Measles, a disease that public health officials declared gone from the United States more than a decade ago, is now clearly back. And it is yet another infectious disease that frontline health care personnel need to spot quickly to prevent potential transmissions to unvaccinated and immunocompromised patients.
As of February 20, the Centers for Disease Control (CDC) in Atlanta, GA, reported that at least 154 people in 17 states were confirmed to have measles, and that at least 118 of these cases were associated with a large, multi-state outbreak that started in December 2014 at an amusement park in southern California. Two other unrelated outbreaks of measles were reported: one in Nevada and the other in Illinois. In total, more than 600 confirmed cases of measles were reported in 2014.
With EDs already on alert for potential cases of Ebola, many experts say that cases of measles shouldn’t be that difficult to pick up, but the disease does present some significant challenges, according to Kristi L. Koenig, MD, FACEP, FIFEM, director of the Center for Disaster Medical Sciences and a professor of emergency medicine at the University of California at Irvine, CA.
First, since the live vaccine for measles was licensed in 1963, a high percentage of health care providers have never encountered a measles case, so recognition can be an issue. “Measles can mimic other childhood rashes or rashes of any sort … so it is not necessarily something we would think of unless there is awareness,” says Koenig. “Measles starts on the head and the face and moves downward, as opposed to some other rashes that might start on the torso or the lower extremities and move upward.”
Further complicating recognition is the fact that patients with measles can be symptomatic before the rash appears. “If you are not thinking about measles and asking whether there has been an exposure or about the patient’s immunization status, you might just think someone has a bread-and-butter viral syndrome … like an upper respiratory syndrome,” says Koenig.
She adds that the measles virus is airborne and, thus, spreads from person to person very easily. “It is probably the most contagious disease we know,” says Koenig. “Nine out of 10 people [exposed to the virus] would get it if they are susceptible, and [the virus] can live on surfaces [or in the air] for up to two hours after a [measles] patient has left the room.”
While it is impossible for emergency providers to always be on the outlook for everything, they still need to have some sense of when measles should be considered, according to Carl Schultz, MD, FACEP, a professor of clinical emergency medicine and the director of Disaster Medical Services in the Department of Emergency Medicine at the University of California at Irvine Medical Center. A history of foreign travel can be a strong clue, he says.
“The spark that usually starts these [measles outbreaks] rolling is somebody from outside the country because measles is much less controlled outside [the United States], so if a U.S. citizen goes abroad and then returns to the United States with an infection, a fever, and a rash, or someone from another country comes to the United States with a fever and rash, that would be the time to consider measles,” says Schultz.
Protect providers, emergency staff
The ED at UC Irvine Medical Center in Orange, CA, has seen at least one confirmed case of measles from this year’s outbreak, and it also saw several cases from a smaller measles outbreak that occurred last year, says Koenig. “We are at the epicenter of the measles epidemic,” she says. “We are the only level one trauma center in the county … and we also have a lot of foreign visitors who may not be up to date on their immunizations, particularly from Mexico, but we also see people from all over the world visiting the Disneyland [theme park].”
Given the contagiousness of the measles virus, the ED has put up signage directing patients who have a rash and certain other symptoms to use an alternate entryway rather that coming in through the main triage area where everybody else enters.
“We have tried to get people to self-isolate if they are ill with concerning symptoms until somebody is able to evaluate them,” says Koenig. “Then the person on the front lines doing the evaluation needs to have that awareness as well.”
To improve this awareness, Koenig has proposed a concept she refers to as vital sign zero, a measure she suggests should come before the traditional vital signs of blood pressure, heart rate, respiratory rate, and temperature.1 “What I am saying is before you even go near a patient to measure those standard vital signs, you have to consider what I term ‘vital sign zero’ to make sure [the patient] is not a hazard or a threat, and that they don’t have something that could be contagious, and that you could catch as a health care provider and spread to other patients in your waiting area,” she says.
In cases in which patients may be contagious, such as is the case with measles or Ebola, Koenig has developed a construct: identify, isolate, and inform.2 Specifically, once the clinician has identified that the patient may be contagious, the next step is to isolate the patient with respiratory protection such as an N-95 respirator. When the provider has confirmed or has high suspicion, he or she needs to inform both public health authorities and the hospital’s infection control department.
The approach should not just apply to measles and Ebola, but other infectious disease threats as well, stresses Koenig. “There are many more of these emerging infectious diseases coming along,” she says. “Measles is something that is known and recurring, but there are new things all the time like SARS [severe acute respiratory syndrome] and MERS [Middle East respiratory syndrome] and whatever the next big thing is going to be.”
Bolster screening, education
One of the first steps clinical leaders at the University of Chicago Medicine Comer Children’s Hospital in Chicago, IL, took upon being notified of a measles outbreak in the region was to check to make sure all frontline personnel and ED staff were protected from the virus.
“Our occupational medicine folks went back and double checked all of the records of everyone who works in our adult and pediatric EDs and all of the rest of our pediatric providers, to verify that we did have documentation [showing that all staff were immune to the virus],” explains Allison Bartlett, MD, MS, an assistant professor of pediatrics and the associate medical director for the Infection Control Program at Comer Children’s Hospital. “That is a reassuring thing from a staff standpoint.”
