Minimum Period of Isolation of Patient
Through the 4th day after the onset of rash (counting the day of rash onset as day zero).
Minimum Period of Quarantine of Contacts
Students and staff born in or after 1957, who are not appropriately immunized and do not have serologic evidence of immunity, will be excluded from school from the 5th through the 21st day after their exposure. If exposure was continuous and/or if multiple cases occur, susceptibles will be excluded through the 21st day after rash onset in the last case. Healthcare workers who are not appropriately immunized and do not have serologic evidence of immunity will be excluded from work from the 5th day after their first exposure through the 21st day after their last exposure. These restrictions for students, school staff, and healthcare workers apply even if they had received IG.
A. Protection of Contacts of a Case
- Implement control measures before serologic confirmation.
- Inquire about contact with a known or suspected case or travel during the measles exposure period (8–18 days prior to onset).
- Isolate the case during his/her infectious period, as defined above.
- Identify all those exposed. Think in terms of the “zones of exposure” and consider members of the following groups, if they were in contact with the case during his/her infectious period.
- Household members
- School/child care contacts (students and staff)
- Staff and patients at medical facility where patient was seen (including staff with and without direct patient contact)
- Individuals at workplace of case (especially child care centers, schools, and medical settings)
- Members of the same religious/social groups
- Members of sports teams, or other extracurricular groups
- Bus or carpool associates
- Close friends
- Persons potentially exposed at social events, travel sites, etc.
Note: Measles is so contagious that sometimes everyone at an entire institution is considered exposed.
- Identify high-risk susceptibles with whom the case had contact during his/her infectious period. Pregnant women, immunocompromised individuals, and infants < 12 months old should be referred to their healthcare provider.
- Identify all other susceptibles, that is, individuals without proof of immunity as defined below:
- Born in the United States before January 1, 1957 (Year of birth as proof of immunity does not apply in healthcare settings); or
- Two doses of measles containing vaccine, given at least 4 weeks apart, with both doses administered at >12 months of age; or
- Serologic proof of immunity.
- Documentation of physician-diagnosed measles
- Foreign-born individuals must have documentation of immunization or serologic proof of immunity. “Born before 1957” is not acceptable (see below for explanation).
- Susceptibles include those with medical and religious exemptions to immunization.
Year of Birth as Proof of Immunity—Epidemiologic data indicate that most individuals born in the United States before January 1, 1957 are immune to measles. This has not been found to apply to those born in other countries, where the epidemiology of measles is not well known and where measles immunization may not have been routine.
Exceptions to the “1957 Rule” are employees in healthcare settings. Because persons born before 1957 have acquired measles in healthcare settings, vaccination of these older employees, including those who are United States-born, with 1 dose of measles, mumps, rubella (MMR) vaccine is recommended. Data suggest that healthcare personnel have a risk of acquiring measles that is 13-fold greater than that of the general population. Measles is highly transmissible and frequently misdiagnosed during the prodromal stage. It is essential that all healthcare personnel have documentation of measles immunity, regardless of their length of employment or whether they are involved in patient care. Although persons born before 1957 are generally considered to be immune to measles, serologic studies indicate that 5% - 9% of healthcare personnel born before 1957 may not be immune.
- Immunize all susceptibles. All susceptibles >12 months of age, for whom vaccine is not contraindicated, must be immunized, keeping in mind the following:
- MEASLES VACCINE GIVEN WITHIN 72 HOURS OF EXPOSURE CAN PREVENT DISEASE.
- The combined MMR vaccine is the preferred formulation for all those >12 months of age. It will provide additional protection against mumps and rubella.
- Vaccinating an individual who may be incubating measles is NOT harmful.
- Vaccinate susceptibles even if it is >72 hours post-exposure. It will protect against exposure to the next potential generation of cases. In addition, the situation should be viewed as an opportunity to vaccinate.
- Immunization during an outbreak. During an outbreak, MMR may be given. However, seroconversion rates after MMR immunization are significantly lower in children immunized before the first birthday than are seroconversion rates in children immunized after the first birthday. Therefore, children immunized before their first birthday should be reimmunized with MMR at 12-15 months old (at least 4 weeks after initial measles immunization) and again at school entry (4-6years).
- Consider recommending immune globulin (IG) for susceptibles with contraindications to measles vaccine if it is within 6 days of exposure. IG may be used within 6 days of exposure for susceptible household or other contacts for whom risk of complications is very high (particularly contacts under 1 year old, pregnant women without evidence of immunity or immunocompromised persons), or for whom measles vaccine is contraindicated.
Live measles vaccine should be given 5-6 months later to those for whom vaccine is not contraindicated.
