One case of measles leads to more than 1,000 exposures to HCWs and patients
‘This would not be a very interesting story if that was the end of it.’
There are accidents -- and then there is the docking of the Hindenburg.
There are maddening, laborious measles exposure incidents in hospitals, and then there is the epic disaster that unfolded in May 2014 at Inova Health System in Fairfax, VA. A cautionary tale on steroids, here is what can happen if you are not prepared to deal with a 3-year-old child from India admitted with upper respiratory symptoms.
“It was a Sunday afternoon around 3:00 and our on-call infection preventionist got a call that we had a confirmed case of measles in our children’s hospital,” said Dana Cole, MPH, CIC, an infection preventionist at Inova who described the incident recently in Nashville at the annual conference of the Association for Professionals in Infection Control and Epidemiology (APIC).1 “He was admitted [directly] to our pediatric surgical unit, so we were relieved he didn’t come through the ED.”
However, the first red light was already blinking about the timing of the call.
“He had been admitted to pediatric urgent care the Thursday prior to this phone call — so he had been in the hospital four days,” she said.
A pediatric infectious disease consult had been done, but the patient was put in droplet precautions, a step down from the airborne precautions warranted for measles. One confounder might have been that the child’s immunizations appeared up to date, but a rubeola IgM test was ordered as part of the differential diagnosis and the patient developed the classic rash on day three of admission. Again, infection prevention was not notified and the call that came in four days after the admission was a notification of confirmed measles by the health department.
“Another [factor] is that the Inova healthcare system does not currently require any proof of immunity or vaccination for vaccine preventable diseases with the exception of influenza,” Cole said, drawing a few gasps out of the APIC audience. “We didn’t hear about this patient until that Sunday afternoon phone call. So we had no clue what was going on.”
Damage control
Now completely in damage-control mode, Cole and colleagues assessed their options.
“We knew the patient had not been in an airborne isolation room because the physician ordered droplet, thinking that was sufficient,” she said. “It was already hospital day four. We looked at [CDC recommendations] and knew our exposed staff had to have proof of immunity or be restricted from work by the fifth day after exposure. So again it is a Sunday night and they had to be restricted starting Monday morning.”
The IPs immediately notified hospital administration, which formed a multidisciplinary response team that included employee health, nursing and physician leadership, infection prevention, lab, emergency management, and security.
“We also needed to look at our exposed patients because they would have to be placed on airborne precautions on day five after exposure if they did not have proof of immunity,” she said. “The healthcare department recommended that we find out if they had an oral history of measles, were born before 1957 or they had a history of [at least] one MMR vaccine.”
“Just as a side note, one of the things we learned were that different standards for proof of immunity were really confusing for our leaders that were trying to figure out if their staff and patients were exposed to measles,” she added. “They asked a lot of questions and it became really challenging for them, but we are also not sure if there is anything that we could have done to change that in a safe and practical way.”
Employee health and infection prevention personnel went to the hospital that Sunday afternoon after the call and began investigating possible staff and patient exposures in the pediatric unit.
“By the end of the evening we had evaluated all of these people and identified that we only had one nurse who needed to be restricted from duty until she could provide proof of immunity,” Cole said. “Four patients who were all immune suppressed required further follow-up and were placed on isolation. So at that point we were feeling pretty good about ourselves because we had gotten a lot done. But this would not be a very interesting story if that was the end of it.”
It gets worse
The measles patient was admitted to the pediatric surgical unit in Inova’s literal “original building,” which was constructed in the early 20th century as Fairfax Hospital.
“Later that [Sunday] evening our engineering department reviewing our HVAC system found that the [heating and air ventilation] for that unit circulated throughout the entire original building,” Cole said. “It’s called the original building for a reason and I’m pretty sure it’s held together with chewing gum and paper clips at this point. The [measles] patient room itself was actually slightly [air-flow] positive to the hallway and the air returns.”
That means measles virus, a notorious airborne spreader, could now have been moving through the various building departments with impunity for several days. It was time to call the state health department and the CDC. The decision made in consultation was to err on the side of caution and “consider everyone in the building who did more than just pass through as exposed to measles,” Cole said. “So our exposure just got a lot larger.”
Patients potentially exposed to measles included an inpatient psychiatric unit and a postpartum unit. “Diagnostics radiology was our big killer because they serve inpatients from all over the hospital as well as a huge outpatient population,” she said.
As their office was also in the original building, the infection prevention staff almost got caught up in the outbreak they were investigating. “Three of us almost got excluded from work because they couldn’t find our [immunization] records,” Cole said. “The cafeteria and engineering are also in this building so it became a huge exposure at this point.”
