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Series of National Guidelines (SoNGs)

Measles
National guidelines for public health units

The Series of National Guidelines have been developed in consultation with the Communicable Diseases Network Australia and endorsed by the Australian Health Protection Committee. Their purpose is to provide nationally consistent advice and guidance to public health units in responding to a notifiable disease event. These guidelines capture the knowledge of experienced professionals, build on past research efforts, and provide advice on best practice based upon the best available evidence at the time of completion.

In this section:

Communicable disease factsheet

Print friendly version of Measles: National guidelines for public health units (includes the Investigation form) (PDF 188 KB)

Endorsed by CDNA: 29-30 July 2008
Endorsed by AHPC: OOS item, September 2008
Released by DoHA: 19 February 2009

Revision history
Version
Date
Revised by
Changes
1.0 19 February 2009 VPDS, OHP Updated URL links, and addition of link to state and territory legislation

Disclaimer

The guidelines are necessarily general and readers should not rely solely on the information contained within these guidelines. The information contained within these guidelines is not intended to be a substitute for advice from other relevant sources including, but not limited to, the advice from a health professional. These guidelines are intended for information purposes only. The membership of the Communicable Disease Network Australia (‘CDNA’) and the Commonwealth of Australia (‘the Commonwealth’), as represented by the Department of Health and Ageing, does not warrant or assume any legal liability or responsibility for the accuracy, completeness, or usefulness of any information, or process disclosed at the time of viewing by interested parties.

The CDNA and the Commonwealth expressly disclaim all and any liability to any person, in respect of anything and of the consequences of anything done or omitted to be done by any person in reliance, whether in whole or in part, upon the whole or any part of the contents of this publication.



1. Summary

Public health priority

  • Urgent.

    Case management

  • Laboratory confirmation should be sought in all sporadic cases.
  • Cases should not attend school/preschool/child care/work from onset of symptoms to 4 days after onset of rash and should stay home (unless isolated in hospital). Cases should avoid contact with susceptible persons.

    Contact management

  • Recommend either immunisation or normal human immunoglobulin to defined contacts where indicated.
  • Exclude unimmunised contacts from school/preschool/child care.
  • Ask contacts to be alert for signs and symptoms of measles and advise those who develop symptoms to call ahead before seeking medical advice (so as to avoid common waiting areas in doctors’ rooms or Emergency Departments [EDs]), and to telephone the local Public Health Unit.
  • Ask hospital EDs, GPs, school principals and child care directors to notify new cases promptly.
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    2. The disease

    Infectious agents

    The measles virus, a member of the genus Morbillivirus (paramyxovirus).

    Mode of transmission

    Measles is transmitted by airborne droplets and direct contact with discharges from respiratory mucous membranes of infected persons and less commonly by articles freshly soiled with nose and throat secretions. It is highly infectious.

    Timeline

    The incubation period is variable, about 10 days (varying from 7 to 18) to the onset of fever and about 14 days to the onset of the rash.

    Infectious period

    A rule of thumb is that measles is infectious 5 days before, to 4 days after, the appearance of the rash. However in cases with a clear history of time of onset of prodromal illness, the infectious period should be considered commencing 24 hours prior to the onset of prodromal symptoms.

    Clinical presentation

    The disease is characterised by a prodrome that usually lasts 2 to 4 days and includes fever followed by conjunctivitis, coryza and cough. Koplik spots may be present on the buccal mucosa. A characteristic maculopapular rash appears about 2 to 7 days after the onset of the prodrome, and begins on the face or upper neck, spreads to become generalised and lasts 4 to 7 days. The rash is not itchy. Cases are usually miserable, and complications such as middle ear infection, bronchopneumonia and encephalitis can follow. Infection in pregnancy can be severe for the woman and can result in increased risk of premature labour or spontaneous abortion. Although there is no association with congenital abnormalities, congenital measles infection can occur if the infection is contracted late in pregnancy. Prophylaxis and specialist care are required in these cases.

    3. Risk assessment

    Routine prevention activities

    Measles vaccine, as MMR, is currently recommended as part of the National Immunisation Program schedule for all children at ages 12 months and 4 years. However in the future the 9th edition of The Australian Immunisation Handbook (in press) will recommend MMR at ages 12 months and 18 months.

    Persons considered susceptible to measles are those who were born in or after 1966 who have neither serological evidence of measles immunity nor documented evidence of receiving two doses of measles containing vaccine. Two doses of MMR, given at least 4 weeks apart, are recommended for susceptible persons.

