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 paramyxovirusReservoir: HumansTransmission: spread person to person by direct contact with nose and throat secretions or respiratory droplets, Incubation period: 7-18 days, av 10 daysInfectious 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

Region   Confirmed (by Colindale)

Not confirmed

Not yet tested

Grand total

EM East Midlands North 8 (8) 1 3 12EM East Midlands South 9 (9) 3 8 20

EoEBedfordshire and

Hertfordshire 4 (4) 0 0 4London South West London  0 0 2 2

NE North East 4 (4) 0 11 15NW Cumbria and Lancashire 30 (29) 2 13 45NW Cheshire and Merseyside 13 (13) 1 6 20NW Greater Manchester 9 (9) 0 3 12SE Sussex and Surrey 4 (4) 1 3 8SE Thames Valley 2 (4) 0 3 5SW South West (North) 1 (1) 0 1 2WM West Midlands East 15 (15) 0 7 22WM West Midlands North 6 (6) 0 8 14WM West Midlands West 10 (10) 0 5 15Y&H South Yorkshire 2 (1) 0 2 4

Y&HNorth Yorkshire and

Humber 10 (10) 1 7 18Y&H West Yorkshire 1 (1) 0 0 1

  Grand Total 128 (126) 9 82 219

Measles cases in travellers reported in HPZone 2012 (up to Sep 2012)

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%

%England 91.2

East Midlands 92.9Bassetlaw PCT 90.1Derby City PCT 93.4Derbyshire County PCT 94.5Leicester City PCT 93.0Leicestershire County & Rutland PCT 94.6Lincolnshire Teaching PCT 91.8Northamptonshire Teaching PCT 93.9Nottingham City PCT 88.8Nottinghamshire County Teaching PCT 92.0

MMR Percentage of children immunised by their 2nd birthday, 2011-12 by PCT

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.Immunocompromised2.Pregnant women, infants3.Health Care Workers4.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

MMR HNIG 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/1223019390211?printable=true

4. Department of Health, The Green Book https://www.wp.dh.gov.uk/immunisation/files/2012/07/Chap-21-dh_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/public-health/immunisation/nhs-immu-stat-eng-2011-2012/nhs-immu-stat-eng-2011-12-rep.pdf

Acknowledgements

Jane Freeman, East Midlands HPU (North)

Vanessa Macgregor, East Midlands HPU (North)