day r13

    Isolation measures for hospitalized patients with suspected or confirmed measles:

    • Maintain respiratory precautions; single patient airborne isolation room r13
    • All caretakers are required to use N95 respirators, regardless of their vaccination status

    Antibiotics are recommended only for treatment of bacterial complications; prophylactic use of antibiotics is not recommended r2

    Drug therapy

    • Vitamin A r9c50c51c52c53c54
      • Vitamin A Oral emulsion; Neonates: 15,000 mcg RAE (50,000 International Units) PO once daily for 2 days, followed by an additional dose 4 to 6 weeks later if clinical signs of vitamin A deficiency.
      • Vitamin A Oral emulsion; Infants 1 to 5 months: 15,000 mcg RAE (50,000 International Units) PO once daily for 2 days, followed by an additional dose 4 to 6 weeks later if clinical signs of vitamin A deficiency.
      • Vitamin A Oral emulsion; Infants 6 to 11 months: 30,000 mcg RAE (100,000 International Units) PO once daily for 2 days, followed by an additional dose 4 to 6 weeks later if clinical signs of vitamin A deficiency.
      • Vitamin A Oral emulsion; Children and Adolescents: 60,000 mcg RAE (200,000 International Units) PO once daily for 2 days, followed by an additional dose 4 to 6 weeks later if clinical signs of vitamin A deficiency.

    Nondrug and supportive care r2

    Age-appropriate antipyretics may be administered c55c56c57

    • Avoid aspirin in children and adolescents

    Ensure adequate hydration c58

    • High fevers can deplete fluids quickly
    • Encourage oral fluids c59
    • Administer parenteral fluids when clinically indicated c60
    Procedures c61

    Comorbidities

    • Immunocompromised status r16c62
      • Includes those patients with defective or suppressed cell-mediated immunity (eg, patients with congenital deficiency or advanced HIV infection, those undergoing current cancer chemotherapy, transplant recipients) c63c64c65c66
      • These patients experience more severe infection and are at higher risk for complications (eg, pneumonitis, encephalitis)
      • Many immunocompromised patients do not develop typical rash
      • Diagnosis can be difficult because the disease often presents atypically in these patients; poor antibody response makes serologic diagnosis unreliable
      • Passive immunization with immunoglobulin is indicated for any exposed person, even those with previous active immunization r2
      • Immunocompromised patients require isolation for duration of hospitalization
    • Tuberculosis c67d5
      • May be exacerbated by concurrent measles owing to measles-related suppression of cell-mediated immunity r2
      • Consider deferring measles vaccination in patients known to have tuberculosis until after antituberculosis treatment has been established r2

    Special populations

    • Neonates born to mothers with active measles infection
      • Can develop mild to severe infection
      • Passive immunization with immunoglobulin is indicated for any exposed neonate r17
    • Pregnant patients
      • Are at high risk for severe manifestations of measles, measles complications (eg, pneumonia), and pregnancy-related complications (eg, spontaneous abortion, premature delivery) r2
      • Commonly need to be admitted to ICU owing to respiratory complications r2
      • Early and aggressive supportive care is indicated
      • Passive immunization is indicated for nonimmune exposed pregnant patients r17r18r19

    Monitoring c68

    Complications and Prognosis

    Complications

    • Patients at high risk for complications include the following: r9
      • Children younger than 5 years r9
      • Adults older than 20 years r9
      • Pregnant patients
        • Risk for poor pregnancy outcomes (eg, premature delivery, spontaneous abortion) is high r1c69c70
        • Risk for other complications (eg, pneumonia, death) is high r1c71c72
      • Immunocompromised patients (eg, HIV, leukemia, severe malnutrition) c73c74c75
    • Complications may be directly due to the measles virus, secondary to viral or bacterial superinfection, or caused by other mechanisms
      • Respiratory
        • Otitis media c76
          • Most common complication (7%-9%) r6
        • Pneumonia
          • May be viral (ie, caused by measles or a secondary virus) or bacterial
          • Occurs in 1% to 6% of patients with measles;r6 most common in younger children, immunocompromised people, and pregnant patients r2c77c78c79
          • Most common cause of mortality, accounting for 60% of deaths r6
        • Croup and bronchiolitis c80c81
          • May develop as a direct result of measles virus r2
      • Encephalitis r20
        • Primary measles encephalitis c82
          • Uncommon manifestation of acute measles infection; occurs in about 1 to 3 of 1000 patients with measles
          • Presents with recurrence of fever, headache, and seizures, and alterations in mental status
          • Mortality is 10% to 15%, and about 25% of survivors have neurologic sequelae
          • Viral RNA can be demonstrated in cerebrospinal fluid
        • Acute postmeasles encephalitis c83
          • Usually presents during convalescence; altered vision, difficulty urinating, and hyporeflexia are characteristic
          • Some authorities recommend steroid treatment
          • Mortality is about 5% in children and 25% in adults
        • Inclusion body encephalitis c84
          • Occurs primarily in immunodeficient children, and presents within a year of measles infection
          • Characterized by changes in mental status, focal motor deficits, and seizures
          • Measles-specific antibodies may be detected in cerebrospinal fluid; brain biopsy may reveal measles RNA
        • Subacute sclerosing panencephalitis c85
          • Chronic degenerative, fatal neurologic disease
          • Characterized by slowly progressive behavioral changes and decline in cognitive function. Deterioration of motor function and onset of seizures eventually develop
          • Presents 7 to 10 years after primary wild-type virus infection r4
          • Occurs in about 1 of 25,000 cases. Most common in children who were infected at an early age (younger than 2 years)r4
          • High levels of virus-specific antibody often are detected in cerebrospinal fluid
      • Keratoconjunctivitis c86
        • May be severe in nutritionally deficient children, resulting in blindness r16
      • Suppressed cell-mediated immune function c87
        • Measles virus results in suppression of cell-mediated immune function
    • Recurrent infection c88
      • Extremely rare; lifelong immunity develops in most after natural infection r2

