Question 1

Jane Doe (28 years, F), 18 weeks pregnant, reported to the midwife that she had contact with her nephew (Age: 1 year), who has been seen by his GP for a maculopapular rash. GP is suspecting measles.  The midwife is asking for your advice regarding further management.

What additional information would you ask?

What investigation would you advise?

Which additional healthcare professionals need to be notified?

Answer:

This is a common scenario microbiologist encounter in their day to day practice in the UK. The guidance can be found in –
1. Guidance on the investigation, diagnosis and management of viral illness, or exposure to viral rash illness, in pregnancy
2. Measles: the green book, chapter 21
3. Measles: guidance, data and analysis
4. Guideline for PEP for measles.
5. Rubella (German measles): guidance, data and analysis

Additional information

1. Confirm the diagnosis.
Get as much information as possible about the diagnosis.
Was it made by a healthcare professional (in this case it is a GP)? Enquire about the sign and symptoms – could it be any other disease (Rubella, Parvo, HHV 6, HHV 7, drug rash, Enterovirus, EBV, CMV…)?
Enquire about the child’s vaccination history.
You may ask a specific question to have an idea about the diagnosis for example – did the child have cough, coryza and conjunctivitis (suggestive of measles).
(Some of this information may not be available at the time of the first consult, but it is essential to glean as much information as possible).

2. The specific measles-related question to assess the likelihood of the disease –
Is there any epidemiological link to a measles case?
Has the patient been abroad (or the rash contact happened when the patient was abroad)?
Confirm MMR vaccine history.
Was there any recent hospitalisation?

3. Ask about the contact history
when did it happen?
Was it a significant contact?
[Significant contact is defined as being in the same room (eg house or classroom or 2-4 bed hospital bay) for a significant period of time (15 minutes or more) or face-to-face contact. ]
Is it repeated/ongoing contact (parent-child)?

4. Ask the midwife about the MMR history of the pregnant patient (this should be documented in the maternity records)

5. Collect contact details of the midwife, the patient and the GP.

Investigation

The diagnosis in the child needs investigating in this case. Measle and Rubella are notifiable to PHE (HPT) on suspicion. This is a public health issue.
PHE would do a risk assessment and help in testing the case – oral fluid test and serology.

Assuming measles has been confirmed an assessment should be done for the pregnant patient and Measle IgG should be tested if required.

Depending on the scenario, test for Rubella and Parvovirus B19 immunity could be considered. For example, if measles was not confirmed.

  1. Born before 1990 & History of measles
    infection – Assume immune and assure.
  2. Born before 1990 & No history of measles infection – Test and administer Human normal immunoglobulin (HNIG) within six days of contact only if measles antibody negative.
  3. Born in 1990 or after & documented history of two measles vaccines – Assume immune and assure.
  4. Born in 1990 or after & one measles vaccine – Test and administer HNIG within six days of contact only if measles antibody negative.
  5. Born in 1990 or after & unvaccinated – Test and administer HNIG if measles antibody negative. If not possible to test within six days of exposure, offer HNIG.

Notification

Public Health England or HPT. Measles and Rubella are notifiable on suspicion.

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