Request for Measles PCR Testing

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Please complete this form with as much detail as possible, including upload of available records and photos.

An ADPH Medical Officer will review the information provided and determine if measles testing is indicated and approved.

Please ensure that CDC Healthcare Provider Measles Control Measures are in place

Mask the presumptive measles patient immediately with procedure or surgical mask.
Isolate patient in a negative pressure room, if available, or in a private room with the door closed.
- Do not use any regular exam room for at least 2 hours after the patient has left.
Do not allow measles patients to remain in the waiting room or other common areas.
Only staff with presumptive evidence of immunity should enter the patient's room.
Staff should use respiratory protection that is at least as protective as a fit-tested, NIOSH-certified, disposable filtering facepiece respirator regardless of presumptive evidence of immunity.

Condition

* must provide value

Date of Report:

M-D-Y

Measles symptoms appear 7 to 14 days after contact with the virus.

Common early symptoms include:
- High fever, up to 105°F
- Cough
- Runny nose
- Red or watery eyes

Koplik spots (tiny white spots inside the mouth) may appear 2-3 days after symptoms begin.

Measles rash appears 3 to 5 days after the first symptoms.

A rash of flat red spots appear on the face and spread to the neck, chest, arms, legs and feet
- Small raised bumps may appear on top of the flat red spots
- The spots may become joined together as they spread from the head to the rest of the body

CDC Healthcare Provider Measles Control Measures

Mask the presumptive measles patient immediately with procedure or surgical mask.
Isolate patient in a negative pressure room, if available, or in a private room with the door closed.
- Do not use any regular exam room for at least 2 hours after the patient has left.
Do not allow measles patients to remain in the waiting room or other common areas.
Only staff with presumptive evidence of immunity should enter the patient's room.
Staff should use respiratory protection that is at least as protective as a fit-tested, NIOSH-certified, disposable filtering facepiece respirator regardless of presumptive evidence of immunity.

Reporter's Name

Reporter's Facility:		Reporter's Phone:
Facility Address:

	,

Provider's Name:

Direct Phone Number

(For use by the ADPH Medical Officer to quickly reach the provider directly)

Email:

(To send notification of testing approval)

Patient's Name			Date of Birth
If <18 years, proxy name
Patient's Address

Patient's Age (in years):

View equation

District

Symptom		Onset Date
Fever:

Cough:
Coryza:
Conjunctivitis:
Koplik Spots:
Rash:

Did the rash start on the face?

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Yes

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Describe where the rash began and how it spread:

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Has the patient been administered antibiotics recently?

Patients with throat or ear infections occasionally develop a rash following administration of antibiotics.

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Yes No Unknown

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Does the patient have any other current diagnoses or prescriptions that could cause a rash?

Yes No

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Please describe other diagnosis or prescription being considered as a cause for the rash:

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Have other rash–causing illnesses such as parvovirus B19, enteroviruses, or human herpesvirus–6 (roseola) been considered?

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Yes, considered and have ruled out

Yes, considered and have not ruled out

No, have not considered

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Has any other testing been performed?

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Yes No Unknown

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Other tests performed

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Please check ImmPRINT to verify whether or not the patient has received the recommended measles vaccines.

Click HERE to login to ImmPRINT.

https://siis.state.al.us/ImmPrint/login/login.aspx

Has this patient received a measles-containing vaccine?

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Yes No Unknown

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Data sources used for immunization history

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Immunization Registry (ImmPRINT)

Medical Records

Patient Provided Copy of Vaccine Record

Total Number of Doses Received:

* must provide value

Dose 1 Date:

* must provide value

M-D-Y

Dose 2 Date:

* must provide value

M-D-Y

Dose 3 Date:

* must provide value

M-D-Y

Is there laboratory evidence of immunity or measles confirmation?

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Yes, Documented positive Rubeola IgG

Yes, Laboratory confirmation of prior measles infection

In the past 21 days, has the patient traveled:

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Outside the county, but within Alabama

Outside Alabama, but within US

Outside the continental US

No travel

Provide 'Outside the county, but within Alabama' details of locations and dates.

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Provide 'Outside Alabama, but within US' details of locations and dates.

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Provide 'Outside the continental US' details of locations and dates.

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In the past 21 days, has the patient been in contact with a known measles case?

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Yes No Unknown

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In the past 21 days, has the patient had contact with an international visitor?

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Yes No Unknown

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You may upload up to three laboratory reports and/or supporting documents for this patient. Patient information must be included in any upload.

