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On 8 March 2017, an adult airline passenger developed **rash and swollen
eyes during a flight from Hong Kong to Los Angeles**, after recent travel to
Indonesia. Conjunctivitis and cough followed on arrival, and the patient went
to an urgent care clinic.
A measles diagnosis was not considered.
They returned the next day. Measles was confirmed by PCR on 14 March — six
days after the rash began, and after the patient had sat in a waiting room.
Then it happened again
Patient B was in that waiting room on 8 March. They were not immune,
were traced, and were instructed to self-quarantine until 29 March.
On 24 March they developed fever, cough and sore throat, went to an urgent
care clinic, and told the clinician about the measles exposure.
Measles was not considered.
It was confirmed three days later, after the patient themselves notified the
health department when the rash appeared.
And a flight attendant with two doses
Patient C served patient A on the 8 March flight and **had received two
MMR doses.** They developed a cough on 23 March **while working a flight to the
United States**, then fever and rash. At an urgent care clinic on 25 March they
tested negative for measles IgM — and specimens taken five days later
confirmed measles by PCR.
Two doses is the recommended schedule and it is very good, not perfect. The
negative antibody test is the other lesson: **a serologic test taken too early
is negative** whether or not you have measles.
Two more, with no link anybody could find
Patients D and E, siblings aged 14 and 12, neither vaccinated, in the
same county as patient C, with rash on 2 and 11 April. **Further investigation
could not establish a link between patient C and patients D and E.**
The genetics say there was one:
**Isolates from all five patients were genotyped as D8 with an identical
corresponding nucleotide sequence, and were the only isolates identified in
the United States during March–April 2017.**
One virus, five people, and a chain of transmission that contact tracing could
not reconstruct — which is what **"the high communicability of measles
continues to challenge identification of epidemiologic linkage"** means in
practice.
What it cost
| Investigation | Contacts |
|---|---|
| Patient A — flight | 22, across seven US states and two countries |
| Patient A — community | 483, of whom 81 were told to self-quarantine |
| Patient B | 31, mostly linked to a home-based day care centre where they lived |
| Patient C — flight | 164 passengers from 27 states and eight countries |
| Patients D and E | 338, with six students excluded from school and one quarantine order |
Approximately 1,000 contacts required follow-up. Contact investigation
during a measles outbreak is costly and labour-intensive — and this was
five cases.
What to take from it
- **Adult travellers without evidence of immunity should have two MMR doses
before travelling internationally** - Clinicians should always consider measles in a patient with febrile rash
illness and international travel — **and in any patient reporting a measles
exposure, regardless of rash** - **Anyone with a known recent exposure should self-isolate at the first sign
of illness** and contact their local public health authority immediately
The middle one exists because of patient B, who did everything right and told
the clinician, and was still sent away.
**Measles cases in flight attendants, including this one, prompted CDC to
issue new measles recommendations for airlines.**
Source: Centers for Disease Control and Prevention, MMWR.
Licenza: CC0 1.0 (pubblico dominio) · Tratto da www.cdc.gov
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