    Threat and vulnerability

    Until the mid 1960s, most Australian children were infected with wild measles. With increasing uptake of measles vaccine since the 1960s, the introduction of a 2-dose schedule in 1980s, and the school-based national Measles Control Campaign in the 1990s, transmission of measles was interrupted throughout Australia by the late 1990s. The Australian Childhood Immunisation Register (ACIR) and its related incentives for GPs and parents have improved immunisation rates in recent years to 94% of 2 year olds and 89% of 6 year olds in 2007. Serological surveys indicate that immunity is high (98%) in people born before 1968 due to exposure to wild measles, but lower (89%) in people born 1974-1980 due to less frequent exposure to wild virus or vaccine. Although measles is no longer endemic in Australia, measles continues to circulate internationally ensuring that it will be reintroduced from time to time, with the potential to cause small to moderate outbreaks. The risk of outbreaks may increase in the future as the pool of susceptible people grows.
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    Risk mitigation


    Achieving and maintaining high rates of immunity to measles throughout the population is the mainstay of measles control in Australia, both through routine immunisation of children, and the promotion of immunisation in people born in or after 1966. Control of measles outbreaks relies on an effective and sensitive surveillance system to identify cases early and allow public health control measures, including case isolation, contact tracing and protection, and promotion of immunisation in susceptible groups.

    4. Surveillance objectives

  • To identify cases and their contacts in order to prevent further spread
  • To monitor the epidemiology of measles in Australia and so inform the development of better prevention strategies
  • To monitor progress towards regional measles elimination targets
  • To monitor maintenance of Australia’s measles-free status.

    5. Data management

  • Suspected, probable and confirmed cases should be entered onto the notifiable diseases database, ideally within 1 working day following notification. The date of onset is the onset of illness, not of the rash.
  • Enter information on viral typing (if done) on notifiable diseases database within 3 working days of receipt of results.
  • Cases subsequently shown not to have measles should be removed from notifiable diseases database within 1 working day.
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    6. Communications

  • As soon as is practicable and ideally within 1 working day following notification:
  • Notify the State/Territory Communicable Diseases Branch (CDB) of the case’s age, sex, date of onset, vaccination history, laboratory status, likely source of infection, other people at risk of infection and follow up action taken.
  • The State/Territory CDB should notify the case details and response plan to the CDNA secretariat.
  • Where there are cases or contacts among people from overseas, the State/Territory CDB should notify the Commonwealth Department of Health and Ageing’s National Incident Room (via Health Ops) who will comply with the International Health Regulations reporting requirements.
  • For outbreaks with the potential to involve multiple jurisdictions, the State/Territory CDB should liaise with the chair of CDNA and determine whether an urgent teleconference should be convened.

    7. Case definition

    The current national surveillance measles case definition can be found at: www.health.gov.au/casedefinitions
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    8. Laboratory testing

    Since recent MMR immunisation affects some laboratory tests, the results should be interpreted in the context of the clinical findings. The clinical diagnosis of measles may be confused with other diseases such as rubella, roseola, scarlet fever, human parvovirus infection, enterovirus, adenovirus, HIV, Kawasaki disease and some arboviral infections, so laboratory definitive evidence should be sought for all sporadic suspected cases.

    Testing guidelines

    Public Health Laboratory Network (PHLN) provides information on the laboratory diagnoses of measles. This is available at: www.health.gov.au/internet/main/publishing.nsf/content/cda-phln-pubs-measles.htm

    For sporadic cases:
  • Patients seen within 1 week of onset of rash should have respiratory and urine samples collected for direct detection (immunofluorescence or PCR) and culture, and clotted blood collected for serology (also see Case investigation below).
  • Patients seen between 1 week and 3 weeks after the onset of rash should have clotted blood collected for serology and a respiratory and/or urine sample for PCR.
  • Patients seen more than 3 weeks after onset of rash should only have clotted blood collected for serology.

    In an established outbreak, laboratory confirmation by isolation or measles antigen/genome detection should be obtained on at least two cases, but may not be necessary for cases who meet the clinical case definition and have a clear epidemiological link to a confirmed case. Serological confirmation is encourage for these cases.

    The reliability of serological and direct detection tests for asymptomatic contacts is unknown. Testing of asymptomatic contacts is not recommended.

    Measles serology

  • An IgM response will be present in approximately 75% of measles cases 3 days after rash onset, rising to approach 100% after 7 days. A measles IgG antibody test should preferably be performed together with the IgM assay to aid interpretation.
  • Measles-specific IgM is a sensitive and specific marker of recent measles infection, but can also be detected for 1 to 2 months following immunisation.
  • A negative result does not rule out a diagnosis of measles if the sample was taken earlier than 72 hours after onset of the rash. When no measles IgM or IgG antibody is detected in a sample collected within 3 days of rash onset from a suspected case of measles, repeat testing is recommended after 7 days. (Alternatively, a measles PCR could be requested upon the sample – see below.)
  • False positive measles IgMs can also occur, and if suspected, the IgM test should be repeated. For sporadic cases, results should be confirmed, ideally by a reference laboratory using the Dade Behring assay.
  • Where a false negative or false positive IgM result is suspected, testing for measles specific IgG seroconversion by EIA on paired sera collected 10-14 days apart is helpful.
  • Testing paired sera using the complement fixation test (which expresses results in titres) may also be helpful, especially in cases with a history of measles vaccination.
  • A 5 mL tube of clotted blood is the preferred specimen for serological testing.
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    Measles culture and immunofluorescence

