This report documents the prompt, co-ordinated and effective public health response to a measles outbreak in Queensland in 2013. There were 17 cases in a large, high-security, regional correctional facility, a setting with unique challenges. Recommendations are provided to reduce the likelihood and magnitude of measles outbreaks in correctional facilities

Baldwin, Anne M.

Chatterji, Madhumati

Lambert, Stephen B.

Prakash, Rajendra

Vlack, Susan A.

University of Queensland eSpace

E294 CDI Vol 38 No 4 2014
Short reports 
Short reports
Abstract
This report documents the prompt, co-ordinated and 
effective public health response to a measles out-
break in Queensland in 2013. There were 17 cases 
in a large, high-security, regional correctional facility, 
a setting with unique challenges. Recommendations 
are provided to reduce the likelihood and magni-
tude of measles outbreaks in correctional facilities. 
Commun Dis Intell 2014;38(4):E294–E297.
Keywords: measles, prisoner, justice, 
correctional, offender, outbreak, epidemic, 
Queensland, guidelines, vaccination
Background
The World Health Organization recently declared 
that Australia has been in a period of sustained 
measles elimination since at least 2009.1 However 
this does not mean an absence of cases; imported 
cases continue to occur in returned international 
travellers, and those exposed to them whilst infec-
tious, leading to local outbreaks. By early October 
2013, Queensland had experienced more year-to-
date notifications (20) than the annual average of 
the previous 5 years (15), with an ongoing outbreak 
of 13 cases in South East Queensland.2 This report 
documents the public health response to an out-
break of measles in a correctional facility. Measles 
is a highly contagious disease transmitted by 
droplet and airborne routes.3 Correctional facilities 
present unique challenges for communicable dis-
ease control, for reasons including the close living 
conditions, and number and turnover of prisoners 
and staff.4
Outbreak
On 29 October 2013, the treating physician of a 
South East Queensland, high-security correctional 
facility (capacity approximately 1,000 males) noti-
fied the local public health unit (PHU) of 4 pris-
oners with fever and rash suspected to be measles.
Presentations were atypical. One case had a rash 
starting in the left thoracic area. Another had a 
protracted flu-like illness with severe cough for 
7 days and a rash that started on an elbow before 
progressing to the rest of the body. The third had 
diffuse spots with maculopapular rash starting 
the same day as high fever. The fourth had a 
flu-like illness for 2 days with a transient ‘spotty’ 
rash on the chest. The following day, a 5th pris-
oner was notified with a classical measles rash. 
Measles virus was detected by polymerase chain 
reaction (PCR) testing of upper respiratory tract 
swabs from each case.
Review of case notes for prisoners with recent 
rash and fever was undertaken to identify the 
primary case. Approximately 2 weeks previously, 
a prisoner was diagnosed with a drug rash from 
antibiotics administered for a respiratory tract 
infection. Following look-back, measles virus 
was detected by PCR in a sample taken from the 
prisoner. Airborne transmission of the virus is 
possible and this case had moved widely in the 
correctional facility, sharing facilities with each 
of the 5 cases and others during the infectious 
period. The exposure period, movements and 
genotype (G3) suggest the prisoner acquired the 
infection from a community outbreak2 before 
entering the correctional facility.
Overall, 17 cases were linked to the outbreak 
(Table). Cases were laboratory confirmed by PCR, 
with the exception of 1 confirmed by measles-
specific immunoglobulin M in serum. Exposure 
and infectious periods suggest the correctional 
facility’s primary case infected 8 cases who in 
turn infected 7 cases (Figure). Vaccine-strain 
virus was detected in 1 further case who was 
vaccinated in the mass vaccination program. One 
staff case produced documentation of 1 previous 
dose of measles vaccine. Prisoners’ vaccination 
histories were not available.
The outbreak was declared over when 36 days 
(2 maximum expected incubation periods) since 
the last case’s infectious period had passed without 
a new, epidemiologically-linked case.
As this response and release of data are provided for 
under the Public Health Act 2005,5 human research 
