Missouri Department of Health & Senior Services Healt h Health Advisory March 27, 2014 Advi•s o ry: FROM: GAIL VASTERLING DIRECTOR Q Fever Cases SUBJECT: Q Fever Cases in Missouri in Missouri Q fever is a zoonotic disease caused by the bacteria Coxiella burnetii. C. burnetii is distributed worldwide and causes sporadic infections and outbreaks in animal species and humans. In 2013, 22 human Q fever cases were reported March 27, 2014 to the Missouri Department of Health and Senior Services (DHSS). The purpose of this DHSS Health Advisory is to increase awareness among health care providers of Q fever, and to provide guidance on the epidemiology, diagnosis, This document will be updated as new and treatment of Q fever, including the identification of persons who are at information becomes available. The higher risk of Q fever infection and its complications. current version can always be viewed at http://www.health.mo.gov Background The Missouri Department of Health & Senior Services (DHSS) is now using C. burnetii are spore-forming bacteria that can survive for long periods of time in the 4 types of documents to provide environment. The primary sources of Q fever are infected cattle, sheep, and goats, which important information to medical and shed the organism in feces, milk, nasal discharge, placental tissue, and amniotic fluid. C. public health professionals, and to other interested persons: burnetii is known to be present in roughly 20-30% of goat herds, and is also endemic in cattle and sheep. Infection of humans usually occurs by inhalation of C. burnetii from air that Health Alerts convey information contains airborne barnyard dust contaminated by infected animals. Inhalation of just a single of the highest level of importance which warrants immediate action or organism is sufficient to cause infection. Cases of Q fever have been documented among attention from Missouri health people living downwind from infected livestock without having direct exposure to infected providers, emergency responders, animals. Other, less common routes of transmission include: the consumption of raw dairy public health agencies, and/or the products, human-to-human transmission (baby infected during delivery by infected mother, public. exposure during autopsy), or a blood transfusion from an infected donor. Ticks can harbor C. Health Advisories provide burnetii, but infections acquired through a tick bite are rare. Because of the high infectivity important information for a specific of this organism, C. burnetii is designated a Category B bioterrorism agent. incident or situation, including that impacting neighboring states; may not require immediate action. Human cases are rare, with typically fewer than 200 Q fever cases reported annually in the United States, and 0-5 cases per year reported in Missouri between 2008 and 2012. Health Guidances contain However, because Q fever may resemble other diseases, be mild, or even cause no comprehensive information pertaining to a particular disease or condition, symptoms (asymptomatic seroconversion occurs in 50-60% of infected persons), cases of and include recommendations, human Q fever are likely under-recognized. Q fever outbreaks associated with animal guidelines, etc. endorsed by DHSS. farms have been reported in the United States. Health Updates provide new or updated information on an incident or Q fever can cause acute and chronic illness in humans. Illness onset typically occurs 2-3 situation; can also provide informa- weeks after exposure to the organism. Symptoms may include: high fever (104°-105° F), tion to update a previously sent chills and/or sweats, severe headache, malaise, myalgia, non-productive cough, chest pain, Health Alert, Health Advisory, or and possibly gastrointestinal symptoms such as nausea, vomiting, diarrhea, or abdominal Health Guidance; unlikely to require pain. Most acute Q fever cases will recover completely, but some persons experience immediate action. serious illness and severe complications, including: pneumonia, granulomatous hepatitis, myocarditis, and central nervous system complications. Pregnant women who are infected Office of the Director may be at risk for pre-term delivery or miscarriage. The estimated case fatality rate is < 2% 912 Wildwood of hospitalized patients. Early treatment with an appropriate antibiotic may shorten the P.O. Box 570 duration of illness and lessen the risk of complications. Jefferson City, MO 65102 Telephone: (800) 392-0272 Chronic Q fever is a severe disease occurring in < 5% of acutely infected patients. It may Fax: (573) 751-6041 occur as early as six weeks after an acute infection, or may manifest years later. Chronic Q Web site: http://www.health.mo.gov fever is a risk for anyone with a history of acute Q fever illness, particularly those persons 2 with valvular disease, blood vessel abnormalities, immunosuppressed persons (such as may occur through cancer treatments, advanced HIV infection, prior organ transplants, or some medications), and women who were pregnant when they became infected. Endocarditis is the major form of chronic disease, comprising 60- 70% of all reported cases, and with an estimated case fatality rate in untreated patients of 25-60%. Other forms of chronic Q fever include aortic aneurysms and infections