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Please see the Health Protection Scotland Quick reference guide for the control of measles incidents and outbreaks in Scotland.
Please also refer to the NHS GG&C Control of Infection Committee Measles guidance. Measles Guidance V7 (interim)
This guidance document will be superseded by an update in the event of widespread community transmission of measles in Scotland.
In 2018 measles virus transmission was re-established in the UK. Measles is the most infectious of all diseases transmitted via the respiratory route, with a reproduction (R) number of between 15 and 20.
The most effective control measure is high uptake of 2 doses of the measles, mumps, and rubella (MMR) vaccine. Vaccination with 1 dose is at least 95% effective in preventing clinical measles, and 92% effective in preventing secondary cases amongst household contacts (1). In the UK, the first dose of MMR vaccine is offered between 12 and 13 months, the second dose at 3 years and 4 months.
Reassuringly vaccine uptake rates in Scotland are high, but still fall below the WHO target of > 95% uptake of 2 doses by 5 years of age. In the quarter ending 30 September 2023, 93.3% of children had had the first dose of MMR vaccine by 24 months of age. This rose to 95.8% for children who had reached age 5 years of age. Uptake of the second dose of MMR vaccine by 5 years of age was 89.6%, rising to 91.0% by age 6 years of age (2).
Whilst the overall risk of measles to the Scottish population is low, current vaccination rates are below the herd immunity threshold, and imported cases could propagate local outbreaks within un- and under-vaccinated communities.
Measles starts with a 2- to 4-day prodromal phase, with high fever, cough, coryza and conjunctivitis, before a maculopapular rash develops.
Fever typically increases during the prodromal phase, peaks (generally >39°C) at around the time of onset of the rash and gradually decreases after that. Measles is very unlikely if there is no history of fever.
The maculopapular rash generally starts on the face and behind the ears. The number of lesions/spots increases over the first 2-3 days. The rash spreads to the face and trunk, and can become generalised, the lesions can become confluent. The rash is not itchy. It lasts for around 3-7 days, fading gradually. It may end with peeling of the skin. (See pictures below as example).
Koplik spots may appear around the time of the rash, sometimes 1 day before, and last for 2-3 days after the rash appears. These are small white or bluish- white lesions, of about 2-3mm in diameter, on an erythematous base on the buccal mucosa. These can be confused with other lesions in the mouth and therefore their suspected presence is an unreliable marker for measles.
Symptoms typically peak on the first day of the rash.
Above figure taken from: UK HAS National measles guidelines, February 2024
Pictures from UK HAS National measles guidelines, February 2024
Further example pictures available at:
Patients who are immunosuppressed may present with an atypical rash or no rash at all. They may also present directly with pneumonia or encephalitis. Immunosuppressed patients may have prolonged excretion of the virus in respiratory tract secretions and can be contagious for the duration of the illness.
Cases are considered infectious from 4 days before to 4 days after onset of the rash.
Significant contact is defined as being in the same room for 15 minutes or more, or face-to-face contact of any length.
For immunosuppressed individuals, any level of contact is assumed significant.
The incubation period is typically around 10 to 12 days but can vary from 7 to 21 days.
Complications are more common and more severe in immunosuppressed patients and young infants. These include:
Pre-alert:
Pre-alerted possible or confirmed measles case (Primary Care):
No pre-alert:
ED greeter identifies ‘possible’ case during ‘RHC ED Greeter ‘Screening’ questions SOP’
Screening questions:
AND
OR
Check immunisation status of patient – if had 2 MMR immunisations AND NO confirmed case contact in last 21 days, then no indication to isolate and patient should follow existing patient pathways based on their presenting complaint.
If unvaccinated or partially vaccinated child OR confirmed measles contact in last 21 days then follow below.
ED clinical assessment of a ‘possible’ case in CDU isolation room
The following recommendations are based on the Health Protection Scotland Guidance for the Control of Measles Incidents and Outbreaks in Scotland, revised May 2019.
Young infants, pregnant young people, and immunosuppressed children and young people may benefit from post-exposure prophylaxis. This is with immunoglobulin or the MMR vaccine.
The recommendation to give post-exposure prophylaxis should be made by the Public Health Protection Team, following a risk assessment.
MMR vaccine will be administered in the community.
Immunoglobulin will be administered at the RHC. The preparation and dose of immunoglobulin varies according to the indication. If there are queries about the administration of immunoglobulin, discuss with the on-call pharmacist and the Paediatric Infectious Diseases Team.
