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29DLL6x63JkF4A6UeE3FXiA5k3bjfIurga3eSqDxLmb52XwLEN7MUA2AApW9zyK

Request Measles PCR Testing and/or Consultation

Please complete this form with as much detail as possible. If you are requesting testing, an ADPH physician will review the information provided and determine if measles testing is indicated and approved. If you are requesting a consultation, please indicate in the comments any specific concerns or questions for the physician to consider.

Please do not ship any specimens unless you have received confirmation that testing is approved.

Condition

* must provide value

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

http://alabamapublichealth.gov/immunization/provider_poster_measles_control_measures.pdf

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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Date of Report:

M-D-Y

Reporter's First Name:

* must provide value

Reporter's Last Name:

* must provide value

Reporter's Facility Name:

* must provide value

Reporter's Phone Number:

Provider's Name

* must provide value

Provider Call Back Number

* must provide value

Provider's Email Address

* must provide value

Patient's First Name:

* must provide value

Patients's Last Name:

* must provide value

Patient's Date of Birth:

* must provide value

M-D-Y

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 patient < 18 years old, provide parent/proxy's name:

* must provide value

Patient's Street Address of Residence:

* must provide value

Patient's City of Residence:

* must provide value

Patient's State of Residence:

* must provide value

Patient's County of Residence:

* must provide value

Patient's Zip Code of Residence:

Patient's Phone Number:

* must provide value

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

One or more valid doses of documented MMR vaccine is evidence of immunity.

Was patient found in ImmPRINT?

Yes

I am not able to login to ImmPRINT

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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

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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

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

Koplick Spots

Generalized, maculopapular rash

Temperature Onset Date:

* must provide value

M-D-Y

Measured Temp

* must provide value

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

Koplick Spots Onset Date:

* must provide value

M-D-Y

Rash Onset Date:

* must provide value

M-D-Y

Did the rash start on the face?

* must provide value

Yes

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

* must provide value

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

* must provide value

Yes

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If yes, please select all that apply.

* must provide value

Outside the county, but within Alabama

Outside Alabama, but within US

Outside the continental US

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

* must provide value

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

* must provide value

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

* must provide value

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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

Is there laboratory evidence of immunity or measles confirmation?

Yes, Laboratory evidence of immunity

Yes, Laboratory confirmation of measles

Has the patient been administered antibiotics recently?

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

* must provide value

Yes

Unknown

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

Yes

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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?

* must provide value

Yes, considered and have ruled out

Yes, considered and have not ruled out

No, have not considered

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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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Other tests performed

* must provide value

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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?:

* must provide value

Document/Result 1

Upload file

Document/Result 2

Upload file

Document/Result 3

Upload file

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

http://alabamapublichealth.gov/immunization/guidanceformeaslesspecimencollectionshippingtesting.pdf

Do not ship specimens before notification of approval for measles PCR testing.

Comments

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

Approved or Denied for Testing

Approved

Denied

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ADPH approval or denial determination made by:

Select the Specimen Then Enter Information

Select Swab and/or Serum

Swab
Serum

SWAB: BCL Lab ID

SERUM: BCL Lab ID

SWAB: Date Received at BCL

M-D-Y

SERUM: Date Received at BCL

M-D-Y

SWAB: Date Sent From BCL

M-D-Y

SERUM: Date Sent From BCL

M-D-Y

SWAB: Shipped to

Wisconsin

CDC

SERUM: Shipped to

Wisconsin

CDC

SWAB: Result

Positive

Negative

Indeterminant

Unsat

SERUM: Result

Positive

Negative

Indeterminant

Unsat

Reporter Type or On Behalf Of:

* must provide value

Investigator Type Code:

Patient's Race:

* must provide value

If patient's race is other, please specify:

Patient's Ethnicity:

* must provide value

Patient's Gender:

* must provide value

REPORT Card Complete?

* must provide value

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

reset

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

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.

Request Measles PCR Testing and/or Consultation

*** 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. *