EXECUTIVE SUMMARY

Measles was declared all but finished as recently as 2000. However, the disease has re-emerged in the wake of declines in the number of people receiving vaccinations against it. As of late March, 268 cases had been confirmed in the United States this year, with the largest outbreaks of the virus occurring in Clark County, WA, and Brooklyn, NY, mostly among children who have not been vaccinated. The disease is a significant concern for EDs because of the highly contagious nature of measles.

  • As of mid-March, the CDC reported several hundred cases of measles had been confirmed in more than a dozen states so far this year.
  • Since the current outbreak of measles began in October 2018, more than 200 cases have been confirmed in two New York City burroughs. In the state of Washington, more than 70 cases of measles have been confirmed since Jan. 1, with all but one case centralized to a single county.
  • The ED at PeaceHealth Southwest Medical Center in Vancouver, WA, is asking patients who think they may have measles to call ahead before coming to the ED, and then to wait in their cars when they arrive. A provider will assess the patient at his or her vehicle.
  • Providers are most concerned about the potential exposure of measles to vulnerable populations, including children younger than age 5, immune-compromised patients, and pregnant women who have not been vaccinated.

Measles, a disease thought to be eliminated in the United States as recently as 2000, is popping up across the country, driven in large measure by people who are reluctant to vaccinate themselves or their children against the virus. Public health authorities report they have confirmed more cases of measles in just the first two months of 2019 than they confirmed in all of 2017.

The CDC’s preliminary data reveal that as of March 21, there had been 314 individual cases of measles reported in 15 states in 2019. In areas that have reported especially high numbers, the CDC attributes that to “communities with pockets of unvaccinated people” and “an increase in the number of travelers who get measles abroad and bring it into the U.S.” (Editor’s Note: For more data about the measles outbreak, which the CDC updates weekly, visit: https://bit.ly/1hR3aN8.) The challenge for hospitals and EDs is the fact that measles is a highly virulent disease. Consequently, if a patient presents to an ED with the illness, the chances are high that other patients or visitors in the vicinity who are susceptible to measles will contract the illness. This means emergency personnel and other frontline providers not only need to recognize a disease that they might never have seen before, but also should be ready with precautions if a patient with a suspected case presents. Further, practitioners need to stay in close contact with appropriate public health authorities so that steps can be taken quickly to limit subsequent exposures.

Establish Procedures

As of March 27, there have been 214 confirmed cases of measles in Brooklyn and Queens, NY, since October 2018. EDs in the region are on heightened alert for any signs of the telltale rash and fever associated with the disease. (Editor’s Note: The New York City Department of Public Health and Mental Hygiene maintains its own database about measles outbreaks, along with plenty of other useful resources on this topic, all of which are available at: https://on.nyc.gov/2G5njWS.)

“Even if there is only a relatively low or moderate suspicion for possible measles, we want to get [the patient] out of the general population as quickly as possible in case we have patients otherwise in the ED who are potentially susceptible to this illness,” explains Eitan Dickman, MD, the vice chair in the department of emergency medicine at Maimonides Medical Center in Brooklyn. “There is an outbreak in the local community, staff is aware, and that is why we are attuned to these patients and getting them into isolation quickly.”

Indeed, just before Dickman spoke with ED Management on March 18, a woman with suspected measles presented to the ED. “She was noted in triage to have a fever as well as a rash ... the physician working in triage was quickly alerted to the case. The patient was rapidly moved into our isolation room so that we can do further testing,” he says.

The patient was an adult female and a member of the Orthodox Jewish community, which has experienced a high number of measles cases during the current outbreak. Most of these cases have involved children who have not been vaccinated against the disease. In this case, the woman indicated that she thought she had been vaccinated, but was not sure, Dickman explains. “In an abundance of caution, we did take the extra step of putting her in an isolation area.”

Since October, the ED at Maimonides has seen seven confirmed cases of measles. Some cases have involved patients who were exposed to the disease because of travel to other areas where measles is prevalent; others have contracted the illness from living in close quarters with people who have the disease. However, for many clinicians, this outbreak has been their first encounter with a measles case.