Infants under 12 months of age are unvaccinated and at high risk of developing measles if exposed. Recommended post-exposure prophylaxis depends on their age and whether they are a household contact and includes both Subcutaneous Immunoglobulin (SCIG), referred to as Human Normal Immunoglobulin (HNIG), and MMR vaccination. See the table below for guidance.
Post-exposure prophylaxis in infants of UK born mothers*
*As the pattern of maternal antibody waning in infants shows significant geographical variation and as vaccination programmes were introduced at different times, this advice may not be applicable to infants of mothers born outside the UK. In such cases an individual risk assessment is required by the Public Health Team.
Guidance for the Control of Measles Incidents and Outbreaks in Scotland, Scottish Health Protection Network, Health Protection Scotland, May 2019
It is the responsibility of the Public Health Protection Team to contact the parent/carer and discuss the recommendations. The discussion will be documented on the patient’s Clinical Portal record.
If the recommendation is for MMR, this will be arranged in the community.
If the recommendation is for immunoglobulin, the Public Health Protection Team will discuss the case with the on call Paediatric Infectious Diseases Team (Consultant via the RHC switchboard 0141 2010000). The Paediatric Infectious Diseases Team will then contact the RHC Clinical co-ordinator (85770) to determine when and where the patient can attend. The location may need to be determined on a case-by-case basis, will depend on capacity and nursing resource. The Paediatric Infectious Diseases Team will then contact the patient with details of when and where to attend.
Patients should be booked in on arrival to the RHC ED, admitted under the care of the Paediatric Infectious Diseases Team.
Please note that contacts are not considered infectious until 5 days after exposure, so standard infection prevention and control measures are sufficient until this time.
All patients should have a set of observations and weight on arrival. The Paediatric Infectious Diseases Team should be contacted to discuss consent for and prescribe the immunoglobulin.
Patients should be observed with a set of observations 30 minutes after administration of immunoglobulin, prior to discharge home.
Please complete the immunoglobulin request form, using the red indication ‘specific antibody deficiency’ and give to the 2C pharmacy team (office on ward 2C). Approval can be granted retrospectively if out of hours.
The product supplied will depend on availability, in March 2024 the preferred local products are Hizentra, followed by Cutaquig. Other products may also be used if the preferred products are not available, as discussed with the pharmacy team.
Dose: 0.6ml/kg to a maximum of 1g
Administered subcutaneously or intramuscularly. Please note the intramuscular route is off label, but is suggested as an alternative practical route of administration in this situation by the UKHSA, given the clinical imperative to treat these contacts urgently. The intramuscular route of administration has been agreed as the preferred route at the RHC.
For intramuscular administration The Green Book recommends that if volumes of more than 3ml are needed, immunoglobulin should be given in divided amounts and given into different sites.
Subcutaneous administration should only be done by nursing staff with competence, with the appropriate infusion device/pump. See product Summary of Product characteristics (SPC) for subcutaneous administration instructions.
Please discuss with the ward/on-call pharmacist if needing further advice.
Immunosuppressed patients also require a risk assessment and may require measles post-exposure prophylaxis, as intravenous immunoglobulin (IVIG).
The recommendation to give post-exposure prophylaxis should be made by the Public Health Protection Team, following a risk assessment.
If any immunosuppressed person (e.g. patients with leukaemia or on high dose immunosuppressant) is exposed there is a very low threshold for follow-up: even a very short exposure (minutes) should trigger investigation. In a highly immunosuppressed child or young person who is unlikely to be immune, it may be worth considering prophylaxis where the possibility of exposure has occurred e.g. by entering a room within a short period after a case has been present.
All immunosuppressed individuals should be considered for treatment with IVIG as soon as possible after the exposure occurred (preferably within 3 days, but treatment may be effective within 6 days).
People with severe defects of cell mediated immunity who are on regular IVIG replacement therapy do not require additional IVIG if the most recent dose was administered ≤3 weeks before exposure.
See for definitions of immunosuppressed individuals, and further details on risk assessment.
If a specialty team is contacted by a parent/carer with concerns about possible exposure, this can be discussed with the Public Health Protection Team (0141 201 4917 Mon-Fri 9-5pm).
Following exposure to a confirmed case of measles, it is the responsibility of the Public Health Protection Team to contact the parent/carer and discuss the recommendations. The discussion will be documented on the patient’s Clinical Portal record.
Following risk assessment, the Public Health Protection Team should contact the on call responsible clinical team for the individual, to discuss the recommendations (Consultant via the RHC switchboard 0141 2010000).
