What is the issue?
There have been three confirmed cases of confirmed measles in Melbourne in March this year, with the infection likely to have been acquired overseas. The cases attended a number of locations in and around Melbourne whilst infectious including:
- Saturday 3 March - Flinders Backpackers (Elizabeth Street, Melbourne), Flinders Street Railway Station, tram routes 16 and 96 to and from St. Kilda beach, St Kilda beach
- Sunday 4 March - Flinders Backpackers, Coles Central (Flinders and Elizabeth St), McDonalds (Elizabeth St)
- Monday 5 March - Flinders Backpackers, Phillip Island: Nobbies Visitor Centre Café
- Tuesday 6 March - Flinders Backpackers, Westpac bank (Elizabeth Street), Medicare office (Galleria Shopping Centre, Bourke Street)
- Wednesday 7 March - Flinders Backpackers, multiple sites along the Great Ocean Road between Geelong and Warrnambool
- Wednesday 7 March - AirAsia flight D7214 from Kuala Lumpur to Melbourne and at Tullamarine Airport from 9.30am until midday
- Saturday 10 March - Qantas flight QF44 from Denpasar to Sydney arriving at 06.25am, Qantas flight QF 415 from Sydney to Melbourne, arriving at 10.35am, Tullamarine Airport until midday and Lentil as Anything restaurant at Abbotsford Convent from 2pm until 3pm.
As measles is highly infectious through airborne transmission, other secondary cases may occur in susceptible people. Measles has an incubation period of between seven and 18 days (average 14 days from exposure to rash) so should be considered in the differential diagnosis of any susceptible person who presents with a compatible illness, with an onset date between 10 March and 28 March 2018.
Anyone who presents with signs and symptoms compatible with measles should be immediately notified to the Department on 1300 651 160 and tested. Do not wait for test results before notifying. There should be an especially high index of suspicion if the patient has attended any of the areas stated above and are unvaccinated or partially vaccinated for measles.
Who is at risk?
Children or adults born during or since 1966 who do not have documented evidence of receiving two doses of a measles-containing vaccine or do not have documented evidence of immunity are considered to be susceptible to measles. People who are immunocompromised are also at risk.
Symptoms and transmission
Clinical features of measles include prodromal fever, a severe cough, conjunctivitis and coryza. Individuals are typically unwell, especially children.
The most important clinical predictors are the following features:
- generalised, maculopapular rash, usually lasting three or more days, AND
- fever (at least 38°C, if measured) present at the time of rash onset, AND
- cough, coryza or conjunctivitis.
Measles is transmitted by airborne droplets and direct contact with discharges from respiratory mucous membranes of infected persons. Less commonly, transmission occurs through articles freshly soiled with nose and throat secretions. Measles is highly infectious and can persist in the environment for up to two hours. The infectious period of patients with measles is roughly five days before, to four days after, the appearance of the rash.
Use the most appropriate tests for diagnosis depending on timing of symptoms and presentation:
- Take blood for serological confirmation in all suspected cases. If a patient has measles, IgM is reliably positive if the rash has been present for three or more days. IgG in the absence of IgM indicates the patient is protected and means measles is unlikely.
- Nose and throat swabs for PCR diagnosis are best for early diagnosis (including prior to rash); you must contact the Department prior to taking swabs to gain approval for these to be tested at the Victorian Infectious Diseases Reference Laboratory. PCR testing for measles does not attract a Medicare rebate.
This picture is typical of rash on the face. This is a rash on day three in a young boy.
Picture courtesy of U.S. Centers for Disease Control and Prevention
Summary of recommendations
- Be alert for new measles cases - ensure all staff, especially triage nurses, have a high index of suspicion for patients presenting with a febrile rash.
- Notify suspected cases immediately to the Communicable Disease Prevention and Control Section via telephone on 1300 651 160 (24 hours).
- Manage suspected cases in the GP setting if appropriate and avoid sending to a hospital emergency department unless your patient is severe enough to warrant admission to hospital.
- To minimise the risk of measles transmission within your department/practice:
- avoid keeping patients with a febrile rash illness in shared waiting areas
- give the suspected case a single use mask and isolate them, until a measles diagnosis can be excluded
- leave vacant all consultation rooms used in the assessment of patients with suspected measles for at least 30 minutes after the consultation.
- Seek advice from the Department of Health and Human Services Communicable Disease Prevention and Control Section regarding:
- the management of susceptible hospital or clinic contacts
- prevention of measles in susceptible contacts.
- Take blood for serological confirmation.
- Call the department to discuss the need for PCR diagnosis.
- On advice, follow up all persons who attended the emergency department or clinic at the same time as a case and for 30 minutes after the visit. These people are considered to be exposed to the measles virus.
- Check your staff vaccination records.
- Earlier outbreaks have affected health care workers, including some who have not been involved in the direct care of measles cases and have only been in the same ward, clinic, or department as a case. All staff born during or since 1966 should have documentation of two doses of measles-containing vaccine, or laboratory-confirmed evidence of past measles infection.
The Australian Immunisation Handbook; 10th edition, 2013
The Blue Book – Guidelines for the control of infectious diseases
Better Health Channel
For further information please contact the Communicable Disease Prevention and Control section at the Department of Health and Human Services on 1300 651 160 (24 hours).