Guidance

Measles: guidance for Health Protection Teams on cases linked to international travel including air, sea and land crossings

Updated 16 April 2025

Who this guidance is for

This guidance provides recommendations for health protection teams (HPTs) responding to a likely (probable) or confirmed case of measles who has recently travelled by air, sea or land crossings.

This guidance should be used alongside the UKHSA national measles guidelines and the International Health Regulations (IHR) National Focal Point guidance on international communications for contact tracing and other public health responses.

There are also guidelines from the European Centre for Disease Prevention and Control (ECDC) on risk assessment for diseases transmitted on aircraft (RAGIDA).

Rationale, principles and background

Background

Measles is highly infectious – the most infectious of all diseases transmitted through the respiratory route. It is caused by a morbillivirus of the paramyxovirus family and spreads through airborne droplets or direct contact with nasal or throat secretions. Symptoms usually include fever, conjunctivitis, rhinitis, cough and a characteristic red blotchy rash. Measles can be severe, particularly in immunosuppressed individuals and young infants. It is also more severe in pregnancy, and increases the risk of miscarriage, stillbirth or preterm delivery (1).

The most effective way to control measles is by achieving high uptake of 2 doses of measles, mumps, rubella (MMR) vaccine. High sustained coverage is key to achieving measles elimination – defined by the World Health Organization (WHO) as the absence of endemic measles circulation for at least 12 months in a country with a high-quality surveillance system. Uptake of MMR in England (2022 to 2023) is below 90% for the first dose at 2 years of age and at 85% for 2 doses at 5 years of age, well below the ≥95% WHO target.

After briefly achieving endemic measles elimination in 2016 and 2017, by 2018 measles virus transmission had re-established in the UK, at a time when the whole of Europe was experiencing large epidemics. Measles transmission reduced during the COVID-19 pandemic due to societal and travel restrictions, resulting in measles elimination status being regained in 2023 (reflecting 2022 surveillance data). However, measles incidence increased globally after this point, with large outbreaks seen in multiple countries, and incidence also increased in the UK during 2023 and 2024.

This document provides public health guidance on the risk assessment of likely or confirmed cases of measles linked to international travel and travel by air, sea and land crossings. This is set in the context of a national surveillance system which is required to support and monitor progress towards WHO elimination targets.

Rationale for public health action

Measles is a notifiable disease in the UK, and in line with WHO elimination targets there is intensive case-based surveillance to detect, investigate and confirm every suspected case. A risk assessment is undertaken for every reported case, as outlined in the national measles guidelines, and the need for urgent public health action is assessed. The aim of these assessments is to ensure early identification of chains of transmission, so that effective interventions can be targeted appropriately and started promptly to limit further spread.

Reporting of cases linked to international travel is an essential part of international surveillance. Reporting should not be limited to cases where immediate post-exposure interventions can be carried out. Classification of imported cases and identifying international links between cases is an important component of the plans for regional and global elimination.

The objectives of the public health response to a likely case of measles on a flight or travelling internationally are:

• to identify and exclude secondary cases of measles early and therefore limit ongoing transmission (secondary waves)
• to provide timely post exposure prophylaxis to vulnerable individuals who may have been exposed
• to identify linked cases as part of high quality surveillance to support elimination
• to cooperate with requests from other countries to supply information on measles cases within their territory or on individuals exposed to a measles case in the UK

Measles cases who have flown or travelled internationally whilst infectious are usually identified either:

• as part of routine HPT duty desk work
• by a notification from the IHR National Focal Point of UKHSA

Principles of public health action

Restrictions on travelling internationally while infectious

Medical clearance is required if someone who intends to travel internationally is suffering from a disease which is believed to be actively contagious and communicable. The International Air Transport Association (IATA) medical manual suggests that any person with infectious measles should not be given clearance to fly.

The infectious period for measles starts 4 days before the onset of rash, and ends 4 days after the rash appears. HPTs should therefore advise likely or confirmed cases of measles to not travel during this infectious period. Where someone still intends to travel against public health advice, the HPT should contact the UKHSA Border Health Team on 020 8745 7209 for further support. Additionally, the individual should tell the airline or port health authority in advance of their journey.   

Unimmunised contacts of the case should also not travel for the duration of the incubation period – this is until 21 days after their last contact with the case.

