Rash Decisions: The Colorado Experience with

“Maybe Measles”

Emily Spence Davizon, Colorado Department of Public Health and Environment

Today’s talk:

-Epidemiology and clinical picture

-Rule outs: process, 3 areas of concern, and testing

-Results of the CO experience

Learning objectives:

-Describe rule out process

-Name the “3 Cs” and the 3 areas of concern

-Understand who can and cannot issue quarantine/isolation orders

Epidemiology of measlesReservoir: Human. No known asymptomatic

carrier state.

Transmission: Respiratory droplets. Airborne transmission via aerosolized droplets; documented in closed areas up to 2 hours after a person with measles occupied the area.

Communicability:Highly communicable. Secondary attack rate up to 90%. People with measles are contagious 4 days before to 5 days after rash onset.

Average Incubation: 14 days (range 7-21).Source: CDC, Epidemiology and Prevention of Vaccine-Preventable Diseases, “The Pink Book,” 12th Edition, 2011

Worldwide trendsMeasles is still common in many parts of the world and

is often fatal in developing countries

Over 22,000 cases were reported in Europe in 2014-2015

122,000 estimated deaths worldwide in 2012

http://www.who.int/features/2015/measles-vaccination-liberia/en/

Cases since elimination achieved in 2000

Measles in Colorado

• Measles outbreaks in Colorado :•115 cases (1988)•101 cases (1989)•138 cases (1990)

2000 2004 2006 2013 2014 20150

1

2

3

Colorado Measles Cases, 2000-2015

year

# of cases

Clinical picture

Prodrome: -High fever (>101 degrees) -Malaise-Cough, coryza, and conjunctivitis.

Clinical picture

Rash: -Maculopapular and begins 2-4 days after prodrome onset

-Begins on face and spreads down and out

-Fades in order of appearance

-Koplik spots (appear like tiny white spots with red ring) may be present in mouth

Which rash is measles?

A B

Ruling out measlesSuspect case reported

1. Gather information- demographics, clinical, travel, IZ history

2. Recommendations for infection prevention and isolation

•Cases isolated through 4 days after rash (onset of rash day 0)

•Airborne isolation or private room with door closed, mask if feasible

•Ensure healthcare personnel have evidence of immunity

3. Communicate with partners

4. Test?

Three areas of concernClinical

CompatibilitySusceptibility Exposure

Rash is maculopapular (not

vesicular)

Unvaccinated Contact of a known or suspect case

Rash started on face and spread down and

out

Unknown MMR vaccine history

Travel abroad

Rash and high fever concurrently

Immunocompromised Travel via airplane (lower risk)

Prodrome of 2-4 days

No strong alternate dx- e.g. antibiotic rash, + strep test

Test Type

Specimen(s)

Timing of collection

Availability

Considerations

PCR Respiratory (NP/OP) or urine

onset-3 days post rash is best;10-14 days after rash RNA may still be detectable

CDPHE only (FFS)

Fast (3-4 hours once specimen received), sensitive

IgM Whole blood or serum

Onset- 1 month post rash

CDPHE (FFS) or commercial lab

False positives and negatives possible

Testing

Recommend consultation with CDPHE epidemiologists

Results- the Colorado Experience

The “Maybe Measles” Epidemic in Colorado

12/1

3/20

14

12/2

0/20

14

12/2

7/20

14

1/3/

2015

1/10

/201

5

1/17

/201

5

1/24

/201

5

1/31

/201

5

2/7/

2015

2/14

/201

5

2/21

/201

5

2/28

/201

5

3/7/

2015

3/14

/201

5

3/28

/201

5

4/4/

2015

0

2

4

6

8

10

12

14

16

18

Suspect measles cases reported to CDPHE, December 2014-April 2015

Test Date

Week ending

Number of reports1 confirmed CO measles case reported

74 PCR tests run at CDPHE lab

Quarantine and isolation ordersQuarantine separates and restricts the movement of

people who were exposed to a contagious disease to see if they become sick

Isolation separates sick people with a contagious disease from people who are not sick

Both order types can be issued by local public health agencies or CDPHE

Excellent compliance with requests for voluntary isolation of suspect cases until ruled out or were out of infectious period

No orders were issued for the suspect cases that were ruled out in 2015

Guidance Communicable Disease Manual updates \

New specimen collection instructions and guidance for HCPs

Encouraged all health care facility staff to have documented evidence of immunity (especially small clinics and urgent care)

Take home messageEvents outside of Colorado that cause concern among

the public or health care providers can generate a substantial work load for public health

As a result of this experience, we developed additional tools to assist our partners in ruling out (or in) measles

Measles is a serious communicable disease that cannot be reliably diagnosed only based on signs and symptoms

Measles, even suspect measles in the absence of diagnostic results, is a 24-hour reportable condition in CO- call us! (303-692-2672 or 303-692-2671 or 303-370-9395 after hours)

Take home messagePublic health plays an important role in ruling out

suspect cases:

-Specimen collection

-Timing of testing and interpreting results (IgM vs IgG)

-Education on case definition, signs, symptoms

Resources CDPHE Communicable Disease Manual:

https://www.colorado.gov/pacific/sites/default/files/DC_CD_ComDisManual-Meningococcal-Disease.pdf

Specimen collection instructions: https://www.colorado.gov/pacific/sites/default/files/CD_CD_VPD_Measles-Specimens-for-Diagnostic-Testing_1.pdf

Guidelines for physicians evaluating patients with fever and rash: https://www.colorado.gov/pacific/sites/default/files/DC_CD_VPD-Measles-Guidance-for-HCPs-Evaluating-Patients-with-Rash-Illness.pdf

Measles information sheet: https://www.colorado.gov/pacific/sites/default/files/DC_CD_VPD-Measles-Information-Sheet.pdf

Utah Experience – 3 cases, 2015

• 1,600 calls to 117 individuals on voluntary quarantine

• 586 doses of the measles, mumps, rubella (MMR) vaccine in Jan

• > 600 staff hours• Direct cost for outbreak ~ $115,000• 3,000 staff hours

Source: Utah Department of Health Press Release, February 25, 2015

• 3 August 2015• Since the beginning of the year, a measles epidemic

has been ravaging Katanga Province in the southeast of the Democratic Republic of Congo. The Office for the Coordination of Humanitarian Affairs (OCHA) declared around 16,500 cases of measles and more than 267 deaths in the first six months of the year. Having led the response during the last few months, Médecins Sans Frontières (MSF) is stepping up its support to the Ministry of Health, providing free medical care for patients, carrying out vaccination campaigns for children and strengthening epidemiological surveillance.