    Prognosis

    • Otherwise healthy patients r21
      • Course of uncomplicated illness usually lasts 7 to 10 days, and recovery is often uneventful with appropriate supportive care r2
      • From a global perspective, measles represents 1 of the most severe infectious diseases acquired in childhood r21
        • 1 of the most common causes of death in nonimmunized children worldwide
        • Deaths occur owing to pneumonia, encephalitis, or dehydration
          • Most measles deaths occur in children younger than 5 years r21r22
          • 1 to 3 out of 1000 children with measles will die from respiratory and neurologic complications r9
    • Immunocompromised patients r2
      • Severe measles may occur in patients with compromised cellular immunity (eg, posttransplant, postchemotherapy, AIDS, congenital immunodeficiency)
      • Fatality rate is very high (40%-70%)

    Screening and Prevention

    Screening c89

    At-risk populations

    • Individuals who are unvaccinated or who have received only 1 dose of vaccination, particularly if they are traveling internationally, attending college, or working in a health care setting r23

    Prevention

    • Active immunization is the primary means of prevention r17c90
      • Measles vaccine is safe and effective
        • Active immunization remains paramount, owing to recent outbreaks in the United States. Continued global burden of disease indicates that measles accounts for more than 100,000 preventable deaths annually r11
      • A 2-dose series of live-attenuated virus vaccine—separated by at least 28 days with first dose given after first birthday—is 97% to 99% effective in generating immunity r4r9
        • Immunity is established for many years after vaccination and probably lifelong in most patients r2
        • Recommended for all nonimmune people who do not have contraindications r9r17
          • In the United States, people born in 1957 or later are considered to be susceptible unless they received 2 doses of live measles virus vaccine or there is laboratory evidence of immunity r9
          • In countries without endemic disease and in nonoutbreak settings:
            • Administer first dose at age 12 to 15 months r9
            • Administer second dose at age 4 to 6 years r9
              • Second dose is required for school entry in many jurisdictions
          • In countries with endemic disease or in outbreak settings: r16
            • Recommended timing of first dose may be as early as age 6 months because declining transferred maternal antibodies are unlikely to be protective after age 6 months r9
          • Nonimmunized or incompletely immunized patients age 6 months or older traveling from nonendemic countries to endemic regions: r9
            • 2 doses should be given at least 28 days apart before travel r9
      • Measles vaccine is contraindicated in the following populations: r2
        • Pregnant patients
        • Immunocompromised patients, especially those with deficiency in cell-mediated immunity
          • Special circumstances include the following: r2
            • HIV
              • Administer vaccine to asymptomatic children with HIV infection according to immunization schedule
              • Consider administering vaccine to symptomatic children who are HIV positive as long as CD4 T cell levels are relatively well preserved, particularly when exposure risk may be high (eg, inner city living)
            • Malignancy
              • Administer vaccine at least 3 months after completion of chemotherapy
      • Recent immunoglobulin or high-dose systemic corticosteroid administration r4
        • May interfere with serologic response to measles vaccine for variable periods of time
        • Reimmunization or alteration of immunization timing may be required
      • Measles vaccine is highly effective in preventing infection among vaccinated people, but a 95% uptake rate is required to provide herd immunity and to prevent measles from becoming endemic in a population owing to the highly contagious nature of the virus r1r24
        • Vaccination policies in many developed countries are not sufficient to achieve this owing to rising parental vaccination hesitancy and the antivaccination movement r24r25
        • In the United States, Europe, and other areas in which measles was eradicated, outbreaks (including fatal cases) occur when vaccine coverage falls below 95% r26
        • Disease is often inadvertently introduced by a traveler who acquired the disease in an endemic country; nonimmunized people can then acquire and disseminate infection r26
      • Vaccine adverse effects
        • Transient rash and fever are common about 1 week after dose r2
        • Benign febrile seizures can occur in susceptible children r4
    • Postexposure prophylaxis r9c91
      • Recommended for people who lack evidence of immunity or who are at high risk for complications
        • Acceptable evidence of immunity for purposes of postexposure prophylaxis decision-making consists of 1 of the following: r9
