Measles
- Patients with a compatible rash illness should be isolated immediately. Follow the advice in the 'Infection Prevention and Control - Measles At-a-Glance' document for information on contact tracing. Contact Micro/ID if measles is suspected.
- For background information see Measles: the green book
- For full guidance see the National measles guidelines
- Non-vulnerable contacts with no, or unclear, immunity to measles should be offered the MMR vaccine, ideally within 72 hours of exposure
- Vulnerable contacts (infants (up to 6 months or 9 months if household contact), pregnant women and immunosuppressed patients) will be assessed by Micro/ID with support from an Infection Control Doctor for immunoglobulin
- Immunoglobulin does not need to be arranged overnight (8pm-8am). If a vulnerable contact is approaching the end of the recommended window since exposure, then overnight administration can be considered but the additional risks of administering immunoglobulin overnight must be considered
- MMR vaccine should only be arranged during the day (9am-5pm, Mon-Sun)
Non-vulnerable contacts - MMR Vaccine
- Non-vulnerable contacts with incomplete measles vaccination history (i.e. less than two doses of a measle containing vaccine) and a negative history of measles infection should be offered the MMR vaccine, ideally within 72 hours of exposure.
- Vaccine-induced measles antibody develops more rapidly than that following natural infection, and there is some evidence that it may prevent diseases or reduce its severity. Even where it is too late to provide effective Post Exposure Prophylaxis (PEP) with MMR, the vaccine can provide protection against future exposure to all three infections (measles, mumps and rubella) and individuals should still be opportunistically vaccinated.
- If there is doubt about an individual’s vaccination status, MMR should still be given as there are no ill effects from vaccinating those who are already immune.
- If the individual is already incubating measles, MMR vaccination will not exacerbate the symptoms. The typical incubation period is 10 to 12 days from exposure to onset of symptoms but can vary from 7 to 21 days. In these circumstances, individuals should be advised that a measles-like illness occurring shortly after vaccination is most likely to be due to natural infection.
- MMR vaccine should only be arranged during the day (9am-5pm, Mon-Sun)
Vulnerable contacts - human normal immunoglobulin (HNIG)
- Although PEP is of limited effectiveness, there may be an opportunity to offer some protection to exposed vulnerable contacts with HNIG, namely infants (up to 6 months or 9 months if household contact), pregnant women and immunosuppressed patients.
- Vulnerable contacts should be rapidly assessed as, where indicated, HNIG should be given within 6 days of exposure (ideally 3 days for some immunosuppressed individuals and infants up to 9 months)
- People with severe defects of cell mediated immunity who are on regular Intravenous immunoglobulin (IVIG) replacement therapy do not require additional IVIG if the most recent dose was administered 3 weeks or less before exposure.
- To decide which patients may benefit from HNIG, Infection Prevention and Control (IPC) team will assist clinical staff to assess:
- measles vaccination history
- prior measles infection
- nature and level of immune suppression if present. (Micro/ID can assist in defining when assessing for HNIG). (See National measles guidelines Annexe 2. Classification of immunosuppression (measles))
- Once this information has been gathered, discuss with Micro/ID with support from Infection Control doctor who will assess the need for HNIG.
- A rapid measles IgG test may be required to assess immunity to measles. Results should be available within 24 hours or less from the OUH microbiology department.
- HNIG does not need to be arranged overnight (8pm-8am). If a vulnerable contact is approaching the end of the recommended window since exposure, then overnight administration can be considered but the additional risks must be considered
Immunosuppressed patients
Identify which classification of immunosuppression the patient meets and then see the relevant tables below: National measles guidelines Annexe 2. Classification of immunosuppression (measles)
This guidance is based largely on the assessment of individuals born and raised in the UK. For patients born and raised in other countries please refer to the National measles guidelines 2.2.3 Immunosuppressed patients
Group A - Individuals who should develop and maintain adequate antibody from past exposure or vaccination.
|
Age |
History of measles exposure or vaccination |
Recommendation |
|
All ages |
Previous IgG positive |
Assume immune – do not give IVIG |
|
Born before 1970 |
Positive history of infection |
Assume immune – do not give IVIG |
|
No history of infection |
Rapid IgG test – give IVIG if negative or equivocal. If not possible to test within 6 days of exposure: assume immune - do not give IVIG |
|
|
Born between 1970 and 1990 |
Positive history of infection or vaccination |
Rapid IgG test – give IVIG if negative or equivocal. If not possible to test within 6 days of exposure: assume immune - do not give IVIG |
|
No history of infection or vaccination |
Rapid IgG test – give IVIG if negative or equivocal. If not possible to test within 6 days of exposure: give IVIG |
|
|
Born after 1990 |
History of 2 measles containing vaccines |
Rapid IgG test – give IVIG if negative or equivocal. If not possible to test within 6 days of exposure: assume immune - do not give IVIG |
| History of 1 measles containing vaccines |
Rapid IgG test – give IVIG if negative or equivocal. If not possible to test within 6 days of exposure: give IVIG |
|
| Unvaccinated | Give IVIG |
Group B – Individuals who lose or may not maintain adequate antibody levels from past exposure or vaccination.
