Amid what could well be another annual record for measles in the post-vaccination era by the end of 2015, employee health professionals must ensure that staff are immunized to avoid the chaos that can ensue when a single undiagnosed case enters a hospital.
“It has become clear that we are in the midst of a larger, very disturbing trend,” the Pediatric Infectious Diseases Society said in a recent statement on the situation. “Despite the fact that measles was eradicated from the United States 15 years ago, this country had 644 measles cases in 2014, more than in any year since 1994. 2015 is now on pace to well exceed that number.”
There is little doubt that some of the infections and outbreaks can be traced to the influence of a high profile anti-vaccine movement that cites discredited research in falsely linking the MMR (measles-mumps-rubella) vaccine to autism. “It is a tragedy that some parents, often because of misinformation they may have received from friends, colleagues, or the Internet, are putting their children and others in harm’s way by refusing to vaccinate,” the Pediatric ID group said.
From January 1 to March 20, 2015, 178 people from 17 states and the District of Columbia were reported to have measles, the Centers for Disease Control and Prevention reports. Most of these cases -- 131 (74%) -- are part of a large, ongoing multi-state outbreak linked to Disney Land in Anaheim, CA.
The current situation is characterized by the volatile combination of pockets of non-immunized populations and travelers coming into the country from areas where measles is much more common. Given measles legendary transmission ability, a measles case reaching these non-vaccinated groups is like throwing a lit match on gasoline.
As a result health care facilities must be vigilant for measles introductions, with employee health ensuring that all workers have presumptive evidence of immunity, the CDC recommends.1 This information should be documented and readily available at the facility. Recently vaccinated health care workers do not require any restriction in their work activities. According to the CDC, presumptive evidence of immunity to measles for persons who work in health-care facilities includes any of the following:
- written documentation of vaccination with 2 doses of live measles or MMR vaccine administered at least 28 days apart
- laboratory evidence of immunity
- laboratory confirmation of disease
- birth before 1957.
If this information is not readily available, a measles case can set off a laborious and expensive follow-up of exposed patients and health care workers. For example, a single imported case of measles once cost two Arizona hospitals some $800,000, with much of the expense related to ensuring the immunity of employees and furloughing workers.2
Because of the greater opportunity for exposure, health care workers are at much higher risk than the general population for becoming infected with measles. During 2001–2008, in the 23 health-care settings in which measles transmission was reported, eight cases occurred among health care workers, six of whom were unvaccinated or had unknown vaccination status, the CDC reports. One health-care provider was hospitalized in an intensive care unit for 6 days from severe measles complications.
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, measles has been added to the 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],” she says. “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.”
A history of international travel should raise a red flag in a patient presenting with the common measles symptoms of fever and rash, says Carl Schultz, MD, FACEP, a professor of clinical emergency medicine at the University of California at Irvine Medical Center.
“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],” he says. “So if a U.S. citizen goes abroad and then returns to the U.S. with an infection, a fever, and a rash, or someone from another country comes to the U.S. with a fever and rash, that would be the time to consider measles.”
The hospital is at the epicenter of the current measles outbreak, and has taken several steps to detect and prevent transmission to staff and patients, says Kristi Koenig, MD, FACEP, FIFEM, a professor of emergency medicine at the UC Irvine Medical Center in Orange, CA.
The emergency department has put up signs directing patients who have a rash and other common 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.”
Indeed, many health care workers may not recognize the classic childhood infection. “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 prevention efforts is the fact that patients with measles can be symptomatic before the rash appears. Measles is an airborne virus infamous for its ability to spread.
“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.”
- CDC. Measles: http://1.usa.gov/1CfIIhG
- Chen SY, et al. Health care-associated measles outbreak in the United States after an importation: challenges and economic impact. J Infect Dis 2011;203:1517–25.