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Measles Information for Health Care Providers

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Reporting suspect or confirmed cases

Suspect or confirmed cases of measles, whether clinically diagnosed or laboratory confirmed, must be reported to the Porcupine Health Unit immediately. Reporting a suspect measles case should not be delayed pending the return of confirmatory laboratory results.

  1. If calling during business hours (Monday to Friday, 8:30 AM to 4:30 PM), call the Infectious Diseases (ID) department at 705-267-1181.
    If calling after hours or on holidays    , call the on-call service at 1-800-461-1818.
  2. Complete the Reportable Communicable Disease Notification Form and fax the form to the ID department’s confidential fax at 705-360-7324.

Diagnosing measles

  • Assess signs and symptoms. Signs and symptoms of measles include the following:
    • A prodromal fever (≥38.3 oral)
    • Coryza
    • Cough
    • Conjunctivitis
    • Drowsiness
    • Irritability
    • Koplik's spots
    • 3 to 7 days after the start of symptoms, a characteristic maculopapular rash appears on the face and spreads down the patient's body, lasting at least 3 days
    • Photos from CDC
  • Assess travel history and immunization history.
  • Call Public Health Ontario Laboratory prior to collecting samples at 1-877-604-4567.
  • Complete the laboratory requisition form for each sample. The form must include the following information:
    • Ordering physician or health care professional's name and telephone number
    • Test(s) requested and type of specimen
    • Indications for testing = “Suspect case of measles”
    • Checked Diagnosis check box
    • Patient setting/population/source
    • Exposure history and travel history outside the area for 21 days prior to start of symptoms
    • Vaccination history
    • Clinical information with symptoms and onset date
    • For acute serology:Clearly mark "acute measles serology IgG and IgM” for samples collected within 7 days of rash
    • Indicate whether the local public health unit was notified
  • Check expiration date of collection kit. PHOL will not test samples collected with expired kits.
  • Collect samples.
    • Nasopharyngeal swab. Use the Virus Respiratory Kit and collect the sample within 7 days of rash onset. 
      Throat swab. Use the Virus Culture Kit and collect the sample within 7 days of rash onset.
    • Urine. Use a sterile container and collect the sample within 14 days of rash onset.
    • Whole blood or serum for Acute serology IgG and IgM. Use blood, clotted vacutainer tubes (SST) and collect the sample. Acute serology should be collected within 7 days of rash onset.
  • Send samples to Public Health Ontario Laboratory (PHOL) for testing. To expedite testing, send the samples to the Toronto PHOL site.
    • Place specimen in biohazard bag and seal.Specimens should be stored in a refrigerator at 2-8°C following collection and shipped to the Public Health laboratory on ice.
    • STAT measles specimens must be shipped separate from routine specimens.
  • Provide patient counselling.

Counselling and instructions for suspect or confirmed cases

Initiation of control measures do not need to await laboratory confirmation of the case.

  • Advise persons under investigation and confirmed cases to:
    • Stay home. Self-isolate from child care settings, schools, post-secondary educational institutions, work places, places of worship, sporting events, health care and other group setting, and away from non-household contacts for 4 days after the appearance of the rash. This applies to all cases, regardless of their vaccination history.
    • Avoid contact with non-household contacts, and avoid contact with high-risk individuals (pregnant individuals, infants less than 12 months of age, and immunocompromised individuals).
  • If seeking medical attention, advise your patient to contact health care providers and the hospital prior to arrival so appropriate IPAC precautions can be initiated to avoid exposures.
  • Advise your patient to expect a call from public health.

Counselling and instructions for contacts

If your client calls to advise you that they have been exposed to measles:

  1. Review the patient immunization status.
  2. Assess if the patient has any symptoms.
Symptom Status Immunization Status Action
Symptomatic Not applicable
  • Instruct the patient to stay home. See Section C: Counselling and instructions for suspect or confirmed cases.
  • Arrange for testing. Schedule the patient’s visit to minimize exposure to others, and instruct the patient to wear a tight-fitting, well-constructed mask and limit contact with others. HCP must wear a fit tested N95 mask. See Section E.I: IPAC measures for health care workers.
  • Report to public health. (See Section A: Reporting suspect or confirmed cases.) Advise your patient to expect a call from the public health unit to discuss isolation requirements.
Asymptomatic Susceptible or immunization status is unknown
  • Refer to Section I: Post-exposure prophylaxis (PEP) for non health care worker contacts for PEP guidance.
  • Report to public health. (See Section A: Reporting suspect or confirmed cases.) Advise your patient to expect a call from the public health unit to discuss isolation requirements.
Asymptomatic Fully immunized
  • Advise your patient to monitor for symptoms of measles for 21 days post exposure. If they develop symptoms, advise your patient to stay home and call you.
  • No isolation required.

