Measles—Child Care and Schools

What is measles?

• Measles is a highly contagious and acute viral disease caused by the measles virus. Humans are the only natural host for the measles virus.

• Outbreaks occur when underimmunized people become infected and infect others. Measles was under control but has reemerged in states where vaccination rates have decreased. Refer to the Centers for Disease Control and Prevention and your local health department for the most up-to-date recommendations regarding measles at www.cdc.gov/measles/index.html.

What are the signs or symptoms?

• Fever, cough, runny nose, and red, watery eyes.

• Small, typically white spots in the cheek area inside the mouth (called Koplik spots).

• Appearance of rash 2 to 4 days after symptoms start, which starts at hairline spreading downward over body.

• May have diarrhea, pneumonia, or ear infection as a complication.

• Serious complications include secondary bacterial pneumonia, brain inflammation, convulsions, deafness, intellectual disability, or death.

What are the incubation and contagious periods?

• Incubation period: 7 to 21 days (average of 11?12 days) from exposure to onset of signs or symptoms

• Contagious period: From 1 to 2 days before the first signs or symptoms appear (4 days before the rash) until 4 days after the appearance of the rash

How is it spread?

• Airborne route: Transmission occurs when the virus becomes airborne from fluid released from vesicles or from small respiratory droplets expelled after a cough or sneeze. These germ-containing particles can quickly dry out in the air and settle onto surfaces, later attaching to dust particles and becoming airborne again. Air currents can carry the particles and can infect people in the same or another room. Even brief exposure or shared airflow poses a high risk of infection for individuals who have not had measles before, have not been protected by the measles vaccine, or have a weakened immune system.

• Measles virus can remain airborne for up to 2 hours after an infected person coughs or sneezes.

Face of a child with measles, characteristic of the third day of the rash

CENTERS FOR DISEASE CONTROL AND PREVENTION

Child faces towards us with measles rash on their face and body. Hundreds of red spots begin at the hairline and spread across the child's face onto their bare shoulders, with some spots joining together to form patches.

Measles rash on a child's face

CENTERS FOR DISEASE CONTROL AND PREVENTION

Close-up of the upper portion of a child's face with measles rash. The faint, patchy rash is concentrated around the forehead and the bridge of the nose. The numerous small, slightly raised bumps appear slightly lighter than the surrounding skin.

How do you control it?

• Measles is a vaccine-preventable infection. Immunize according to the current schedule—when a child is 12 to 15 months of age and with a second dose at 4 to 6 years of age. In the setting of an outbreak or high-risk exposure (eg, travel), alternative dosing schedules allow for earlier administration of the first or second vaccine dose.

• Review measles immunization status of all children and staff members and identify those who are not protected by vaccine in the event there is a risk of exposure to measles.

• Exclude infected children until 4 days after the rash starts when they are no longer contagious. Measles is a highly contagious infection. Because measles viruses are spread by the airborne route, infected children should not be cared for in any child care area and should be sent home as soon as possible. They should not be placed in a special room for children who are ill.

• Exclude exposed children and staff members who are underimmunized until they receive either an immunization or postexposure prophylaxis (PEP) and meet other quarantine requirements to return. If they are not immunized because of an accepted exemption from immunization, continue to exclude them until the local health department determines it is safe for them to return. (See the section Exclude from educational setting? for duration of exclusion of these individuals.)

• Postexposure prophylaxis in underimmunized individuals is either in the form of a vaccine or an immune globulin infusion. The indications for the type of PEP depend on the age and vaccination history of the individual.

• In general, infants younger than 6 months, pregnant individuals, and those that are immune compromised will qualify for immune globulin as PEP within 6 days of exposure.

• In an outbreak, infants 6 to 11 months of age can be immunized and then re-immunized at 12 months of age. The 12-month immunization is still necessary because the child's immunity from the previous dose of vaccine may be blocked by the mother's measles antibodies that cross the placenta during pregnancy and are present in the child for a year; they will also need the standard additional dose at 4 to 6 years of age.

• A single case of measles anywhere in the United States is a reportable outbreak.

• Use good hand-hygiene technique at all the times listed in Chapter 2 of Managing Infectious Diseases in Child Care and Schools: A Quick Reference Guide, 7th Edition and routine infection control measures.

What are the roles of the educator and the family?

• Report the infection to the staff member designated by the early childhood education (ECE) program or school for decision-making and action related to care of ill children and staff members. That person, in turn, alerts possibly exposed family and staff members and parents of underimmunized children to watch for symptoms and notifies the Child Care Health Consultant.

• Report the infection to the local health department. The health professional who makes the diagnosis may not report that the infected child is a participant in an ECE program or school, and this could lead to delay in controlling the spread.

• Review and ensure all children have received the measles, mumps, rubella (MMR) vaccine according to the current immunization schedule.

• Ensure staff members who have had fewer than 2 doses of vaccine are properly immunized unless they are documented to have had the disease or were born before 1957. Individuals born before 1957 are presumed immune because measles was so widespread before vaccine became available, although being in this group is not a guarantee of immunity. A laboratory test is available for testing immunity.

• During investigation of a suspected case, the educational facility should exclude exposed children who have weakened immune systems or who are underimmunized for MMR.

Exclude from educational setting?

Yes.

• All children and adults without evidence of immunity who are exposed to a case of measles will be required to be excluded from the program from day 8 to at least 21 days after the onset of rash in the last case of measles at that program.

  Note: If there are multiple cases of measles at a particular program, exclusion might be extended beyond 21 days, since the 21-day time period would reset with each newly identified case.

• Underimmunized children and adults who have been exposed to measles may avoid exclusion if they receive a measles immunization within 3 days of exposure.

Readmit to educational setting?

Yes, when all the following criteria are met:

• For children or adults who become sick with measles, 4 days after beginning of rash

• When the child is able to participate and staff members determine they can care for the child without compromising their ability to care for the health and safety of the other children in the group

• For children or adults exposed but not yet ill: Underimmunized individuals exposed to measles who are older than 6 months of age and who are not pregnant or immune compromised may avoid exclusion if they receive a measles immunization within 3 days of exposure.

• Individuals that require immune globulin for PEP should be monitored for symptoms for 28 days after the last exposure. Discuss these cases with the local or state department of health to determine when the individual can return, as protocol may vary by location and outbreak circumstances. Factors such as the intensity and duration of the exposure, vaccination status of other individuals in the program, and presence of other high-risk populations in the program are considered in this decision.