Command Center News: Measles Update

CCPN Implements Required Measles Screening Questions Across All Ambulatory Clinics

in response to a rise in positive measles cases within Tarrant, Denton, and Collin Counties, Cook Children's Physician Network (CCPN) clinical leadership has made the decision to mandate measles screening questions for all patients across all ambulatory clinics. This change elevates the screening questions from a recommended practice to a required one, effective immediately.

This decision aligns all CCPN ambulatory clinics with the current protocols in place at the Urgent Care Centers (UCCs), Dodson Specialty Clinic locations, Prosper, and Fort Worth medical centers, which have already implemented required measles screening. The move aims to ensure consistent and comprehensive identification of potential measles cases throughout the system, thereby safeguarding the health of patients and staff.

This measure is a proactive step to mitigate the spread of measles within the community and maintain a safe healthcare environment.

IMPORTANT: Confirmed Measles Cases in North Texas - Exposure Risk

Please read the following update from Marc Mazade, M.D., Medical Director of Infection Prevention and Control

This message is to inform you of recent confirmed measles cases in our region and potential exposure risks:

• Mansfield Methodist ED Exposure (April 29-30): Between approximately 8 p.m. on Monday, April 29, and 3 a.m. on Tuesday, April 30, an adult and a child who were later confirmed to have measles were present and contagious in the Mansfield Methodist Emergency Department. Importantly, no travel history or known exposures have been identified for these individuals.
• Prosper ED Exposure (May 1): On Wednesday, May 1, a returned traveler from Vietnam presented to the Prosper Emergency Department and was confirmed to have measles. The Denton County Health Department is currently reviewing the flight manifest and contacting potentially exposed individuals. They are also reaching out to individuals who were present in the Prosper CCMD ED during the exposure window.

We will keep you updated on the latest information.

Morning Coffee Talk on May 7

Kaitlin Williamson, M.D., from our Infectious Diseases team will guide a special Coffee Talk conversation at 7:30 a.m. on May 7. The topic will be, "Discussions with families regarding pros and cons of early MMR vaccination. Please read this article to help prepare for the meeting. 

• Topic: Coffee Talk - Journal Club - MMR early vaccination
• Time: May 7, 2025 07:30 AM Central Time (US and Canada)
• Join Zoom Meeting
  • https://cookchildrens.zoom.us/j/97810220753?pwd=H3m0ioVdsIBtX6hZQWwRP5UzsiWeJM.1

Immunizations Update for Vaccines

At this time, all of our CCPN Primary Care Clinics and Neighborhood Health Centers have ample supply of private and state Measles vaccines. Our supplier has assured us that there is not a national shortage, so obtaining higher than normal doses should not be a problem. We also have a secondary back up with another vendor should our primary vendor’s supply become sparse/depleted.

These vaccines are administered to established patients within our system. They are not available for the general public at this time

We've also provided a few resources and tips to help families find a place to take their child for immunizations:

1. Check with your child’s doctor. Ask which vaccines are due and make an appointment. If your child needs a doctor, see our locations or call 211 for help. 
2. Visit a public health vaccine clinic.  Anyone from any county can call Tarrant County Public Health at 817-248-6299 to make an appointment or to find a walk-in clinic.
3. Check with your local school district for vaccine events. 
4. Enter your zip code at Vaccines.gov to find other options. 

Streamlining Measles Response: Guidance on IMIGs (GamaSTAN) and Working with Your Local Health Departments, Plus Information on Virtual UCC 

We understand everyone is working incredibly hard, and we want to share a couple of important updates that will significantly support our Urgent Care Centers during this busy time. Your cooperation in these matters is deeply appreciated.

Regarding IMIG Requests:

To ensure the most efficient process for potential measles cases requiring Immune Globulin Intramuscular (IMIG), we kindly request that primary care clinics begin by contacting your local Health Department, rather than calling the Urgent Care Center directly.

The Health Department plays a crucial role in verifying exposure and determining the necessity for testing. Should IMIG be deemed appropriate, the health department's epidemiologist will then directly contact the Cook Children's Urgent Care Center to inform them of the patient and the need for an appointment. The health departments want to be informed of patients that do not arrive for their dose of IMIG, as ongoing contact tracing may be needed for that patient This process helps us manage resources effectively and ensures timely care for those who truly need it.

NOTE:  Only Fort Worth and Prosper UCCs Currently Offer IMIG if Approved by Health Department

Here's what you need to know:

• Teams identify an unimmunized or immunocompromised patient with direct exposure to measles.
• Teams should call regional health department for discussion on need for referral for IMIG

Tarrant County: Epidemiologist will determine if exposure warrants referral

• 9 a.m.-5 p.m., Monday through Friday: (817) 321-5350
• After 5 p.m., weekends and holidays: (817) 994-3708

Denton County uses the same phone number during business hours as they do for after-hours reporting: Epidemiologist will determine if exposure warrants referral

• Phone: 940-349-2909
• Fax: 940-349-5078

Collin County - Health department Prefers to be notified online by using this form Suspected Measles Reporting Form.

