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11/2/2018 - PUBLIC HEALTH ALERT: MEASLES OUTBREAK IN OCEAN COUNTY, MULTIPLE EXPOSURES
Public Health Alert: Measles Outbreak in Ocean County, Multiple Exposures
 
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NJLINCS Health Alert Network                                 
Distributed by the Ocean County Health Department
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The New Jersey Department of Health is warning residents about 2 additional confirmed cases of measles-a highly contagious disease- who could have exposed others to the infection while in Ocean County between October 25 and 30, 2018. These individuals developed symptoms after being exposed to an individual who acquired measles while traveling internationally. The New Jersey Department of Health is considering this to be an outbreak of measles in the community. The press release is available here: https://www.nj.gov/health/news/ 

Anyone who visited the following locations in Ocean County may have been exposed to measles:

NPGS, 231 Main St, Lakewood, NJ 08701

             October 25 between 9:00 a.m. and 12:00 p.m.
             October 29 between 2:15 p.m. and 4:45 p.m.

Pizza Plus, 241 4th St, Lakewood, NJ 08701

             October 28 between 12:30 p.m. and 3:30 p.m.

The Department is working in collaboration with the Ocean County Health Department to identify and notify people who might have been exposed during the time the individuals were infectious. In the event that additional exposure locations are identified, information will be updated on the NJDOH measles page (https://www.state.nj.us/health/cd/topics/measles.shtml). Individuals potentially exposed, if infected, could develop symptoms as late as November 20.

Due to the outbreak of measles, Ocean County healthcare providers should:

- Consider offering an MMR vaccine to all infants 6-11 months of age without contraindications. Infants who get one dose of MMR vaccine before their first birthday should get two more doses (one dose at 12 through 15 months of age and another dose separated by at least 28 days).
- Offer MMR vaccine at the earliest opportunity to all unvaccinated eligible patients 12 months and older.
- Offer a second dose of MMR vaccine to eligible patients 1 year and older who have previously received one dose of vaccine, separated by at least 28 days.
- Offer teenagers and adults who do not have evidence of immunity against measles two doses of MMR vaccine separated by at least 28 days. If proof of immunity is not readily available, do not delay administering MMR to persons without contraindications. Extra doses of MMR are not harmful. 

Individuals who might have been exposed are urged to contact their healthcare providers to discuss their exposure and risk of developing illness. Anyone who develops symptoms consistent with measles is urged to call their healthcare provider BEFORE going to the medical office or emergency room so that special arrangements can be made to minimize exposure in the healthcare setting.

In light of the increase of measles in the New York and New Jersey area, as well as in Israel and parts of Europe, Asia and Africa, the NJDOH continues to urge providers to remain vigilant for cases of measles (consider measles in persons who present with fever and rash) and would like to remind all healthcare and public health professionals about the importance of receiving up-to-date immunizations, especially prior to international travel. 

Measles Overview
Measles is a highly contagious disease that is transmitted by respiratory droplets and airborne spread. Following exposure, approximately 90% of susceptible persons will develop measles. The disease can result in severe complications, including pneumonia and encephalitis. The incubation period for measles ranges from 7 to 21 days. Individuals are infectious 4 days before through 4 days after rash onset. The diagnosis of measles should be considered in any person with a generalized maculopapular rash,
fever, and cough, coryza, or conjunctivitis. Immunocompromised patients and patients who are not fully immune may have an atypical presentation.

Recommendations
Health care providers should maintain vigilance for measles importations and have a high index of suspicion for measles in persons with a clinically compatible illness who have traveled abroad or who have been in contact with travelers. Measles is endemic in many countries, including popular travel destinations.

Before international travel:
- Infants 6 through 11 months of age should receive one dose of MMR vaccine. Infants who get one dose of MMR vaccine before their first birthday should get two more age-appropriate doses as this dose does not count towards completion of the routine schedule.
- Children 1 year and older should receive two doses of MMR vaccine, separated by at least 28 days.
- Teenagers and adults who do not have documented evidence of immunity against measles should get two doses of MMR vaccine separated by at least 28 days even if they believe they received childhood vaccinations.

Suspected measles cases should be reported immediately to the local health department, and serologic and virologic specimens (throat/nasopharyngeal swabs and urine) should be obtained for measles virus detection and genotyping. A culture is preferable to serology in vaccinated individuals. Laboratory testing should be conducted in the most expeditious manner possible.

Preventing Transmission in Health Care Settings
All health care personnel should have documented evidence of measles immunity on file at their work location. Having high levels of measles immunity among health care personnel and such documentation on file minimizes the work needed in response to measles exposures, which cannot be anticipated.

As an added precaution, hospital Emergency Departments are encouraged to provide signage which directs staff and/or patients to identify anyone presenting with fever and rash.

To prevent transmission of measles in health care settings, airborne infection control precautions (available at http://www.cdc.gov/hicpac/2007IP/2007isolationPrecautions.html) should be followed stringently. Suspected measles patients (i.e., persons with febrile rash illness) should be removed from emergency department and clinic waiting areas as soon as they are identified, placed in a private room with the door closed, and asked to wear a surgical mask, if tolerated. In hospital settings, patients with suspected measles should be placed immediately in an airborne infection (negative-pressure) isolation room if one is available and, if possible, should not be sent to other parts of the hospital for examination or testing purposes.

In Summary
1) When obtaining the medical history of a patient with a febrile rash illness consistent with measles, please inquire as to whether the person visited any of the exposure locations listed above during the times specified or has any other risk factors. Additionally, please inquire if the patient visited Ocean County, New York (Brooklyn or Rockland County), or traveled internationally.
2) Report all suspect measles cases (febrile illness accompanied by generalized maculopapular rash) immediately (DO NOT WAIT FOR LABORATORY CONFIRMATION) to the local health department. If unable to reach the local health department, notify the NJDOH during regular business hours at (609) 826-5964. After business hours, or on the weekend, call NJDOH at (609) 392-2020.
3) Place all patients with suspected measles in airborne isolation immediately.
4) Obtain appropriate clinical specimens: blood (for both IgM and IgG to measles), urine, and nasopharyngeal aspirates/throat swabs for diagnostic testing (https://www.state.nj.us/health/cd/documents/topics/measles/quickguide_measles_specimen_collection_testing.pdf)
5) Determine the immune status of contacts. Offer measles vaccine or immune globulin to susceptible exposed contacts as appropriate. Quarantine contacts who cannot produce documentation of immunity from day 5 through day 21 following exposure.
6) Assure that all those eligible for MMR vaccine receive appropriate and timely vaccination.

Additional information regarding measles is available:

NJDOH website: http://www.nj.gov/health/cd/topics/measles.shtml
Centers for Disease Control and Prevention (CDC): http://www.cdc.gov/measles/index.html
CDC Travel Health Notices: https://wwwnc.cdc.gov/travel/notices#watch
American Academy of Pediatrics: http://www.aap.org/en-us/about-the-aap/aap-press-room/Pages/American-Academy-of-Pediatrics-Urges-Parents-to-Vaccinate-Children-to-Protect-Against-Measles.aspx
 
Brian Albers
Health Preparedness and Planning
OCEAN County Health Department
175 Sunset Avenue, PO Box 2191
Toms River, NJ 08754
Cell: (732) 300-2314
www.OCHD.org
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