Measles

Notify the South West Health Protection Team (HPT) (UKHSA) immediately via 0300 303 8162, and complete Notifiable diseases: form for registered medical practitioners on diagnosis of suspected measles. Don’t wait for laboratory confirmation of a suspected infection before notification. Send the form to UKHSA within 3 days of your telephone notification.

If clinicians wish to test a suspected measles case, this should be discussed with the South West Health Protection Team (HPT) when the suspected case is reported. Please see section ‘how can I report a suspected measles case?’ above for further information.

MMR vaccination prevents cases of Measles and a 95% uptake of vaccination in a population prevents outbreaks. Consider encouraging questions about MMR by displaying information in waiting rooms and on websites.

Please see UKHSA think Measles Poster for A&E, Walk-in and GP Centres.
 
Measles starts with a 2 to 4 day “prodromal” phase before the rash appears, with coryza, cough, conjunctivitis, and a fever.
fever typically increases, to peak around rash onset.
rash generally starts behind the ears, spreads to the face, and then expands onto the trunk and can become generalised. The rash is red, blotchy, maculopapular (not itchy) and lasts around 3 to 7 days.
 the rash is more difficult to spot on dark skin.
Koplik spots may appear around the time of the rash and last for 2 to 3 days so can easily be missed. They are small white or bluish/white lesions on the buccal mucosa. They can be confused with other lesions in the mouth and so their suspected presence is an unreliable marker of measles.

the infectious period spans 8 days i.e. cases are infectious from 4 days before rash onset and for 4 full days after.
several other common rash illnesses have similar presentations (especially in young children) e.g. roseola, parvovirus infection and scarlet fever, and so identification on clinical features alone may be unreliable.

• Pneumonia or bronchitis
• Convulsions
• Diarrhoea
• Meningitis or encephalitis
• Immune thrombocytopenic purpura (ITP)
• Late-onset subacute sclerosing panencephalitis (SSPE).

• Unvaccinated individuals
• Pregnant women
• Immunocompromised patients
• Chronically ill patients

Management of cases is described in Scenario: Management | Management | Measles | CKS | NICE

Measles is transmitted via airborne respiratory particles or direct contact with nasal/throat secretions of infected individuals. Measles is a highly infectious, notifiable, vaccine-preventable, acute viral disease. Please see Guidance for risk assessment and infection prevention and control measures for measles in healthcare settings.

Please see Guidance for risk assessment and infection prevention and control measures for measles in healthcare settings. Measles has an incubation period ranging between 7 to 21 days (mean: 10 to 12 days) and individuals are typically infectious from 4 days before and up to 4 full days after rash onset.

Please see Guidance for risk assessment and infection prevention and control measures for measles in healthcare settings. To support application of these principles’ organisations should ensure that:

immunisation status/records are available for all staff (clinical and non-clinical) that may be exposed to a suspected or confirmed case of measles and staff are supported to ensure they are fully immunised. Satisfactory evidence of protection would include documentation of having received 2 doses of MMR or having had a positive antibody test for measles. Please be aware that Health care workers who are exposed to a confirmed or suspected case of measles and do not have satisfactory evidence of protection (2 documented doses of measles containing vaccine or measles IgG positive) should be excluded from work from the 5th day after their first exposure to 21 days after the final exposure. For occupational health measures, please see Section 2.6 of Guidance for risk assessment and infection prevention and control measures for measles in healthcare settings

patient screening, triaging and testing protocols are in place for all relevant care settings to ensure prompt isolation of suspected or confirmed cases of measles. All staff undertaking a reception and triage role, should be trained and fully aware of the questions to be asked when talking to patients requesting an appointment, especially those who report, fever, coryza or cough, conjunctivitis, and rash. Please note that some symptoms are experienced before the rash appears but are still infectious. Please see Appendix 2: Think Measles – primary care actions for screening, triage and management.

a respiratory season or winter plan is in place to ensure, for example, appropriate segregation of patient cases depending on the pathogen and management of increasing case numbers where they occur.

FFP3 respirator fit testing is completed for staff who may be required to assess or clinically care for a suspected or confirmed measles case. Please see Fit2Fit RPE Fit Test Providers Accreditation Scheme and Fit Testing in the UK – RPA for all your Fit Testing needs for fit testers.

training in IPC measures is provided to all staff, including: the correct use of PPE and the correct technique for donning and doffing (putting on and removing) PPE safely. Please see NHSE national infection prevention and control manual chapter 2.4 Personal protective equipment (PPE) and respiratory protective equipment (RPE)
 
risk assessment(s) is undertaken for staff who may be at high risk of infection and/or complications from infection with measles.
Make every contact count by ensuring patients visiting your practice have their immunisation status checked and offered MMR if appropriate.