- Isolation/exclusion (non-healthcare settings):
Isolate and exclude the case during his/her infectious period (from 4 days before through 4 days after rash onset, counting the day of rash onset as day zero). He/she may return to normal activities on the 5th day.
Criteria for isolation/exclusion of cases are more rigorous for immunocompromised individuals and for others in healthcare settings.
Susceptibles include all unvaccinated individuals without proof of immunity as specified in sections 5 and 6 above, including:
- Medical/religious exemptions
- Individuals who have other contraindications to MMR vaccine
- Those vaccinated >72 hours post exposure.
- Those that received IG will be assessed on an individual basis
Quarantine susceptibles on days 5–21 post exposure.
Several criteria are used to determine when to quarantine susceptible contacts, and when they can return to normal activities, as outlined below.
- If there was a discrete (one-time) exposure—quarantine on days 5 through 21 from that exposure. They may return to normal activities on the 22nd day.
- If there was continuous exposure— quarantine on days 5 through 21 from the day of rash onset in the case. (However, in healthcare settings, exclusion must begin 5 days after the earliest exposure and extend through 21 days from the last exposure.) They may return to normal activities on the 22nd day.
- If there is more than one case of measles—susceptibles will need to be quarantined until 21 days after the onset of rash in the last reported case in the outbreak setting. They may return to normal activities on the 22nd day.
Summary of Measles Exclusion Requirements
Case and Symptomatic Contacts
Isolate through the 4th day after rash onset (count day of rash onset as day zero). They may return to normal activities on the 5th day.
One case: Quarantine susceptibles for 5–21 days post-exposure.
Multiple cases: Quarantine susceptibles for 21 days from date of rash onset in last case.
Healthcare settings: Exclude or quarantine susceptibles from 5 days after the earliest exposure through 21 days after the last exposure.
- Conduct surveillance for 2 incubation periods after rash onset in the last case or the last exposure in the setting, whichever is later.
B. Managing Special Situations
- School Settings
Remember to determine if there are any:
- Pregnant teachers, staff (including those without direct contact with students) and students (do not forget about student teachers) anywhere in the school.
- Immunocompromised individuals among the students, teachers and staff anywhere in the school.
- Medical/religious exemptions anywhere in the school, among both students and staff. It is particularly important to identify these individuals in the classroom and grade of cases. Remember, these susceptible individuals must be excluded from attending school until 2 incubation periods after the last case.
- Susceptible contacts, including those in classrooms, extracurricular activities, and other settings, who have already received one dose of MMR and receive a second dose of measles vaccine within 72 hours of exposure, can be readily readmitted; otherwise, they should be excluded as discussed above.
- In some settings, individuals who have received their first or second dose >72 hours post exposure, but within a specified time period (as determined by the Iowa Department of Public Health and with the local board of health), may be allowed to continue to attend classes.
If multiple cases occur, guidelines may be revised to include other classrooms and their teachers.
Interactions in sports and other extracurricular activities facilitate the spread of measles. Additional recommendations to prevent the spread of measles between schools can be found in the table below, “Control Guidelines for Sports Teams and Extracurricular Groups.”
Iowa Department of Public Health
Control Guidelines for Sports Teams and Extracurricular Groups
Control guidelines DIFFER and are dependent on whether measles is currently occurring at your institution. Schools without cases, but that will be involved with an institution that is experiencing cases, also need to follow control guidelines. Please refer to the appropriate category below for the recommendations for your facility.
A. At the School where Measles Cases Are Reported:
1. All students, staff, supporters and media personnel leaving to attend activities at other schools or participating in sports or other group activities at your school must have proof of immunity as defined below:
- Born in the United States before January 1, 1957, or
- Two doses of measles vaccine with both doses administered at >12 months of age, given at least 4 weeks apart (the second dose must have been given before the rash onset of the first case, or within 72 hours of exposure to the known case), or
- Serologic proof of immunity
- Documentation of physician-diagnosed measles
If the second dose of measles-containing vaccine is given >72 hours after the onset of the first case, the student must wait 21 days before participating in sporting events or traveling to another school. If multiple cases occur, the student must wait until 21 days after the onset of rash in the last reported case in the outbreak setting.
2. Notify the schools to which students are traveling and inform them of:
- The cases or suspected cases at your school
- The immune status of your students and staff who will be traveling to the other school
B. Schools without Measles Cases Receiving Students from or Traveling to a School with Measles Cases:
All students, staff, supporters and media personnel, participating in activities with students from a school with cases, must have proof of immunity as defined below.
- Born in the United States before January 1, 1957, or
- Documentation of physician-diagnosed measles
- Two doses of measles vaccine with both doses administered at >12 months of age, given at least 4 weeks apart (as outlined above), or
- Serologic proof of immunity
- Healthcare Settings
Recommendations for healthcare facilities are more rigorous.
a. Proof of immunity—The risk of acquiring measles in medical settings is up to 13-fold higher than in other settings. Therefore, documentation of immunity is extremely important.