In addition to these steps, infection control specialists have bolstered telephone screening procedures for patients calling into the health system’s outpatient clinic. “Our appointment schedulers, who routinely ask Ebola travel-related questions, have added a couple of questions about fever, cough, runny nose, rash, and red eyes,” says Bartlett. “If they get some positive answers to those questions, we are referring the call to a clinic nurse to do an additional round of screening.”
If the clinic nurse suspects that any of these patients have measles, she will guide them toward the ED rather than a clinic appointment. “The [outpatient clinic] is less equipped to handle [measles cases] … so unless we become overwhelmed, our plan is to have these patients seen in the ED where we have a negative pressure room, and we can have better control over the situation for evaluating them,” explains Bartlett.
Infection control specialists have also taken steps to insure that the ED is prepared to recognize and treat any measles cases. “We already have a robust screening in place for our ongoing Ebola patients, so we have added some additional screening questions that are educational in and of themselves,” says Bartlett. “We have provided education to the frontline nursing staff that will be screening the patients, and we have discussed this [information] with our physicians as well.”
Infection control staff have distributed a screening tool and pictures of patients with measles to better familiarize emergency personnel with how measles can present, says Bartlett. “As we get additional information, we are sharing that with clinicians,” she says.
At press time, the ED at Comer Children’s Hospital had not yet seen any cases of measles associated with the current outbreak, although one patient was evaluated as a possible case of measles.
However, Bartlett notes there is particular concern about certain groups of patients who are most at risk for the disease.
“We have seen many cases in infants who are between 6 and 12 months of age,” she says. “Infants who are younger than 6 months old generally have protective immunity left from their mother, which is why the youngest infants are not at risk, so it is that 6- to 12-month time frame of infants that are too young to be vaccinated, according to our standard schedule, who are at risk.”
The other populations at risk include school-aged children who never received the measles vaccine, immunocompromised patients, such as young people with cancer, adults who only received one dose of the measles vaccine, and some older adults with less robust immune systems, explains Bartlett.
Consider potential complications
In addition to being able to quickly identify measles cases, emergency providers also need to determine which patients need to be admitted and which patients can be safely discharged, explains Koenig. Factors to consider include whether the patient is well nourished, not living in poverty, and whether the patient is vitamin A deficient. “Vitamin A seems to be very important in the body’s [ability] to fight measles, and it is commonly administered in refugee camps where people are very deficient,” explains Koenig.
It is also important to rule out any serious complications. For example, measles can cause respiratory complications such as measles-pneumonia or neurologic problems; the disease can also cause otitis media, which can lead to deafness in some cases, explains Koenig. However, if there are no serious complications or concerning deficiencies, a discharge with appropriate supportive care instructions and follow-up may be the best course of action, she says.
“The vast majority of people [with measles] are going to do OK, and you don’t necessarily need to admit them,” says Koenig. Given the highly contagious nature of measles, you don’t want otherwise healthy patients with the disease to be in a position in which they can potentially expose immunecompromised patients or others who may be at risk for the disease, she explains.
While most healthy patients will recover and do well following a case of measles, Koenig is nonetheless worried about the potential of the current outbreaks to expand. “My sense is that we need to pay really close attention to this,” she says. “I have been, and continue to be, very concerned. It is hard to predict [how many cases the current outbreak will produce], but, of course, the better we are at contract tracking, the better able we will be to control it, but resources are very thin.”
In particular, Koenig is worried about the ability of public health departments to respond quickly. “We are supposed to have 24/7 contact-ability … but they are stretched so thin that it can be very difficult to reach someone in a timely manner when you are in the middle of managing multiple emergency patients,” she observes. “If this heats up more, [resources] are going to get stretched even thinner because our public health system is just not that robust in the country right now. It is underfunded.”
Editor’s note: For more information about the emergency response to the measles outbreak, visit the CDC’s information page for health care providers at http://www.cdc.gov/measles/hcp/index.html. Also see the American College of Emergency Physicians’ information on measles at http://www.acep.org/measles/.
• Allison Bartlett, MD, MS, Assistant Professor, Pediatrics, and Associate Medical Director, Infection Control Program, University of Chicago Medicine Comer Children’s Hospital, Chicago, IL. E-mail: [email protected].
• Kristi L. Koenig, MD, FACEP, FIFEM, Director, Center for Disaster Medical Sciences, and Professor of Emergency Medicine, University of California, Irvine, CA. E-mail: [email protected].
• Carl Schultz, MD, FACEP, Professor of Clinical Emergency Medicine, and Director, Disaster Medical Services, Department of Emergency Medicine, University of California, Irvine, CA. E-mail: [email protected].
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Koenig KL. Ebola Triage screening and public health: The new “vital sign zero.” Disaster Medicine and Public Health Preparedness 2014; DOI: http://dx.doi.org/10.1017/dmp.2014.120 .
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Koenig KL. Identify, isolate, inform: A 3-pronged approach to management of public health emergencies. Disaster Medicine and Public Health Preparedness 2014; DOI: http://dx.doi.org/10.1017/dmp.2014.125.