  • Measles virus may be identified by cell culture from blood, conjunctival swab, throat swab, nasopharyngeal swab or aspirate if taken within 5 days of the onset of the rash, and from urine for up to 10 days after the onset of rash. Antigen testing by immunofluorescence may also be performed on respiratory or urine samples collected during the prodrome or in the first few days after rash onset. Any isolate or immunofluorescence positive material should be referred to the Victorian Infectious Diseases Reference Laboratory (VIDRL) for genotyping. These samples may allow epidemiological identification of a measles importation source.
  • Nasopharyngeal aspirates or nasopharyngeal swabs are the preferred sample for antigen detection by immunofluorescence and culture. Throat swabs or nasal washes are suitable for culture but not for immunofluorescence. The swabs should be placed immediately after collection into viral transport medium, and all these samples should be transported at 4°C.

    Measles PCR

  • Respiratory specimens and early catch urine (collected up to 3 weeks after onset of the rash) or sera collected early in the illness can be referred to an approved reference laboratory for measles PCR on an urgent basis if necessary. The PHU should facilitate communication with and between the laboratories involved concerning collection of suitable specimens and transport arrangements.
  • Nasopharyngeal aspirates or nasopharyngeal swabs are the preferred sample for nucleic acid detection by PCR. Throat swabs or nasal washes are also suitable for PCR. A dry sterile swab of the nasal passage combined with a similar swab from the back of the throat is the recommended specimen for detection of viral nucleic acid (PCR). Swabs should be cotton, rayon or dacron-tipped, plastic-coated or aluminium shafted swabs. They should be placed into viral transport medium. Samples should be stored and transported at 4°C. If arrival at the testing laboratory will be delayed more than 72 hours then, if possible samples should be frozen at –70°C and transported on dry ice. Do not freeze at –20°C.
  • Early catch urine samples should be stored and transported at 4°C. If arrival at the testing laboratory will be delayed more than 72 hours then, if possible samples should be frozen at –70°C and transported on dry ice. Do not freeze at –20°C.
  • Heparinised blood for PCR should be stored and transported at room temperature.

    The effect of recent vaccination

  • Vaccine-induced “measles” is a modified form of measles occurring 5-12 days after measles vaccination. It is not transmissible and should NOT be classified as measles.
  • Serologically-diagnosed cases who received a measles-containing vaccine 8 days to 8 weeks before testing may be classified as confirmed measles ONLY if they are also epidemiologically linked to a confirmed case.
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    9. Case investigation

    Response times

    Investigation

    On same day of notification of a suspected, probable or confirmed case, begin follow-up investigation using the Measles Investigation Form.

    Response procedure

    Case investigation

  • The response to a notification will normally be carried out in collaboration with the case’s health carers. Regardless of who does the follow-up, PHU staff should ensure that action has been taken to:
  • Seek the doctor’s permission to contact the case or the relevant care-giver
  • Find out what the case or relevant care-giver has been told what the diagnosis is before beginning the interview
  • Review case and contact management
  • Review the measles vaccination status of the case
  • Confirm the onset date and symptoms of the illness. For a suspected or probable case, ensure that the clinical evidence is consistent with the case definition. If not, consider rejecting the diagnosis (particularly if the case is age-appropriately vaccinated and there is no epidemiological link to another case)
  • Confirm results of relevant pathology tests, or recommend that the tests be done. The choice of tests depends on the time since rash onset (see testing guidelines, above). Check with the State/Territory reference laboratory first, but this usually requires:
    • 5 mL of blood (EDTA tube at room temperature)
    • nose/throat aspirates or swabs (transferred immediately into viral transport media) kept at 4°C and transported to the reference laboratory within 72 hours of collection
    • 10 mL urine in a sterile container at 4°C and transported to the reference laboratory within 72 hours of collection
  • Ensure that laboratories send copies of these results to the PHU
  • Any isolate or PCR or immunofluorescence positive material should be referred to VIDRL for genotyping.

    Case treatment

    Supportive only.
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    Education

    The case or relevant caregiver should be informed about the nature of the infection and the mode of transmission. By the time the case of measles is identified and notified, the case may already have transmitted the virus to other susceptible people. The case should be advised to stay at home in isolation while infectious and to avoid contact with susceptible people (see below) and immunosuppressed people.

    Isolation and restriction

    Exclude cases from work, school, preschool or child care and advise to stay in isolation (and specifically advise against interaction with susceptible people) until 4 days after the onset of the rash.
    When measles is suspected, hospitalised cases should be kept in strict respiratory isolation (and preferably in a negative pressure room) until 4 days after the onset of the rash. Only healthcare workers who are immune should care for these patients.