of the bone, liver, or reproductive organs, such as the testes in males. Post-Q fever fatigue syndrome has been reported to occur in 10-25% of some acute patients. This syndrome is characterized by constant or recurring fatigue, night sweats, severe headaches, photophobia, pain in muscles and joints, mood changes, and difficulty sleeping. Diagnosis Healthcare providers must use their judgment to treat patients based on clinical suspicion alone. While Q fever should be considered in patients who have close contact with domestic ruminants and cats, such an exposure may not always be reported. Information such as recent travel to rural or agricultural communities where infected livestock may be present, or employment in high risk occupations such as veterinarians or farmers, can be helpful in making the diagnosis. Clues such as a prolonged fever with low platelet count, normal leukocyte count, and elevated liver enzymes are suggestive of acute Q fever infection. Diagnosis can later be confirmed using specialized confirmatory laboratory tests. Treatment should never be delayed pending the receipt of laboratory test results, or be withheld on the basis of an initial negative laboratory result. Laboratory Diagnosis Clinical diagnoses of Q fever are confirmed by serological testing or polymerase chain reaction (PCR) where available. Antibody titers to C. burnetii are usually detectable by 7-10 days after illness onset, and a negative test during the first week of illness does not rule out Q fever as a cause of illness. There are two distinct antigenic phases (Phase I and Phase II) to which humans develop antibody responses. In acute infection, an antibody response to C. burnetii Phase II antigen is predominant and is higher than Phase I antibody response; the reverse is true in chronic infection which is associated with a rising Phase I IgG titer that is often much higher than Phase II IgG. The gold standard serologic test for diagnosis of acute Q fever is the indirect immunofluorescence assay (IFA) using C. burnetii antigen. The first sample should be taken as early in the disease as possible, preferably in the first week of symptoms, and the second sample should be taken 2 to 4 weeks later. IgM antibodies usually rise at the same time as IgG near the end of the first week of illness and remain elevated for months or longer. Also, IgM antibodies are more likely to result in a false positive result. Physicians should request both Phase I and Phase II IgG and IgM serologic titers for diagnostic confirmation of acute and chronic Q fever. Approximately 3% of currently healthy people in the U.S. general population and up to 20% of people in high-risk professions (veterinarians, ranchers, etc.) have elevated antibody titers due to past exposure to C. burnetii. Therefore, if only one sample is tested it can be difficult to interpret the findings. Paired samples taken 2-4 weeks apart demonstrating a significant (four-fold) rise in antibody titer provide the best evidence for a correct diagnosis of acute Q fever. Diagnosis of chronic Q fever is confirmed by elevated Phase I IgG antibody (current U.S. case definitions >1:800 and higher than Phase II IgG) and an identifiable persistent focus of infection (e.g., endocarditis). Elevated Phase I titers alone do not confirm a chronic Q fever diagnosis. During the acute phase of illness, a sample of whole blood can be tested by PCR assay to determine if a patient has Q fever. PCR is most sensitive in the first week of illness, and decreases in sensitivity following the administration of appropriate antibiotics. Although a positive PCR result is helpful, a negative result does not rule out the diagnosis, and treatment should not be withheld due to a negative result. 3 Culture isolation of C. burnetii is only available at specialized laboratories; routine hospital blood cultures cannot detect the organism. The Missouri State Public Health Laboratory (MSPHL) can perform PCR assays on whole blood samples taken during the first week of illness and prior to initiation of antibiotic therapy, with prior arrangements. Testing requested on additional samples other than blood will be conducted at the Centers for Disease Control and Prevention (CDC) in Atlanta, GA. Please contact the Virology unit at MSPHL by calling 573/751-3334 for assistance. Treatment Doxycycline is the first line treatment for all adults and for children with severe illness. Treatment should be initiated immediately whenever Q fever is suspected. Use of antibiotics other than doxycycline or other tetracyclines is associated with a higher risk of severe illness. Doxycycline is most effective at preventing severe complications if it is started early in the course of disease. Failure to respond to doxycycline suggests that the patient’s condition might not be due to Q fever. Recommended Dosage for Acute Q fever Doxycycline is the first line treatment for children with severe illness of all ages and adults: • Adults: 100 mg every 12 hours • Children under 45 kg (100 lbs): 2.2 mg/kg body weight given twice a day Patients should be treated for at least 3 days after the fever subsides and until there is evidence of clinical improvement. Standard duration of treatment is 2-3 weeks. Recommended Dosage for Chronic Q fever • Adults: Doxycycline 100 mg