Measles Exposure Assessment

A 40 year-old accountant presents for advice on measles prevention. He reports disembarking from an airplane approximately 40 hours ago, and now being notified that one of the passengers on the plane has been diagnosed with measles today. He denies any chronic health problems, states he received “all the shots I should have” when he was a child. However, he is unable to produce documentation of childhood vaccinations. 

Which of the following represents the most appropriate action? 

A. This is an example of a low risk rubeola exposure without need for specific prophylactic action.  

B. Obtain rubeola IgG titers and provide appropriate prophylaxis based on results.  

C. Administer a single dose of MMR vaccine now with advice to contact the practice if there are concerning signs and symptoms.  

D. Order a dose of immunoglobulin and arrange for MMR vaccination update.

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Transcript

Voiceover: Welcome to NP certification Q&A presented by Fitzgerald Health Education Associates. This podcast is for NP students studying to pass their NP certification exam. Getting to the correct test answers means breaking down the exam questions themselves. Leading NP expert Doctor Margaret Fitzgerald shares her knowledge and experience to help you dissect the anatomy of a test question, so you can better understand how to arrive at the correct test answer. 

So, if you're ready, let's jump right in. 

Margaret Fitzgerald: A 40-year-old accountant presents for advice on measles prevention. He reports disembarking from an airplane about 40 hours ago and now being notified that one of the passengers on the airplane has been diagnosed with measles. Today, the patient denies any chronic health problems and states he received “all the shots I should have had" when he was a child. 

However, he is unable to produce documentation of childhood vaccinations. Which of the following represents the most appropriate action?  

A: This is an example of a low risk rubeola exposure without need for specific prophylactic action.  

B: Obtain rubeola IgG titers and provide appropriate prophylaxis based on the results.  

C: Administer a single dose of MMR vaccine now with advice to contact the practice if there are any concerning signs and symptoms. 

D: Order a dose of immune globulin and arrange for MMR vaccine.  

The correct answer is C: Administer a single dose of MMR vaccine now with advice to contact the practice if there are concerning signs and symptoms. Where should you start? First, consider what kind of a question this is. Given that we're being asked to take action, this is a planning question. 

A bit of background information: measles is, of course, a vaccine-preventable disease. This is caused by the rubeola virus and is one of the most contagious diseases ever reported. It is 2 to 4 times more contagious than COVID-19. At least 2 to 4 times more contagious than influenza. The list goes on and on. The number of measles cases has grown recently, typically with the virus arriving in the USA carried by a person who's not immune to measles, has traveled abroad and then imports the virus. 

Most cases of measles occur in children. In younger adults who have not been immunized with MMR, the measles, mumps and rubella vaccine. Of course, no vaccines are perfect. No vaccines provide 100% protection against anything. Therefore, some cases will occur in people who have received two members at the appropriate intervals. And we've got this patient saying to you, I got all the shots I should have when I was a kid.  

There's a high likelihood he probably has had MMRs, but we can't assume that because he doesn't have his vaccine record. So two doses of MMR vaccine are 97% effective at preventing measles, and one dose is 93% effective. I've been in practice long enough that I remember for years we only gave one dose of MMR vaccine. 

Why did we add that second dose? It was to fill in that gap, and push measles protection from 93% with a single dose to 97% with the second dose. It is uncommon for somebody who is fully vaccinated to develop measles. However, breakthrough infections when someone becomes infected when they've been vaccinated can occur, particularly in communities experienced an outbreak where there are high levels of measles virus circulating and or less significant exposure to a person with measles. 

And that's exactly what this guy is reporting, is that there was a significant exposure to somebody with measles. The spread of the rubeola virus is via respiratory droplets, and it has an incubation period of 10 to 14 days. The clinical presentation of measles includes, fever, nasal discharge, cough, generalized lymphadenopathy, conjunctivitis with copious clear, eye discharge, photophobia in mild pharyngitis. 

In other words, the first few days of measles can resemble the clinical presentation of so many different viral infections that we often see at the same time, people with measles, particularly kids, usually look and act sicker in that pre-rash stage than a person was, like, let's say a rhinovirus or an adenovirus. You are right, a maculopapular rash develops 3 to 4 days after the onset of the standard viral syndrome presentation. And the rash often coalesces to a generalized erythema. There's also an expression that's used-absolutely a colloquial term. There's no ICD-10 code on this one, where the person with measles appears to stare off into space during the clinical exam. This is often referred to as the 100-mile stare, because the person- 

It's not that the person isn’t up to it. They are just so sick that they really cannot interact. As a person who has a cold might be interacting and saying, yeah-the person with the cold is like, I get a sore throat, my nose is running, and they're giving you chapter and verse on what's going on. 