Reporting suspected cases of measles

Identification of suspected measles cases is vital to facilitate appropriate public health action. Aviation guidelines support the reporting of infectious disease if symptoms develop during flight. International Civil Aviation Organization (ICAO) regulations and the IHR require the captain to report a suspected case of infectious disease to air traffic control.

WHO and IATA have produced a passenger locator form (PLF) to collect passenger details should a case of infectious  disease be suspected onboard a flight. The PLF should be distributed to all passengers and crew, completed and returned to airline staff before passengers disembark the aircraft.

In line with IHR and the Public Health (Ships) Regulations 1979 (as amended), it is a requirement that any cases or symptoms of infectious disease onboard a vessel are notified to the relevant port health authority before the vessel arrives in port. If symptoms of infectious disease are suspected, the ship’s Master must submit a completed Maritime Declaration of Health (MDH) form.

Symptoms may also develop following travel. These cases should be identified using established surveillance systems. Measles is a notifiable disease under the Health Protection Legislation (England) Guidance 2010. Clinicians are required to notify all suspected measles cases as soon as possible to their local HPT. For any likely or confirmed case of measles, any travel whilst infectious should be identified and reported to the UK IHR National Focal Point at UKHSA Colindale.

Informing passengers of potential exposure/contact tracing following exposure

Individuals with primary measles infection are infectious from 4 days before rash onset until 4 full days after the rash appears. Generally, secondary transmission of measles is higher among close contacts, such as members of a household or individuals who have close contact with each other over a long period of time. However, while most transmission events require face-to-face and/or prolonged contact, transmission through more casual contact, including on flights, has also been documented. An evidence review first undertaken in 2011 (see Appendix A) found that:

• secondary measles cases can occur both during flights and from contact in departure lounges and airports
• secondary measles cases have been identified from contact tracing of confirmed cases in adjacent seating and other rows quite a distance away within the same aircraft
• secondary cases have been reported during a variety of international and domestic flights, indicating that the duration of contact required for transmission is variable
• there has been a confirmed case identified in a flight attendant highlighting the potential of occupational exposure

The ECDC produced RAGIDA in 2009. This acknowledges the limited evidence base in this area for the majority of diseases, including measles, and that contact tracing needs to take place within available resources. The resources required to implement contact tracing have been described as extensive and at high cost to public health agencies, often with little evidence of additional case prevention.

For these reasons, where a large group of people have been exposed but the level of contact cannot be defined on an individual basis, such as during air travel, it is appropriate and preferable to initiate a prompt mass communication. This could be carried out by email or text messaging to ‘warn and inform’ all passengers and crew who may have been exposed.  

The aim of the ‘warn and inform’ approach is to:

• ensure that all those at risk are aware of the potential exposure and the signs and symptoms of measles
• encourage rapid self-identification of those who may be vulnerable individuals at higher risk (immunocompromised, pregnant women and unvaccinated infants)
• ensure that any linked cases are identified, diagnosed and excluded promptly
• provide reassurance to those who are likely to already be protected

In order for this approach to have the biggest impact prompt action should be taken. The time period when effective interventions can be given in line with current UKHSA guidance is as follows:

• MMR in eligible immunocompetent individuals within 72 hours of exposure
• human normal immunoglobulin (HNIG) to vulnerable contacts as soon as possible after exposure, ideally within 72 hours, but up to 6 days after exposure if necessary

HPTs should refer to the UKHSA national measles guidelines for more information on the MMR vaccine and HNIG.

Warning and informing beyond this 6 day period is however still beneficial in terms of early case identification and exclusion, therefore it should still be undertaken for 21 days after the infectious person travelled.

Notification to national authorities when a suspected measles case departs from or arrives in the UK

HPTs should notify all likely or confirmed cases linked to international travel by email to the UK IHR National Focal Point (IHRNFP@ukhsa.gov.uk), and to the national immunisation team (immunisation.lead@ukhsa.gov.uk).

For likely or confirmed cases who were infectious while travelling to another country [note 1], or who are likely to have acquired their infection in a non-endemic country, contact with the relevant National Focal Point should be made through the UK IHR National Focal Point and the national immunisation team. Further information can be found in the International Health Regulations 2005: UK National Focal Point.

