DEPARTMENT OF HEALTH RELEASES MEASLES IN BROOKLYN ALERT

Dr. Gordon just sent me this alert from the Department of Health:

Dear HAN Subscriber:

We have just released a DOHMH Alert concerning Measles in Brooklyn. It is available on the HAN home page , is appended to this email, and is also attached as a pdf file. To read the attachment, you will need the Adobe reader. If you do not have that software, it can be downloaded at no cost at http://www.adobe.com/products/acrobat/readstep2.html.

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February 25, 2008

2008 DOHMH HEALTH ALERT # 5: Measles in Brooklyn

1) Two measles cases have been identified in a family in Brooklyn. The cases have not travelled outside of New York, indicating exposure to measles within the City.
2) All clinically suspect cases of measles (febrile illness accompanied by generalized maculopapular rash) must be reported immediately (prior to laboratory confirmation) to the New York City Department of Health and Mental Hygiene at (212) 676-2292 or 2313 (weekdays 9 am to 5 pm). For after hours and weekends, please call Poison Control 212-764-7667. Suspect cases of measles must be placed in respiratory isolation immediately.
3) Appropriate clinical specimens should be sent to the NYC DOHMH Public Health Laboratories for testing.

Please Distribute to All Primary Care Staff, Including Infectious Disease, Emergency Medicine, Internal Medicine, Pediatrics, Family Medicine, and Laboratory Medicine and All Infection Control Personnel

Dear Colleagues,

On February 13, 2008, the New York City Department of Health and Mental Hygiene (NYC DOHMH) was notified about a confirmed case of measles. The person had onset of rash on February 7, 2008 (contagious period 2/2-2/12/2008). Subsequently, an unvaccinated household contact developed measles on 2/17/2008. The index case denies international travel and had no known contacts with other measles cases. The Bureau is currently conducting an investigation to try to identify contacts, as well as the source of initial infection.

Endemic measles has not been seen in New York City in several years. The confirmation of a case of measles in a resident of the city without a recent travel history indicates exposure within the city. Currently, there are outbreaks of measles in California, United Kingdom, Belgium, and Israel, as well as endemic measles in much of the developing world. Over the last year, we have seen several cases of recent travelers with measles but up to this point no secondary cases have been identified. The confirmation of a case of measles in an individual without a travel history suggests the possibility of ongoing transmission of measles among non-immune individuals within the city.

Measles is an acute viral illness characterized by a prodrome of fever (101o - 105oF), cough, coryza, conjunctivitis and Koplik's spots (punctate blue-white spots on the bright red background of the buccal mucosa). The measles rash is erythematous, maculopapular and lasts 5-6 days. It usually starts on the face and proceeds down the body to involve the extremities last, including the palms and soles. The maculopapular rash is usually discrete but may become confluent on the upper body. The rash resolves in the same order that it appeared. Complications such as diarrhea, otitis media and pneumonia are frequent in young children.

The diagnosis is confirmed by the serologic testing (ELISA or EIA) of a blood sample for measles-specific IgM antibody. Because IgM may be negative in the first 72 hours after rash onset, negative IgM results in patients that have had a rash for more than 72 hours should be repeated. The IgM response is detectable for approximately one month after rash onset; the IgG response persists for years. The NYC DOHMH, Public Health Laboratory (PHL) is capable of obtaining rapid IgM results, within 12-24 hours. Most measles IgM testing conducted in the City is "sent out" to outside laboratories, and may take as long as a week to obtain results. By notifying NYC DOHMH, we can facilitate more rapid testing. In clinically compatible cases the NYC DOHMH will arrange testing to isolate virus from nasopharyngeal aspirates or throat swabs.

The NYC DOHMH recommends that measles vaccine be administered to susceptible persons within 72 hours of measles exposure to interrupt or prevent measles transmission. Susceptible household contacts of patients with measles, children less than 1 year of age, pregnant women and high risk immunocompromised persons should be given immune globulin rather than vaccine, within 6 days of exposure, to prevent or modify measles. Please note that immune globulin should not be given to household contacts who have received 1 dose of vaccine at 12 months of age or older unless they are immunocompromised; these children should receive a second dose of MMR. The recommended dose for immune globulin is 0.25mL/kg of body weight intramuscularly; immunocompromised children should be given 0.50 mL/kg. Note that use of immune globulin may require a delay in vaccination of infants when they reach 1 year of age.

The successful initiation of measles post-exposure prophylaxis (PEP) requires rapid intervention. One of the major delays in institution of measles PEP is delayed reporting. Clinically suspect cases of measles must be reported immediately to the NYC DOHMH. Reports should be made at time of initial clinical suspicion. If you are considering the diagnosis of measles and are ordering diagnostic testing for measles then you should report the case at that time. In addition, NYC DOHMH can facilitate rapid measles IgM testing and results through the PHL.

Specimens should be collected on all suspected cases and delivered to the NYC DOHMH Public Health Laboratory at 455 1st Ave, New York, NY 10016. During weekdays from 9 AM to 5 PM, the specimens should be dropped off at the Central Specimen Receiving and Shipping Unit, Room 136 (for questions about specimen collection call: 212-447-6112 or -6156). After business hours specimens will be placed into appropriate storage until the next work day. Blood samples for testing should be drawn into red-topped vacutainer tubes (no additives) and centrifuged. They can be stored overnight in a refrigerator (not frozen!), if necessary. Urine samples, nasopharyngeal aspirates and throat swabs can also be refrigerated overnight. Blood samples should be transported to the lab on ice. Shaking and thawing should be avoided because they lead to hemolysis. After hours and on weekends, specimens should be refrigerated (not frozen) and blood should be centrifuged prior to refrigeration. Notify the Bureau of Immunization at the numbers given below.

Fever/rash illness may also be caused by other infections that are also contagious and require isolation; two examples are rubella and varicella zoster virus infection. A high index of suspicion must be maintained to avoid transmission to other patients.

In summary:
1) Report all suspect measles cases (febrile illness accompanied by generalized maculopapular rash) immediately (DO NOT WAIT FOR LABORATORY CONFIRMATION) to the Bureau of Immunization at 212-676-2292, x2313, or if after hours to Poison Control 212-764-7667;
2) Place all patients with suspected measles in respiratory isolation immediately;
3) Obtain clinical specimens for diagnostic testing from blood (for both IgM and IgG to measles), urine, nasopharyngeal aspirates, or throat swabs, and send for testing at the NYC DOHMH Public Health Laboratory.
4) Offer measles vaccine or immune globulin to susceptible exposed contacts.

Please contact the Bureau of Immunization if you have any questions (during business hours: 212-676-2284; after hours, contact the Poison Control Center at 212-764-7667). As always, your cooperation is appreciated.

Sincerely,

Christopher M. Zimmerman, MD, MPH 
Director of Epidemiology and Surveillance
Bureau of Immunization
Division of Disease Control

Jane R. Zucker, MD, MSc
Assistant Commissioner
Bureau of Immunization
Division of Disease ControlDear HAN Subscriber: