1. Amanda Shoemate, MPH, CPH Epidemiologist
MMRV
Amanda Shoemate, MPH, CPH
Epidemiologist

2. IT ISN’T JUST A LITTLE RASH
Measles
IT ISN’T JUST A LITTLE RASH

3. What is measles? Highly contagious disease caused by the measles virus
AKA: rubeola, hard measles, 7-day measles
Most cases start with mild-moderate fever, cough, runny nose, red eyes, and sore throat.
About 3-5 days later, a red rash appears.
Rash begins at the hairline, then spreads down to the rest of the body of the course of a few days.
High fever >101º
2-4 days prior to rash: “3 C’s”
Spreads from head to trunk & extremities over ~3 days
4-7 days

4. What is measles?
When the rash appears, the fever can be as high as 103℉ to 105℉.
Other symptom’s may include Koplik’s spots (tiny white spots with bluish-white centers in the mouth), and feeling run down or achy.
Symptoms of measles may last 1-2 weeks.
High fever >101º
2-4 days prior to rash: “3 C’s”
Spreads from head to trunk & extremities over ~3 days
4-7 days

5. How is measles spread?
Measles is passed from person to person by airborne droplets through coughing or sneezing.
Measles can also be spread by contact with nose and throat secretions of an ill person, or touching a contaminated surface.
The infectious droplets can survive in an airspace where an infected person coughs or sneezes or on a surface for up to two hours.
High fever >101º
2-4 days prior to rash: “3 C’s”
Spreads from head to trunk & extremities over ~3 days
4-7 days

6. How long is measles infectious?
Infected people can spread the virus to others four days before their rash starts to four days after rash onset.
Measles is so contagious that if one person has it, up to 90% of people close to that person who are not immune/vaccinated will also become infected.
High fever >101º
2-4 days prior to rash: “3 C’s”
Spreads from head to trunk & extremities over ~3 days
4-7 days

7. High fever >101º
2-4 days prior to rash: “3 C’s”
Spreads from head to trunk & extremities over ~3 days
4-7 days

8. Is measles dangerous?
Measles can be a serious disease in all age groups. However, children younger than 5 years of age and adults older than 20 years of age are more likely to suffer from measles complications.
Common complications include ear infections and diarrhea.
Severe complications can include pneumonia (infection of the lungs) and encephalitis (swelling of the brain). Persons with these complications may need to be hospitalized and could die.
High fever >101º
2-4 days prior to rash: “3 C’s”
Spreads from head to trunk & extremities over ~3 days
4-7 days

9. Is measles dangerous?
As many as one out of every 20 children with measles will get pneumonia, which is the most common cause of death from measles in young children.
About one child out of every 1,000 who gets measles will develop encephalitis that can lead to seizures and can leave the child deaf or with intellectual disabilities.
For every 1,000 children who get measles, one or two will die from it.
Measles may cause pregnant women to give birth prematurely, or have a low-birth-weight baby.
High fever >101º
2-4 days prior to rash: “3 C’s”
Spreads from head to trunk & extremities over ~3 days
4-7 days

10. Public Health Investigation of Measles
Measles is an immediately notifiable condition.
One cases of measles is considered an outbreak.
Exclude case from public (if still infectious).
Obtain extensive history of the cases movements during their infectious period.
Public notification of exposure settings, dates/times.
Interview all exposed contacts to assess for disease, immunization status, and provide follow up recommendations (exclusion if needed).
High fever >101º
2-4 days prior to rash: “3 C’s”
Spreads from head to trunk & extremities over ~3 days
4-7 days

11. Measles Prevention

12. Measles Prevention
Measles can be prevented by the measles vaccine. It is usually given in combination with rubella and mumps vaccine, aka the MMR vaccine.
One dose of MMR is approximately 93% effective against measles
Two doses of MMR vaccine is approximately 97% effective against measles.
The two doses of vaccine normally provide lifelong immunity.
High fever >101º
2-4 days prior to rash: “3 C’s”
Spreads from head to trunk & extremities over ~3 days
4-7 days

13. When should I get the vaccine?
Routine MMR vaccine recommendations:
CHILDREN: Children should receive 2 doses of measles-containing vaccine with the first dose at months of age, and the second dose between 4 and 6 years.
ADULTS: Adults should have at least one dose of MMR vaccine. Certain groups at high-risk need two doses of MMR, such as international travelers, healthcare workers, and college students. Adults born in the U.S. before 1957 are considered immune to measles from past exposures (they lived through several years of epidemic measles before development of the vaccine).
High fever >101º
2-4 days prior to rash: “3 C’s”
Spreads from head to trunk & extremities over ~3 days
4-7 days

14. When should I get the vaccine?
Routine MMR vaccine recommendations:
NOTE FOR ADULTS GIVEN THE MEASLES VACCINE BEFORE 1968: Adults who were given measles vaccine before 1968 should be revaccinated with at least one dose of the current MMR vaccine. This is because they may have received a less-effective measles vaccine that was commonly used in the U.S. during that time.
High fever >101º
2-4 days prior to rash: “3 C’s”
Spreads from head to trunk & extremities over ~3 days
4-7 days

15. When should I get the vaccine?
MMR vaccine recommendations for persons traveling internationally:
INFANTS: Infants 6 months through 11 months of age should receive one dose of MMR vaccine 4-6 weeks prior to travel.
ALL U.S. RESIDENTS OVER 12 MONTHS: should receive 2 doses, with each dose separated by a least 28 days (unless you already have evidence of immunity)
Evidence of immunity includes birth before 1957, laboratory evidence of immunity, or laboratory confirmation of disease due to measles.
High fever >101º
2-4 days prior to rash: “3 C’s”
Spreads from head to trunk & extremities over ~3 days
4-7 days

16. High fever >101º
2-4 days prior to rash: “3 C’s”
Spreads from head to trunk & extremities over ~3 days
4-7 days

17. Measles: Past vs. Present

18. History of Measles – U.S.
Before the measles vaccine, about 3-4 million people in the U.S. were affected by measles annually, died from it, and another 1000 developed chronic disabilities from measles-related encephalitis.
Measles was declared eliminated in the U.S. in 2000.
However, in recent years large measles outbreaks have lead to a significant increase in cases.
High fever >101º
2-4 days prior to rash: “3 C’s”
Spreads from head to trunk & extremities over ~3 days
4-7 days

19. History of Measles – U.S.
From January 1 to September 5, 2019, 1,241 individual cases of measles have been confirmed in 31 states. This is the greatest number of cases reported in the U.S. since 1994 and since measles was declared eliminated in 2000.
U.S. measles cases in the first five months of 2019 surpassed the total cases per year for the past 25 years.
The majority of measles cases (more than 75%) that have occurred in 2019 are linked to the outbreaks in New York, which are primarily among unvaccinated persons.
This large event in NYC, as well as outbreaks in other states, are attributed to persons who were infected during international travel to countries with measles outbreaks.
Recent outbreaks have been driven by misinformation about measles and MMR vaccine, which has led to undervaccination in vulnerable communities.
High fever >101º
2-4 days prior to rash: “3 C’s”
Spreads from head to trunk & extremities over ~3 days
4-7 days

20. History of Measles – U.S. High fever >101º
2-4 days prior to rash: “3 C’s”
Spreads from head to trunk & extremities over ~3 days
4-7 days

21. History of Measles – Oklahoma
Oklahoma has confirmed 8 cases of measles between 2015-present.
2015: 1 case
2018: 3 cases (in Feb, Apr, May)
2019: 4 cases (1 index case + 3 secondary cases in unvaccinated close contacts)
Prior to the case in 2015, the last case of measles in Oklahoma was in 1997, where there was only one confirmed case that year.
High fever >101º
2-4 days prior to rash: “3 C’s”
Spreads from head to trunk & extremities over ~3 days
4-7 days

22. Measles Outbreaks – By the Numbers
New York City recently declared the end of their outbreak on September 3, This means there have been no new cases identified in 2 incubation periods (42 days). The outbreak began in October 2018.
In the midst of the outbreak in April 2019, an emergency order was issued which instituted mandatory MMR vaccines and fines for non-compliance in certain zip codes in Brooklyn. Outbreak was heavily concentrated in the ultra-Orthodox Jewish community.
The city spent over $6M, and deployed more than 500 staff.
A total of 654 people were infected, and 52 of them were hospitalized, including 16 who required intensive care because of serious complications.
73% of cases were unvaccinated, 7% were incompletely vaccinated (1 dose) and 15% did not know their vaccination status.
72% of cases occurred in 4 Brooklyn neighborhoods.
High fever >101º
2-4 days prior to rash: “3 C’s”
Spreads from head to trunk & extremities over ~3 days
4-7 days

23. Have I been to a state with a measles outbreak?
Do I have measles?
Do I have measles symptoms?
Have I traveled internationally within the last 21 days?
Am I vaccinated for measles?
Have I had contact with anyone else that’s sick with similar symptoms?
Have I been to a state with a measles outbreak?
High fever >101º
2-4 days prior to rash: “3 C’s”
Spreads from head to trunk & extremities over ~3 days
4-7 days

24. Do I have measles?
If you or your child has symptoms that may be measles, contact your medical provider and advise them of the symptoms you/your child are experiencing.
If your physicians suspects measles, they should confirm your diagnosis by laboratory testing. The testing process may include drawing a blood specimen, swabbing your throat, and/or collecting a urine specimen, depending of the type of testing being done.
If measles is suspected, you/your child will be recommended to stay at home during your infectious period (through day 4 after rash onset) to avoid potentially infecting others in public settings like school, daycare, work, etc.
High fever >101º
2-4 days prior to rash: “3 C’s”
Spreads from head to trunk & extremities over ~3 days
4-7 days

25. Mumps

26. What is mumps? Viral infection caused by the Mumps virus
Hallmark symptom: Parotitis which can last up to 10 days and is seen in 95% of symptomatic individuals.
Other symptom may include: low-grade fever, headache, malaise, myalgia, anorexia
Approximately 15-20% of infections are asymptomatic, but still communicable.
High fever >101º
2-4 days prior to rash: “3 C’s”
Spreads from head to trunk & extremities over ~3 days
4-7 days

27. How is mumps spread?
Droplet transmission of respiratory secretion and/or direct contact with saliva
Incubation Period: days [range: days]
Infectious Period: 2 days prior to onset through 5 days after onset of parotitis
High fever >101º
2-4 days prior to rash: “3 C’s”
Spreads from head to trunk & extremities over ~3 days
4-7 days

28. Can it cause complications?
YES, Mumps infection can cause:
Orchitis in 30% of post-pubertal males
Oophoritis in 7% of post-pubertal femals
Aseptic meninigitis in 1-10% of individuals
Pancreatitis
Deafness
Infection in the 1st trimester of pregnancy is associated with 25% rate of spontaneous abortion
High fever >101º
2-4 days prior to rash: “3 C’s”
Spreads from head to trunk & extremities over ~3 days
4-7 days

29. Other Causes of Parotitis
Viral:
Parainfluenza 1 and 3
Coxackieviruses
Influenza A
HSV 1
Cytomegalovirus (CMV)
Bacterial:
Staphylococcus aureus
Streptococcus mitis
Haemophilus
Mycobacterium tuberculosis (TB)
Other:
Tumor
Dental infection
High fever >101º
2-4 days prior to rash: “3 C’s”
Spreads from head to trunk & extremities over ~3 days
4-7 days

30. Mumps Testing
Viral PCR for a buccal specimen collected within 5 days of symptom onset (best within first few days)
Serology, IgM and IgG
High fever >101º
2-4 days prior to rash: “3 C’s”
Spreads from head to trunk & extremities over ~3 days
4-7 days

31. Public Health Investigation of Mumps
Mumps is a reportable disease in Oklahoma.
During a public health investigation, our county nurses identify exposed persons and inquire about vaccination history. If unvaccinated persons are found, mumps vaccination is recommended to protect against future exposures.
The case is recommended to be excluded from all public settings through Day 5 after their parotitis onset. They can resume normal activities on Day 6
High fever >101º
2-4 days prior to rash: “3 C’s”
Spreads from head to trunk & extremities over ~3 days
4-7 days

32. Mumps in Oklahoma
Between , Oklahoma had 5 or less cases of mumps each year.
In , Oklahoma experienced a mumps outbreak which resulted in an explosion of cases:
2016: 505 cases
2017: 177 cases
Case began to decline after the outbreak. We had 19 cases confirmed in 2018.
There were numerous outbreaks in 2016 in other states including surrounding states of AR, MO, & TX
High fever >101º
2-4 days prior to rash: “3 C’s”
Spreads from head to trunk & extremities over ~3 days
4-7 days

33. Mumps in Oklahoma High fever >101º 2-4 days prior to rash: “3 C’s”
Spreads from head to trunk & extremities over ~3 days
4-7 days

34. Rubella

35. What is rubella? Contagious disease caused by the rubella virus
AKA: German measles, 3-day measles
Most people who get rubella usually have a mild illness, with symptoms that include a low-grade fever, sore throat, and a rash that starts on the face and spreads to the rest of the body (lasts about 3 days).
For children who have symptoms, the rash is typically the first sign.
High fever >101º
2-4 days prior to rash: “3 C’s”
Spreads from head to trunk & extremities over ~3 days
4-7 days

36. How is rubella spread?
Rubella is passed from person to person by airborne droplets through coughing or sneezing.
Rubella can also be spread by contact with nose and throat secretions of an ill person, or touching a contaminated surface.
High fever >101º
2-4 days prior to rash: “3 C’s”
Spreads from head to trunk & extremities over ~3 days
4-7 days

37. How long is rubella infectious?
Infected people can spread the virus to others up to 1 week before their rash starts to 4 days days after rash onset.
25-50% of rubella cases are asymptomatic but still infectious.
High fever >101º
2-4 days prior to rash: “3 C’s”
Spreads from head to trunk & extremities over ~3 days
4-7 days

38. Can rubella cause complications?
YES, rubella infection can cause:
Miscarriage in pregnant cases
Newborn death
Congenitial Rubella Syndrome (CRS) – serious birth defects that can result in the newborn if mother is infected with rubella (especially in the first trimester)
Birth defects can include heart problems, loss of hearing or eye sight, intellectual disability, and liver or spleen damage
Up to 70% of women who get rubella experience arthritis (rare in men and children)
Encephalitis and hemorrhaging
High fever >101º
2-4 days prior to rash: “3 C’s”
Spreads from head to trunk & extremities over ~3 days
4-7 days

39. Public Health Investigation of Rubella
Rubella is a reportable disease in Oklahoma.
During a public health investigation, our county nurses identify exposed persons and inquire about vaccination history. If unvaccinated persons are found, rubella vaccination is recommended to protect against future exposures.
The case is recommended to be excluded from all public settings through Day 7 after their rash onset. They can resume normal activities on Day 8.
High fever >101º
2-4 days prior to rash: “3 C’s”
Spreads from head to trunk & extremities over ~3 days
4-7 days

40. History of Rubella – U.S.
Rubella was declared eliminated from the U.S. in 2004, and is no longer endemic. However, it can still be brought into the U.S. from other parts of the world.
Before the rubella vaccination program started in 1969, rubella was a common and widespread infection in the U.S.
Last major rubella epidemic was :
2.5M people got rubella
11,000 pregnant women lost their babies
2,100 newborn deaths
20,000 babies born with congenital rubella syndrome
High fever >101º
2-4 days prior to rash: “3 C’s”
Spreads from head to trunk & extremities over ~3 days
4-7 days

41. History of Rubella – U.S.
Once the vaccine became widely used, the number of cases decline dramatically.
Today, less than 10 people in the U.S. are reported to have rubella each year.
Since 2012, all rubella cases had evidence that they were infected when they were living or traveling outside the U.S.
To maintain rubella elimination, it is important that children and women of childbearing age are vaccinated against rubella.
High fever >101º
2-4 days prior to rash: “3 C’s”
Spreads from head to trunk & extremities over ~3 days
4-7 days

42. Varicella

43. What is varicella? Contagious disease caused by the varicella virus
AKA: chickenpox
Acute onset of diffuse (generalized) maculopapular-vesicular rash
Fever may occur at time of rash
Lesions develop rapidly, and occur in several stages of development simultaneously
Distribution density is on head and trunk
High fever >101º
2-4 days prior to rash: “3 C’s”
Spreads from head to trunk & extremities over ~3 days
4-7 days

44. How is varicella spread?
Varicella is passed from person to person by airborne droplets through coughing or sneezing and by close contact with an infected person.
Chickenpox can be spread from people with shingles to others who have never had chickenpox or had the vaccine.
High fever >101º
2-4 days prior to rash: “3 C’s”
Spreads from head to trunk & extremities over ~3 days
4-7 days