FFP3 fit testing should be completed for staff who may be required to assess or care for suspected or confirmed cases.
As standard infection prevention practice, line with the health and safety at work act (1974), the personal protective equipment at work regulations (1992) and the health and social care act (2012), all healthcare providers should implement a robust internal system that ensures all staff caring for patients with a suspected confirmed pathogen spread wholly or partly via the airborne route have the appropriate respiratory protective equipment (RPE); the poster When do I need to wear a mask? Information for primary care can support mask selection, and for a more comprehensive guide, the respiratory protective equipment section of NHSE national infection prevention and control manual chapter 2: Transmission based precautions.
Please note that staff must be fit tested with FFP3 masks annually to ensure the masks offer any protection to the wearer. There will be a mask to fit everyone, but not everyone will fit every mask due to variations in facial structure, which can change over time (the rationale behind regular fit testing requirements). Please see HSE fit-testing basics for further information.
Please see Fit2Fit RPE Fit Test Providers Accreditation Scheme and Fit Testing in the UK – RPA for all your Fit Testing needs for fit testers.

Please ensure all staff are aware of Chapters 1 and 2 of the National Infection Prevention Control Manual and that standard Infection control precautions and transmission-based precautions are adhered to at all times. Please ensure all staff undertaking any procedure assess any likely exposure. Airborne transmission based precautions (TBPs) are required when managing a suspected or confirmed measles case.
 
If remote consultation is not possible, or, if following telephone triage, the patient is advised to attend your primary care setting, please ensure a separate entry area and uncluttered consulting room with a window can be used (if possible) as this allows for minimal transmission within your practice and for the area to be ventilated and all surfaces cleaned following the visit. Please note: If your practice has air conditioning and the air is re-circulated you should also turn this off during the visit, again to reduce risk. Please also see the Harrogate patient placement and assessment for infection risk policy for general practice – which lists the requirements for isolation listed below and the Harrogate safe management of the care environment policy for general practice – which lists requirements for cleaning and disinfection processes.
 
An identified room or designated area should be used for isolation.
A notice should be displayed on the door stating, ‘Isolation area – no unauthorised entry’.
The room should be free from clutter and, where possible, equipment not required for the consultation should be removed from the room before the patient enters.
Always use SICPs and TBPs.
Ensure appropriate personal protection equipment (PPE) is available, e.g. disposable aprons, gloves, facial protection. RPE is required for suspected or confirmed airborne pathogens  please see primary care when do I need to wear a mask?
Ensure hand hygiene facilities are available, e.g. wall mounted liquid soap, paper towels, wall mounted alcohol hand rub or in a pump dispenser.
A foot operated lidded waste bin with a liner should be available and waste disposed of as infectious waste.
Medical devices and care equipment used in the room should be disposable. If reusable items are used, they should be appropriately decontaminated before removal from the room.
Do not use linen pillowcases and ‘modesty’ blankets, couch roll should be used. If a pillow is used, it should be encased in a cleanable plastic case.
Where possible, ensure good ventilation by opening windows.
The isolation room or area used for isolation should be decontaminated, i.e. cleaned, and disinfected, after use. If the room cannot be decontaminated immediately, a notice should be displayed stating ‘Isolation area – awaiting deep clean, do not enter’.
 
PPE required for confirmed or suspected cases is:
FFP3 mask or respirator, that the individual has been fitted for, please see above section for further information.
Apron
Gloves
Eye protection
 
Please see some examples of high-level disinfectant products:
Clinell clorox wipes
PDI sani-cloth Chlor wipes
Clinell peracetic acid wipes
Chlor-Clean tablets
Actichlor Plus tablets
 
For it to be effective, fogging requires stringent cleaning prior to using the machine, so settings should not rely on fogging alone.
 
Should a patient require an inter health and social care transfer, please inform the ambulance service and admitting department, to ensure the appropriate actions and isolation facilities are available when the patient arrives.

After a suspected or confirmed measles case has left a clinical treatment room, the room should be left for a period of time (fallow time) to allow airborne particles to settle and/or be removed from the room through ventilation. The length of time required will vary depending on the number of air changes per hour (ACH) in the treatment room.

In hospital settings, the majority o general wards/single rooms should have at least 6 ACH, the fallow times required in these settings is a minimum of 20 minutes. If the air changes within the room/area are unknown or known to be lower than 6 ACH, the fallow time should be extended.

Measles virus can survive in the air for up to 2 hours, if the ACH in a room are unknown this can be used to guide decision making regarding fallow times.

When reporting the suspected case, please follow advice from the South West Health Protection Team (HPT) (UKHSA), see ’management of single cases’ (page 55) section of UKHSA national measles guidelines. Further information can be found NICE Scenario: Management of measles.

Please see:

• MMR (measles, mumps and rubella) vaccine
• MMR resources for general practice
• Green Book chapter 21: Measles

Taking blood to assess immunity is an occupational health intervention, so staff blood samples should be arranged via an occupational health service only, they cannot be sent straight to the lab.