- All staff born on or after January 1, 1957 should have proof of two doses of measles vaccine or serologic proof of immunity, with a second dose having been given <72 hours after exposure.
- Medical personnel born before January 1, 1957 have acquired measles from cases in medical facilities. Therefore, strong consideration should be given to requiring at least one dose of measles vaccine for staff born before 1957. Vaccinating immune persons is not harmful.
- In special high-risk healthcare settings such as transplant, oncology, neonatal units, etc., exclusion criteria should be even more rigorous. Infection prevention personnel may wish to exclude all susceptible personnel even if they have been immunized within 72 hours.
b. Initial management of patients with febrile rash illness—Assess and screen all patients with febrile rash illness, either prior to or immediately on arrival at the intake area.
- Escort patients to a separate waiting area or place immediately in a private room.
- Both patients and staff should wear appropriate masks/respirators (masks for patients to prevent generation of particles, and respirators for staff, if possible, to filter airborne particles).
- If not admitted, maintain airborne precautions (including while patient is exiting the facility, e.g., separate exit). Patients should be instructed to remain in isolation at home, through 4 days after rash onset (with onset of rash being day zero).
- Measles virus can remain suspended in the air for up to 2 hours. Therefore, we recommend that susceptible patients NOT be placed in a room, which has been occupied by a suspect case for 2 hours following the case’s exit from that room.
c. Infectious period
- Cases are considered to be infectious from 4 days before rash onset through 4 days after rash onset, counting the day of rash onset as day zero. Therefore, cases are considered infectious for a total of 9 days.
- Immunocompromised patients may have prolonged excretion of viral particles in their secretions, and should be considered infectious for the duration of their illness.
d. Exclusion/isolation of cases
- Personnel who become sick should be excluded from work for 4 days after they develop a rash consistent with measles. They may return on the 5th day.
- If admitted, patients should be on airborne precautions (in addition to standard precautions) while infectious (4 days before rash onset through 4 days after rash onset) in a negative pressure room. They may be taken off isolation on the 5th day.
- If not admitted, patients should maintain respiratory isolation while exiting the facility, e.g., mask, separate exit, and remain in isolation at home through 4 days after rash onset. They may return to normal activities on the 5th day.
e. Exclusion/isolation of contacts—The exclusion periods are extended in the healthcare setting.
The above recommendations are summarized in the table below, "Measles Control in Medical Settings."
Iowa Department of Public Health
Measles Control in Medical Settings
This table summarizes additional control measures to decrease nosocomial measles transmission.
1. Assess and screen all patients with rash illness or with other potential airborne diseases, prior to arrival at intake area, i.e. outside.
2. Escort patients to a negative pressure private room.
3. Both patients and staff should wear appropriate masks/respirators (masks for patients to prevent generation of particles, and respirators for staff, if possible, to filter airborne particles).
4. If admitted: maintain on airborne precautions (in addition to standard precautions) while infectious in a negative pressure room. (Patients are considered infectious for 4 days before through 4 days after rash onset, counting the day of rash onset as day zero.)
5. If not admitted: maintain respiratory isolation, including while patient is exiting the facility, (e.g., mask, separate exit). Ideally the patient would be assessed outside of the healthcare facility. Patient should remain in isolation at home through 4 days after rash onset, counting the day of rash onset as day zero. The patient may resume normal activities on the 5th day.
6. Avoid placing susceptibles in a room, which has been occupied by a suspect case for 2 hours following the case’s exit.
7. Identify all contacts among patients and staff:
- This includes patients and families in the waiting and examination rooms up to 2 hours after index case was present;
- Includes all staff both with and without direct patient contact;
- Due to airborne route of transmission, those exposed often include everyone at the entire facility.
8. Identify susceptibles (particularly high-risk susceptibles) and offer:
- MMR as soon as possible but within 72 hours of exposure (will most likely prevent illness if given in this window), or
- For high-risk susceptibles and those ineligible for vaccination, IG as soon as possible but within <6 days after exposure (may modify or prevent illness, but a recipient can still be considered infectious)
9. Notify infection prevention, employee health, department heads and the healthcare providers of exposed patients.
10. Exclusion of susceptibles:
- All staff born in or after 1957, who have not received a second dose of measles vaccine <72 hours post exposure, must be excluded from 5 days after their earliest exposure through 21 days after their last exposure to the case during his/her potential infectious period.
- All staff born before 1957 that have not received 1 dose of MMR <72 hours post exposure must be excluded 5 through 21 days post exposure.