If your patient is immunocompromised:

  • SeePost-exposure prophylaxis (PEP) for non health care worker contacts.
  • Report to public health. (SeeReporting suspect or confirmed cases.)
  • Advise your patient to expect a call from the public health unit to discuss isolation requirements.

Infection prevention and control (IPAC) measures

IPAC measures for health care workers

  • All health care workers (HCWs) should have documented immunity to measles.
  • Only HCWs with presumptive immunity to measles should provide care to patients with suspect or confirmed measles.
  • All HCWs, regardless of presumptive immunity, should wear a fit-tested, seal-checked N95 respirator when entering the room and/or caring for a patient with suspect or confirmed measles.
  • HCWs should complete a point of care risk assessment (PCRA) before entering the room. Additional personal protective equipment (PPE) may be added as required based on PCRA.

Isolation precautions for suspected or confirmed cases of measles

  • Patients should be managed under Routine Practices and Airborne Precautions.
  • If you schedule a patient to be assessed for measles in a clinic or office setting, schedule the patient’s visit to minimize exposure to others, for example, last appointment of the day.
  • Patients should be immediately placed in a single room with negative air flow (airborne infection isolation room [AIIR]) with the door closed and signage posted.
  • If an AIIR is not available, the patient should be immediately placed in a single room with the door closed and the patient should be given a medical mask to wear during the visit.
  • After the patient leaves, the door to the room where the patient was examined must remain closed with signage to indicate that the room is not to be used. Allow sufficient time for the air to change in the room and be free of respiratory particles before using the room for non-immune individuals. Two hours is a conservative estimate if air changes are not known.

Proof of measles immunity for employees in healthcare setting

All employees (for example, nurses, physicians, support staff) should ensure that they are up to date with their immunizations, including their measles vaccine. Up to date measles immunization means that the employee has received two (2) doses of measles-containing vaccine.

When reviewing an employee’s immunization, the following is considered as acceptable proof of measles immunity.

Proof of measles immunity for employees in healthcare setting:

  • Documentation of receipt of two doses of measles-containing vaccine on or after the first birthday, with doses give at least four weeks apart; OR
  • Laboratory evidence of immunity

Exclusion guidance for health care workers who have measles

Health care workers, regardless of year of birth, should be excluded from work if they have measles. They may return to work after they are no longer infectious (4 days after rash onset).

Post-exposure prophylaxis recommendations and exclusion guidance for health care workers with an exposure to measles

Any health care worker (HCW) who has a significant exposure to a person who has measles, either in the health care setting or the community, must report this exposure to their occupational health. Occupational health must review the immune status of a HCW that has been exposed to a confirmed case of measles.

Criteria Recommendations

Exposed HCW who has proof of immunity (defined above)

May continue to work and can be assigned to care for patients with suspected or confirmed measles.
Exposed HCW who has previously received one dose of measles-containing vaccine and who does not have laboratory evidence of measles immunity

Should be tested for measles IgG antibody.
AND
Should receive a second dose of a measles-containing vaccine (i.e., MMR vaccine) if no contraindications exist.
AND
Should be excluded from work or any health care setting while awaiting serology results.

Recommendations for excluding HCW based on serology results:

  • If measles IgG is positive, the HCW may return to work.
  • If measles IgG is negative, the HCW is considered to be susceptible and should be excluded from work or any health care setting from the 5th day after the first exposure to the 21st day after the last exposure. Individuals should be excluded regardless of whether they received MMR vaccine or immune globulin after the exposure.
Exposed HCW who has no documentation of proof of immunity (i.e. no previous serology for measles antibodies and no proof of having received measles containing vaccine)

Should be tested for measles IgG antibody.
AND
Should receive one dose of a measles-containing vaccine (i.e. MMR vaccine) if no contraindications exist. 
AND
Should be excluded from work or any health care setting while awaiting serology results as they are considered susceptible.