Reporting of cases linked to international travel is an essential part of international surveillance and reporting should not be limited only to cases where immediate post-exposure interventions can be conducted. Classification of imported cases and identifying international links between cases is an important component of regional and global elimination and would be expected by most other countries. 

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Note 1: Since global outbreaks frequently occur and the measles status of a country can change rapidly if you are in doubt, contact the national immunisation team and/or the National Focal Point, or refer to the updated WHO country data

Public health management

Responsibilities for public health actions

For likely or confirmed cases of measles who have travelled internationally, the current convention is that the country of arrival is responsible for contact tracing. Therefore, UKHSA HPTs are responsible for contact tracing of individuals arriving in England.

HPTs do not complete contact tracing for outgoing flights departing from the UK, but should notify the UK IHR National Focal Point (IHRNFP@ukhsa.gov.uk) if there is a case who has flown outbound while infectious. The UK IHR National Focal Point will communicate with other countries as required.

The management of the case (including contact tracing) is the responsibility of the HPT where the case is resident. Where the case is not a UK resident, then contact tracing is the responsibility of the HPT where the case presents for treatment. If the case is neither resident nor seeking treatment in the UK, for example the case only transited via a UK airport, responsibility for contact tracing falls on the HPT that covers that airport/port.

Information gathering and review

When the HPT is made aware that a likely or confirmed case has travelled on a flight while infectious with measles, they should obtain information from caller to include:

• case – passenger’s name, date of birth, mobile number, and address in the UK
• symptoms and date/time of onset
• test results
• seat number
• country and airport of departure of flight (direct, or stop-over)
• country and airport of departure of the case, if different from country of departure of flight
• whether the case is part of a group or tour – if so, obtain information on the total number in group and details of organiser

This information will inform the risk assessment and public health actions, as outlined below.

Management of case(s) of measles:

Cases who travelled by air while infectious (domestic or international flights)

Follow the UKHSA national measles guidelines to conduct a risk assessment.

All reported cases of measles should have an oral fluid sample taken and tested for confirmation by the UKHSA Virus Reference Department. Travel information should be included in the laboratory request form for the oral fluid test. This will ensure that the case is classified as imported in UKHSA’s reporting to WHO.

If the case is assessed as likely measles, the HPT should undertake the following actions.

Advise the case to not conduct any onward travel while infectious. For air travel, airlines will require a passenger to have received medical clearance before travelling with any disease which is believed to be actively contagious and communicable. The IATA medical manual suggests that any person with infectious measles should not be given clearance to fly.

If the infection was identified during a flight, the local HPT or Port Health Officer should be informed shortly after the plane lands. A completed PLF will be supplied to the HPT local to the airport. However, responsibility for the management of the case, and any subsequent contact tracing of flights, continues to sit with the HPT of residence irrespective of where they land in the UK.

All flight details should be collected and added to CIMS so that colleagues across UKHSA can access the details if other linked cases are reported later. When adding flight information, use the recommended format for consistency in recording (see Appendix B for full details).

Where the airport or port of arrival is in a different geographical area to the residence of the case, you should also notify the HPT with responsibility for the port in case they receive enquiries .

If your assessment suggests that the case is most likely to have acquired their infection overseas, add all relevant travel under the ‘Travel and Contexts’ question package in CIMS to allow linking of cases. Please use the recommended format to allow consistent recording (see Appendix B for full details of how to add different travel-related contexts).

The country/countries in which the case had resided or travelled through while infectious will require information about the case, for example the addresses the individual stayed at and any institutions or gatherings attended. This information sharing is particularly important for countries with low measles prevalence. Contact with other countries’ responsible authorities will be made by the UK IHR National Focal Point.

Report the case (see Appendix C for details to include in your email) to the UK IHR National Focal Point (IHRNFP@ukhsa.gov.uk), and the national immunisation team (immunisation.lead@ukhsa.gov.uk) by email promptly. 

The immunisation.lead@ukhsa.gov.uk inbox is monitored Monday to Friday 9am to 5:30pm; the Colindale Duty Director is the contact point outside of these hours for any urgent advice.

The IHRNFP@ukhsa.gov.uk inbox is monitored 7 days a week, although only urgent issues will be actioned out of hours.