45. How long is varicella infectious?
Infected people can spread the virus to others up to 5 days before their rash starts to 5 days days after rash onset.
Infectious period extends until lesions are crusted.
Exclusion (i.e. from school or daycare) is recommended until lesions crusted over.
High fever >101º
2-4 days prior to rash: “3 C’s”
Spreads from head to trunk & extremities over ~3 days
4-7 days

46. Can it cause complications?
YES, but NOT COMMON in healthy people:
Persons at high-risk for complications include infants, adolescents, adults, pregnant women, and immunocompromised persons.
Complication can include:
Secondary bacterial infections of skin and soft tissues including Group A streptococcal infections
Pneumonia
Encephalitis
Hemorrhaging
Sepsis
Dehydration
Deaths are very rare now due to implementation of varicella vaccine.
High fever >101º
2-4 days prior to rash: “3 C’s”
Spreads from head to trunk & extremities over ~3 days
4-7 days

47. Public Health Investigation of Varicella
Varicella is NOT a notifiable condition in Oklahoma.
However, we do monitor, track, and assist in outbreak control if a setting (i.e. a school or daycare) experiences an outbreak of varicella.
High fever >101º
2-4 days prior to rash: “3 C’s”
Spreads from head to trunk & extremities over ~3 days
4-7 days

48. History of Varicella – U.S.
Varicella used to be very common in the U.S. In the early 1990s, an average of 4 million people got chickenpox, 10,500 to 13,000 were hospitalized, and 100 to 150 died each year.
Chickenpox vaccine became available in the U.S. in Each year, more than 3.5M cases of chickenpox, 9,000 hospitalizations, and 100 deaths are prevented by the chickenpox vaccination in the U.S.
High fever >101º
2-4 days prior to rash: “3 C’s”
Spreads from head to trunk & extremities over ~3 days
4-7 days

49. Summary

50. Rubella Virus (Rubivirus)
Cause
Symptom
Rash
Transmission
Susceptibility
Rubella Virus (Rubivirus)
Prodrome uncommon in children. Adults may have 1-5 day prodrome of mild fever, HA, malaise, mild coryza, and conjunctivitis. Lymphadenopathy may occur 5-10 days prior to rash.
Pink macules and papules that develop on forehead and spread down and to extremities within one day; fading of macules and papules in reverse order by 3rd day. May not appear in 50% of cases.
Droplet spread, incubation avg days. Communicable 1 week prior to rash until 4 days after rash appears. Vaccine will not prevent disease in exposed persons.
Infants born to immune mothers are protected up to 6 months of age. Single vaccine dose is 98 – 99% effective.
Rubeola Virus (Measles)
Prodromal fever of 101F or high; three C’s (cough, coryza, and conjunctivitis), Koplik spots
Generalized maculopapular rash occurring on 3rd day of symptoms. Begins on face, neck and shoulders and spreads centrifugally and downward. Becomes generalized in 3-7 days.
Airborne spread. Incubation 7-18 days (typically 10). Communicable 4 days prior to rash onset, through 4 days after rash onset. Vaccine given within 72 hours of exposure may prevent disease.
Infant born to immune mothers are protected for 6-9 months of age. Single vaccine dose is 94 – 98% effective, 2nd dose is 99% effective.
Varicella Virus (Chickenpox)
Sudden onset of slight fever. Mild constitutional symptoms.
Maculopapular rash occurs and within a few hours progresses to vesicular rash, lasting 3-4 days, then to scabs. Rash pattern is centripetal, beginning on face and spreading to trunk and extremities. Crops of rash are noted in different stages simultaneously.
Airborne and contact spread. Incubation 2-3 weeks (usually days) after exposure. Communicable up to 5 days (usually 1-2) before rash up until lesions are crusted (usually around 5 days). Vaccine given within 3 days of exposure may prevent disease.
Susceptible persons are potentially contagious between days after exposure. Single vaccine is 85 – 90% effective and 100 effective in reducing severity of disease.

52. MMRV Prevention High fever >101º 2-4 days prior to rash: “3 C’s”
Spreads from head to trunk & extremities over ~3 days
4-7 days

53. MMRV Prevention High fever >101º 2-4 days prior to rash: “3 C’s”
Spreads from head to trunk & extremities over ~3 days
4-7 days

54. Thank you!