ethics committee approval was not required.
Public health resPonse to a measles outbreak 
in a large correctional facility, Queensland, 
2013
Madhumati Chatterji, Anne M Baldwin, Rajendra Prakash, Susan A Vlack, Stephen B Lambert
CDI Vol 38 No 4 2014 E295
 Short reports
Response
On 29 October 2013, suspected cases of measles 
were isolated, advice was provided to staff and 
staff and prisoner movements were restricted. On 
30 October following laboratory confirmation, an 
outbreak control team (OCT) of staff from the 
state justice department including the correctional 
facility, state department of health, public health 
laboratory, local PHU, hospital pharmacy and 
other hospital and health service (HHS) teams, 
was assembled.
As prisoners and visitors shared air space via grilles 
in visitation stalls, prisoner visits were cancelled 
on 1 November. No admissions of new prisoners 
were accepted. Prisoners recently transferred out 
were monitored for symptoms at receiving facili-
ties. Transfers of non-immune prisoners were sus-
pended state-wide.
With around 900 prisoners and 450 staff poten-
tially exposed, individual contact tracing and 
immune status determination were not considered 
feasible or sufficiently timely. Consistent with pub-
lic health recommendations for the management 
of measles outbreaks in large institutions,6,7 a mass 
vaccination approach was adopted.
The department of health procured sufficient 
vaccine (M-M-R© II, bioCSL/Merck) within 
24 hours of planning the activity. The HHS 
mobilised nurses to vaccinate alongside correc-
tional facility staff, and provided consumables. 
Pre-vaccination assessment, informed consent, 
standing orders8 and adverse event procedures, 
documents and other resources were developed. 
The standing orders enabled the measles vac-
cine administration without a prescription for 
each prisoner. Key messages regarding measles’ 
infectiousness, complications, prevention and 
control were disseminated to prisoners, staff, 
visitors and the general public. State health hot-
line staff were briefed and the service publicised 
for enquiries.
On 31 October, approximately 80 staff were vacci-
nated. Over the next 2 days, approximately 1,150 vac-
cinations of staff and inmates were administered. 
In the following week, correctional facility staff 
conducted mop-up vaccinations, and movement 
and visitor restrictions were gradually lifted. All 
were vaccinated except 1 prisoner and 3 staff who 
refused. These were isolated or excluded from work 
until the maximum expected incubation period (18 
days) had elapsed without symptom onset.
Discussion
Measles in institutional settings can result in 
explosive outbreaks with large numbers of cases, 
and difficulties in containing successive waves 
of infection. The response to this correctional 
facility measles outbreak was rapid and highly co-
ordinated, limiting further cases.
The clinical suspicion of measles in the first 4 
identified but atypical cases was crucial to the 
immediate diagnostic testing and implementation 
of control activities. It is known that a proportion 
of all measles cases will not present with classic 
symptoms—the reason for the clustering of unu-
sual presentations in this outbreak is unknown.
Swift commencement of mass vaccination meant 
most prisoners and staff received a vaccine within 
3 days of the outbreak identification.
The early assembly and central co-ordination of an 
OCT of key stakeholders and experts meant that 
Table: Demographic characteristics of measles 
cases associated with the correctional facility 
(n=17)
Age Range 18–41 years
Median 28 years
Sex Female 3 cases
Male 14 cases
Indigenous 
status
Indigenous 1 case
Non-Indigenous 13 cases
Unknown 3 cases
Group Prisoner 14 cases
Correctional centre staff 3 cases
Figure:  Symptom onset dates of measles 
cases associated with the correctional facility, 
12 October 2013 to 13 November 2013 (n=17)
0
1
2
3
4
5
6
S S M T W T F S S M T W T F S S M T W T F S S M T W T F S S M T W
1213141516171819202122232425262728293031 1 2 3 4 5 6 7 8 9 10111213
Oct Nov
C
as
es
Onset date
Vaccine strain virus not detected
Vaccine strain virus detected*
Mass 
vaccinationNotification of 
outbreak to 
public health unit
* This result does not preclude infection with wild-type 
virus.
E296 CDI Vol 38 No 4 2014
Short reports 
those best placed to provide expertise contributed 
to decision-making and facilitated speedy deploy-
ment of interventions.