For flights from other UK devolved administrations, the HPT should notify the respective national public health departments:

• Wales: aware@wales.nhs.uk (out of hours: 0300 00 300 32)
• Scotland: NSS.HPSImmunisation@nhs.net (out of hours: 0141 300 1100, option 7)
• Northern Ireland: pha.immunisation@hscni.net

If within 21 days of the flight, the HPT should contact the airline and ask them to cascade a ‘warn and inform’ message to all passengers and crew on the flight via text, email or letter. This should include a link to further information about measles prevention and control, information about when and how passengers should contact their local HPT, and about what to do if they develop symptoms. Where appropriate, the information for passengers and crew on a flight with a case of measles (also provided in Appendix D) can be used for this. A template warn and inform text message can be found in Appendix E.

Cases who travelled internationally by transport other than by air while infectious

Follow the UKHSA national measles guidelines to conduct a risk assessment.

All reported cases of measles should have an oral fluid sample taken for confirmation by the UKHSA Virus Reference Department. Travel information should be included in the laboratory request form for the oral fluid test. This will ensure that the case is classified as imported in our reporting to WHO for elimination purposes.

If the case is assessed as likely measles, the HPT should undertake the following actions.

Advise the case to not conduct any onward travel while infectious. If your assessment suggests that the case is most likely to have acquired their infection overseas, add all relevant travel  under the ‘Travel and Contexts’ question package in CIMS to allow linking of cases. Please use the recommended format to allow consistent recording (see Appendix B for full details of how to add different travel-related contexts).

The country/countries in which the case had resided or travelled through while infectious will require information about the case, for example any addresses stayed and any institutions or gatherings attended. This information sharing is particularly important for countries with low measles prevalence. Contact with other countries’ responsible authorities will be made by the UK IHR National Focal Point.

Report the case (see Appendix C for details to include in your email) to the UK IHR National Focal Point (IHRNFP@ukhsa.gov.uk) and the national immunisation team (immunisation.lead@ukhsa.gov.uk) by email promptly. The immunisation.lead@ukhsa.gov.uk inbox is monitored Monday to Friday 9am to 5:30pm; the Colindale Duty Director is the contact point outside of these hours for any urgent advice. The IHRNFP@ukhsa.gov.uk inbox is monitored 7 days a week, although only urgent issues will be actioned out of hours.

If the travel was in the last 21 days, the HPT should consider sending a ‘warn and inform  message’ through the transport provider. This could be done via text or email. Where appropriate, the information for passengers and crew on a flight with a case of measles (also provided in Appendix D) can be used for this. If the transport provider does not have contact details of passengers, no further action is required, unless a defined group is known from the index case and can be contacted through other means (for example, children on a school trip).

Where arrival is in a different geographical area to the residence of the case, you should also notify the HPT with responsibility for the port  in case they receive enquiries. If the transport provider is unable to contact passengers, no further action needs to be taken, unless there are special circumstances (for example early notification and vulnerable group who are contactable).

Management of contacts of measles who were exposed during travel

A person who receives a ‘warn and inform’ message may contact their local HPT for advice. This may be a different HPT to that of the index case. If an individual contacts your HPT believing they have travelled with a person who had infectious measles:

• ask why they believe they were exposed, and whether they have received an email or text message and from whom
• log the contact on CIMS and check whether a context has been entered for their flight/travel. If the only information you have is a flight number, check whether this has been entered as a context
• if a flight/travel context is listed on CIMS, check whether the index had likely or confirmed measles as assessed by UKHSA
• if a flight/travel context is NOT listed on CIMS, further investigation may be needed to ascertain whether the reported index case has been notified and had likely or confirmed measles as assessed by UKHSA
• in either circumstance, follow the UKHSA national measles guidelines to risk assess the contact’s exposure to the index case, and follow the post-exposure prophylaxis guidance for contacts of likely or confirmed measles cases as appropriate

The UK IHR National Focal Point are regularly contacted by foreign authorities with information regarding the following:

• UK-based travellers who have been diagnosed with measles while travelling abroad but were infectious prior to their departure
• UK-based travellers who may have been exposed to cases of measles (and other infectious diseases) while travelling abroad
• confirmed cases of measles from other countries who travelled within the UK whilst infectious prior to returning to their country

In these circumstances the information will be passed on to the HPT and HPTs will be requested by the UK IHR National Focal Point to a send a warn and inform message to contacts resident in their area or to follow up with contacts as per their usual protocol.   