    When a case is isolated at home he or she should not mix with people who may be susceptible. For example, the household should not have visitors while the case is infectious.

    Active case finding

    Alert local doctors and laboratories in the areas where the measles case may have acquired the infection or was infectious to the possibility of further cases and ask them to report cases to the PHU promptly. Consider the need for a media alert to assist in case finding. Contacts (see below) who develop symptoms should be asked to inform the PHU as well as to seek medical advice.
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    10. Control of environment

    None routinely required.

    11. Contact management

    Identification of contacts

    Since measles is transmitted by airborne means, anyone who has shared the same air for any length of time with a case while the latter was infectious can be defined as a contact. In general, contacts may be prioritised in the following order, although it will not always be feasible for the PHU to identify individuals and arrange prophylaxis for them. In unclear or unusual situations, contact management should be discussed with State/Territory CDB.

    Contact definition

    Contacts include (in priority order for prophylaxis):
  • All household members
  • All people sleeping overnight in the same room as the case (for example, in a hospital, boarding school or military barracks)
  • All children and adults at family day care, child care, preschool, school or other educational setting who share a classroom with the case
  • People who stayed in a waiting area at the same time as the case (for example, patients in a health care facility’s waiting room and any people accompanying these patients) and people who waited in the waiting area or who were seen in the same consultation room up to 2 hours after the case left
  • All work colleagues of the case who share the same work area
  • Others who attend or work in the same educational institution as the case, and may have spent time in the vicinity of the case, but do not share a classroom (for example, a high school, college, lecture theatre block)
  • Passengers on an aeroplane who were seated in the same row and two rows in front of and behind a case1
  • For others who cannot be individually identified but who may have been present in the general area where the case was known to be (for example, cinemas, shopping centres, aeroplane flights and restaurants) consideration should be given to the need to provide notices, or media informing them of their possible exposure.
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    A person considered susceptible to measles is someone who cannot provide acceptable presumptive evidence of immunity to measles. A person can be considered to have acceptable presumptive evidence of immunity to measles if they meet one of the following criteria:
  • Persons born during or since 1966 who have documented evidence of receiving 2 doses of a measles-containing vaccine when both doses have been given at >= 12 months of age and at least 4 weeks apart (unless serological evidence indicates otherwise)
  • Persons born before 1966 (unless serological evidence indicates otherwise)
  • Documented evidence of immunity
  • Documented laboratory definitive evidence of prior measles.

    Prophylaxis

    Susceptible contacts should be provided with either MMR vaccine or normal human immunoglobulin (NHIG) according to:
  • time elapsed since exposure to an infectious case. Where there has been ongoing exposure (such as with household contacts) the time since exposure should be calculated from the first contact during the infectious period;
  • age;
  • previous MMR vaccination history; and
  • current pregnancy or immunosuppression.

    1. Contact tracing on aeroplanes is limited for pragmatic reasons to the surrounding seats, based on the likely risk and information about how air is recirculated on board the aeroplane, see CDNA. Revised guidelines for the follow-up of communicable diseases reported among travellers on aeroplanes available at: http://www.health.gov.au/internet/main/publishing.nsf/Content/cda-cdna-gl-airtravlers.htm


    Tables 1 and 2 (Post exposure guidelines for exposures that have occurred within 144 hours) are provided in the appendix for this purpose.

    NB: MMR and varicella vaccines should be delayed for 5 months after administration of NHIG to prevent measles.
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    Not infrequently, contacts may believe that they have been vaccinated but do not have the necessary documentation to prove vaccination readily available. If time allows, it may be possible, on a case-by-case basis, to determine whether individual contacts are susceptible by requesting measles IgG serology.

    However, this is quite impractical on any large scale, so pragmatic decisions have to be made. If within 72 hours of exposure to a case, MMR vaccine should be given to those with an uncertain history of measles vaccination (Table 1). However, beyond 72 hours, it may be quite impractical to use NHIG on any large scale, but should always be considered for immunosuppressed individuals and for pregnant women who cannot provide evidence of either immunisation or immunity.

    In settings with large numbers of individuals with uncertain vaccination histories (e.g., in high schools, in company workers) it is reasonable to recommend prompt MMR vaccination, even if it is >72 hours after the exposure. In this circumstance, it cannot be assured that further cases of measles will not occur (as someone may already be incubating the disease), but the liberal use of MMR should further reduce the likelihood of further ongoing transmission of the measles virus.

    Education

    Advise susceptible contacts (or parents/guardians) of the risk of infection and counsel them to watch for signs or symptoms beginning 7 to 18 days after the first contact with an infectious case (or longer if the contact received NHIG). They should avoid contact with other susceptible people and immunosuppressed people during this period. If symptoms develop, they should also be advised to call ahead before visiting doctors’ rooms, hospital EDs or pathology services so as to avoid mixing with other people, and to telephone the local PHU if measles is suspected.