How many would you like to upload?

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Document/Result 1

Upload file

Document/Result 2

Upload file

Document/Result 3

Upload file

Provide and additional information that may be helpful to the reviewers:

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Immune Status
Imm History	Source of Immunization History	Total Doses	First Dose Date	Second Dose Date	Evidence of Immunity	DOB
______	______	______	______	______	______	______

Clinical Presentation

Fever

Rash

Other Symptoms

Recent Antibiotics

Other Cause of Rash

______

Temp:______

Onset Date:______

______

Onset Date:______

Rash start on face:______

Rash spread:______

Cough;______

Coryza:______

Koplik:______

Conjunctivitis:______

______

Describe:______

Other illness ruled out: ______

Epidemiologic / Exposure Risk
Known Contact of Measles Case:______	International Visitor Contact:______
Travel Last 21 Days	Travel Details
Outside the county, but within Alabama	______
Outside Alabama, but within the U.S.	______
Outside the continental U.S.	______

RISK ASSESSMENT CRITERIA TABLE

Risk Score Criteria	Immune Status	Clinical Presentation	Epidemiologic / Exposure Risk
	Low: 0 Documented vaccination(s); OR Birth before 1957; OR Lab evidence of disease or immunity (e.g. positive titer)	Low: 0 Very atypical presentation (e.g. no fever or no rash); OR Other cause of rash more likely, recent antibiotics or new medications, contact with cases of other rash illness with known etiology	Low: 0 No exposure to confirmed cases; AND No travel to places outside of patient's typical setting
	Some: 1 No vaccination records available, patient is unsure of vaccination status	Some: 1 Not typical prodrome (e.g. fever begins at same time as rash, some symptoms not present): OR Not typical rash (e.g. starts on trunk or extremities)	Some: 1 Unsure/unknown; OR Travel to low risk area (place with no known transmission, no airport)
	High: 2 No evidence of immunity; i.e. unvaccinated, never had disease, born after 1957	High: 2 Typical prodrome; AND Typical rash	High: 2 Epi linkage to confirmed cases; OR Travel to areas with known transmission; OR Time spent in airport
Medical Officer Risk Score
RISK TOTAL:
4+ High Risk - Recommend Testing
3 Some Risk - Consider Testing
< 3 Low Risk - Testing Not Recommended

ImmPRINT Search

ImmPRINT Match Type
ImmPRINT History Available?
Patient ImmPRINT ID
Name		DOB
Address
Dose	Vaccination Date	Description
1
2
3

Approved or Denied for Testing

Approved

Denied

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ADPH approval or denial determination made by:

Medical Officer testing decision comments

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Did patient or provider decline testing?

Reason for declining:

Select the Specimen Then Enter Information

Select Swab and/or Serum

Swab

Serum

Urine

Swab Specimen

BCL Lab ID

Date Received at BCL

Date Sent from BCL

Shipped to

Result

Serum Specimen

BCL Lab ID

Date Received at BCL

Date Sent from BCL

Shipped to

Result

Urine Specimen

BCL Lab ID

Date Received at BCL

Date Sent from BCL

Shipped to

Result

Reporter Type or On Behalf Of:

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Investigator Type Code:

Patient's Race:

* must provide value

If patient's race is other, please specify:

Patient's Ethnicity:

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Patient's Gender:

* must provide value

REPORT Card Complete?

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Please educate staff and patients with the Measles Fast Facts flyer: http://www.alabamapublichealth.gov/immunization/assets/measles_flyer.pdf

Measles symtpoms:

Common early symptoms include:
- High fever, up to 105°F
- Cough
- Runny nose
- Red or watery eyes
Two to three days after symptoms begin, the patient may have:
- Tiny white spots appear inside the mouth
Three to five days after the symptoms begin, the patient may have:
- A rash of flat red spots appear on the face and spread to the neck, chest, arms, legs and feet
- Small raised bumps appear on the flat red spots

* must provide value

Yes No

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Are you requesting measles PCR testing or a consultation with a physician?

Measles PCR testing only

Physician consultation only

BOTH Measles PCR testing and Physician consultation

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Please note that patient birth prior to 1957 is a CDC Evidence of Immunity Criterion : https://www.cdc.gov/measles/hcp/index.html#immunity

If there is reason to continue to suspect measles please continue completing this form.