If measles IgG testing or IVIG is indicated, the responsible clinical team should liaise with the Clinical co-ordinator (85770) to determine when and where the patient can attend. The location may need to be determined on a case-by-case basis, will depend on capacity and nursing resource. The responsible clinical team should then liaise with the patient to arrange admission.
Please note that contacts are not considered infectious until 5 days after exposure, so standard infection prevention and control measures are sufficient until this time
Patients should be booked in on arrival to the RHC ED before being transferred to the allocated clinical area, admitted under the care of the responsible clinical team.
If attending for IVIG, patients should have a set of observations and weight on arrival. The responsible clinical team should be contacted to review, should ensure IV access, discuss consent and prescribe the immunoglobulin.
Patients should be observed, with a set of observations 30 minutes after administration, prior to discharge home.
Treatment with Intravenous Immunoglobulin (IVIG) for immunosuppressed children
Please complete the immunoglobulin request form [Sharepoint link], using the red indication ‘specific antibody deficiency’ and give to the 2C pharmacy team (office on ward 2C). Approval can be granted retrospectively if out of hours.
The preparation used will depend on available stock. There is a likelihood that immunosuppressed patients will have been treated with IVIG in the past. If the preparation is known, use the same brand if available.
Dose - 0.15 g/kg.
For administration guidance refer to the product Summary of Product characteristics (SPC) or ‘Normal Immunoglobulin IV schedules – other brands’ [Sharepoint link], available on the Staffnet hub.
Please prescribe IVIG on both the ‘Normal Immunoglobulin IV schedules – other brands’ form and also on HEPMA.
Please note that patients with known severe defects of cell-mediated immunity, who are on regular IVIG replacement therapy, do not require additional IVIG if the most recent dose was administered 3 weeks or less before exposure.
Please discuss with the ward/on-call pharmacist if needing further advice.
If unsure about recommendations for testing or prophylaxis, please discuss with the Paediatric Infectious Diseases Team.
Detailed NHSGG&C guidance is available here.
Non-essential visitors should be minimised.
Parents, carers or visitors with symptoms should not be permitted to enter a care area, unless it is considered essential.
PPE is not required for household contacts.
Healthcare workers are encouraged to know their own measles vaccine and/or serology status. Those unsure of their status should contact the Occupational Health Team (directly by email occupational.health@ggc.scot.nhs.uk or telephone 0141 201 0600 or through their line manager).
Healthcare workers who are not immunosuppressed and have had at least 2 doses of a measles-containing vaccine, or who have documented positive measles serology (at any time) are considered immune. For these individuals no action is required other than to be alert for the symptoms of measles in the 21 days following exposure due to the rare possibility of breakthrough infection.
Healthcare workers who are non-immune or unsure of their status, or those who are pregnant or immunosuppressed, should contact the Occupational Health Team on 0141 202 0594 or 0141 201 0600 for advice. They may be offered post-exposure MMR vaccination (or IVIG prophylaxis if pregnant/immunosuppressed) and urgent serology testing.
They can continue to work until 5 days after exposure. Those with positive serology (immune) can return to work, those with negative serology (non-immune) and confirmed exposure will be excluded from work until 21 days post-exposure. Exclusion time may be reduced if post exposure vaccination is undertaken - this should be confirmed with the Occupational Health Team on 0141 202 0594 or 0141 201 0600.
Roseola (exanthema subitem, sixth disease)
https://dermnetnz.org/topics/roseola
Fifth disease (‘slapped cheek syndrome’)
https://dermnetnz.org/cme/viral-infections/specific-viral-exanthems
Rubella (German measles)
Scarlet fever
Last reviewed: 05 April 2024
Next review: 30 April 2026
Author(s): Dr Katherine Longbottom, Consultant General Paediatrics & Paediatric Infectious Diseases, RHCG, Dr Louisa Pollock, Consultant General Paediatrics & Paediatric Infectious Diseases, RHCG, Dr Steve Foster, Consultant in Paediatric Emergency Medicine, RHCG, Dr Ciara Carrick, Consultant in Paediatric Emergency Medicine, RHCG.
Author Email(s): steven.foster@ggc.scot.nhs.uk
Co-Author(s): Ms Shahad Abbas, Advanced Pharmacist - Antimicrobials and Medical Paediatrics, RHCG.
Approved By: RHC Medical Paediatrics & Paediatric Emergency Department Clinical Governance Groups