#303 Measles in the OR

Measles can walk into your OR before the rash ever shows up, and that’s what makes perioperative measles planning so high stakes. We break down the timing that drives everything: incubation, the contagious window from four days before rash onset through four days after, and how recent exposure during an outbreak should change your elective surgery decisions.

We also zoom out to the bigger picture behind today’s resurgence of measles, including declining vaccination rates and travel-related reintroduction. Then we get practical about what anesthesia professionals need at the bedside: how to confirm immunity status, what symptoms and complications to watch for, and why supportive care is still the core treatment strategy since there are no antivirals. We talk through high-risk groups, from infants to pregnant and immunocompromised patients, and why measles immune suppression can create downstream risk for secondary infection and delayed wound healing well after the acute illness.

On the infection control side, we outline the precautions that protect your team and your facility: strict contact and airborne precautions and smart workflow choices like limiting staff to those with confirmed immunity status and using a negative pressure room for urgent or emergent procedures when possible. We also cover post-exposure prophylaxis options that can prevent or blunt infection, including vaccine timing and when immune globulin is indicated.

For the full checklist mindset, we point you to the featured APSF article and the summary table that pulls the perioperative considerations together. Subscribe, share this with a colleague who takes call, and leave a review so more clinicians can find clear guidance on measles anesthesia safety and operating room infection control.

For show notes & transcript, visit our episode page at apsf.org: https://www.apsf.org/podcast/303-measles-in-the-or/

