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February 10, 2012 Dear Health Care Provider: Two cases of measles have been confirmed in unvaccinated residents of Hamilton County. Two probable cases linked to the confirmed cases have been identified in internationally adopted children in Boone County. The attached Indiana Health Advisory Notification (IHAN) was emailed to registered health care providers on February 6. The onset of in the index case began around January 3. The last identified case developed at the end of January, with rash occurring on February 4. Measles typically begins with prodromal including a mild to moderate fever accompanied by cough, coryza, and conjunctivitis. Koplik spots (tiny red spots with bluish-white centers on the buccal mucosa), a characteristic sign of measles, may appear. Fever continues to increase during the prodrome, and may reach as high as 104-105°F with onset of rash. Three to five days after the start of the prodrome, the measles rash will appear. The rash is a blotchy erythematous, maculopapular rash that may become confluent, usually appearing first on the face - along the hairline and behind the ears. The rash may be itchy, and rapidly spreads downward and outward to the chest and back and, finally, to the thighs and feet. The rash fades in about a week in the same order it appeared. Desquamation can occur after the rash fades. Immuno-compromised patients may not exhibit rash or may exhibit an atypical rash. Measles is extremely contagious in unvaccinated populations. Patients with measles are contagious from onset of prodromal until 4 days after rash onset. The incubation period from exposure until develop is typically 10-14 days, but may range from 7-21 days. The potential for this measles outbreak to spread across the state to other pockets of unvaccinated Hoosiers exists. A rash illness in a patient with high fever should prompt immediate consideration of measles in the differential diagnosis, especially in unvaccinated individuals or individuals with risk factors including recent overseas travel and unknown vaccination status. Recommendations for Health Care Providers To minimize the risk of measles transmission in health care settings: 1. While scheduling a patient with febrile rash for an appointment, ask about a history of international travel, contact with foreign visitors, transit through an international airport, or possible exposure to a measles patient in the 3 weeks prior to onset. 2. If possible, schedule suspect measles patients at the end of the day. 3. Notify the Indiana State Department of Health (ISDH) immediately of any suspect measles patients; call (317) 233-7125. ---PAGE BREAK--- 4. Mask suspect measles patients immediately and move them to an isolation room. Do not allow suspect measles patients to remain in the waiting area or other common areas. Use an airborne infection isolation room if one is available. For more information: http://www.cdc.gov/hicpac/2007IP/2007isolationPrecautions.html 5. Only health care personnel with documentation of 2 doses of live measles vaccine or laboratory evidence of immunity (measles IgG positive) should be allowed to enter the room of a suspect measles case. 6. Do not allow susceptible visitors in the patient room. 7. Do not use the examination room for at least two hours after the suspect measles patient leaves. 8. Notify locations where the patient is being referred for additional evaluation or testing, and instruct suspect measles patients and exposed persons to inform all health care providers of the possibility of measles prior to entering a health care facility. 9. Document staff and other patients who were in the area during the time the suspect measles patient was in the facility. 10. Obtain specimens for testing, including IgM and IgG antibody titers for rubeola (measles) and viral swabs for confirmation and genotyping. Please reference attached flow chart for guidance in submitting measles specimens to ISDH laboratory. For more information on measles testing, please see: http://www.in.gov/isdh/files/CLI_measles.PDF What else can you do? Identify patients and staff susceptible to measles infection and urge them to get vaccinated! The following individuals are considered susceptible to measles: 1. Individuals born after 1957 who do NOT have one of the following: a medically documented history of measles disease documentation of 2 appropriately spaced measles-containing vaccine (eg. MMR, MMRV) protective levels of IgG to rubeola (measles) All health care providers, regardless of year of birth, should have evidence of measles immunity. Two doses of measles vaccine, when administered appropriately, are 99% effective at preventing measles infection. Sincerely, GREGORY N. LARKIN, MD, FAAFP STATE HEALTH COMMISSIONER Attachments