Recommendations for excluding HCW based on serology results:

  1. If measles IgG is positive, the HCW may return to work.
  2. If measles IgG is negative, the HCW is considered to be susceptible and should be excluded from work or any health care setting from the 5th day after the first exposure to the 21st day after the last exposure. Individuals should be excluded regardless of whether they received MMR vaccine or immune globulin after the exposure.
Exposed HCW who has negative serology for measles antibodies and who has never received measles containing vaccine:

Should receive a measles-containing vaccine (i.e. MMR vaccine) as soon as possible after the exposure if no contraindication exists.
AND
Should be excluded from work or any health care setting from the 5th day after the first exposure to the 21st day after the last exposure. Individuals should be excluded regardless of whether they received MMR vaccine or immune globulin after the exposure.

If clinical measles does not develop after exposure, a second dose of measles-containing vaccine (i.e., MMR vaccine) should be given at least four weeks after the first.
Exposed HCW in whom measles containing vaccine is contraindicated for medical reasons, (e.g. immunocompromised, pregnancy):

Should be offered human immune globulin within 6 days of exposure.
AND
Should be excluded from work or any health care setting from the 5th day after the first exposure to the 28th day after the last exposure as immunoglobulin may prolong the incubation period of measles. Individuals should be excluded regardless of whether PEP was administered.

MMR vaccine should be postponed five to six months after immune globulin is administered if their contraindications are reevaluated (e.g., pregnant HCWs).

Post-exposure prophylaxis (PEP) for non-health care worker contacts

The timely administration of Measles, Mumps, and Rubella (MMR) vaccine or immunoglobulin (Ig) through the intramuscular route (IMIg) or the intravenous route (IVIg) can reduce the risk of infection in susceptible individuals exposed to measles or in the case of IMIg/IVIg can reduce clinical severity if measles infection occurs.
PEP is not 100% effective and all susceptible contacts who receive PEP should be counseled on the signs and symptoms of measles; to avoid contact with high-risk individuals, infants < 12 months of age, immunocompromised individuals, and susceptible pregnant individuals); and to avoid settings or gatherings where high-risk individuals are likely to frequent.

When MMR vaccine is offered greater than 72 hours after exposure, it is no longer considered PEP but represents an opportunity to update immunizations and offers protection from any subsequent measles exposures.

If an individual is born prior to 1970 and is a contact of a measles case, in some circumstances a dose of MMR vaccine would be warranted. Although adults born before 1970 are generally presumed to have acquired natural immunity to measles, the type of exposure, the timing of the exposure, the susceptibility of the contact (if known), the health status of the contact, and their occupation should be considered to determine if they should receive publicly funded vaccine. For example, a dose of MMR vaccine would be warranted for an immunocompetent household contact of a measles case with unknown vaccine history and identified within 72 hours of exposure. There is no harm in giving these individuals a dose of MMR vaccine.

As per the 2018 National Advisory Committee on Immunization (NACI) recommendation, it is not recommend that susceptible immunocompetent individuals older than 12 months of age, who are not pregnant, receive Ig for PEP due to the low risk of disease complications and the practical challenges of administering Ig products

Population Time since exposure to measles*
≤ 72 hours		 Time since exposure to measles*
73 hours – 6 days
Susceptible infants zero to six months of age [8] IMIg (0.5 mL/kg) [2] IMIg (0.5 mL/kg) [2]
Susceptible immunocompetent infants six to 12 months of age MMR vaccine1 IMIg (0.5 mL/kg) [2,7,8]
Susceptible immunocompetent individuals 12 months of age and older MMR vaccine series [3,7] MMR vaccine series [3,7]
Susceptible pregnant individuals4 IVIg (400 mg/kg)
or
IMIg (0.5 mL/kg), limited protection if 30kg or more [5]		 IVIg (400 mg/kg)
or
IMIg (0.5 mL/kg), limited protection if 30 kg or more [5]
Susceptible immunocompromised individuals six months of age and older IVIg (400 mg/kg)
or
IMIg (0.5 mL/kg), limited protection if 30kg or more [5,6]		 IVIg (400 mg/kg)
or
IMIg (0.5 mL/kg), limited protection if 30 kg or more [5,6]
Individuals with confirmed measles immunity No PEP required No PEP required

