1. What is one of the most contagious diseases? Measles 2015 Dr. Michael Levy

2. Measles Cases Grow To 95 In Eight States & Mexico The Los Angeles Times report on 1/29/15 said that yesterday healthcare officials said that the number of measles cases grew to 95 in eight states and Mexico. In California, there are now 79 cases, “of which 52 can be linked directly to Disneyland.” Additionally, “officials reported one case in Michigan that was connected to the California outbreak.” However, the outbreak has expanded beyond visitors of Disneyland and is now “infecting people in the broader community.” Officials across California are “scrambling to get ahead of the outbreak, identifying farmers markets, grocery stores, malls and other

3. Measles Basic Information Measles is a highly contagious respiratory disease caused by a virus. It spreads through the air through coughing and sneezing. Measles starts with a fever, runny nose, cough, red eyes, and sore throat, and is followed by a rash that spreads all over the body. About three out of 10 people who get measles will develop one or more complications including pneumonia, ear infections, or diarrhea. Complications are more common in adults and young children.

4. Incubation period: Typically onset symptoms at 8-12 days after exposure, rash onset at 14 days (range 7-21 days) Infectious period: 4 days before rash onset through 4 days after rash onset Lab diagnosis: Contact the Section of Epidemiology to facilitate testing Measles Basic Information

5. Measles Background Before live vaccine (1963): 549000 cases and 495 deaths per year Most cases not reported so likely 3-4M people infected, 48000 hospitalizations and 1000 permanent disability In 2000: declared eradicated from US http://www.cdc.gov/measles/hcp/index.htmlhttp://www.cdc.gov/measles/hcp/index.html.

6. Complications Common: otitis media, bronchopneumonia, laryngotracheobronchitis, and diarrhea. Even in previously healthy children, measles can cause serious illness requiring hospitalization. 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.

7. People at High Risk People at high risk for severe illness and complications from measles include: – Infants and children aged <5 years – Adults aged >20 years – Pregnant women – People with compromised immune systems, such as from leukemia & HIV infection

8. Transmission of Measles 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.

9. Diagnosis Healthcare providers should consider measles in patients presenting with; – febrile rash illness – clinically compatible measles symptoms, (especially if the person recently traveled internationally or was exposed to a person with febrile rash illness). Healthcare providers should report suspected measles cases to their local health department within 24 hours.

10. 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 esopharyngeal 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 Diagnosis

11. Evidence of Immunity Acceptable presumptive evidence of immunity against measles includes at least one of the following: 1. Written documentation of adequate vaccination 2. 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 3. Two doses of measles-containing vaccine for school-age children and adults at high risk, including college students, healthcare personnel, and international travelers 4. Laboratory evidence of immunity 5. Laboratory confirmation of measles 6. Birth in the United States before 1957

12. Vaccination Measles can be prevented with measles-containing vaccine, which is primarily administered as the combination measles- mumps-rubella (MMR) vaccine. The combination measles-mumps-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

13. Vaccine Recommendations Children: 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.

14. Students at post-high school educational institutions: – 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. Adults – 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. Vaccine Recommendations

15. Post-Exposure Prophylaxis People exposed to measles who cannot readily show that they have evidence of immunity against measles should be offered post-exposure prophylaxis (PEP) or be excluded from the setting (school, hospital, childcare). MMR vaccine, if administered within 72 hours of initial measles exposure, or immunoglobulin (IG), if administered within six days of exposure, may provide some protection or modify the clinical course of disease.

16. MMR vaccine as post-exposure prophylaxis (PEP) If MMR vaccine is not administered within 72 hours of exposure as PEP, MMR vaccine should still be offered at any interval following exposure to the disease in order to offer protection from future exposures. People who receive MMR vaccine or IG as PEP should be monitored for signs and symptoms consistent with measles for at least one incubation period

17. If many measles cases are occurring among infants younger than 12 months of age, measles vaccination of infants as young as 6 months of age may be used as an outbreak control measure. Note that children vaccinated before their first birthday should be revaccinated when they are 12 through 15 months old and again when they are 4 through 6 years of age. Except in healthcare settings, unvaccinated people who receive their first dose of MMR vaccine within 72 hours after exposure may return to childcare, school, or work. MMR vaccine as post-exposure prophylaxis (PEP)

18. Post-Exposure-Prophylaxis for Health Care Professionals. If a healthcare provider without evidence of immunity is exposed to measles, MMR vaccine should be given within 72 hours, or IG should be given within 6 days when available. Exclude healthcare personnel without evidence of immunity from duty from day 5 after first exposure to day 21 after last exposure, regardless of post- exposure vaccine.

19. Measles 3 C’s Cough Coryza – running nose, sneezing, watery eyes Conjunctivitis

20. Measles Clinical Koplick spots

21. Conjunctivitis

22. Rash