“Especially among the younger staff members, many of them have never seen a case of measles. We have done education, and we talk about it routinely at staff meetings,” Dickman shares. “We spend a lot of time [talking about] recognition of the classic appearance of the rash as well as recognizing that sometimes people may have the illness before the appearance of the rash.”

To make sure any cases of suspected measles are identified quickly, triage nurses ask patients routinely about whether they have a rash and check for fever. “Any time the triage nurse sees a patient with a rash and fever, that is an immediate indication to go get the attending physician to come and evaluate the patient,” Dickman notes. “Even an isolated rash [prompts triage nurses] to call over the attending physician to rapidly assess the patient.”

Throughout the outbreak, the hospital has been in contact with public health authorities, Dickman explains. “We interact with them any time there is a suspected case ... and they are very involved with the testing of the patient and then the follow-up coordination,” he says. “We are working very closely with the department of health to make sure that anyone who has been potentially exposed receives the necessary treatment.”

The hospital also works internally to make sure any people potentially exposed to the virus receive proper notification and care. For instance, in the case of the woman who had just presented to the ED with suspected measles, the next step involves confirming whether the patient has measles. “If testing is positive, then we will see if anyone needs to be notified about that exposure,” Dickman adds.

Employ Precautions

As part of employment at Maimonides Medical Center, staff members undergo blood tests to ensure their blood contains antibodies to measles, indicating that they have been vaccinated or have had measles already, making them immune to the disease. However, when the outbreak became apparent in the local community last year, the hospital double-checked the immune status of staff.

“I am not sure anyone required a booster shot, but the plan was if anyone did, they would be offered [the shot] through employee health,” Dickman says.

While measles is a rare occurrence, Dickman’s advice to other EDs is to review with staff how the disease typically presents and what procedures to follow in the event the disease is suspected in a patient.

“It is warranted to have some education for both the nursing staff and physicians on the appearance of the rash, the typical symptoms, and how the rash progresses from the head down to the rest of the body,” he says. “Provide all those things as a brief reminder to help refresh in people’s minds the idea that this is a very serious illness with potentially serious ramifications.”

Further, clinicians must understand that any patient who comes in with a rash and fever should be immediately evaluated by a physician for the characteristic signs of measles. “In addition, especially if a physician is not immediately available, place the patient in isolation until a further determination is made as to the etiology of the rash,” Dickman offers.

While most people will recover from a case of measles, some become very sick from the illness, Dickman adds. “One of the key things that stands out about measles is that up to 90% of people who are susceptible to the disease will become infected if they are exposed to the virus,” he says. “This is a very virulent virus, and even if someone is in a room two hours after a patient with measles has left the area, there is still the possibility that the person will contract the illness.”

Another hot spot for measles during the current outbreak is in Washington state where 74 cases were confirmed just between Jan. 1 and March 22. Health officials warn that this number is still rising. All but one of these cases occurred in Clark County, which is in the southwest part of the state, separated from Oregon to the south by the Columbia River.

Hospitals and EDs in the region have taken multiple steps to address the outbreak and answer community concerns about the virus. “It has had a pretty big impact administratively as well as on the doctors and nurses on the ground,” noted Jason Hanley, MD, medical director of the ED at PeaceHealth Southwest Medical Center in Vancouver, WA, during a Facebook live chat in February. “We moved pretty quickly with our infection prevention team to prepare the ED as well as our outpatient clinics to make sure we can keep our community safe, to not only care for the people who could possibly have measles, but also everybody else they could possibly expose to [the virus].”

In fact, the hospital is asking patients who think they may have measles not to come to the hospital; rather, these patients should call ahead and let the ED know they are on the way so staff can prepare. On arrival, Hanley noted that the ED will send a physician out to a patient’s car to perform an assessment.

“If there is any risk at all of it being measles, we will put a mask on the patient and bring [him or her] through a back door into a room that is safe and keep [the patient] away from all of the other patients in the waiting room,” Hanley explained. “Most concerning to us are vulnerable populations — children under 5, immune-compromised people, [such as] people with cancer or another medical problem, and pregnant women.”