          • 1 or more doses of a measles-containing vaccine administered on or after first birthday for preschool-aged children and adults not at high risk
          • 2 doses of measles-containing vaccine for school-aged children and adults at high risk, including college students, health care personnel, and international travelers
          • Laboratory evidence of immunity (positive for measles IgG)
          • Laboratory confirmation of measles
          • Birth before 1957
      • Consider contacting state health department for guidance regarding most appropriate postexposure prophylaxis
      • Postexposure prophylaxis options include vaccine or immunoglobulin administration
        • Live measles vaccine
          • Alternative to passive immunoglobulin in susceptible exposed people. Do not administer to the following populations: r2
            • Infants younger than 6 months
            • Pregnant patients
            • Immunocompromised patients
          • Effective in preventing or mitigating disease if administered within 72 hours of exposure r13
          • Infants who are given a dose between ages 6 and 11 months also should be given the regularly scheduled 2-dose course (ie, a subsequent dose at age 12-15 months and again at age 4-6 years) for a total of 3 dosesr4
        • Passive immunization with immunoglobulin
          • Usually reserved for susceptible individuals who are most at risk for severe disease and complications r18
          • Indications
            • Exposed immunocompromised patients, regardless of vaccination status
            • Susceptible patients who have a contraindication to the vaccine, including pregnant individuals and infants younger than 6 months
            • Susceptible patients, when more than 72 hours have elapsed and vaccine would be ineffective as postexposure prophylaxis r18
              • Give priority to contacts with close and prolonged exposure
          • Recommended dose
            • Intramuscular immune globulin
              • Immune Globulin (Human) Solution for injection; Infants†: 0.5 mL/kg/dose (Max: 15 mL) IM as a single dose.
                • Can be used for other susceptible contacts but measles-mumps-rubella vaccine is preferred if it can be administered within 72 hours of exposure
            • IV immune globulin
              • Immune Globulin (Human) Solution for injection; Infants, Children, and Adolescents: 400 mg/kg IV as single dose immediately after exposure in patients younger than 12 months (who have not received 1 dose of measles-containing vaccine) and those with immunodeficiency.
              • Immune Globulin (Human) Solution for injection; Adults: 400 mg/kg IV as single dose immediately after exposure in patients with immunodeficiency and pregnant women without immunity.
          • Must be administered within 6 days of exposure to be effective r3r13
          • Do not administer immunoglobulin and measles-mumps-rubella vaccine simultaneously r9
            • Wait 3 to 11 months after administering immunoglobulin before administering measles-mumps-rubella vaccine r18
          • Contraindications to immunoglobulin include previous anaphylactic reaction to immunoglobulin r18
    • Isolation r9r27c92
      • Patients with measles
        • Isolation is recommended for 4 days after rash onset
          • Isolation for duration of hospitalization is recommended for immunocompromised patients
        • In the hospital setting, patient is placed in a single patient airborne infection isolation room; caretakers must use N95 or similar respirator
        • Health care workers without presumptive evidence of measles immunity should not enter the room of a known or suspected measles patient r27
      • Exposed susceptible health care workers r27
        • Administer postexposure prophylaxis
        • Exclude from work from day 5 after first exposure through day 21, regardless of postexposure prophylaxis
      • Exposed susceptible people in the community who did not receive timely postexposure prophylaxis
        • Exclude from institutions in outbreak area until 21 days after rash onset in the last case involved in outbreak
      • Health care personnel r27
        • Ensure that all health care workers have presumptive evidence of immunity to measles. This includes:
          • Documentation of vaccination with 2 doses of measles virus-containing vaccine (first dose administered at age 12 months or older, second dose administered no fewer than 28 days after first dose)
          • Laboratory evidence of immunity (measles IgG positive; equivocal results are considered negative)
          • Laboratory confirmation of disease
          • Birth before 1957
            • Consider vaccinating health care workers born before 1957 who do not have other evidence of immunity to measles
            • During a measles outbreak, 2 doses of measles virus-containing vaccine are recommended for all health care workers, regardless of birth year
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