post-exposure prophylaxis for measles

Last edited 06/2019 and last reviewed 11/2023

Seek expert advice and check local guidelines.

All immunosuppressed patients are at risk of severe measles and should be considered for intravenous immunoglobulin (IVIG) following any exposure to measles.

• prophylaxis will depend on the level of immunosuppression and the likelihood that the individual would have retained any pre-existing measles immunity
  • many adults and older children with immunosuppression will have immunity due to past infection or vaccination
  • prophylactic immunoglobulin is unlikely to offer additional benefit to those who have detectable measles antibody using standard assays, as their antibody levels are probably significantly higher than those achieved after a prophylactic dose of immunoglobulin.

Group A includes most patients with immunosuppression

• these individuals should be able to develop and maintain adequate antibody from any prior successful vaccination or infection and can therefore be managed on the basis of evidence of protection at any time (prior to or since the diagnosis or treatment end)
• patients in this group are likely to have developed an adequate response to vaccination or measles during childhood, and so it is recommended that their measles status is established prior to exposure (for example at the next out-patient appointment) so that post-exposure prophylaxis can be informed
• for individuals born and raised abroad, where the history of measles may be less reliable, an individual risk assessment, ideally with rapid IgG antibody testing, is recommended.

Group B includes individuals who are unlikely to have developed or maintained adequate antibody levels from past exposure or vaccination

• his group can be further subdivided into:
  • B(i) individuals who can be managed based on a measles IgG test at the time of exposure or at any point since the end of treatment/diagnosis and
  • B(ii) individuals who require IVIG following an exposure without the need for testing. In principle, individuals should be vaccinated or have had their immunity against measles tested after completing their treatment.

Other individuals who do not meet the criteria for either Group A or B (for example HIV individuals with CD4 cell count>200/mm3, individuals receiving non-biological immune modulating drugs more than 3 months ago), should be considered as immunocompetent for the purposes of measles PEP

• however, the decision on the use of IVIG in these groups may be taken on an individual basis by their specialist clinician.

Group A - individuals who should develop and maintain adequate antibody from past exposure or vaccination

Manage on basis of evidence of protection at any time (prior to or since the diagnosis or treatment end)

• patients receiving or within 6 months of completing immunosuppressive chemotherapy or radiotherapy for malignant disease, (other than those with ALL, a lymphoproliferative disorder or who have had HSCT)
• patients receiving systemic high-dose steroids, or who have received high dose steroids in the past 3 months. This would include:
  • children who receive prednisolone, orally or rectally, at a daily dose (or its equivalent) of 2mg/kg/day for at least one week, or 1mg/kg/day for one month
  • adults who receive short term high-dose corticosteroids (>40mg prednisolone per day or equivalent for more than 1 week)
  • adults who receive long term lower dose corticosteroids (>20mg prednisolone per day or equivalent for more than 14 days)
• patients receiving high doses of non-biological oral immune modulating or other types of immunosuppressive drugs (alone or in combination with steroids) or who have received such therapy in the past 3 months. This would include:
  • adults who receive methotrexate >25mg per week
  • adults who receive azathioprine >3.0mg/kg/day or
  • adults who receive 6-mercaptopurine >1.5mg/kg/day
  • adults on cyclosporin, cyclophosphamide, leflunomide AND
  • children (<16years) who receive any dose of the above drugs
• patients with human immunodeficiency virus (HIV) infection:
  • i) >5 years of age and with a CD4 count <200 cells/µl (but without a diagnosis of AIDS) or
  • ii) aged 5 years or less, with a CD4 count <500 cells/µl

Group B - individuals who lose or may not maintain adequate antibody levels from past exposure or vaccination

B (i): Manage on basis of IgG obtained at the time of exposure (or since the diagnosis or treatment end)

• patients on or after completion of immunosuppressive chemotherapy for acute lymphoblastic leukaemia (ALL)
• patients with lymphoproliferative disorders (including haematological malignancies such as indolent lymphoma, leukaemia and plasma cell lymphoma)
• patients who have received a solid organ transplant
• patients more than 12 months after receiving a haematopoietic stem cell transplant (HSCT)
• patients receiving or within 6 months of completing biological therapies (alone or in combination with steroids). These include:
  • monoclonal antibodies, for example alemtuzumab, ofatumumab and rituximab cytokine inhibitors, for example etanercept
• patients with a diagnosis of acquired immunodeficiency syndrome (AIDs)

B (ii): Offer PEP regardless of status

• patients who have received a haematopoietic stem cell transplant (HSCT) within the past 12 months
• patients with severe primary immunodeficiency*

* this group may already be on long term IVIG replacement, which should provide equivalent protection to post exposure immunoglobulin.

Reference:

• Public Health England. Guidelines on Post-Exposure Prophylaxis for measles June 2019.