    Advise the case’s doctor that all people who used the same waiting room area or consultation room up to two hours following the case’s departure require immediate assessment and prophylaxis if susceptible. Similarly, inform the relevant Infection Control Officer if the case has been in hospital while infectious (see below).

    A sample script and “Measles: information for contacts” factsheet can be found in the appendix.
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    Isolation and restriction

    Children who are enrolled in primary school, preschool or child care should be excluded as follows:
  • Susceptible contacts should be excluded until 14 days after the onset of the rash in the last case occurring at the facility. However they may return if vaccinated within 72 hours of first exposure to an infectious case or if they receive NHIG within 144 hours of exposure.
  • Immunosuppressed children or staff should be excluded (regardless of their measles vaccination status) until 14 days after the onset of the rash in the last case occurring at the facility. Exclusion is advised for their own safety even if they receive NHIG.

    Susceptible contacts in high school should be advised to stay away until 14 days after the onset of the rash in the case. They may return if vaccinated within 72 hours of first contact with an infectious case or if they receive NHIG within 144 hours of exposure.

    12. Special situations

    Since the transmission of measles frequently occurs before diagnosis, the spread of the disease can be facilitated wherever susceptible individuals gather in groups.

    Cases among children or staff at school or in child care

    In addition to routine case and contact management, ask about possible cases occurring among attendees or employees within the previous 18 days. Daily surveillance to detect possible cases may be needed and should be considered for 18 days after the last infectious case attended. All suspected cases should be investigated and measures taken to minimise or eliminate secondary transmission from these cases.

    Parents and staff should be provided with information about the disease and its prevention. Written information such as a fact sheet is recommended, but an information meeting for parents may also be useful (see appendix for sample letters to parents). Vaccination of all susceptible contacts should be recommended. Consider holding an immunisation clinic at the facility.

    Cases among staff or patients in a health care facility

    For suspected, probable or confirmed cases among staff or patients in a health care facility, consult immediately with staff from infection control or staff health to institute a management plan appropriate to the facility. This should include procedures for:
  • Defining and identifying contacts
  • Informing contacts and organising management where appropriate
  • Keeping infectious patients in respiratory isolation for 4 days after the appearance of the rash, and ensuring that susceptible individuals do not enter any room for 2 hours after an infectious case has used it. Susceptible people entering this room within the 2 hour period should be considered as contacts
  • Ensuring that only staff who are immune provide direct care to infectious patients
  • Vaccinating susceptible contacts (ie. those who do not have documentation of having received 2 doses of a measles-containing vaccine) among patients and staff.
    • Susceptible patients who are not vaccinated within 72 hours or do not receive NHIG within 144 hours of first exposure, should be isolated and discharged from hospital as soon as possible
    • Susceptible staff who are not vaccinated within 72 hours or receive NHIG within 144 hours of first exposure should be redeployed to duties not requiring direct patient care (for up to 14 days after the rash onset in the last case at the facility)
  • Carrying out active surveillance for measles, where practical, among exposed inpatients, inpatients discharged before the diagnosis of the first case, staff, students, volunteers and visitors
  • Investigating staff members presenting with prodromal symptoms and ensuring that the affected person stays away from work until 4 days have elapsed after the onset of the rash (or until a measles diagnosis is excluded)
  • Reviewing staff health records to ensure that all have been protected in line with current recommendations.
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    Local transmission of measles

    Where transmission of measles is identified within Australia, then additional control measures should be considered. Depending on the people affected and nature of the setting, control strategies may include:
  • Epidemiological studies to determine risks for infection
  • Additional alerts to doctors directly and to the wider community through the media
    Key messages to be communicated usually include:
  • Awareness of the signs and symptoms of measles
  • Reviewing vaccination status and prompt MMR vaccination if necessary
  • Early case finding and isolation
  • Contact tracing
  • Prophylaxis
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    13. Additional sources of information

  • The Australian Immunisation Handbook
  • Heymann DL, ed. Control of Communicable Diseases Manual

    14. Appendices

  • Tables 1 and 2: Post exposure guidelines for exposures that have occurred within last 7 days
  • PHU Check list
  • Sample letter: Exclusion of susceptible primary school, child care or preschool child contacts
  • Sample letter: Immune primary school, child care or preschool child contacts
  • Sample letter: High school contacts
  • Sample script: Waiting room contacts
  • Measles Investigation Form
  • Factsheet “Measles"
  • Factsheet “Measles: information for contacts"

    15. Jurisdiction specific issues

    Links to State and Territory Public Health Legislation and the Quarantine Act

    http://www.health.gov.au/internet/main/publishing.nsf/Content/cda-state-legislation-links.htm

    NSW

    Legislation

    NSW Public Health Act 1991

    Measles is to be notified by:
  • medical practitioners and hospital CEOs on clinical suspicion
  • laboratories on confirmation
  • school principals and directors of child care facilities on receipt of a report that an attendee has measles.