Reference: Measles vaccines: Canadian immunization guide – Canada.ca

Notes:

  • [1] Two additional doses of MMR vaccine provided after 12 months of age are required for long-term protection.
  • [2] If injection volume is a major concern, IVIg can be provided at a dose of 400mg/kg.
  • [3] Susceptible immunocompetent individuals 12 months of age and older are not a priority to receive Ig following measles exposure due to low risk of disease complications and the practical challenges of administration contact management.
  • [4] Provide MMR vaccine series postpartum for future protection.
  • [5] For individuals 30kg or more, IMIg will not provide complete protection but may prevent some symptoms.
  • [6] In HIV-infected individuals, measles antibody titer is known to decline more rapidly over time as compared to those who are not HIV-infected. A dose of Ig should be considered in HIV-infected individuals with severe immunosuppression after a known exposure to confirmed measles, even with documented previous MMR immunization.
    Regardless of vaccination status pre-transplant, Ig should be considered for hematopoietic stem cell transplantation (HSCT) recipients, unless vaccinated post-HSCT and known to have an adequate measles antibody titre.
  • [7] MMR vaccine will not provide PEP protection after 72 hours of exposure, however, starting and completing a two dose series should not be delayed to provide long term protection,
  • [8] Two doses of measles-containing vaccine are still required after the first birthday for long-term protection.
  • [*] Ig should only be provided within 6 days of measles exposure; unless it is contraindicated, individuals who receive Ig should receive measles-containing vaccine after a specified interval, once the measles antibodies administered passively have degraded. For more information, refer to Blood Products, Human Immunoglobulin and Timing of Immunization in Part 1.

Accessing immunoglobulin (Ig)

If Ig is indicated for an individual, the usual process is that hospitals order the product through Canadian Blood Services (CBS) and it is administered by the health care provider, as opposed to the health unit.

CBS carries multiple manufacturers brands of Ig available for IMIg and intravenous infusion (IVIg). Both products are available through local hospitals’ Transfusion Medicine Laboratories. IVIg can only be ordered by hospital-based providers using the appropriate (non-Neurology) Ministry of Health Ig Request form, as it requires in-hospital administration and active patient monitoring over several hours of infusion. ORBCoN and the Ministry of Health are aware of NACI’s recommendations for the use of IVIg for measles PEP and plans to add measles PEP to Ontario IG Utilization Management Guidelines in a future update.

Hospitals that have questions can refer to the Hospital Services section on the CBS website at Hospital services - Canadian blood services. Public health units that have questions regarding the supply of Ig in relation to measles, should contact their local hospital blood bank.

Current eligibility criteria for publicly funded measles-containing vaccines for those who are unimmunized or without documentation of immunization

Age Recommended doses Criteria
 6 to 11 months  1 dose
  • Travelling to areas with increased measles transmission.
  • Two additional doses are required on or after the first birthday, see row below.Two additional doses are required on or after the first birthday, see row below.
1 to 17 years   2 doses 

Routinely given at:

  • 1 year of age (1st dose as MMR) and
  • 4 to 6 years of age (2nd dose as MMRV) [9] 
18 years+ 1 or 2 doses

A 2nd dose can be given:

  • Based on health care provider’s clinical judgement
  • To health care workers
  • To post-secondary students
  • To individuals travelling to areas with increased measles transmission

Notes:

[9]The optimal timing for the 4 to 6 year booster dose is at 4 years of age.

Resources

  1. Measles in Ontario, Surveillance Report, Public Health Ontario
  2. Measles: Information for Health Care Providers, Public Health Ontario
  3. Technical Brief: Interim IPAC Recommendations and Use of PPE for Care of Individuals with Suspect or Confirmed Measles, Public Health Ontario
  4. Laboratory Requisition
  5. Measles Diagnostic PCR Testing
  6. Measles Serology Testing
  7. Infectious Disease Protocol Appendix 1: Case Definitions and Disease-Specific Information Disease: Measles, Ministry of Health
  8. Measles: Information for Health Care Providers, Public Health Ontario
  9. Measles vaccines: Canadian immunization guide - Canada.ca
  10. Updated NACI recommendations for measles post-exposure Prophylaxis: CCDR:2018;44(9) - Canada.ca