If you have a patient with presumptive measles, please review the Healthcare Provider Control Measures and complete the appropriate actions.

https://www.cdc.gov/infectioncontrol/pdf/guidelines/Measles-Interim-IC-Recs-H.pdf

Test Types Typically Available to Clinicians and Descriptions for Measles, Mumps, Rubella and Varicella (cdc.gov)

Please educate staff and patients with the Measles Fast Facts flyer: http://www.alabamapublichealth.gov/immunization/assets/measles_flyer.pdf

Measles symtpoms:

Common early symptoms include:
- High fever, up to 105°F
- Cough
- Runny nose
- Red or watery eyes
Two to three days after symptoms begin, the patient may have:
- Tiny white spots appear inside the mouth
Three to five days after the symptoms begin, the patient may have:
- A rash of flat red spots appear on the face and spread to the neck, chest, arms, legs and feet
- Small raised bumps appear on the flat red spots

Please select symptoms.

* must provide value

Temperature ≥101°F or 38.3°C

Cough

Coryza

Conjunctivitis

Koplik Spots

Generalized, maculopapular rash

Temperature Onset Date:

* must provide value

M-D-Y

Cough Onset Date:

* must provide value

M-D-Y

Coryza Onset Date:

* must provide value

M-D-Y

Conjunctivitis Onset Date:

* must provide value

M-D-Y

Koplik Spots Onset Date:

* must provide value

M-D-Y

Rash Onset Date:

* must provide value

M-D-Y

If the rash did not appear on the face first, describe where the rash began and how it has spread:

* must provide value

Was patient found in ImmPRINT?

Yes

I am not able to login to ImmPRINT

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Date of First Valid MMR Dose

* must provide value

M-D-Y

Date of Second Valid MMR Dose (if given):

M-D-Y

Did the patient have one or more valid doses of MMR in ImmPRINT's Tree Vaccine History or Forecaster?

* must provide value

Yes

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Is there alternative documentation of adequate measles vaccination?

Yes No

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Please review the CDC Evidence of Immunity Criteria:

"Acceptable presumptive evidence of immunity against measles includes at least one of the following:

written documentation of adequate vaccination:
- one or more doses of a measles-containing vaccine administered on or after the first birthday for preschool-age children and adults not at high risk
- two doses of measles-containing vaccine for school-age children and adults at high risk, including college students, healthcare personnel, and international travelers
laboratory evidence of immunity*
laboratory confirmation of measles
birth before 1957

Healthcare providers should not accept verbal reports of vaccination without written documentation as presumptive evidence of immunity. For additional details about evidence of immunity criteria, see Table 3 in Prevention of Measles, Rubella, Congenital Rubella Syndrome, and Mumps, 2013: Summary Recommendations of the Advisory Committee on Immunization Practices (ACIP).

*People who have negative or equivocal results for measles IgG should be vaccinated or revaccinated. In some cases it is not possible to vaccinate a patient, and you may need to test them with a second line diagnostic assay to determine whether they are immune to measles. Because the sensitivity and specificity of commercial measles IgG assays vary, state public health departments can provide information on appropriate second line assays.

https://www.cdc.gov/measles/hcp/index.html#immunity

Please review the CDC Measles Serology website for important information on testing: "In countries such as the United States where endemic circulation of measles has been eliminated, most suspected cases are not measles, and rash and fever illnesses are more likely due to a number of other rash-causing illnesses such as parvovirus B19, enteroviruses, or human herpesvirus-6 (roseola). The presence of rheumatoid factor (RF) can also result in a false positive IgM. Indirect EIA's appear to be more affected by RF than IgM capture assays. Additionally, patients with throat or ear infections occasionally develop a rash following administration of antibiotics. Subsequent serologic specimens sent for measles IgM testing may result in a false positive test." https://www.cdc.gov/measles/lab-tools/serology.html

Has any other testing been performed and ruled out?

* must provide value

Yes

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* If approved for testing, a swab AND serum for serology must be collected. *

Has the patient traveled outside the county, state or country within the last 3 weeks?

* must provide value

Yes

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Healthcare providers should collect a throat or nasopharyngeal swab for molecular identification at first
contact with the patient.

Please review the ADPH Guidance for Measles Specimen Collection, Shipping and Testing:

https://www.alabamapublichealth.gov/immunization/assets/measles-test-collect-ship.pdf

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Request for Measles PCR Testing

*** If approved for testing, a swab AND serum for serology must be collected. ***

You have selected an option that triggers this survey to end right now.

* If approved for testing, a swab AND serum for serology must be collected. *