    Policies

    Occupational Assessment, Screening & Vaccination Against Specified Infectious Diseases PD2007_006

    Obtaining NHIG

    NHIG is available through the Australian Red Cross Blood Service (ARCBS) during working hours by calling the Transfusion Medical Officer on 9229-4347, or the After Hours Medical Officer on call 9229 4444. ARCBS keeps a small stock of NHIG at its Clarence Street, Sydney and Newcastle Distribution Departments. These departments are not set up for public access. For individual doses, the ARCBS may provide NHIG from stock at a local hospital, issue stock direct or supply it via CSL, depending on the urgency.

    For outbreaks, the PHU should discuss with ARCBS the number of potential patients involved and the best way to distribute the product according to whether a clinic will be set up or whether patients will be referred to individual GPs. If a clinic is planned, ARCBS will arrange for product to be transported to the site of clinic, but the PHU will need to ensure availability of suitable storage for the NHIG (e.g., the hospital blood bank or pharmacy). If it is planned to refer patients to individual GPs, a suitable central access point for NHIG will need to be identified (e.g., a local hospital blood bank or pharmacy). The PHU is responsible for notifying GPs on the process for accessing NHIG for their patients.

    Small stocks of NHIG may be held at some hospitals including: Westmead, Wollongong, Gosford, John Hunter, Cessnock, Albury, Orange, Macksville, Port Macquarie, Lismore, Tamworth, Armidale, Narrabri, Wagga Wagga, Tumut, Griffith, Broken Hill, Hornsby and Sutherland.

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    Table 1: Post exposure guidelines - within 72 hours of first exposure to infectious case

    Age or
    immune status
    		 MMR vaccination history
    0 doses MMR or unknown 1 dose MMR 2 doses MMR
    Immunosuppressed
    (any age)
    		 Normal Human Immunoglobulin
    0.5 mL/kg to max of 15 mL    		 Normal Human Immunoglobulin
    0.5 mL/kg to max of 15 mL    		 Normal Human Immunoglobulin
    0.5 mL/kg to max of 15 mL
    birth to 5 months
    		 Normal Human Immunoglobulin
    0.2 mL/kg
    only if mother has had <2 doses MMR and no history of past measles infection (otherwise no NHIG)    		 Not applicable Not applicable
    6 to 8 months
    		 Normal Human Immunoglobulin 
    0.2 mL/kg    		 Not applicable Not applicable
    9 to 11 months
    		 MMR now, then second dose at 12 months of age or 4 weeks later (whichever is later) Not applicable Not applicable
    12 months to
    <4 years
    		 MMR   MMR
    (unless first dose was given <4 weeks ago)    		 Nil necessary
    ≥4 years 
    and born after 1965
    		 MMR if not pregnant.
    If pregnant, offer NHIG (0.2 mL/kg to a maximum of 15 mL) and inform obstetrician or GP    		 MMR if not pregnant.
    If pregnant, offer NHIG (0.2 mL/kg to a maximum of 15 mL) and inform obstetrician or GP    		 Nil necessary

    Table 2: Post exposure guidelines - 73 to 144 hours after first exposure to infectious case

    Age or
    immune status
    		 MMR vaccination history
    0 doses MMR or unknown 1 dose MMR 2 doses MMR
    Immunosuppressed
    (any age)
    		 Normal Human Immunoglobulin
    0.5 mL/kg to max of 15 mL    		 Normal Human Immunoglobulin
    0.5 mL/kg to max of 15 mL    		 Normal Human Immunoglobulin
    0.5 mL/kg to max of 15 mL
    birth to 5 months
    		 Normal Human Immunoglobulin
    0.2 mL/kg
    only if mother has had <2 doses MMR and no history of past measles infection (otherwise no NHIG)    		 Not applicable Not applicable
    6 to 8 months
    		 Normal Human Immunoglobulin
    0.2 mL/kg    		 Not applicable Not applicable
    9 to 11 months
    		 Normal Human Immunoglobulin
    0.2 mL/kg    		 Not applicable Not applicable
    12 months to
    <4 years
    		 Normal Human Immunoglobulin
    0.2 mL/kg    		 Nil necessary Nil necessary
    ≥4 years 
    and born after 1965
    		 Normal Human Immunoglobulin
    0.2 mL/kg to max of 15 mL    		 Nil necessary
    Consider MMR if not pregnant    		 Nil necessary



    PHU Measles Checklist

    Patient ID number: ____________
    Contact the patient’s doctor to:
    Obtain patient’s history
    Confirm results of relevant pathology tests
    Recommend that the tests be done if need be
    Determine if others were exposed in the clinic