every 12 hours and hydroxychloroquine 200 mg every 8 hours. Standard duration of treatment is 18 months. The use of doxycycline is recommended to treat Q fever in children of all ages who are hospitalized or are severely ill. Children with mild illness who are less than 8 years of age may be treated with co- trimoxazole, but therapy should be switched to doxycycline if their course of illness worsens. Treatment of pregnant women diagnosed with acute Q fever with once daily co-trimoxazole throughout pregnancy has been shown to significantly decrease the risk of adverse consequences for the fetus. Patients at highest risk for progression to chronic Q fever should be serologically and clinically monitored at intervals of 3, 6, 12, 18, and 24 months after diagnosis of acute Q fever. Patients without obvious risk factors for chronic Q fever should receive a clinical and serologic follow-up approximately 6 months after diagnosis of acute illness to identify potential progression to chronic disease. The prophylactic antimicrobial treatment for prevention of Q fever after a known exposure and prior to symptom onset is not indicated. Attempts at prophylaxis will likely extend the incubation period but will not prevent infection from occurring. Please report any suspected Q fever cases within 1 day to your local public health agency (LPHA), or to DHSS at 573/751-6113. 4 References: 1. Centers for Disease Control and Prevention (CDC). Notes from the Field: Q Fever Outbreak Associated with Goat Farms — Washington and Montana, 2011. Morbidity and Mortality Weekly Report 2011; 60(40); 1393. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6040a5.htm. 2. Centers for Disease Control and Prevention (CDC). Diagnosis and Management of Q Fever — United States, 2013: Recommendations from CDC and the Q Fever Working Group. Morbidity and Mortality Weekly Report 2013; 62(RR03);1-23. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6203a1.htm. 3. Centers for Disease Control and Prevention (CDC). Q fever Homepage. Go to http://www.cdc.gov/qfever/. Missouri Department of Health & Senior Services Healt h Health Advisory May 6, 2014 Advi•s o ry: FROM: GAIL VASTERLING DIRECTOR Confirmed Middle East Respiratory Syndrome SUBJECT: Confirmed Middle East Respiratory Syndrome Coronavirus (MERS- Coronavirus (MERS-CoV) Case in Indiana, 2014 CoV) Case in Indiana, 2014 On May 3, 2014, the Centers for Disease Control and Prevention (CDC) issued a Health Advisory describing the first case of Middle East Respiratory Syndrome Coronavirus (MERS-CoV) infection in the United States, which was recently May 6, 2014 identified in Indiana in a traveler from Saudi Arabia. The CDC Health Advisory encourages medical providers to increase their index of suspicion for the possibility This document will be updated as new of MERS-CoV infection in travelers from the Arabian Peninsula and neighboring information becomes available. The current version can always be viewed countries. It also provides guidance on the identification and evaluation of possible at http://www.health.mo.gov cases, and on appropriate infection control practices. The Missouri Department of Health & Senior Services (DHSS) is now using No suspected cases of MERS-CoV infection have been reported in Missouri. 4 types of documents to provide important information to medical and The CDC Health Advisory is reproduced below with some added information from public health professionals, and to the Missouri Department of Health and Senior Services (DHSS) for Missouri other interested persons: medical providers and laboratories. Health Alerts convey information ______________________________________________ of the highest level of importance which warrants immediate action or attention from Missouri health Confirmed Middle East Respiratory Syndrome providers, emergency responders, Coronavirus (MERS-CoV) Case in Indiana, 2014 public health agencies, and/or the public. Distributed via the CDC Health Alert Network Health Advisories provide important information for a specific May 3, 2014 incident or situation, including that impacting neighboring states; may not Summary require immediate action. The first case of Middle East Respiratory Syndrome Coronavirus (MERS-CoV) Health Guidances contain infection in the United States, identified in a traveler, was reported to CDC by the comprehensive information pertaining to a particular disease or condition, Indiana State Department of Health (ISDH) on May 1, 2014, and confirmed by and include recommendations, CDC on May 2. The patient is in a hospital in Indiana after having flown from guidelines, etc. endorsed by DHSS. Saudi Arabia to Chicago via London. The purpose of this HAN is to alert Health Updates provide new or clinicians, health officials, and others to increase their index of suspicion to updated information on an incident or consider MERS-CoV infection in travelers from the Arabian Peninsula and situation; can also provide informa- tion to update a previously sent neighboring countries. Please disseminate this information to infectious disease Health Alert, Health Advisory, or specialists, intensive care physicians, primary care physicians, and infection Health Guidance; unlikely to require preventionists, as well as to emergency departments and microbiology laboratories. immediate action. Background Office of the Director 912 Wildwood The first known cases of MERS-CoV occurred in Jordan in April 2012. The virus is P.O. Box 570 associated with respiratory illness and high death rates, although mild and Jefferson City, MO 65102 asymptomatic infections have been reported too. All reported cases to date have Telephone: (800) 392-0272 been linked to six countries in the Arabian Peninsula: Saudi Arabia, Qatar, Jordan, Fax: (573) 751-6041 the United Arab Emirates (UAE), Oman, and Kuwait. Cases in the United Web site: http://www.health.mo.gov 2 Kingdom, France, Italy, Greece, Tunisia, Egypt, and Malaysia have also been reported in persons who traveled from the Arabian Peninsula. In addition, there have been a small number of cases in persons who were in close contact with those infected travelers. Since mid-March 2014, there has been an increase in cases reported from Saudi Arabia and UAE. Public health investigations are ongoing to determine the reason for the increased cases. There is no vaccine yet available and no specific treatment recommended for the virus. In some cases, the virus has spread from infected people to others through close contact. However, there is currently no evidence of sustained spread of MERS-CoV in community settings. Additional information is available at (http://www.cdc.gov/coronavirus/mers/index.html). Recommendations Healthcare providers should be alert for and evaluate patients for MERS-CoV infection who 1) develop severe acute lower respiratory illness within 14 days after traveling from countries in or near the Arabian Peninsula, excluding those who only transited at airports in the region; or 2) are close contacts of a symptomatic recent traveler from this area who has fever and acute respiratory illness; or 3) are close contacts of a confirmed case. For these patients, testing for MERS-CoV and other respiratory pathogens can be done simultaneously. Positive results for another respiratory pathogen (e.g., H1N1 Influenza) should not necessarily preclude testing for MERS-CoV because co-infection can occur. Clusters of patients with severe acute respiratory illness (e.g., fever and pneumonia requiring hospitalization) without recognized links to cases of MERS-CoV or to travelers from countries in or near the Arabian Peninsula should be evaluated for common respiratory pathogens. If the illnesses remain unexplained, providers should consider testing for MERS-CoV, in consultation with state and local health departments. Healthcare professionals should immediately report to their state or local health department any person being evaluated for MERS-CoV infection as a patient under investigation (PUI). Additional information, including criteria for PUI are at http://www.cdc.gov/coronavirus/mers/interim-guidance.html. Healthcare providers should contact their state or local health department if they have any questions. Persons at highest risk of developing infection are those with close contact to a case, defined as any person who provided care for a patient, including a healthcare provider or family member not adhering to recommended infection control precautions (i.e., not wearing recommended personal protective equipment), or had similarly close physical contact; or any person who stayed at the same place (e.g. lived with, visited) as the patient while the patient was ill. Healthcare professionals should carefully monitor for the appearance of fever (T> 100F) or respiratory symptoms in any person who has had close contact with a confirmed case, probable case, or a PUI while the person was ill. If fever or respiratory symptoms develop within the first 14 days following the contact, the individual should be evaluated for MERS-CoV infection. Ill people who are being evaluated for MERS-CoV infection and do not require hospitalization for medical reasons may be cared for and isolated in their home. (Isolation is defined as the separation or restriction of activities of an ill person with a contagious disease from those who are well.). Providers should contact their state or local health department to determine whether home isolation, home quarantine or additional guidance is indicated since recommendations may be modified as more data becomes available. Additional information on home care and isolation guidance is available at http://www.cdc.gov/coronavirus/mers/hcp/home-care.html. Healthcare providers should adhere to recommended infection-control measures, including standard, contact, and airborne precautions, while managing symptomatic contacts and patients who are persons under investigation or who have 3 probable or confirmed MERS-CoV infections. For CDC guidance on MERS-CoV infection control in healthcare settings, see Interim Infection Prevention and Control Recommendations for Hospitalized Patients with MERS-CoV at http://www.cdc.gov/coronavirus/mers/infection-prevention-control.html. Providers should notify their state or local health departments if they suspect MERS-CoV infection in a person. State or local health departments should notify CDC if MERS-CoV infection in a person is suspected. Additional information is available at http://www.cdc.gov/coronavirus/mers/guidelines- clinical-specimens.html. If a Missouri medical provider has a patient that appears to meet the