Contacting airlines

To contact an airline, please use the ‘ITCT Stakeholder and Airline Contacts Database ’ uploaded to the Flight Contact Tracing Toolkit on the UKHSA Regions Directorate SharePoint site. If after 24 hours you don’t get a helpful response from the airline using contact details listed on the database, please contact the HCU on heathrow.HCU@ukhsa.gov.uk or call the Border Health team on 020 8745 7209 for further support such as alternate contact details.

Appendix A: Contact tracing evidence review

Background

In 2012, international guidance on infectious disease in aircrafts and the published literature were reviewed by the Health Protection Agency to ensure that national guidance on contract tracing were both feasible and evidence-based. A refreshed evidence review is underway as part of the UKHSA Border Health Transformation Programme in 2024 to 2025 and will inform future revisions of this guidance.

International guidance on infectious disease in aircraft

ECDC initiated the RAGIDA project in 2007. The resulting disease-specific guidance was published in June 2009, following a systematic review of published evidence, consultation with expert panels and a review of risk assessment guidance in current existence.

The ECDC guidance advises that contact tracing for measles cases is strongly recommended if post-exposure prophylaxis can still protect susceptible persons, prevent complications and limit further transmission – provided that risk assessment, available resources, and the feasibility of measles control allow that effort.

An algorithm for contact tracing recommends that this should be considered if the index case is a probable or laboratory-confirmed measles (according to EU definition), or likely to have measles based on epidemiological links and the case has travelled whilst infectious (4 days prior to 4 days post-onset of rash) and the flight has occurred within the previous 5 days.

Five days is identified as the limit to implement appropriate public health action (6 days for administration of human immunoglobulin minus day of organisation).

Contact tracing after 5 days is recommended as an option if the following criteria are met:

• infectious case
• incubation period not elapsed
• information of passengers available
• evidence of transmission in the country of origin
• measles elimination achieved or within reach of country of arrival
• resources available

ECDC recommends that contact tracing should be considered for all passengers and crew, but that priority should be given to children below 2 years of age, pregnant women and immunosuppressed patients.

Further practicalities of action are discussed in brief, recommending that contact tracing should commence with children below the age of 2, then passengers in the same row as the index case and then row by row in each direction, as long as it remains possible to carry out post-exposure prophylaxis and effective containment.

ECDC acknowledges that the RAGIDA guidelines have inherent limitations, in particular, the limited evidence base for the majority of diseases. The majority of the studies identified for measles are observational and include limited information on the effectiveness or cost effectiveness of public health action/contact tracing.

Guidance has been developed from discussions of the expert panel taking into account the evidence available. They stress that the template is indicative only and should be adapted according to the specific situation.

IATA passenger contact tracing guidance

IATA published a position statement on passenger contact tracing in February 2018. IATA regards passenger contact tracing as a controversial issue due to a lack of standardisation and harmonisation. WHO asked IATA to draft the template for a PLF; this was accepted by WHO and the ICAO.

IATA does not advocate contact tracing, but states that if a public health authority decides to implement contact tracing the process should be generated and led by the public health authority. The data collection should be in electronic format and the request/requirement for data collection should be directly between the country requesting the data and the passenger.

AIRSAN project: contact tracing – collaboration between the public health and the aviation sector

The AIRSAN project is an EU-funded project that presents a joint perspective for public health authorities, airlines and airports and a joint mission statement of recommended common best practice in the area of contact tracing.

The document does not provide any specific suggestion on how and when to conduct contact tracing but acknowledges that, in certain circumstances, contact tracing measures need to be initiated to contain the spread of a communicable disease.

The main discussion point of the guidance is regarding the availability of contact details of passengers. Airline operators have access to contact information from their travel booking systems, the so-called passenger name record (PNR) data.

PNRs are individual airline tools, so, while the basis of PNRs is similar, the information may vary significantly from one airline to the other. PNR data is used as reservation data for the operating airline and are likely to contain telephone numbers and email addresses. However, these data may be variable between airlines and not necessarily validated.

