Health Advisory: Increase in Global and Domestic Measles Cases and Outbreaks

Ensure Children in the U.S. and Those Traveling Internationally (age 6+ months) have MMR Vaccination

March 22, 2024

Action Requested

• Be aware that there has been an increase in global and U.S. measles cases. The Centers for Disease Control and Prevention (CDC) has issued a Health Advisory including guidance on measles prevention for all international travelers aged ≥6 months, and all children aged ≥12 months who do not plan to travel internationally.
  • From January 1 to March 14, CDC has been notified of 58 confirmed U.S. cases of measles across 17 jurisdictions, including seven outbreaks. In comparison, there were 58 total cases and four outbreaks reported the entire year in 2023. 
  • Most cases (93%) were linked to international travel. And most cases have been among children 12 months and older who had not received MMR vaccine. 
  • Many countries, including travel destinations such as Austria, the Philippines, Romania, and the United Kingdom, are experiencing measles outbreaks.
• Healthcare providers, schools, and early childhood education providers should work to ensure students are current with MMR vaccine.
  • Children who are not traveling internationally should receive their first dose of MMR at age 12 to 15 months and their second dose at 4 to 6 years.
• All U.S. residents older than 6 months without evidence of immunity who are planning to travel internationally should receive MMR vaccine prior to departure.
  • Infants aged 6 through 11 months should receive one dose of MMR vaccine before departure. Infants who receive a dose of MMR vaccine before their first birthday should receive two more doses of MMR vaccine, the first of which should be administered when the child is age 12 through 15 months and the second at least 28 days later.
  • Children 12 months (1 year) or older should receive two doses of MMR vaccine, separated by at least 28 days.
  • Teenagers and adults without evidence of measles immunity should receive two doses of MMR vaccine separated by at least 28 days.
• At least one of the following is considered evidence of measles immunity for international travelers: 
  • birth before 1957, 
  • documented administration of two doses of live measles virus vaccine (MMR, MMRV, or other measles-containing vaccine), or 
  • 3) laboratory (serologic) proof of immunity or laboratory confirmation of disease.
• Consider measles as a diagnosis in anyone with fever (≥101°F or 38.3°C) and a generalized maculopapular rash with cough, coryza, or conjunctivitis who has recently been abroad, especially in countries with ongoing outbreaks.
• When considering measles:
  • Isolate: Do not allow patients with suspected measles to remain in the waiting room or other common areas of a healthcare facility; isolate patients with suspected measles immediately, ideally in a single-patient airborne infection isolation room (AIIR) if available, or in a private room with a closed door until an AIIR is available. Healthcare providers should be adequately protected against measles and should adhere to standard and airborne precautions when evaluating suspect cases, regardless of their vaccination status. Healthcare providers without evidence of immunity should be excluded from work from day 5 after the first exposure until day 21 following their last exposure. Offer testing outside of facilities to avoid transmission in healthcare settings. Call ahead to ensure immediate isolation for patients referred to hospitals for a higher level of care.
  • Notify:Report any suspected cases of measles in Snohomish County to the Snohomish County Health Department within 24 hours. 
    • Call 425-339-3503 to reach the Communicable Disease program by phone.
    • Please complete and fax the Communicable Disease Report Form (PDF) and any accompanying lab reports to 425-339-8706. 
  • Test: Follow CDC’s testing recommendations and collect either a nasopharyngeal swab, throat swab, and/or urine for reverse transcription polymerase chain reaction (RT-PCR) and a blood specimen for serology from all patients with clinical features compatible with measles. RT-PCR is available at many state public health laboratories, through the APHL Vaccine Preventable Disease Reference Centers, and at CDC. Given potential shortages in IgM test kits, providers should be vigilant in contacting the Health Department (425-339-3503) for guidance on testing.
  • Manage: In coordination with the Health Department, provide appropriate measles post-exposure prophylaxis (PEP) as soon as possible after exposure to close contacts without evidence of immunity, either with MMR within 72 hours or immunoglobulin within 6 days. The choice of PEP is based on time from exposure or medical contraindications to vaccination.

For more information, see full CDC HAN Alert.

Background

Measles is a highly contagious viral illness and can cause severe health complications, including pneumonia, encephalitis (inflammation of the brain), and death, especially in unvaccinated persons. Measles typically begins with a prodrome of fever, cough, coryza (runny nose), and conjunctivitis (pink eye), lasting 2 to 4 days before rash onset. The incubation period for measles from exposure to fever is usually about 10 days (range 7 to 12 days), while rash onset is typically visible around 14 days (range 7 to 21 days) after initial exposure. The virus is transmitted through direct contact with infectious droplets or by airborne spread when an infected person breathes, coughs, or sneezes, and can remain infectious in the air and on surfaces for up to 2 hours after an infected person leaves an area. Individuals infected with measles are contagious from 4 days before the rash starts through 4 days afterward.

Declines in measles vaccination rates globally have increased the risk of measles outbreaks. Measles is almost entirely preventable through vaccination. MMR vaccines are safe and highly effective, with two doses being 97% effective against measles (one dose is 93% effective). When more than 95% of people in a community are vaccinated, most people are protected through community or “herd” immunity. However, vaccination coverage among U.S. kindergartners has decreased from 95.2% during the 2019–2020 school year to 93.1% in the 2022–2023 school year. Thirty-six states plus D.C. had less than 95% MMR coverage among kindergartners during the 2022–2023 school year. Of states with less than 95% MMR coverage, ten reported more than 5% of kindergartners had medical and nonmedical exemptions, highlighting the importance of targeted efforts at increasing vaccine confidence and access.

The most recent outbreak of measles in Washington State was in Spokane County. 

Resources

• www.snohd.org/measles 
  • Measles information page in additional languages
• www.doh.wa.gov/measles 
• www.cdc.gov/measles
• Immunization Schedules | CDC
• Safety Information for Measles, Mumps, Rubella (MMR) Vaccines | Vaccine Safety | CDC
• For Healthcare Professionals - Diagnosing and Treating Measles | CDC
• Interim Measles Infection Prevention Recommendations in Healthcare Settings | CDC