above-mentioned CDC criteria for who should be evaluated for MERS-CoV, that provider should immediately contact DHSS at 800/392-0272 (24/7). The provider will be directed to the department’s Bureau of Communicable Disease Control and Prevention (BCDCP) to discuss sending specimens for testing at the Missouri State Public Health Laboratory (MSPHL). Note that before any specimen is sent for testing, BCDCP staff must first be consulted at 800/392-0272. After consultation with BCDCP and determination has been made that the patient meets the criteria for testing, the medical provider should then contact the MSPHL at 573/751-3334 or 800/392-0272 for guidance on specimen collection and shipping prior to collecting the specimens. This will help ensure that proper specimens are obtained in the right quantity, and that they are packed and transported properly. For suspected MERS-CoV cases, healthcare providers should collect the following specimens for submission to CDC or the appropriate state public health laboratory: nasopharyngeal swab, oropharyngeal swab (which can be placed in the same tube of viral transport medium), sputum, serum, and stool/rectal swab. All of the swabs mentioned above must be Dacron swabs. Recommended infection control precautions should be utilized when collecting specimens. Specimens can be sent using category B shipping containers. Additional or modified recommendations may be forthcoming as the investigation proceeds. For More Information For more information, for consultation, or to report possible cases, please contact the CDC Emergency Operations Center at 770/488-7100. For Missouri providers, questions can be directed to DHSS’ Bureau of Communicable Disease Control and Prevention at 573/751- 6113, or 800/392-0272 (24/7). Missouri Department of Health & Senior Services Healt h Health Advisory June 6, 2014 Advi•s o ry: FROM: GAIL VASTERLING DIRECTOR Record Number of Reported Measles Cases SUBJECT: Record Number of Reported Measles Cases in the U.S. in in the U.S. in 2014 2014 On May 29, 2014, the Centers for Disease Control and Prevention (CDC) issued a press release entitled “Measles Cases in the United States Reach 20-Year June 6, 2014 High.” A brief summary of the press release along with other pertinent information is provided below. This document will be updated as new Summary and Background information becomes available. The current version can always be viewed Three hundred thirty-four cases of measles were reported to the Centers for Disease at http://www.health.mo.gov Control and Prevention (CDC) in the United States between Jan. 1 and May 30, 2014. This The Missouri Department of Health & is the largest number of measles cases in the United States reported in the first five months Senior Services (DHSS) is now using of a year since 1994. Missouri is one of many states reporting measles cases this year. 4 types of documents to provide Nearly all of the measles cases this year have been associated with international travel by important information to medical and public health professionals, and to unvaccinated persons or persons whose vaccination status was unknown. other interested persons: The large number of measles cases this year stresses the importance of vaccination. Health Alerts convey information Healthcare providers should use every patient encounter to ensure that all patients are up to of the highest level of importance date on vaccinations; especially before international travel. Travelers with measles which warrants immediate action or attention from Missouri health continue to bring the disease into the U.S., which can then spread to communities or groups providers, emergency responders, of people who are unvaccinated. public health agencies, and/or the public. Measles was declared eliminated in the U.S. in 2000 due to high 2-dose measles vaccine Health Advisories provide coverage, but it is still endemic, or large outbreaks are occurring, in countries in Europe important information for a specific (including France, the United Kingdom, Spain, and Switzerland), Africa, Asia (including incident or situation, including that India), and the Philippines. The increase in measles cases and outbreaks in the U.S. this impacting neighboring states; may not year underscores the ongoing risk of importations, the need for high measles vaccine require immediate action. coverage, and the importance of prompt and appropriate public health response to measles Health Guidances contain cases and outbreaks. comprehensive information pertaining to a particular disease or condition, Measles is a highly contagious, acute viral illness that is transmitted by contact with an and include recommendations, infected person through coughing and sneezing. Patients are considered to be contagious guidelines, etc. endorsed by DHSS. from 4 days before until 4 days after the rash appears. After an infected person leaves a Health Updates provide new or location, the virus remains contagious for up to 2 hours on surfaces and in the air. Measles updated information on an incident or can cause severe health complications, including pneumonia, encephalitis, and death. situation; can also provide informa- tion to update a previously sent Recommendations for Health Care Providers. Health Alert, Health Advisory, or Health Guidance; unlikely to require Exposure to measles is not a contraindication to immunization. Available data suggest that immediate action. the measles vaccine, if given within 72 hours of measles exposure, will provide protection in some cases. If the exposure does not result in infection, the vaccine should induce protection Office of the Director against subsequent measles exposures. (MMWR, June 14, 2013 / 62(RR04);1-34) 912 Wildwood For those who travel abroad, CDC recommends that all U.S. residents older than 6 months P.O. Box 570 Jefferson City, MO 65102 be protected against measles and receive the MMR vaccine, if needed, prior to departure. Telephone: (800) 392-0272 • Infants 6 through 11 months old should receive 1 dose of the MMR vaccine before Fax: (573) 751-6041 departure.