No subsequent community cases were epidemio-
logically linked to this outbreak. Most cases with 
onset after the mass vaccination were most likely 
already incubating the disease.
Timely and appropriate communication ensured 
that the situation and associated risks were well 
communicated. Surveillance for cases and move-
ment restrictions within the correctional facility 
allowed rapid responses when new cases were iden-
tified. Safety, security and order were maintained.
There were challenges. A higher clinical suspicion 
of measles in the primary case, given the local 
outbreak,2 may have enabled better containment.
Correctional facilities are advised to isolate prisoners 
with infectious diseases to minimise transmission, 
where appropriate.9 Specific guidance for measles 
outbreak management in correctional facilities is 
however, absent from national7 and state6 health and 
correctional guidelines,9 leading to some depend-
ence on expert advice regarding interpretation and 
implementation of generic guidelines for this setting. 
As with most measles responses, success came from 
relying on first principles: timely contact immunisa-
tion, case isolation and limiting the movements of 
exposed individuals.
There are no specific measles immunity data 
available for Queensland prisoners. However, they 
are more likely than the general adult popula-
tion to be born since 1966, thus less likely to have 
pre-existing natural immunity.10–12 Additionally, 
14% of prison entrants in New South Wales in 
2010 who were born since 1969 and tested, were 
susceptible to measles, compared with 8%–9% 
of the general population of similar age.13,14 For a 
highly contagious virus like measles in a confined 
institutional setting, this represents a high risk of 
serial waves of transmission if initial cases are not 
promptly recognised, and the outbreak response is 
not swift and comprehensive.
Although measles vaccine is funded in 
Queensland,15 it is not routinely offered to prison-
ers, nor is there screening for measles immunity 
on prison entry. Immunity and vaccination records 
were also not readily available during this out-
break, preventing rapid identification of suscepti-
ble prisoners.
The setting presented logistical difficulties. Floor 
plans were unavailable to the OCT for security rea-
sons, preventing the usual outbreak mapping of case 
movements. It was not feasible for public health staff 
to directly interview cases. Standard immunisation 
procedures needed to be modified to maintain cor-
rectional facility security and staff safety.
To reduce the likelihood of outbreaks in cor-
rectional facilities and improve public health 
responses, it is recommended that:
1. specific guidance for managing correctional 
facility measles outbreaks is developed and 
included in prison and health guidelines;
2. measles vaccination is routinely provided to 
Queensland’s susceptible prisoners; and
3. a high degree of clinical suspicion for measles 
is maintained, particularly during community 
outbreaks.
Acknowledgement
The authors acknowledge all who contributed to 
this response.
Author details
Dr Madhumati Chatterji1
Ms Anne M Baldwin2
Dr Rajendra Prakash3
Dr Susan A Vlack4
Assoc Prof Stephen B Lambert5
1. Public Health Physician, Central Queensland Public 
Health Unit, Central Queensland Hospital and Health 
Service; Senior Lecturer, Faculty of Medicine and 
Biomedical Sciences, The University of Queensland, 
Brisbane, Queensland
2. Senior Epidemiologist, Sunshine Coast Public Health 
Unit, Sunshine Coast Hospital and Health Service, 
Maroochydore, Queensland
3. Visiting Medical Officer, Queensland Health, Brisbane, 
Queensland
4. Public Health Physician, Metro North Public Health 
Unit, Metro North Hospital and Health Service; Senior 
Lecturer, Faculty of Medicine and Biomedical Sciences, 
The University of Queensland, Brisbane, Queensland
5. Senior Medical Officer, Communicable Diseases 
Unit, Queensland Health; Medical Epidemiologist, 
Queensland Children’s Medical Research Institute, The 
University of Queensland, Brisbane, Queensland
Corresponding author: Ms Anne Maree Baldwin, PO Box 
577, MAROOCHYDORE QLD 4558. Telephone: +61 7 
5409 6609. Email: annemaree.baldwin@health.qld.gov.au
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Public health response to a measles outbreak in a large correctional facility, Queensland, 2013

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