Measles Updates for CCPN

Learning Point: Measles PCR testing close to an MMR Vaccine

By Alice Phillips, M.D.

A recent case at one of our CCPN Primary Care Clinics highlighted an important learning point when considering Measles PCR testing. 

 Case:

1. A 12-month-old patient received their routine MMR Vaccine
2. 10 days later the infant developed fever and rash
3. A measles PCR was completed due to the outbreak in Texas which was POSITIVE
4. Was this vaccine related or wild type? Further analysis of the sample confirmed this was vaccine related

What’s a Doc or APP to do?

1. Evaluate timing of MMR vaccine and onset of symptoms
2. Up to 5 % of patients may experience a rash 7-10 days after receipt of MMR vaccine
3. Measles PCR testing can be positive due to the vaccine during this time
4. Consulting with the Public Health Department can be helpful to obtain guidance
5. Testing can be completed at the Physician/APP judgement, but interpretation can be tricky
6. If the patient recently received an MMR vaccine and has no additional risk factors or further symptoms of measles, additional public health response may be unnecessary
7. Consulting with the health department and/or Cook Infectious Disease can help interpretation of results

Reference:

Implications of Measles Inclusion by Commercial Syndromic Polymerase Chain Reaction Panels — United States, May 2022–April 2023 | MMWR

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.

Public Health Exposure Screening Update

We want to provide you with the latest screening questions for measles that you will find in EPIC:

Public Health Exposure:

1. Have you traveled outside the United States to an area with an outbreak of Measles in the last 21 days?
2. Has your child had a known exposure to measles in the last 21 days?
3. Has your child been vaccinated against the measles?
4. Have they received one or two vaccines?
5. Has your child recently had fever?
6. Is your child experiencing of any of the following signs and symptoms of measles, cough, congestion, red eyes or rash?

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