* Web site: http://www.health.mo.gov 2 • Children 12 months of age or older should have documentation of 2 doses of the MMR vaccine (separated by at least 28 days). • Children 1 through 12 years of age may receive the MMRV vaccine for protection against measles, mumps, rubella, and varicella; however, MMRV vaccine is not recommended for the first dose in the MMR series of vaccinations for children ages 12 months through 47 months.** CDC recommends that the MMR vaccine and the varicella vaccine be administered separately for the first dose in this age group. Providers who are considering administering MMRV vaccine should discuss the benefits and risks of both vaccination options with the parents or caregivers. • Teenagers and adults without evidence of measles immunity† should have documentation of 2 appropriately spaced doses of the MMR vaccine. Health-care providers should maintain a high suspicion for measles among febrile patients with a rash. Patients with clinical symptoms compatible with measles (febrile rash plus cough, coryza, and/or conjunctivitis, should be asked about recent travel abroad and contact with returning travelers, or contact with someone with a febrile rash illness. Their vaccination status should also be verified. Immunocompromised patients may not exhibit rash or may exhibit an atypical rash. The incubation period for measles from exposure to fever is usually about 10 days (range, 7 to 14 days) and from exposure to rash onset is usually 14 days (range, 7 to 21 days). Persons who have been exposed to measles should contact their healthcare provider if they develop cold-like symptoms with a fever and/or rash. They should NOT go to any healthcare facility without calling first. The suspect case should be kept separate from others to prevent further spread. Isolate suspect measles case-patients and immediately report suspected cases to the local public health agency, or to the Missouri Department of Health and Senior Services (DHSS) at 573/751-6113 or 800/392-0272 (24/7). To ensure a prompt public health response, do not wait for laboratory confirmation. Laboratory specimens may be referred to the Missouri State Public Health Laboratory after consultation with the local public health agency or DHSS representative. Obtain a single blood/serum specimen for measles IgM serology testing. A specimen for RT-PCR (throat swab, NP swab, urine) must be collected for simultaneous submission with the serum specimen. For more information, please call 573/751-3334. The sensitivity of measles IgM assays varies and may be diminished during the first 72 hours after rash onset. If the result is negative for measles IgM and the patient has a generalized rash lasting more than 72 hours, a second serum specimen should be obtained and the measles IgM test should be repeated. (AAP. Red Book, 2012; p. 491) ________________________________________________________ * Infants who receive a dose of MMR vaccine before their first birthday should receive 2 more doses of MMR vaccine, the first of which should be administered when the child is 12 through 15 months of age and the second at least 28 days later. **In MMRV vaccine pre-licensure studies conducted among children 12-23 months of age, fever (reported as abnormal or elevated 102°F or higher oral equivalent) was observed 5-12 days after vaccination in 21.5% of MMRV vaccine recipients compared with 14.9% of recipients who received MMR vaccine and varicella vaccine separately. † One of the following is considered evidence of measles immunity for international travelers: (1) Documentation of age-appropriate vaccination with a live measles virus-containing vaccine: for infants aged 6–11 months: 1 dose, for persons aged ≥12 months: 2 doses; or (2) Laboratory evidence of immunity; or (3) Laboratory confirmation of disease; or (4) Born before 1957. For further guidance, please refer to http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6204a1.htm?s_cid=rr6204a1_w. Questions should be directed to DHSS’ Bureau of Immunization Assessment and Assurance at 573/751-6124. 3 For more information: Measles Cases and Outbreaks: http://www.cdc.gov/measles/cases-outbreaks.html For Healthcare Professionals: http://www.cdc.gov/measles/hcp/index.html http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6204a1.htm?s_cid=rr6204a1_w For Travelers: http://www.cdc.gov/measles/travelers.html Laboratory Information: http://health.mo.gov/lab/measlesrubella.php (IgM serology) http://health.mo.gov/lab/measles.php (measles isolation/RT-PCR)