- Staff who contract measles should be excluded for 4 days after their first day of rash onset.
In special high-risk healthcare settings such as transplant, oncology, neonatal units, etc., exclusion criteria should be even more rigorous. Infection prevention personnel may wish to exclude all susceptible personnel even if they have been immunized within 72 hours.
- Management and MMR Vaccination of HIV-Infected Individuals and their Contacts
The American Academy of Pediatrics (AAP) and the Advisory Committee on Immunization Practices (ACIP) have recently revised their recommendations regarding the management of HIV-infected individuals exposed to measles, as well as the routine MMR immunization of those with HIV infection, particularly those with severe immunosuppression. These guidelines, applicable to children and adults, are summarized below.
a. Management of HIV-Infected Individuals Exposed to Measles
1) MMR or IG should be given, depending on the situation:
- Asymptomatic HIV-infected individuals who are not severely immunosuppressed(i.e., with higher age-specific CD4+ T-lymphocyte counts or percentages than those in the table on the next page), if susceptible and exposed < 3 days prior should receive MMR vaccine.
- Asymptomatic HIV-infected individuals who are not severely immunosuppressed(i.e., with higher age-specific CD4+ T-lymphocyte counts or percentages than those in the table on the next page), if susceptible and exposed 3–6 days prior should receive 0.25cc/kg IM immune globulin (maximum 15cc). Live measles vaccine should be given 5-6 months later to those for whom vaccine is not contraindicated.
- Symptomatic HIV-infected individuals who are severely immunosuppressed(as defined in the table on the next page), regardless of past history of immunizations or disease, unless they have recent serologic proof of immunity should receive IG 0.5cc/kg IM (15cc max).
2) If an individual has received intravenous immune globulin (IVIG) (400 mg/kg) < 3 weeks before exposure, no additional IG is required. However, some experts recommend an additional dose of IVIG if > 2 weeks have elapsed since last treatment. (Remember, when deciding to vaccinate these individuals, MMR vaccine should be given > 2 weeks before any IG or other blood products.)
b. Management of Contacts of HIV-Infected Individuals Who Are Themselves Exposed to Measles
- If they are susceptible and exposed < 3 days prior, they should receive MMR vaccine. There is no shedding from the MMR vaccine.
- If they are susceptible and exposed 3–6 days prior, they should receive IG and live measles vaccine should be given 5-6 months later to those for whom the vaccine is not contraindicated.
c. General Guidelines for the Use of MMR Vaccine in HIV-infected and Potentially HIV-infected Individuals
1) Prevaccination HIV testing is NOT recommended.
2) MMR vaccine is recommended for routine immunization of individuals with asymptomatic HIV infection who do not have evidence of severe immunosuppression.
3) MMR vaccine should be considered for all symptomatic HIV-infected persons who do not have evidence of severe immunosuppression, as defined in the table below.
4) It is now recommended that severely immunocompromised HIV-infected individuals (as defined by low CD4+ counts or low percent of CD4+ circulating lymphocytes—see table below) should NOT receive MMR or other measles-containing vaccines.
Measles-containing vaccines are contraindicated for HIV infected individuals with the following:
Total CD4+ Count
CD4+ as a % of Total Lymphocytes
< 12 mo.
> 13 years
5) It is now recommended that severely immunocompromised HIV-infected individuals (as defined by low CD4+ counts or low percent of CD4+ circulating lymphocytes—see above table) should NOT receive MMR or other measles-containing vaccines.
6) Since the immunologic response to vaccines is often poor in HIV-infected patients, the first dose of MMR should be given as early as possible after 12 months old. This will increase the chance of an adequate immune response, before further deterioration of the immune system.
7) Give the second dose of MMR 4 weeks after the first. This will increase the likelihood of seroconversion.
8) During outbreak situations only, consider giving the first dose of monovalent measles vaccine or MMR if monovalent is unavailable at 6–11 months of age to those infants who are not severely immunocompromised. Remember, these children must be revaccinated with 2 doses of MMR beginning at 12 months of age.
C. Preventive Measures
Personal Preventive Measures/Education
Vaccination, including routine childhood vaccination, catch-up vaccination of adolescents, and targeted vaccination of high-risk adult groups (including international travelers), is the best preventive measure against measles. It is particularly important to vaccinate susceptible household contacts of high-risk susceptibles who cannot themselves be vaccinated, such as immunocompromised individuals, pregnant women, and infants. Good personal hygiene (which consists of proper handwashing, disposal of used tissues, not sharing eating utensils, etc.) is also important in preventing measles.
Please refer to the most current versions of the Advisory Committee on Immunization Practices (ACIP) statement on measles, rubella, and mumps.
Iowa Dept. of Public Health, Reviewed 12-13