© 2026, The Anesthesia Patient Safety Foundation

Transcript

Timing, Exposure, And Immunity

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When caring for patients with measles, the timing matters. Here are some important considerations. Immunity status. Ask if the patient ever had measles or two doses of the measles vaccine. If so, then the patient is considered immune. Recent exposure. During a regional outbreak, ask if the patient has been exposed in the last 12 days and delay elective surgery if there's a history of exposure. When contagious, patients are contagious four days before rash onset until four days after. And duration of symptoms. Symptoms of cough, carriza, conjunctivitis, and airway reactivity can persist for days or weeks. Immune suppression can last for two years after infection. Hello and welcome back to the Anesthesia Patient Safety Podcast. I'm your host, Allie Bechtel. Before we continue to talk about keeping patients with measles safe during anesthesia care, we are going to check out a recent note from the APSF newsletter editors Jennifer and Emily to hear how the APSF is evolving. The APSF newsletter has historically released three newsletters each year. This model worked well in the past, but it is now time to adapt to the pace of scientific discovery. Going forward, articles will be published online at APSF.org on a more regular cadence, two to three times per month. There will no longer be only the three newsletters each year. Our goal is to provide important safety information that is timely, relevant, and reflective of the dynamic nature of modern anesthesiology practice. All articles will be easily accessible on our website and highlighted through social media channels and on this podcast. Consider subscribing at apsf.org to make sure that all the latest updates arrive in your inbox. Check out the show notes for more information. We look forward to the new stage of the APSF newsletter and believe that this new approach will improve dissemination of perioperative safety knowledge and practice. We also welcome your feedback and you can write to the newsletter editors at newsletter at apSF.org. Before we dive further into the episode today, we'd like to recognize Frazinius Kabi, a major corporate supporter of APSF. Frazinius Kabi has generously provided unrestricted support to further our vision that no one shall be harmed by anesthesia care. Thank you, Frazinius Kabi. We wouldn't be able to do all that we do without you. Our featured article today is Perioperative Management and Infection Control for Patients with Measles by Brandon Wanta and colleagues, published on February 1st, 2026. To follow along with us, head over to apSF.org and click on the newsletter heading. The first one down is the APSF newsletter articles. Then you can scroll down until you get to our featured article, and I will include a link in the show notes as well. There has been a resurgence of measles in communities around the world. This is a very contagious disease, and perioperative teams need to be ready with the following action plan: early identification, strict adherence to airborne precautions, develop strategies for managing patients with suspected or confirmed measles, and postpone elective procedures until the infectious period has passed to protect staff and other patients. Now let's get into the article. Here is a quick review of measles or rubiola. It is a highly contagious viral illness caused by a paramexovirus from the morbilivirus genus. Measles is spread by respiratory droplets, aerosols, or direct contact with bodily secretions. Individuals are contagious from four days before to four days after the rash onset. After exposure, symptoms develop within 7 to 14 days with an incubation period that lasts for about 11 to 12 days. Symptoms include fever, cough, carriza, and conjunctivitis at first, followed by coplic spots, which are tiny white spots inside the mouth, and a maculopapular rash that spreads from the face down to the rest of the body. Check out figure two in the article for a picture of coplic spots. Complications from measles include otitis media, pneumonia, diarrhea, stomatitis, keratoconjunctivitis, encephalitis, and subacute sclerosing panencephalitis. High-risk patients include infants and patients who are pregnant, immunocompromised, or malnourished. Following measles infection, patients may develop prolonged immune suppression, leading to increased risk for secondary infections and sepsis for months to years after the initial infection. The mortality rate for measles is as low as 0.1% in high-income countries, but is increased to 1.3% in low or middle-income countries. Treatment options include supportive care since there are no antiviral treatments available for measles. Options include hydration and antipyretics with careful monitoring for secondary bacterial infection. Administration of vitamin A is recommended to help reduce the risk for ocular complications. Vaccines are available and effective to help prevent infection, but recent outbreaks are due to declining vaccination rates and increased travel to areas where measles is endemic. There were 16 measles outbreaks in 2024 in the United States, and this increased to 45 outbreaks with 1,753 confirmed measles cases by November of 2025. There are well-documented measles outbreaks dating back to the 1700s. And before the introduction of the vaccine, almost everyone was exposed to the virus at some point. Remember, it is highly contagious. The measles vaccine was introduced in 1963, and receiving two doses provides lifelong immunity, although some people may not maintain adequate antibody levels with aging. Anesthesia professionals are considered immune to measles either from a prior infection or completion of the recommended vaccination series. Many industrialized countries have implemented mandatory measles vaccination policies to reduce the burden from illness and complications. And these vaccination policies worked with the United States declaring measles eliminated in 2000. But with increased travel to areas where measles are endemic and declining vaccination rates, the virus continues to be reintroduced, leading to new outbreaks. Next up, let's talk about anesthetic considerations when caring for a patient with an active measles infection. First, since measles is highly contagious, you must consider the safety of the operating room team as well as the patient. Contact and airborne precautions are recommended with an N95 or powered air purifying respirator, eye protection, gown, gloves, and hat. But wait, anesthesia professionals are considered immune from either vaccination or prior infection. So why all the precautions? Well, immunized healthcare workers who have not used full personal protective equipment have developed measles. Following the surgical procedure and anesthesia, it is important to disinfect the area to prevent further measles transmission. Heat or ultraviolet light may also be effective. For team members who are exposed to measles and have an uncertain immunity status, there are options for post-exposure prophylaxis given the long incubation period. Post-exposure vaccination and antibody administration are options for preventing or mitigating the infection. Recommendations include the following. For unvaccinated or undervaccinated persons, measles vaccine within 72 hours of the exposure. For persons with contraindications to the vaccine, including pregnant or immunocompromised patients or infants less than six months old, human immune globulin within six days of the exposure. Timing of surgery is important for patients with measles. Elective surgery should be delayed until at least four days after the start of the rash when they are no longer infectious and once they have recovered from the illness. For emergency surgery, the perioperative team will need to use strict contact and airborne precautions with N95 masks and, if possible, a negative pressure room before surgery and during recovery. It is important to limit staff to those with confirmed measles immune status if possible. The anesthesia team will need to be prepared for difficult airway management with swollen and friable airway tissues. During the preoperative phase, it is important to screen the patient for any measles complications and verify immunity of the operating room staff. Don't forget about post-exposure prophylaxis with measles vaccination or immune globulin for any exposed non-immune contacts. We talked about one of the complications for measles infection is a period of immune suppression. Even after recovering from measles, patients are at risk for secondary infection and delayed wound healing, and careful monitoring is required. There are no guidelines for surgery deferral beyond the initial measles infection at this time. Here are the big takeaways for keeping patients with measles and healthcare professionals safe during surgery and anesthesia care. Identification of measles infection followed by supportive treatment, consideration of patient immune status and appropriate surgical timing, and timely post-exposure prophylaxis when indicated. And before we go, let's review table one in the article. This provides a summary of considerations for perioperative measles. I will include it in the show notes as well. Here we go. Epidemiology. Sporadic cases and outbreaks of measles are increasing in the United States. Transmission and risk. Measles is highly contagious and spreads via secretions, droplets, and aerosols, which can linger in the air for hours. High risk for anesthesia professionals caring for infected patients. Reporting requirements. Many governments require immediate reporting of suspected or confirmed measles cases regardless of the day or hour. Infectious period. Measles is transmissible from four days before to four days after rash onset. Complications may last longer and increase the perioperative risk. Elective procedures. Defer elective procedures until after the infectious period and symptoms resolve. Urgent and emergent procedures. May proceed with caution, anticipate airway difficulties for mucosal swelling, and implement strict infection control measures. Prevention and post-exposure actions. Measles vaccine is effective. Post-exposure prophylaxis with vaccine or immune globulin is also effective. If you have any questions or comments from today's show, please email us at podcast at apf.org. Please keep in mind that the information in this show is provided for informational purposes only and does not constitute medical or legal advice. We hope that you will visit apSF.org for detailed information and check out the show notes for links to all the topics we discussed today. Thank you for tuning in. If you found this episode valuable, please share it with your colleagues, friends, or anyone interested in improving anesthesia patient care and safety. Your support helps us reach more listeners and spread awareness about the importance of safety in anesthesia. The podcast is available on Spotify and YouTube or wherever you get your podcasts. So it's easier than ever to listen and share and make sure that you subscribe so that you don't miss an episode. Until next time, stay vigilant so that no one shall be harmed by anesthesia care.