Evidence review

Evidence of transmission during air travel

A recently updated literature review (first conducted in 2011) of published evidence of measles transmission during air travel identified 8 case reviews. There is evidence to suggest that secondary cases can occur following flights (2,3,4,5,6,7) but also from contact in departure lounges and airports (2,6,8). Secondary cases have been identified from contact tracing of confirmed cases in adjacent seating and other rows within the same aircraft (2,4,6,7,8). Whilst it is presumed that those at most risk of illness are susceptible individuals without prior immunity, there are documented reports of illness in previously vaccinated passengers (3,7) and airport staff (6). In the published literature secondary cases have been reported following a variety of international and domestic flights indicating that the duration of contact required is variable, consistent with the highly infectious nature of measles.

A confirmed case identified in an air stewardess also highlights the potential of occupational exposure, although all secondary cases reported in this review were healthcare workers and no other secondary cases on flights were identified (5).

Two published reports(9,10) demonstrate a lack of secondary cases despite extensive contact tracing up to 21 days after the exposure (9). Both studies report high proportions of previously vaccinated passengers or passengers with natural immunity. In a survey described by Amornkul and others (9) only one passenger of 336 on board received immunoglobulin despite extensive efforts to contact trace.

Evidence of cost/resources required to contact trace

Two published papers detail the resources required to implement contact tracing (10,11). In one, the time to contact passengers following exposure on a flight was examined and it was noted where passengers were likely geographically dispersed and travelling from private residences, the mean time from exposure to contact could exceed 8 days (range 58 hours to 316) with only 2 individuals contacted within 72 hours, the optimal time period for vaccine administration (11).

In the second paper describing the public health actions following a case in a college in the US (2004), an estimated 2,525 hours of personnel time were expended on public health actions, including reviewing flight manifests, contacting the exposed passengers, setting up vaccination clinics and a free information line for the contact tracing (10). The total estimated cost for delivering such an intervention was $142,452 (10). Two secondary cases were identified, an unvaccinated close contact and a person who had previously had 2 doses of vaccine but sat next to the index case for 2 hours on a small plane prior to the flight being investigated.

Discussion

Risk of transmission

Review of the literature demonstrates that transmission of measles can occur through air travel, with risk of severe disease occurring if a vulnerable individual (an immunosuppressed individual, a pregnant woman or an infant) is exposed.

Secondary cases are likely to occur in susceptible individuals travelling on the same aeroplane or through contact in the airport prior to departure. The risk of transmission is not limited to those passengers in adjacent seats to the case – any passenger or crew member may be at risk of infection. Transmission to vaccinated individuals is unusual but not impossible.

Identifying and contacting passengers

The number of vulnerable passengers is difficult to estimate and such passengers are impossible to identify without an individual contact. PNR data is most likely to be useful in contacting passengers. These data is held by airlines and airlines are best placed to initiate contact with their passengers and crew.

The resources required to implement targeted contact tracing have been described as extensive and at high cost to public health agencies, often with little evidence of additional case ascertainment. Sending a mass email or text message to all potential exposed crew and passengers is a more feasible and resource-efficient approach.

Enabling timely intervention

If the objective is to provide timely prophylaxis, then interventions offered for contacts of cases of measles on planes should be in line with current UKHSA guidance. Human immunoglobulin is proven to be effective in high-risk groups if administered within the first 72 hours and potentially up to 6 days following exposure. However, experience of contract tracing has found this timescale sometimes difficult to achieve due to delays in identifying the index case and in the sharing of information.

If the objective is to detect secondary cases at an early stage. then we require tracing to be conducted within the incubation period (7 to 21 days). Experience suggests that this timescale is achievable.

Both of these objectives may be met by sending an email or text message to all potential exposed crew and passengers as again this serves not only to rapidly identify vulnerable groups but also to remind those who are unvaccinated to receive their MMR vaccine. Additionally, by rapidly contacting potentially exposed cases, public health authorities could provide appropriate health messages or interventions to prevent tertiary spread in the wider community.

Conclusion 

The airline should send a warn and inform text/email to all passengers and crew with a link to the UKHSA guidance on Information for passengers and crew on a flight with a case of infectious measles. If this cannot be arranged through the airline, the managing HPT should send using information obtained from the PLFs.

Appendix B: Adding travel-related contexts on CIMS

Flights and other travel should be added to CIMS under the ‘Travel and Contexts’ question package. For more detail on linking different travel-related contexts, please see below:

1. Regional Border Health contexts have been set up on CIMS to enable linking of all border health-related cases with a region. These can be found by searching ‘Border and Port Health’ or by using the region’s abbreviation, for example, SE, ‘(Region abbreviation) Border and Port Health’ under ‘Congregation’ for example in the South East, the context is ‘SE Border and Port Health’.

