Measles outbreak lesson: Check HCW immunity
Measles outbreak lesson: Check HCW immunity
Hospitals sifted through records, furloughed HCWs
The Swiss tourist with pneumonia who came to the emergency department in a Tucson, AZ, hospital didn't seem like an unusual case. And yet her story would unfold into a cautionary tale for hospitals about why they should be on guard for cases of measles and why they need accessible records on the immune status of employees.
In the ED, no one suspected measles as the underlying cause of her pneumonia, although it is a common complication of the disease, says Rebecca Sonenshine, MD, deputy state epidemiologist, based in Phoenix.
"Up to 30% of people can have a complication from measles. The most common one is pneumonia," she says. "More serious complications include seizures, encephalitis and death. Pneumonia is the most common cause of death. It can be very severe pneumonia."
Measles is highly contagious, and the patient exposed patients and health care workers in the ED and on the floor until she was put in isolation. Ultimately, an outbreak with 21 cases was linked to the Swiss traveler. One of them was a health care worker.
Because there was inadequate documentation of the measles immune status of health care workers, the hospital needed to conduct a massive immunization.
"What was missing was this awareness that measles is on the rise around the world," says Sonenshine. "The more outbreaks there are in the world, the more likely we are to have an introduction in the United States. All the outbreaks in the U.S. have been from travelers from other countries.
"We've really raised physicians' awareness of this disease" in Arizona, she says.
That awareness needs to spread across the country, says Jane Seward, MD, MPH, deputy director of CDC's Division of Viral Diseases. "It was horrifying how poorly the hospitals had documented evidence of [measles] immunity," she says.
Vaccinate HCWs born before 1957
The Advisory Committee on Immunization Practices, a federal panel that makes recommendations and drafts guidelines for the Centers for Disease Control and Prevention, is considering a change related to proof of measles immunity for health care workers. Even health care workers born before 1957 should have at least one immunization, unless they have a documented history of measles infection, says Seward. Under current recommendations, hospitals would need to provide that extra dose of vaccine during an outbreak.
"We know that about 5% of [those born before 1957] are actually not immune to measles and did not have the disease," says Sonenshine. "If you have a health care worker who could potentially expose a lot of patients and other workers, a 5% error is not [acceptable]."
In fact, Sonenshine recommends that all health care workers born before 1957 have two doses of vaccine, which is the current dosage schedule for children and newly hired health care workers. CDC defined a health care worker as "any person (medical or nonmedical, paid or volunteer, full or part time, student or nonstudent, with or without patient care responsibilities) who works at a facility that provides health care to patients."
However, hospitals in Pima County, AZ, had difficulty producing the documentation. For example, hospitals had not gathered documentation on physicians, who were actually employees of medical groups. As a result of the outbreak, the hospitals collectively agreed they would all require physicians to show documentation of immunity to measles to have privileges, says Sonenshine.
"They all shared responsibility for making sure that people were immunized," she says.
Hospitals also suffered if they didn't have electronic records. "Sifting through 5,000 paper records to figure out who has documented immunity to measles is not feasible," she says. "We ran into a lot of cases where they didn't have a database to search. They didn't have time to look through all the records, so they just vaccinated everyone whether they had shown proof or not."
Health care workers who were exposed to the measles but who did not have proof of immunity were required to be on furlough for 21 days.
How an outbreak spread
Measles is highly contagious and is easily spread to immune-suppressed or unvaccinated people. The Swiss traveler spread measles to another patient in the ED, 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.
To control the outbreak, the hospital began active surveillance placing every patient in isolation if they had rash and a fever, until it could be determined whether or not they had measles. A sign posted outside the hospital asked entering patients to wear a mask if they had fever and a rash.
Meanwhile, other small outbreaks were ongoing in other parts of the country. In fact, this year there were more measles cases reported than in any year since 2001.
There have been about 500 cases of measles in the United States since 2000, when endemic measles was declared eliminated. Two of those people died, Sonenshine reports.
The Swiss tourist with pneumonia who came to the emergency department in a Tucson, AZ, hospital didn't seem like an unusual case. And yet her story would unfold into a cautionary tale for hospitals about why they should be on guard for cases of measles - and why they need accessible records on the immune status of employees.Subscribe Now for Access
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