Health Alert: Confirmed Case of Measles - August 2023

The Texas Department of State Health Services (DSHS) is reporting a confirmed case of measles in a resident of McCulloch County. The last confirmed measles case in Texas was in June 2023 in Hood County.

Due to the highly contagious nature of this disease, additional cases may occur, especially in unvaccinated people. DSHS advises clinicians to follow the recommendations below and report any suspected cases to your local health department, preferably while the patient is in your presence.

Two cases of measles have been confirmed in Texas this year, both in non-school-aged children. The first case was diagnosed in June in a resident of Hood County. The second was diagnosed in August in a resident of McCulloch County. Neither has a history of travel to an area where measles is spreading, and no other risk factors for exposure were identified. Both cases had received one dose of the measles-mumps-rubella (MMR) vaccine. At this time, public health officials do not suspect these cases are related.

Measles is a highly contagious respiratory illness. The virus is transmitted by direct contact with infectious droplets or by airborne spread when an infected person breathes, coughs, or sneezes. Measles virus can remain infectious in the air for up to two hours after an infected person leaves an area. Illness onset (high fever, cough, runny nose, and red, watery eyes) begins a week or two after someone is exposed. A few days later, the telltale rash breaks out as flat, red spots, usually on the face first and then spreading down the neck and trunk to the rest of the body. A person is contagious about four days before the rash appears to four days after. People with measles should stay home from work or school during that period.

The best way to prevent getting sick is to be immunized with two doses of measles-containing vaccine, which is primarily administered as the combination MMR vaccine. Two doses of the vaccine are highly effective at preventing measles, however even vaccinated people can occasionally become infected. DSHS and the Centers for Disease Control and Prevention (CDC) recommend children receive one dose at 12 to 15 months of age and another at 4 to 6 years. Children too young to be vaccinated or individuals who have only had one dose of vaccine are more likely to get infected and more likely to have severe complications if they do get measles.

Healthcare providers should consider measles in patients presenting with the following signs and symptoms, particularly those who have traveled abroad or had contact with known measles cases:

• Fever ≥101°F (38.3°C) AND
• Generalized maculopapular rash lasting ≥3 days AND
  • Rash usually begins at the hairline/scalp and progresses down the body
• Cough, runny nose, or conjunctivitis OR Koplik spots (bluish-white specks on a red-rose background appearing on the buccal and labial mucosa usually opposite the molars)

Immediately report any suspected measles cases to your local health department (contacts by county at dshs.texas.gov/idps-investigation-forms/disease-reporting-contacts). If possible, make the report while the patient is present to facilitate testing and the public health investigation, including follow-up of potential exposures.

• Airborne precautions should be followed to reduce possible exposures in healthcare settings.
• In urgent/emergency healthcare settings, suspected cases should be masked with a surgical mask and triaged quickly from waiting areas into a room with a closed door, airborne isolation precautions recommended. In other outpatient settings, suspected cases should be scheduled at the end of the day, if possible. Healthcare workers caring for patients suspected of having measles should use airborne infection control precautions (www.cdc.gov/hicpac/2007IP/2007isolationPrecautions.html).
• Since measles is so highly transmissible and can spread in healthcare settings, people who work in places like a doctor’s office or emergency room should have evidence of measles immunity to prevent any potential outbreak (https://www.cdc.gov/vaccines/pubs/surv-manual/chpt07-measles.html#f21).

Testing for measles should be done for all suspected measles cases at the time of the initial medical visit:

• DSHS strongly encourages providers to submit PCR specimens to the DSHS Laboratory because genotyping will be performed on positive PCR specimens, which can be helpful during outbreaks.
• The DSHS Laboratory can perform PCR testing on throat swabs (preferred) or nasopharyngeal swabs placed in viral transport media and serology on serum specimens.
• Measles PCR and serology (IgM and IgG) testing is available at both the DSHS Laboratory in Austin and at commercial laboratories.
• Providers should work with their local health department or DSHS regional office to coordinate testing at the DSHS Laboratory to ensure specimens are submitted correctly and meet testing requirements. 
• Unless coordinated in advance, specimens may only be received by the DSHS Laboratory during normal business hours, Monday through Friday. 

Control and Prevention Measures

• Measles vaccination may prevent disease in exposed people if given within 72 hours of exposure. People 6 months old and older who have not been fully vaccinated would be eligible for vaccination under those circumstances. This dose does not count for childhood vaccination requirements, if given to a person less than 12 months old. They would still need two more doses at the recommended ages for optimal protection against disease and are needed to meet school vaccine requirements.
• Pregnant women, people with severe immunosuppression, and anyone with a previous anaphylactic reaction to a vaccine component should not get a measles vaccine (https://www.cdc.gov/vaccines/pubs/surv-manual/chpt07-measles.html).    
• Immune globulin (IG) may be indicated within six days of exposure for some people (e.g., unvaccinated people not able to receive the MMR vaccine or those that are immunocompromised) but should not be used to control an outbreak. (https://www.cdc.gov/infectioncontrol/guidelines/isolation/index.html).
• Do not administer MMR vaccine and IG simultaneously as this will invalidate the vaccine (https://www.cdc.gov/measles/hcp/index.html#prophylaxis).

Controlling Outbreaks in Group Settings

• People with confirmed or suspected measles should stay home from school, work, and other group settings until after the fourth day of rash onset.
• During an outbreak, people without documented immunity from vaccination or previous measles infection should be isolated from anyone with measles to protect those without immunity and control the outbreak. Additional information on school exclusion and readmission can be found at dshs.texas.gov/idps-home/school-communicable-disease-chart.

If you think you have measles or have been exposed to someone with measles, isolate yourself from others and call your healthcare provider before arriving to be tested so they can prepare for your arrival without exposing other people to the virus. Measles is extremely contagious and can cause life-threatening illness to anyone who is not protected against the virus.

• For Healthcare Professionals – Diagnosing and Treating Measles | CDC
• Interim Measles Infection Prevention Recommendations in Healthcare Settings | CDC
• Measles – Vaccine Preventable Diseases Surveillance Manual | CDC
• Plan for Travel – Measles | CDC
• Measles Lab Tools | CDC
• Measles Serology | CDC
• Measles Specimen Collection, Storage, and Shipment | CDC
• CDC Measles Toolkit for Health Departments
• Global Measles Outbreaks | CDC