The emergency response team began divvying up tasks, with action items including evaluation of patients and staff for exposure and immune status, establishment of an emergency testing center for drawing titers, development of communication tools for patients and staff, and management of exposed staff and patients. On day seven the hospital implemented its Incident Command System to assist with the response.
A disaster by another name
“We didn’t call it an internal disaster, but we did use that structure to keep our tasks organized,” Cole said. “Infection prevention was managing all of our exposed inpatients with the assistance of nursing. The health department was wonderful and managed all of our exposed outpatients and discharged patients. Employee health managed all of our Inova employees while IPs managed all our licensed independent practitioners [LIPs] and contract employees.”
The hospital communication department developed all needed messaging for staff, visitors, and patients and set up a hotline to help LIPs determine if they were exposed and what they needed to do in order to come back to work. Lab and engineering teamed up to set up some emergency testing centers in large tents for employees, LIPs and contractors, and others that needed titers drawn, increasing testing at one point from three times a week to three times a day.
“Ultimately 362 patients were exposed — 71 inpatients and 291 outpatients,” Cole said. “Of those, 20 required further follow-up and had titers done and placed in isolation. We were fortunate to have enough airborne isolation rooms to accommodate them. Hundreds upon hundreds of staff, LIPs, and contractors were exposed. Overall, 754 people had to have rubeola titers drawn, and given the timing they all had to be restricted from work until we could get the results back — which made people very unhappy. Fortunately, 93% of them demonstrated immunity to measles.”
However, 6% (47 people) had to be completely restricted from duty until day 21 after exposure, while 10 people had to wait and get tests redone because their results were unclear. And, thankfully, neither patients nor staff developed measles. Not one single case.
“We kind of think there was an element of pure dumb luck involved in that,” Cole said.
Among the “hard lessons learned” were poor communications exact a severe toll.
“If we had gotten that one phone call [sooner] we still would have had exposures but it would have been a lot fewer, and we would have had a lot more preparation time to put our response plan together,” Cole says. “The volume of exposures was just crazy. Ultimately, well over 1,000 people were exposed. If we had requirements in place for staff and physician vaccinations and proof of immunity it would have saved a lot — 750 [of them] were kept out of work.”
Though much of the response was positive teamwork, the test results came back only as a name with no job identifiers, so there was more labor needed to connect the dots of possible exposures.
“Recordkeeping was an absolute disaster,” she said. “We got stacks of paper on a daily basis and tried to figure out what to do with them. Our employee health department was in the process of trying to upgrade their system, but what they had right then was not set up to be able to do reporting or easy searches.”
Contact your staff — today
“Communication is key,” Cole said. “So please make sure that your staff know how and when to get in touch with you. Don’t assume that they know. Refresh their memories periodically. Standardize recordkeeping and dissemination — having it come from one place. Implement policies for proof of immunity. That is something that we are actually doing now. We got a little waylaid by Ebola, but our new policies are moving through our med-exec committees as we speak. Hopefully they will be passed by the end of the year, but it would have made a huge difference in the work that we had to do.”
Things that went well in the massive response included the strong support of hospital leadership. “If we needed to have it happen, it happened,” she said. Assistance came through in the form of hotline staffing by employees from sister facilities, and the health department took a very active role that was both supportive and helped coordinate the overall response.
“We were also fortunate enough to use this as an exercise for emergency management, so that met our Joint Commission requirements for the year and made our emergency manager very happy,” she concluded. “As a quick epilogue, about six weeks ago we had another [measles] patient come through our ED and everything went so much better. The patient was isolated quickly. There was a lot of communication between the ED, the [admitting] unit, and our ourselves.”
As Cole concluded her presentation at APIC, Hospital Employee Health did manage to get in one quick but critical question: How much did it cost? Cole said she didn’t know, but it had to be in the “tens of thousands of dollars.”
We respectfully submit that it may have actually been quite a bit more, which makes it all the more frustrating when hospitals lag on preventive measures because they don’t generate revenue. Previous investigations of measles introductions and follow-ups have tallied staggering sums, and the scale of the Inova situation would likely put it in that category. For example, a single imported case of measles ultimately cost two Arizona hospitals some $800,000, with much of the expense related to ensuring the immunity of employees and furloughing workers.2
REFERENCES
- Cole D, Peninger M, Singh S, et al. Measles Emergency Response: Lessons Learned from a Measles Exposure in an 800-bed Facility. Presentation Number 021. APIC Conference. Nashville, TN. June 27-29, 2015.
- Chen SY, Anderson S, Kutty PK, et al. Healthcare–associated measles outbreak in the United States after an importation: Challenges and economic impact. J Infect Dis 2011; 203: 1517-1525.
There are maddening, laborious measles exposure incidents in hospitals, and then there is the epic disaster that unfolded in May 2014 at Inova Health System in Fairfax, VA.
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