2. Ports of Entry: all airports, seaports and ground crossings have been added to CIMS as contexts and include the full name of the port, for example, Birmingham International Airport, Port of Liverpool, Channel Tunnel. Please speak to your regional border health lead if you can’t find a port.

3. Foreign travel: Travel to_Country/City/Town/Village (include as much information as know), for example, Travel to_Spain OR Travel to_Spain/Madrid or Travel to_Turkey/Antalya, OR Travel to_Turkey/Antalya/Belek.

4. Foreign settings: Name_Context type_City_Country_Pin or postcode, for example, Hilton Doubletree Hotel_Accommodation _Paris_France_123456.

5. Flights: Flight number_Airline_Origin to Destination_Date (DD/MM/YYYY), for example, Flight_AA123_ Easyjet_New York to Manchester_01/01/2018.

Recommendations on recording of travel on CIMS may change over time, so always refer to How Teams Use CIMS guidance and regional ART SOPs before adding all relevant travel-related contexts.

Appendix C: Reporting measles with international air travel

Please send the following information for each likely infectious measles case to the UK IHR National Focal Point (IHRNFP@ukhsa.gov.uk) and the national immunisation team (immunisation.lead@ukhsa.gov.uk) by email promptly. Please provide as much information as you can.

Case details

1. Case name

2. Case contact information (address, telephone, email)

3. Date of birth 

4. Onset of rash

5. Is the likely case microbiologically confirmed? (Please give test results and date where available)

6. Did the case undertake international travel during the infectious period (that is, 4 days before to 4 days after onset of rash)?

Departing flight (complete for each flight of multi-leg journeys)

7. Did the case travel on a flight departing from the UK during the infectious period?

8. Date of travel

9. Airline

10. Flight number

11. Start destination

12. End destination

13. Seat number of case if available

Arriving flight (complete for each flight of multi-leg journeys)

14. Did the case travel on a flight arriving to the UK during the infectious period?

15. Date of travel

16. Airline

17. Flight number

18. Start destination

19. End destination      

20. Seat number of case if available

21. Was travel confined to an endemic country? Y/N

If no, please complete questions 22 to 30, supplying details of accommodation and places visited abroad (2 weeks prior to rash onset to 4 days after) – if obtainable. Continue on a separate sheet as necessary.   

Country/accomodation details

22. Country

23. Name and address of accommodation

24. Date arrived 

25. Date departed

Contacts

26. Are there any other close contacts of the case overseas?

27. Name and address of close contact

28. Contact details of close contact (such as phone number or email address)

29. Is the close contact aware of their contact with a measles case?

30. Date of last exposure to the close contact

Appendix D: Sample ‘warn and inform’ letter/email to passengers or airline staff

1. Information for passengers and crew on a flight with a case of infectious measles

This information is only intended for people who have been informed by the UK Health Security Agency or an airline that they have flown on an aircraft (or other enclosed transport) with someone who had infectious measles in the last few days. If you have not been told this, then the contents of this [letter/email] do not apply to you, and you should contact your doctor or check the NHS information on measles if you have any queries about measles.

2. About measles

Measles is an infection that spreads very easily. Once symptoms start, people can become unwell quickly. If you’ve not been fully vaccinated (had 2 doses of the MMR vaccine) or haven’t had the infection before then you should watch out for signs and symptoms of measles, for the 21 days after the flight, and contact your GP if you are unwell.

At the end of this [letter/email], there is more information about measles – please read this to learn more about the symptoms of measles, how it spreads and about vaccination against measles. There is also further information available about measles at www.nhs.uk/conditions/measles.

3. Those who need medical advice

Some people may need to ask their doctor for advice as soon as possible:

People with a weak immune system

If you have a weakened immune system, you should contact your GP and tell them that you have been on the same [flight/other enclosed transport] as someone with infectious measles. Your doctor may want to do a test to find out if you are protected from measles, or give you treatment to reduce your risk of becoming unwell.

Pregnant women

If you are pregnant and think you may have missed a dose of the MMR vaccine, or are unsure if you have had the vaccine, contact your doctor or midwife and tell them that you may have been in contact with someone who has measles.