|
Immunosuppression group |
History of measles exposure or vaccination |
Recommendation |
|
Group B (i) |
IgG positive since diagnosis or treatment completion |
Assume immune – do not give IVIG |
|
No documentation or negative IgG since diagnosis or treatment completion |
Rapid IgG test – give IVIG if negative or equivocal. If not possible to test within 3 days of exposure: give IVIG |
|
|
Group B (ii) |
Give IVIG regardless of status |
|
Pregnant women
Recommendations for pregnant women are based upon a combination of age, history and/or antibody testing. See National measles guidelines 2.2.4 Immunocompetent vulnerable contacts: pregnant women for full definitions.
|
Age |
History of measles exposure or vaccination |
Recommendation |
|
Born before 1990 |
History of measles infection |
Assume immune – do not give HNIG |
|
No history of measles infection |
Rapid IgG test and administer HNIG within 6 days of exposure only if antibody negative |
|
|
History of 2 measles containing vaccines |
Assume immune – do not give HNIG |
|
|
Born 1990 or later |
History of 2 measles containing vaccines |
Assume immune – do not give HNIG |
|
History of 1 measles containing vaccine |
Rapid IgG test and administer HNIG within 6 days of exposure only if antibody negative |
|
|
Unvaccinated |
Rapid IgG test and administer HNIG if antibody negative. If not possible to test within 6 days of exposure: give HNIG |
Infants
Recommendations for infants are based upon age due to short-lived passive maternal immunity and interference of maternal antibodies with the MMR vaccine. See National measles guidelines 2.2.5 Immunocompetent vulnerable contacts: infants for full definitions.
|
Age |
Recommendation |
|
|
Under 6 months |
Assume susceptible and administer HNIG, ideally within 72 hours of exposure but up to 6 days, regardless of maternal status. |
|
|
6 to 8 months |
For household exposure, administer HNIG, ideally within 72 hours of exposure but up to 6 days. |
For non-household exposure, administer MMR vaccine, ideally within 72 hours of exposure. |
|
9 months and older |
Administer MMR vaccine, ideally within 72 hours of exposure. |
|
Due to interference from maternal antibody, the efficacy of a dose of vaccine provided between 6 to 11 months of age is lower than that provided at 12 to 13 months, and therefore doses offered before one year of age should be discounted and children should be offered 2 doses of MMR vaccine according to the national schedule.
Prescribing HNIG
Immunoglobulin (HNIG) for measles requires:
- Micro/ID approval
- Immunoglobulin Request Form completed on the Immunoglobulin Database
- EPR Prescription
HNIG for measles does not come from the UKHSA Rabies and Immunoglobulin Service. Supply will be made from the hospital pharmacy.
Ensure the pharmacist (see screening section below) is promptly contacted before prescribing to ensure the correct brand is prescribed
Immunoglobulin dose and brand:
Subgam, Cutaquig and Hizentra are the recommended products. Note that the intramuscular (IM) route is off-label but recommended as absorption is faster than the subcutaneous (SC) route.
*Cuvitru can be used if no other product is available but IM administration is not routinely recommended. SC administration would be suitable but due to slower absorption is likely to be associated with delayed action. Depending on clinical urgency, off-license IM administration based on a benefit-risk discussion would be a consideration. See National measles guidelines 2.3.2 Immunocompetent infants and pregnant women
|
Vulnerable Patient Group |
Product to prescribe |
Dose and administration |
|
Infants (up to 8 months) |
Subgam, Cutaquig or Hizentra (depending on availability) or Cuvitru* |
0.6ml/kg (max 1g) intramuscular – max 3ml per site See national guidelines if Cuvitru used |
|
Pregnant women |
Subgam, Cutaquig or Hizentra (depending on availability) or Cuvitru* |
3g intramuscular - max 5 ml (Can administer subcutaneously into thigh if abdominal wall too tight) See national guidelines if Cuvitru used |
|
Immunosuppressed |
Pharmacy will advise on available brand. |
0.15g/kg intravenous IVIG infusion For obese patients, ideal bodyweight (IBW) should be used to calculate the dose. Round the dose down to the nearest 2.5g |
Intravenous immunoglobulin (IVIG) should be prescribed using the respective powerplan. The pre-infusion and infusion -reaction medications should also be prescribed. E.g for Gamunex:
Subcutaneous immunoglobulin should be prescribed using the order sentence on EPR as with other standard drugs
Before pharmacy can supply, a referral must be completed on the online Immunoglobulin Database by a doctor.
Screening HNIG
Measles HNIG should be screened by the following pharmacists:
| Mon-Fri (9am-5pm) | Sat (9am-5pm) | Sun & Bank Holidays (9am-5pm) | Out of Hours | ||
| 5pm-7pm | 7pm-8am* | 8am-9am | |||
| Ward pharmacist |
AMS pharmacist #1549 |
Dispensary pharmacist #1884 |
On-call #1884 |
On-call via Switchboard |
On-call #1884 |
*Immunoglobulin does not need to be arranged overnight (8pm-8am). If a vulnerable contact is approaching the end of the recommended window since exposure, then overnight administration can be considered but the additional risks of administering immunoglobulin overnight must be considered.
*MMR vaccine should only be arranged during the day (9-5pm, Mon-Sun)
For immunosuppressed, non-pregnant adults the current preferred IVIG product is Gamunex but this may change based on local availability.
Ensure IVIG is prescribed using the respective IVIG PowerPlan, including pre-meds.
Refer to the respective Medusa injectable monograph for method of administration, including recommended infusion rates.
A referral must be completed online for a supply to be made.
Dispensing HNIG
Dispensing measles HNIG follows the same procedure as for all OUH pharmacy HNIG supplies.