2. Rash Decisions: The Colorado Experience with “Maybe Measles” Emily Spence Davizon, Colorado Department of Public Health and Environment

3. Today’s talk: -Epidemiology and clinical picture -Rule outs: process, 3 areas of concern, and testing -Results of the CO experience

4. Learning objectives: -Describe rule out process -Name the “3 Cs” and the 3 areas of concern -Understand who can and cannot issue quarantine/isolation orders

5. Epidemiology of measles Reservoir: Human. No known asymptomatic carrier state. Transmission: Respiratory droplets. Airborne transmission via aerosolized droplets; documented in closed areas up to 2 hours after a person with measles occupied the area. Communicability:Highly communicable. Secondary attack rate up to 90%. People with measles are contagious 4 days before to 5 days after rash onset. Average Incubation: 14 days (range 7-21). Source: CDC, Epidemiology and Prevention of Vaccine-Preventable Diseases, “The Pink Book,” 12 th Edition, 2011

6. Worldwide trends Measles is still common in many parts of the world and is often fatal in developing countries Over 22,000 cases were reported in Europe in 2014-2015 122,000 estimated deaths worldwide in 2012 http://www.who.int/features/2015/measles-vaccination-liberia/en/

8. Cases since elimination achieved in 2000

9. Measles in Colorado Measles outbreaks in Colorado : 115 cases (1988) 101 cases (1989) 138 cases (1990) Colorado Measles Cases, 2000-2015 year # of cases

10. Clinical picture Prodrome: -High fever (>101 degrees) -Malaise -Cough, coryza, and conjunctivitis.

11. Clinical picture Rash: -Maculopapular and begins 2-4 days after prodrome onset -Begins on face and spreads down and out -Fades in order of appearance -Koplik spots (appear like tiny white spots with red ring) may be present in mouth

12. Which rash is measles? A B

13. Ruling out measles Suspect case reported 1.Gather information- demographics, clinical, travel, IZ history 2.Recommendations for infection prevention and isolation Cases isolated through 4 days after rash (onset of rash day 0) Airborne isolation or private room with door closed, mask if feasible Ensure healthcare personnel have evidence of immunity 3.Communicate with partners 4.Test?

14. Three areas of concern

15. Testing Recommend consultation with CDPHE epidemiologists

16. Results- the Colorado Experience

17. The “Maybe Measles” Epidemic in Colorado 1 confirmed CO measles case reported 74 PCR tests run at CDPHE lab

18. Quarantine and isolation orders Quarantine separates and restricts the movement of people who were exposed to a contagious disease to see if they become sick Isolation separates sick people with a contagious disease from people who are not sick Both order types can be issued by local public health agencies or CDPHE Excellent compliance with requests for voluntary isolation of suspect cases until ruled out or were out of infectious period No orders were issued for the suspect cases that were ruled out in 2015

19. Guidance Communicable Disease Manual updates \ New specimen collection instructions and guidance for HCPs Encouraged all health care facility staff to have documented evidence of immunity (especially small clinics and urgent care)

20. Take home message Events outside of Colorado that cause concern among the public or health care providers can generate a substantial work load for public health As a result of this experience, we developed additional tools to assist our partners in ruling out (or in) measles Measles is a serious communicable disease that cannot be reliably diagnosed only based on signs and symptoms Measles, even suspect measles in the absence of diagnostic results, is a 24-hour reportable condition in CO- call us! (303-692-2672 or 303-692-2671 or 303-370-9395 after hours)

21. Take home message Public health plays an important role in ruling out suspect cases: -Specimen collection -Timing of testing and interpreting results (IgM vs IgG) -Education on case definition, signs, symptoms

22. Resources CDPHE Communicable Disease Manual: https://www.colorado.gov/pacific/sites/default/files/DC_CD_ComDisMa nual-Meningococcal-Disease.pdf https://www.colorado.gov/pacific/sites/default/files/DC_CD_ComDisMa nual-Meningococcal-Disease.pdf Specimen collection instructions: https://www.colorado.gov/pacific/sites/default/files/CD_CD_VPD_Measl es-Specimens-for-Diagnostic-Testing_1.pdf https://www.colorado.gov/pacific/sites/default/files/CD_CD_VPD_Measl es-Specimens-for-Diagnostic-Testing_1.pdf Guidelines for physicians evaluating patients with fever and rash: https://www.colorado.gov/pacific/sites/default/files/DC_CD_VPD- Measles-Guidance-for-HCPs-Evaluating-Patients-with-Rash-Illness.pdf https://www.colorado.gov/pacific/sites/default/files/DC_CD_VPD- Measles-Guidance-for-HCPs-Evaluating-Patients-with-Rash-Illness.pdf Measles information sheet: https://www.colorado.gov/pacific/sites/default/files/DC_CD_VPD- Measles-Information-Sheet.pdf https://www.colorado.gov/pacific/sites/default/files/DC_CD_VPD- Measles-Information-Sheet.pdf

25. Utah Experience – 3 cases, 2015 1,600 calls to 117 individuals on voluntary quarantine 586 doses of the measles, mumps, rubella (MMR) vaccine in Jan > 600 staff hours Direct cost for outbreak ~ $115,000 3,000 staff hours Source: Utah Department of Health Press Release, February 25, 2015

26. 3 August 2015 Since the beginning of the year, a measles epidemic has been ravaging Katanga Province in the southeast of the Democratic Republic of Congo. The Office for the Coordination of Humanitarian Affairs (OCHA) declared around 16,500 cases of measles and more than 267 deaths in the first six months of the year. Having led the response during the last few months, Médecins Sans Frontières (MSF) is stepping up its support to the Ministry of Health, providing free medical care for patients, carrying out vaccination campaigns for children and strengthening epidemiological surveillance.