Measles (child care and school)

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 unprotected people become infected and infect others who are not protected (either through vaccination or immunity from past disease). Measles is rare in the United States but can result in serious complications, such as hearing loss, pneumonia, seizures, brain damage, and death.

Signs and symptoms

• High fever, cough, runny nose, and red, watery eyes
• Appearance of rash at hairline spreading downward over body
• Koplik’s spots (tiny white spots with bluish-white centers found inside the mouth)
• Diarrhea, pneumonia, or ear infections
• People who have previously been vaccinated often have more mild symptoms such as low-grade fever, cough, runny nose, and a mild rash.

Incubation period

Usually 8-14 days (range of 7-21 days) from exposure to onset of symptoms. In rare circumstances, a person who is immunocompromised may have a longer incubation period.

Measles skin rash examples

Source: www.cdc.gov/measles/signs-symptoms/photos.html

Contagious period and spread

• Contagious period: From four days before the rash appears until four days after the appearance of the rash.
• Spread through airborne route: Breathing small particles containing virus floating in the air. These particles travel along air currents and can infect people in another room.
• In a closed setting, measles virus can be transmitted in the air for up to two hours after a person with measles occupied the area.
• Even brief exposure or shared airflow poses a high risk of infection for people who have not had the disease before, have not been protected by the measles vaccine, or who have a problem with their immune system. 

Public health reporting requirements

Report any suspected or confirmed measles immediately to your local public health agency or CDPHE at 303-692-2700 (or after hours: 303-370-9395).. A single case of measles in Colorado requires an immediate public health response. 

Control of spread

• If a child attends a school or child care facility while infectious, public health will work with the facility to provide recommendations on disease control activities and possible exclusion of un- or under-immunized students and staff.
• Measles is a vaccine-preventable infection. Immunize according to current recommendations. Review the immunization status of all children and staff members.
• Use good hand-hygiene techniques at all times and routine infection control measures.
• Do not transfer children to other facilities while infectious or after exposure.

Vaccination

Measles, mumps, and rubella (MMR) vaccination remains the most important tool for preventing measles. 

Routine child/adolescent recommendations:

• Measles, mumps, rubella (MMR) vaccine is routinely given to children at 12-15 months of age, with a second dose at 4-6 years of age before kindergarten.
• Unvaccinated children and adolescents should receive two doses, at least four weeks apart. 

Immunization requirements to attend school are outlined in BOH rule 6 CCR 1009-2.

• Child care/preschool: One dose of MMR vaccine is recommended at 12-15 months of age and required for children  by 16 months of age.Two doses are required before kindergarten entry.
• School (K-12): Two doses of MMR are required, spaced at least four weeks apart.
• College/university: Two doses of MMR are required for students born on or after Jan. 1, 1957.
• A complete medical or nonmedical exemption provided to the student’s school may be accepted in place of documentation of an age-appropriate MMR vaccination series.
  • Students who do not have presumptive evidence of immunity against measles could be excluded from school for 21 days or more if they are exposed to measles.
• Laboratory confirmation of positive titers to measles, mumps, and rubella is an acceptable alternative to age-appropriate MMR vaccination. 

Routine adult recommendations:

• Adults with no evidence of immunity for measles should receive at least one dose of MMR vaccine.
  • Evidence of immunity includes people born before 1957 (except for health care personnel), documentation of receipt of MMR vaccine, or laboratory evidence of immunity or disease.
• Certain adults may need 2 doses. Adults who are going to be in a setting that poses a high risk for measles or mumps transmission should make sure they have had two doses separated by at least 28 days. These adults include students at post-high school education institutions, health care personnel, and international travelers. 

School and child care staff:

Educate and strongly encourage staff to locate their vaccine records and to get vaccinated if they are not protected against measles. 

• CDPHE does not require public K-12 school staff to provide vaccine records to their schools. In preparation for a case of measles at school, staff should be informed of the importance of being up to date with measles-containing vaccine and having their vaccine records readily available.
• Child care and preschool staff (per licensing requirements (2.200, 2.400, and 2.500) must be current for all immunizations required by their employer, and must sign a statement indicating their immunizations are current.
• A statement of immunity without documentation (i.e. vaccine record or lab result) is not acceptable evidence of immunity.
• If staff (including volunteers) are exposed to measles, they should be prepared to present evidence of immunity to measles, which includes one of the following:
  • Written documentation of adequate MMR vaccination
  • Laboratory evidence of immunity
  • Laboratory confirmation of prior measles disease
  • Born before 1957 (except health care providers)
• Staff (including volunteers) who do not have presumptive evidence of immunity against measles could be excluded from school for 21 days or more if they are exposed to measles. 

Treatment

No specific antiviral treatment for measles is available. Supportive care, including vitamin A administration under the direction of a physician, may be appropriate.. People without immunity who have a known exposure to measles can receive post-exposure prophylaxis to reduce the severity of disease.

Exclusion

• Children and staff with measles should be excluded until four days after their rash starts when they are no longer contagious. Discuss when someone with measles can return to school or childcare with the local health department.
• Measles is a highly contagious infection; children suspected of having measles should be sent home immediately. 
  
  Unvaccinated students and staff who have been exposed to measles and are not able to receive post-exposure prophylaxis should be excluded from school for 21 days after exposure
   
• Students and staff who have had one documented dose of MMR vaccine may need to receive a second dose to avoid exclusion from school or child care in certain situations.
• Additional documentation of measles immunity (for example, birth before 1957 or a blood test showing immunity) may be used to avoid exclusion if vaccination records are not available.
• Schools and child care facilities should discuss student and staff exclusion with their local public health department.

Role of teachers, caregivers, and family

• Encourage routine vaccination and enforce the school immunization requirement (6 CCR 1009-2). Review and ensure all children have received MMR vaccine according to current immunization recommendations.
• Immediately report the infection to the local or state public health department. If the health professional who makes the diagnosis does not inform the local health department that the infected child is a participant in a child care program or school, this could delay controlling the spread.
• Report the infection to the staff member designated by the child care program or school for decision-making and action related to the care of ill children. That person, in turn, alerts possibly exposed family and staff members and parents/guardians of unimmunized children to watch for symptoms and notifies the health consultant.
• Ensure staff members are properly immunized unless documented to have had the disease or were born before 1957. Individuals born before 1957 are presumed to be immune because measles was widespread before the 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 suspect case, exposed children with weakened immune systems or who have not received MMR vaccine may be excluded from the facility.
• In an outbreak, public health may make a recommendation for infants aged 6 through 11 months of age to get an early dose of MMR vaccine.
  • Infants who get one dose of MMR vaccine before their first birthday should get two more doses according to the recommended childhood schedule:
    • The first dose should be given at 12-15 months of age.
      • Ensure a minimum interval from the first dose of at least 28 days.
    • The second dose should be given at 4-6 years of age and before kindergarten entry.

Resources

• Measles information (CDPHE)
• What you can do to prepare now for measles (CDPHE) | Spanish (CDPHE)
• Infectious disease guidelines for schools and child care settings (CDPHE)
• Early Care and Education Centers Checklist (CDC)
• K-12 Schools Measles Checklist (CDC)