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The following infection control definitions and guidelines are derived from documents and guidelines produced by the Health Protection Agency in the UK, the Centers for Disease Control and Prevention in the USA, the American Academy of Paediatrics and recent documents issued by the Auckland Regional Public Health Service. For up to date information on the number of cases of Measles in the Auckland area see the website of the Auckland Regional Public Health Service (www.arphs.govt.nz.)
Exposed persons are defined as those who enter the same room or work-space as a person who has Measles infection or who enter the room or work-space within two hours of the infected person leaving (the “two hour” rule does not apply to negative pressure rooms)
This definition does not apply in either of the following circumstances:
Persons at high risk of developing Measles complications:
- Koplik’s spots on buccal mucosa
Laboratory confirmation of Measles infection requires either Measles virus detection by PCR or detection of Measles IgM by serological testing
1. Managing patients with Measles
Patients with laboratory confirmed Measles and patients meeting the clinical case definition for Measles should be managed with Airborne Precautions during the “period of infectivity” (see above). If the patient is immunocompromised (including pregnant women), Airborne Precautions should continue for the entire duration of illness.
2. Managing Staff
3. Managing non-immune exposed patients
See Appendix 1 for guidelines around dosing of Human Normal Immunoglobulin (HNIG) and intravenous immunoglobulin (IVIG) and Appendix 2 for flow chart summary of approach to post-exposure prophylaxis)
1. Immunocompetent patients and staff
· Non-immune, immunocompetent, non-pregnant adults should be offered MMR irrespective of time since exposure
· Non-immune immunocompetent children >1 year should be offered MMR irrespective of time since exposure
The second dose should be given one month after the first
2. Immunocompromised patients (see Appendix 3)
· Measles immune status of “Group A” immunocompromised inpatients (see Appendix 3 for definition) should be determined prior to exposure
· Non-immune immunocompromised patients >12 months of age should be considered for use of immunoglobulin if within 6 days of exposure.
Discuss with the clinical team caring for that patient
· Patients with severe defects of cell-mediated immunity >12 months of age should be considered for use of immunoglobulin if within 6 days of exposure irrespective of whether IgG
can be detected
3. Pregnant patients / staff
· The Measles immune status of pregnant patients should ideally be determined prior to admission to hospital
· Non-immune pregnant patients or staff should be considered for use of immunoglobulin if within 6 days of exposure.
Discuss with the clinical team caring for that patient
· Pregnant patients or pregnant staff who have had at least one previous dose of MMR do not require immunoglobulin
· Exposed infants 6-12 months of age
If immunocompromised discuss use of immunoglobulin with the clinical team caring for that patient if within 6 days of exposure
If immunocompetent offer MMR if within 72 hours of exposure. Alternatively, if within 6 days of exposure, discuss use of immunoglobulin with the clinical team caring for that patient
· Exposed infants <6 months of age
If the Mother is non-immune and exposure occurred less than 6 days earlier, discuss use of immunoglobulin with the team caring for that patient
Premature infants <28 weeks gestation should be considered non-immune irrespective of maternal immune status.
NHIG dosing for Measles post-exposure prophylaxis
According to the New Zealand Blood Service, the level of measles-specific antibody in NHIG is lower than recommended (between 14-16 IU/ml). This is lower than the concentration recommended by the British Pharmacopoeia (50IU/ml). The current MedSafe-approved datasheet for NHIG recommends a dose of 0.2mL/kg for measles post exposure prophylaxis. However, because of the low concentrations of Measles-specific antibody in NHIG at the present time, new doses of NHIG are recommended below. These doses are likely to be amended following further testing of the level of measles-specific antibody in NHIG.
IVIG Dosing for Measles post-exposure prophylaxis
IVIG (Intragam®P) can be considered for immune suppressed measles contacts (who may for example have a central venous catheter) or in patients who require large doses.
The recommended dose of intravenous immunoglobulin is 0.15g/Kg.
See the revised guidance from the Health Protection Agency for further information:
If there are further queries can be directed to the New Zealand Blood Service medical team via the district health board blood bank.
NOTE – If patient is immunocompromised, refer also to Appendix 3.
The following is adapted from  UK guidelines updated May 2009 – full reference available at http://www.hpa.org.uk/web/HPAwebFILE/HPAweb_C/1238565307587
All immunocompromised patients are at risk of severe measles and should be considered for post-exposure prophylaxis with NHIG or IVIG following exposure to measles. However some patients with immunosuppression will have immunity due to past infection or vaccination and measurable levels of measles-specific serum IgG. For patients with severe defects of cell mediated immunity passive immunoglobulin may be indicated even in the presence of measurable antibody.
Group A: These patients may have developed an adequate response to vaccination or measles during childhood therefore their measles status needs to be established prior to exposure (for example at the next out-patient appointment) so that post-exposure prophylaxis can be informed.
This group includes most patients with immunosuppression and is listed below:
For those with unknown status at the time of exposure, management is on the basis of vaccine history and where possible, rapid antibody testing. If measles IgG is negative or unknown Group A should receive immunoprophylaxis with NHIG or IVIG as outlined earlier.
Group B: This group includes patients who are unlikely to have developed or to maintain adequate antibody levels from past exposure or vaccination. This group would include:
It is recommended that, unless already on replacement immunoglobulin therapy, Group B patients should receive immunoglobulin
Use of vitamin A in children with acute measles infection
The World Health Organization currently recommends vitamin A for all children with acute measles, regardless of their country of residence. Vitamin A for treatment of measles is administered once daily for 2 days at the following doses:
All hospitalised children with measles should be given Vitamin A and available formulations require Paediatric Pharmacy input.