First, notify the South West Health Protection Team (HPT) (UKHSA) immediately when a case is suspected. Please see section ‘how can I report a suspected measles case?’ above for further information.

Following your notification to UKHSA and if the case is confirmed or thought to be likely measles, you may be asked to follow-up on known exposures in your practice. The key priorities are outlined below.

The National Guidelines for Measles outlines the public health actions for healthcare settings and healthcare workers following exposure by a case of measles, and provides advice on the assessment for PEP for vulnerable contacts who are exposed to measles.

When a known exposure has occurred within a healthcare setting, the key priorities are as follows:

• Identify when (date and times) and where the case attended the setting, in addition to all locations attended and movements within the setting e.g. different rooms, areas, wards, toilets, canteens.
• Identify which patients and those attending with patients, members of the public and/or staff (including volunteers) may have come into contact (as defined in section 3) with the case within the healthcare setting.
• Determine if any person who encountered the case, is in a vulnerable category and requires PEP.
• Confirm if staff or volunteers who encountered the case, have documented evidence of 2 doses of measles, mumps, or rubella (MMR) vaccination or previous measles infection (confirmed by measles IgG test).

When a suspected or confirmed case of measles has attended a healthcare setting, contact tracing efforts should prioritise the identification of these vulnerable contacts and a risk assessment for each of these identified contacts should be undertaken.

Contact tracing should focus on all patients and those attending with patients, members of the public, e.g. visitors/contractors and all staff (including volunteers).

The risk assessment for each identified vulnerable contact and the recommended follow-up action, will depend on their exposure risk and their likely susceptibility.

‘Contact’ with a likely or confirmed case of measles is defined by the National Measles Guidelines as:

• close contacts including household contacts
• face to face contact of any length
• spending more than 15 minutes in a small, confined area. For example, a 4-bed hospital bay, reception area, treatment room

Please see below suggested approach to contact tracing, with support available from UKHSA and system partners including the ICB IPC team:

1. Confirm case’s period of infectiousness (i.e. 4 days before and 4 days after onset of rash, with rash as day 0). Confirm date(s) of the exposure event(s) within the healthcare setting, with UKHSA.
2. Identify the timeline of the case’s movements within the healthcare setting during the exposure event(s). Investigate where, when and the length of time specific locations were attended e.g. reception area, triage, waiting room, ward, consulting room, chapel, restaurant/canteen, shop, pharmacy.
3. Establish if the case had any contact or attended the same specific locations (regardless of exposure duration and size of room) with people who are immunosuppressed. If yes, assess the contact(s) susceptibility and identify actions required using the National Guidelines for measles.
4. Establish if within 6 days from the exposure event, the case had face to face contact of any length or shared a small, confined space for >15 minutes with any pregnant women or infants <12 months. If yes, assess the contact(s) susceptibility and identify actions required using the National Guidelines for measles.
5. If it is not clear who is vulnerable within a defined list of contacts and therefore not possible to conduct an individual contact risk assessment, a warn and inform letter and/or text should be sent to all potential contacts (in conjunction with UKHSA and system partners).
6. Healthcare workers who are exposed to a measles case and do not have satisfactory documented evidence of protection (i.e. 2 doses of the MMR vaccine or previous measles infection), must be excluded from work. The required exclusion periods are outlined in the National Guidelines for measles.
7. If following the contact risk assessment process, it is identified that follow-up actions are required e.g. administering PEP to vulnerable contacts, sending warn and inform messages, then please contact UKHSA.

For urgent queries, please contact UKHSA via 0300 303 8162.
For general public health queries, please contact the public health team via phnotifications@cornwall.co.uk.
For further vaccination and immunisation queries, please contact the NHS CIOS ICB vaccination and immunisation team via email: ciosicb.vaccinations@nhs.net.
Should you have any infection prevention and control additional queries, please fill out Measles additional infection prevention and control queries
For urgent infection prevention and control (IPC) queries, please contact the IPC team via ciosicb.ipc@nhs.net

• MMR resources for general practice
• What to do if you think your child has measles and when to keep them off school
• Confirmed cases of measles in England by month, age and region: 2023
• NHS national infection prevention and control manual
• Guidance for risk assessment and infection prevention and control measures for measles in healthcare settings
• UKHSA National Measles guidelines
• Viral rash in pregnancy
• NICE Clinical Knowledge Summary – Management of measles
• MMR training slide set for immunisers (found under the vaccination subheading)
• Think Measles! UKHSA poster
• YouTube Measles: how infectious is it compared to other illnesses?
• Green Book chapter 21: Measles
• Fit2Fit RPE Fit Test Providers Accreditation Scheme
• Fit Testing in the UK – RPA for all your Fit Testing needs