Children aged under 12 months old

If you were travelling with a child under 12 months old on the same [flight/other enclosed transport] as someone with infectious measles, please contact your GP for advice.

People who become unwell

You should speak to your GP or contact NHS 111 if you or your child get a high temperature with a cough, runny nose, sore red eyes or rash in the 3 weeks after taking the same [flight/other enclosed transport] as someone with infectious measles. You should try to call your GP or NHS 111 before visiting them in person. This is to avoid spreading measles to others. 

Take this information with you and tell your doctor that you may have been in contact with someone who has measles. Your doctor should seek advice from the local HPT. It can be difficult to know when to seek help if your child is unwell. If you are worried about your child, especially if they are aged under 2 years old, then you should seek medical help.

• People who have not had 2 doses of the MMR vaccine

If you are unsure if you or your child have had 2 doses of the MMR vaccine, which will protect you against measles, contact your GP to arrange vaccination. If you have missed a dose you can still be vaccinated at any age. Please see further information on the MMR vaccine in the UKHSA Measles factsheet.

If you are well and not in the groups listed above (that is, pregnant, child under 12 months, or have weakened immunity) you do not need to take any additional action.

4. When can you return to normal activities if you have measles

Someone who has measles can spread the infection in the 4 days before they get the rash. Once they have a rash, they can still spread the infection for another 4 days.

If someone is thought to have measles, they should stay away from their education or childcare setting, or work, for at least 4 days from when the rash first appears. They should also avoid close contact with children under 12 months, people who are pregnant and people with weakened immune systems.

Kind regards,

Author’s name

Position or title

Appendix E: Sample ‘warn and inform’ text to passengers or airline staff

Dear [name]

A person on flight XXX had measles. If you were also on this flight then you may be at risk of developing measles. Please read the information in this link about the action you need to take to protect yourself and others, and to find out more information about measles: www.gov.uk/government/publications/measles-public-health-response-to-infectious-cases-travelling-by-air/information-for-passengers-and-crew-on-a-flight-with-a-case-of-infectious-measles.

You can also find this information by searching online for UKHSA information for passengers and crew on a flight with a case of infectious measles.

References

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2. Amier RW, Bloch AB, Orenstein WA and others. ‘Imported Measles in the United States’ Journal of the American Medical Association 1982: volume 248, pages 2129 to 2133

3. Coleman KP and Markey PG. ‘Measles transmission in immunized and partially immunized air travellers’ Epidemiology and Infection 2010: volume 138, pages 1012 to 1015

4. de Barros FR, Danovaro-Holliday MC, Toscano C and others. ‘Measles transmission during commercial air travel in Brazil’ Journal of Clinical Virology 2006: volume 36, pages 235 to 236

5. van Binnendijk RS, Hahné S, Timen A and others. ‘Air travel as a risk factor for introduction of measles in a highly vaccinated population’ Vaccine 2008: volume 26, pages 5775 to 5777

6. Nic Lochlainn L, Mandal S, de Sousa R and others. ‘A unique measles B3 cluster in the United Kingdom and the Netherlands linked to air travel and transit at a large international airport, February to April 2014’ Eurosurveillance 2016: volume 21

7. Lim LL, Ho SA and O’Reilly M. ‘In-flight transmission of measles: Time to update the guidelines?’ American Journal of Infection Control 2016: volume 44, pages 958 to 959

8. ‘Interstate importation of measles following transmission in an airport – California, Washington, 1982’ CDC Morbidity and Mortality Weekly Report 1983: pages 401 to 403

9. Amornkul PN, Takahashi H, Bogard AK and others. ‘Low risk of measles transmission after exposure on an international airline flight’ Journal of Infectious Diseases 2004: volume 189, pages S81 to S85

10. Dayan GH, Ortega-Sánchez IR, LeBaron CW and others. ‘The cost of containing one case of measles: the economic impact on the public health infrastructure – Iowa, 2004’](https://publications.aap.org/pediatrics/article/116/1/e1/72918/The-Cost-of-Containing-One-Case-of-Measles-The) Pediatrics 2005: volume 116, pages: e1 to e4

11. Lasher LE, Ayers TL, Amornkul PN and others. ‘Contacting passengers after exposure to measles on an international flight: Implications for responding to new disease threats and bioterrorism’ Public Health Reports 2004: volume 119, pages: 458 to 463