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Cost a factor in checking HCWs measles immunity
CDC draft tightens proof of immunity
Cost considerations may stymie an effort to make sure that all hospital employees are immune to measles, mumps, and rubella (MMR).
The Centers for Disease Control and Prevention is drafting a new recommendation that would tighten the criteria for measles immunity in health care workers. Under the proposal, only documentation of MMR vaccination or laboratory evidence of immunity would be considered evidence of immunity. That would eliminate documentation of physician-diagnosed disease and a birth date before 1957 as evidence of immunity.
"High standards of immunity to measles, mumps, and rubella are appropriate for health care personnel," said Amy Parker, MSN, MPH, an epidemiologist in CDC's Division of Viral Diseases, in a presentation to the Healthcare Infection Control Practices Advisory Committee (HICPAC), an advisory board to CDC. "Health care personnel have a duty to protect themselves and their patients from diseases preventable by vaccine. The current permissive recommendations are confusing."
A rash of outbreaks
CDC also is responding to a spike in measles outbreaks. In 2008, there were 140 cases of measles, representing transmission from imported cases. (While there is no endemic measles in the United States, outbreaks are triggered by travelers from other countries.)
From 2001 to 2008, there were 27 reported cases of measles that were transmitted in health care settings, CDC says. The largest and most troublesome case occurred in Tucson, AZ, in 2008, when a Swiss traveler spread measles to another patient in the emergency department, a woman with a weakened immune system. That woman spread it to four other people in the hospital, including a health care worker. The health care worker spread it to several people, including a patient.
In all, 14 cases were linked to nosocomial spread. The hospital had to review the documentation of immunity for about 2,000 health care workers and provide emergency serology and vaccination of 400 employees. The hospital also conducted about 4,000 other contact investigations. The total cost exceeded $400,000, according to CDC.
However, members of HICPAC expressed reluctance to draft new policy based on an anecdote, however compelling.
"There were 27 cases over an eight- or 10-year period, which is a small number of cases," said HICPAC member William Schecter, MD, a professor of clinical surgery at the University of California, San Francisco and a surgeon at San Francisco General Hospital. "It sounds like the amount of benefit that's going to accrue isn't that great. I'm not sure whether this will be a cost-effective policy or not."
A matter of money
An informal online survey of 35 occupational health professionals found that 10 hospitals (29%) conducted either serologic testing or vaccination of all employees, regardless of age. Another eight (23%) facilities conducted screening or vaccination on all new employees.
However, in California, a survey of 56 hospitals found that almost all (93%) report screening employees for measles regardless of age - although that is primarily conducted among new employees.
"I think it would be useful to have a better handle on how expensive an undertaking this is. Hospitals don't have a lot of extra money right now," said Mark Russi, MD, director of occupational health at Yale-New Haven (CT) Hospital and associate professor of medicine and public health at the Yale University School of Medicine. Russi is the liaison for the American College of Occupational and Environmental Medicine (ACOEM) to HICPAC.
Jane Seward, MD, MPH, deputy director of CDC's Division of Viral Diseases, noted that hospitals must verify health care worker immunity in the event of an outbreak - and that process can be very disruptive.
"We don't know what will happen to measles in the next five to 10 years," she said. "We're worried about the undervaccinated and exemptors [and the potential for greater measles transmission]."
HICPAC and the Advisory Committee on Immunization Practices, another CDC advisory panel, are scheduled to vote on the proposal in June.