    Contact the patient (or care giver) to:
  • Identify likely source of infection
  • Review vaccination status
  • Confirm onset date and symptoms of the illness
  • Recommend exclusions and restrictions
  • Identify contacts and obtain contact details
  • Complete Measles Investigation Form
  • Provide with Measles Factsheet

    Contact laboratory to:
  • Obtain any outstanding results
  • Refer lab specimens for genotyping

    Confirm case
  • Assess information against case definition

    Contact patient’s contacts to:
  • Assess risk of measles (susceptibility, exposure history)
  • Determine current symptoms
  • Recommend intervention (vaccine, NHIG, or no intervention)
  • Explain symptoms and restrictions (waiting rooms, child care, school)
  • Provide with Measles Factsheet and Information for Contacts Factsheet
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    Other issues:
  • Report details of case and action plan to state/territory CDB
  • Assess and arrange best method for delivering intervention to contacts
  • Initiate active case finding
  • Where defined groups of people have been exposed (eg, schools, childcare, workplaces), contact the person in charge to explain the situation and to provide letters to exposed people
  • Consider alerting local doctors and EDs
  • Consider local media release
  • Enter case data onto notifiable diseases database


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    Sample letter: Exclusion of susceptible primary school, child care or preschool child contacts



    Dear Parent or Guardian
    Re: Measles at <school/child care name>

    Several children who attend <name of school or child care centre> have recently been diagnosed with measles. Measles is a serious viral infection that causes fever, cough, a rash and sore eyes. Occasionally measles has dangerous complications. Measles is highly infectious.

    Health records at your child’s <school/child care> indicate that <child’s full name> has not been fully immunised against measles and therefore may be at risk of infection. Measles can easily spread to and from unimmunised children, and so your child will not be allowed to attend <school/child care> until the risk period has passed, in accordance with the Public Health Act 1991.

    Your child may return to school 14 days after onset of measles rash in the last case at the school; or if he or she receives normal human immunoglobulin or MMR vaccine before <date>. The situation will be reviewed daily and the <school/child care centre> will contact you when it is safe for child to return.

    Your child may already have been infected and may currently be incubating measles. Please refer to the attached measles factsheet for more information about measles. If your child develops symptoms of measles you should see a doctor (call ahead to alert your doctor about the possibility of measles before visiting and take this letter along) and ring the Public Health Unit.

    If you believe that your child is immune to measles because of documented prior measles immunisation or past infection, please call the <PHU name> on <telephone number> to discuss this.

    Immunisation against measles is the most effective way to prevent infection. I recommend that you discuss measles immunisation with your general practitioner at the earliest opportunity.

    Yours sincerely





    Director, <PHU name>
    <date>

    Encl < factsheet: measles> and < factsheet: Measles: information for contacts>

    Top of page

    Sample letter: Immune primary school, child care or preschool child contacts


    Dear Parent or Guardian
    Re: Measles at <school/child care name>

    I understand that your child has shared a classroom with another child who has recently been diagnosed with measles. Measles is a serious viral infection that causes fever, cough, rash and sore eyes. Occasionally measles has dangerous complications. Measles is highly infectious.

    Children who have been immunised against measles normally have more than 95% protection against the disease. Sometimes immunised children can still become infected despite immunisation. Please refer to the attached factsheet for more information about measles. If your child develops symptoms:
  • see a doctor (call ahead to alert your doctor about the possibility of measles before visiting and take this letter along)
  • ring the Public Health Unit; and
  • do not allow your child to attend school if he or she has measles.

    If your child has not been immunised against measles, please call the <PHU name> Public Health Unit on <telephone number> as your child may be eligible for immediate immunisation to prevent infection, or your child may need to be excluded from <school/child care>.

    If your child has a weakened immune system (eg. if they have an inherited immune problem or are receiving chemotherapy for cancer), please contact the Public Health Unit to discuss this. Your child may require preventative treatment and may also need to be excluded from school even if he or she has previously been immunised against measles.

    Should you require more information about measles, please call the Public Health Unit on <telephone number>.

    Yours sincerely




    Director, <PHU> <date>

    Encl < measles factsheet>


    Top of page

    Sample letter: High school contacts



    Dear Parent or Guardian
    Re: Measles at <high school name>

    Several children who attend < high school name> have recently been diagnosed with measles. Measles is a serious viral infection that causes fever, cough, a rash and sore eyes. Occasionally measles has dangerous complications. Measles is highly infectious.

    Immunisation with MMR vaccine is now routinely given at 12 months with a second dose at 4 years and your child is likely to be immune if he or she has received two doses of this vaccine.