• Phone: 972-548-4707
• Fax: 972-548-4436

Collin County has IMIG in stock to administer. The epidemiologist will determine if exposure warrants administration. Collin County Health Department has their own GamaSTAN and will administer to patients when they identify them. it is our understanding that the UCCs do not need to provide this service for patients that reside in Collin County at this time.

After receiving confirmation of need for IMIG from Health Department Epidemiologist, PCP clinic should also call and speak to charge nurse at the UCC to which they will travel:

• Fort Worth UCC - 682-885-8012
• Prosper UCC - 682-303-8000

The Value of Virtual UCC Visits:

As a helpful reminder, if your primary care office suspects a child that is not physically present in your clinic may have measles, we encourage you to first inform parents about the availability of our Virtual Urgent Care Center (UCC) through the mycookchildrens portal.

Utilizing the Virtual UCC allows for initial assessment and, if necessary, the ordering of measles testing. This step can help reduce potential exposure in your clinic as well as in our physical Urgent Care locations and guide patients to the most appropriate level of care.

Thank you all for your continued dedication and collaboration. Your partnership is invaluable as we navigate this busy period together.

Measles Post-Exposure Prophylaxis (PEP) Guidance – Immune Globulin

Purpose: To provide clear guidance on the ordering and administration of immune globulin for measles post-exposure prophylaxis (PEP) during a local outbreak.

Background:

• PEP is recommended for susceptible individuals exposed to measles to potentially prevent or modify disease.
• Two PEP options exist:
  • MMR vaccine (within 72 hours of exposure) OR
  • Immune Globulin (IG) – IM or IV (within 6 days of exposure)
    • ** Do not administer MMR vaccine and IG simultaneously. (CDC)

IG Indications and Dosing (Red Book, Lexicomp, CDC)

*dose may need to be divided over two days (0.25 ml/kg x 2 days) due to limitations in IM administration volumes

NOTE: If patient is admitted and has an IV line, IVIG is preferred over IMIG due to number of injections per IM dose (3-4 injections based on age and volume)

GamaSTAN® (IMIG) Administration:

• Administer within 6 days of initial measles exposure.
• Administer IM in the anterolateral aspects of the upper thigh (infants/toddlers/preschool-aged) or deltoid muscle of the upper arm (school-aged children or older). Avoid gluteal region due to risk of injury to sciatic nerve. (Lexicomp)
  • Divide doses >10 mL (adult) and inject in multiple sites; in pediatric patients, consider splitting doses <10 mL based on patient size. (Lexicomp)
  • Refer to Medication Administration Policy (PS 589) Attachment A for needle size and maximum IM injection volume recommendations. (Cook Children's Intranet)

GamaSTAN® (IMIG) Ordering Information (Cook Children's):

• Available at Fort Worth and Prosper Medical Center Pharmacies.
  • Intended locations: ED, ID Clinic, UCCs
  • Pharmacy can supply/courier to UCCs 24/7.
    • In an active outbreak (2+ cases and Health Department "Pod" activated), supply can be made directly available at UCCs.

• Order via Epic: search "GamaSTAN" [ERX 140916].

Important Considerations:

• Prioritize IG for high-risk groups who cannot receive MMR vaccination.
• Consult with Infectious Disease or Public Health for outbreak management and PEP eligibility.
• Consult with an ID physician or pharmacist for any questions regarding dosing or administration.
• Any non-immune person receiving immune globulin should be vaccinated with MMR no sooner than 6 months after immune globulin administration, provided they are then aged ≥12 months and the vaccine is not otherwise contraindicated.
• This guidance is based upon current CDC recommendations. Always consult with the CDC for the most up to date information. (CDC)
• Patient education can be found on Cook Children’s Intranet.

Information from Pharmacy: Vitamin A Prescribing

Vitamin A prescribing

• Inpatient ordering:
  • Order vitamin A palmitate 50,000 units/ml oral suspension

• Choose dose based on dosing recommendations in Order Instructions field:

• Outpatient ordering
  • Type in “vit A measles” and go out to the Database. We are working on moving the orderable to Facility List.

• Choose dose based on dosing recommendations in Order Instructions. It will get rounded to the nearest 0.5 ml increment. Please note that you will need to click one of the buttons for Days/Fill to populate Quantity since it goes unselected when you choose a dose.

• Retail Pharmacy (Retail #1 and Prosper Retail) will dispense two syringes of vitamin A to reduce the risk of overdose and toxicity
• Please direct patients/caregivers to pick up vitamin A from the curbside pickup at each location instead of coming into the building

GamaSTAN prescribing:

• IMIG dosing for measles is 0.5 ml/kg IM x 1. For the time being, we are administering IMIG as 0.25 ml/kg x 2 days because of concerns over administration volumes. There are discussions being had at the administrative level regarding PS 589 and injection volume limits
• The order should look like this:

• If IV access is available, we will administer IVIG 400 mg/kg instead of IMIG to reduce the number of times that we poke the patient. Patients over 15 kg will also receive IVIG instead of IMIG.
• Patients/caregivers should receive education for IMIG, which can be found here: Measles-exposure-and-IMIG.pdf