And that the person, including even toddlers with measles, are so sick that they're just kind of sitting there staring off into space. The duration of measles is usually around 10 to 14 days and much longer with measles complications and 1 in 4 individuals with measles will get a significant complication, and the two most common will be measles pneumonia and measles encephalitis. 

And in fact, the most common cause of death with this disease is pneumonia, and it is usually a pneumonia caused by the rubeola virus. Intervention in measles is largely supportive, includes management of complications as well as vitamin A supplementation. This is a reportable disease to your regional public health department, who can provide great guidance on testing to help confirm the diagnosis. 

With this is background information. Let's take another look at the question and determine next steps. A 40-year-old accountant presents for advice on measles prevention. He reports disembarking from an airplane about 40 hours ago and now being notified that one of the passengers on the plane has been diagnosed with measles today. He denies any chronic health problems state he received "all the shots I should of” when he was a child and is unable to produce documentation of childhood vaccinations. 

Which of the following represents the most appropriate action? A: This is an example of a low risk rubeola exposure without need for any specific prophylactic action. Well, this is of course, incorrect. Why don't you just lay it down in your memory bank that measles is one of the most contagious diseases around. This makes sense. Indeed. There have been numerous reports of measles transmission among passengers in airplanes. 

Think of it. What's an airplane? It's an aluminum tube where everyone is in the same airspace for a fairly protracted period of time. I appreciate that the air is filtered and all that good mitigation going on, but you're still in the same airspace for a protracted period of time. And indeed, this is one of the reasons why this particular patient has had the exposure reported to him, likely by the airline in conjunction with his local and or regional public health department. 

And they're reporting it so that he can do something about mitigating his risk of coming out with measles. They obtain a rubeola IgG titer and provide appropriate prophylaxis based on results. This is also incorrect. Sometimes we as healthcare providers can get really confused about the roles of titers and vaccine-preventable disease. Since we've had assorted titers done, we get titers done technically to prevent us and our patients-okay, us, from contracting certain diseases that we might pick up in the clinical area, and then also to protect us from delivering serious illnesses to certain patients. 

In addition, drawing titers and then saying to the patient, if you're not measles immune, we'll get back to you ASAP and give you an MMR or immune globulin, whatever is appropriate. That adds a level of complexity to the patient's care. In other words, what it would mean is it's probably going to take a couple of days to get the titers back. 

Then you're going after having the patient there, get the patient back, etc., etc.. And there is an adage with immunized patient that says when in doubt, reimmunize and the risk of a systemic reaction and other adverse effects from getting an extra dose of a vaccine is minimal. Given his history, we don't even know if he ever received MMR in the first place. 

So, CDC tells us when a person has either not been immunized against measles or you can't document measles immunization, that this is the best way to go. So, C: Administer a single dose of MMR vaccine now with advice to contact the practice. If there are concerning signs of symptoms. This is of course the best answer. As I just said, the CDC recommends providing that single dose of MMR, which within 72 hours of rubeola exposure to patients such as this, particularly those with unclear MMR vaccine history, are known to have never received MMR vaccine.  

This can reduce the likelihood of becoming ill with measles if the person is susceptible to measles and contracting the illness. Having had the MMR dose also reduces the likelihood of severe disease. Follow up in 28 days to receive MMR two should be arranged, particularly if this person can't get their hands on their childhood vaccine records, which is so common in the adult population, and this person should be advised on rubeola incubation time and concerning signs and symptoms.  

D: Order a dose of immune globulin and arrange for MMR vaccination update. This is incorrect. Immunoglobulin is used for measles prophylaxis in select cases, including in kids under the age of one year, during pregnancy, and in individuals with immunocompromised. In addition, this prophylactic measure can be given up to 6 days post-rubeola exposure. 

Key takeaway: measles infection poses a significant risk to public health. The best way to prevent this potentially deadly disease is through immunization with MMR, as well to be aware of post-exposure prophylaxis is incredibly important as a public into immunity health measure. 

Voiceover: Thank you for listening to NP certification Q&A presented by Fitzgerald Health Education Associates. Please rate, review, and subscribe to this podcast and for more NP resources, visit fhea.com.