    Measles can easily spread to and from unimmunised children. If your child has never received MMR vaccine or has received only one dose, he or she may be at risk of infection and may currently be incubating measles. If your child has never received MMR, it is advisable to stay away from high school until <14 days after the onset of the rash in the case.>

    Please refer to the attached measles factsheet for more information about measles. If your child develops symptoms of measles:
  • see a doctor (call ahead to alert your doctor about the possibility of measles before visiting and take this letter along);
  • ring the Public Health Unit; and
  • do not allow your child to attend school.

    Immunisation against measles is the most effective way to prevent infection. I recommend that you discuss measles immunisation with your general practitioner at the earliest opportunity.

    Please note that many adults born after 1965 and who have only had one dose of MMR may also be susceptible and a second MMR immunisation is recommended.

    Please call the <PHU name> on <telephone number> for more information.

    Yours sincerely





    Director, <PHU name> <date>

    Encl < measles factsheet> and < factsheet: Measles: information for contacts>

    Top of page

    Sample script: Waiting room contacts

    Script
    		 Response Public health action & record
    Preamble

    Hello, this is <name> calling from <hospital or surgery name>. May I speak to <title> <name> please?

    This is an urgent matter – are you able to speak now?

    <Dr name> has provided me with your contact details.

    I’m calling because you may have been exposed to someone with measles while you were in the waiting room at <place> on <date>.

    Can you confirm that you were at <waiting room> between the hours of <time_1> and <time_2> on <date>?

    Measles is a serious viral infection that causes cough, fever, a rash and sore eyes. It’s a highly infectious virus and someone else who was in the waiting room on <date> has recently been confirmed as a case. There may be the chance to stop the infection from developing if you have become infected.

    To assess if you are likely to be susceptible to the infection, I need to ask you a number of questions.

    _ yes

    _ no

    		 

    Medical record number

    		  
    Surname  
    First name  
     

    Date of birth

    		  
    Age  
    Place of exposure  
    Date of exposure  
    Time of exposure from:         to:
    Duration of exposure mins / hrs
    Other  
    1.

    If telephoning after the minimum incubation period (i.e. exposure date +7 days):

    • Do you have a fever/temperature?
    • Do you have sore, runny eyes?
    • Do you have a new cough?
    • Do you have a rash?
    		  

    _ Fever

    _ Conjunctivitis

    _ Cough

    _ Rash

    		 If yes to any symptoms:

    "You may have been infected and should be seen by a doctor."

    • Arrange urgent clinical review +/- pathology testing. Do not allow patient to wait in waiting room.
    • Notify Public Health Unit

    If no symptoms, go to Q 2
    2

    Do you have a weakened immune system? (eg. Are you on chemotherapy for cancer?)

    _ Immunosuppressed
    • Assess whether suitable for NIGH and arrange this
    • Obtain postal address or email address
    • Send or email factsheet / letter
    • Go to Q 5.
    _ Not immunosuppressed
    • Go to Q 3.
    3.

    What year were you born?
    _ Born before 1966
    		 "Because you were born earlier than 1966 when measles was common, you are likely to have had measles before this time and are unlikely to be infected again. You should still be aware of the symptoms of measles and contact the Public Health Unit if these occur"
    • Obtain postal address or email address
    • Send or email factsheet
    • Go to Q 5.
    _ Born since 01/01/1966

    "You may be susceptible to measles unless you have received two doses* of measles vaccine"

    • Go to Q 4.
    4.

    Have you received two doses of measles vaccine? (this is commonly called MMR vaccine and is currently given in Australia at 12 months and 4 years of age)

    _ 2 doses
    		 "You are likely to be immune to measles but should still be aware of the symptoms of measles and contact the Public Health Unit if these occur"
    • Obtain postal address or email address
    • Send or email factsheet
    • Go to Q 5.
    _ 0 doses

    _ 1 dose

    _ unsure

    		 "You may be susceptible to measles."
    • If exposure has occurred within 144 hours, assess suitability for MMR or NHIG based on:
      • time since exposure,
      • MMR vaccination history and
      • pregnancy

    (see Tables 1 and 2).

    • Obtain postal address or email address
    • Send or email factsheet/ letter
    • Explain what to do if symptoms occur (i.e. exclude self, call PHU and go to GP – call prior)
    • Go to Q 5.
    5.

    Did any other friends or relatives wait with you in the waiting room?

    _ No
    • Leave respondent with PHU contact number
    • Thank and end interview
    _ Yes
    • Repeat process for each person exposed.
    Interventions arranged (tick all that apply)

    _ Advice only

    _ Clinical review arranged

    _ Public Health Unit notified

    _ Factsheet sent to postal address or emailed:

    _ MMR immunisation arranged  

    _ NHIG immunisation arranged

    _ No intervention 

    _ Other:
    NOTES / COMMENTS
    Completed by:

     

                                    Signature                                       Print name                                            Date

    * Unless aged under 4 years, where 1 dose is sufficient. 


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