Institute Protocols

Typically, the vaccine for measles is administered in two doses: one dose at age 1 and then a second dose at age 5. Hanley noted that children up to 6 months of age generally receive some protection from their mothers, so the most vulnerable period is between 6 months and 1 year of age.

“We want to protect those children with herd immunity. If enough of us are vaccinated against the disease, we won’t see it pop up in the community like we have seen here recently,” Hanley said.

To deal with the outbreak, the PeaceHealth ED has established some protocols for infants who have been exposed to measles. “If [the exposure] is within 72 hours, we can give the vaccination. Usually, we wait until 6 months of age to do that. We work with Clark County Public Health to make that decision,” Hanley said.

What if a child who has been exposed to measles has received one dose of the vaccine but is not yet old enough for the scheduled second dose? “We have a system where we look at how risky the exposure was and how at-risk the patient is,” Hanley explained. “If the exposure is significant and we see the patient within 72 hours [of the exposure], we may provide the second dose of vaccine earlier [than the scheduled time of age 5].”

Alternatively, Hanley noted if a child presents to the ED and it has been longer than 72 hours post-exposure to measles, providers may provide immunoglobulin instead.

Hanley related that he had seen a few cases of measles during his training. However, just like at Maimonides Medical Center in Brooklyn, many staffers have never seen measles.

“For our first case here about a month ago, one of our physicians grabbed as many nurses, nursing students, techs, and other physicians [as he could] and said to come look at the rash — a classic measles rash ... because it is so rare to see anymore,” he recalled.

Hanley stressed although while most people who contract measles will recover, it remains a dangerous disease. “One or two people out of 1,000 eventually die from measles,” he said, noting the disease can spread extremely quickly. “On the spectrum of diseases, it is very contagious. If you walked into a room [with measles], no one was vaccinated, and no one had been exposed to the disease before, nine out of 10 people would get measles.”

(Editor’s Note: For even more information about the measles outbreak in the United States, be sure to check out an article in the April issue of Hospital Infection Control & Prevention, available online at: https://bit.ly/2UaKcPa.)

SOURCES

  • Eitan Dickman, MD, Vice Chair, Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, NY. Email: edickman@maimonidesmed.org.
  • Jason Hanley, MD, Medical Director, Emergency Department, PeaceHealth Southwest Medical Center, Vancouver, WA. Phone: (360) 514-2142.

Authorities Blame Misinformation

Public health officials in Clark County, WA, lament the fact that the area is referred to as the epicenter of the current measles outbreak; this, for a disease that is entirely avoidable.

At issue is the fact vaccination rates need to be at 90-95% to prevent a measles outbreak. In Clark County, the rate is estimated to stand at just 78%, although some schools in the area have reported even lower rates.

Gov. Jay Inslee has declared a state of emergency in Washington, noting that vaccination rates in the Pacific Northwest are among the lowest in the nation. Washington is one of 17 states that enable parents to opt out of vaccinating their children for “philosophical” reasons.

Why are parents not vaccinating their children? For years, inaccurate information has circulated concerning a discredited 1998 study that linked the measles vaccine with autism. However, the inaccurate information persists despite the fact that the authors of subsequent reputable scientific studies have found no link between the measles/mumps/rubella (MMR) vaccine and autism.

Along with this misinformation, people lack an understanding about the seriousness of the measles virus. According to the CDC, before the measles vaccination program began in 1963, 3-4 million people contracted the illness in the United States each year, resulting in 400-500 deaths. Further, 48,000 people were hospitalized on an annual basis and 1,000 people developed encephalitis.

The CDC notes that widespread use of the vaccine resulted in a 99% reduction in measles cases. The agency also reports that the vaccine has a long record of safety and that adverse reactions are rare. Epidemiologists report that two doses of the MMR vaccine are 97% effective at preventing measles and one dose is about 93% effective at preventing the disease.

Complicating the issue for frontline providers is the fact that the earliest symptoms of measles are runny nose, cough, fever, and red or pink eyes — symptoms that are very similar to other illnesses. These symptoms may occur several days before the measles rash appears; nonetheless, patients are highly contagious during this period. As a result, people can be out in public spreading the disease without knowing that they have measles.

The CDC offers detailed information about the MMR vaccine that clinicians can share with patients: https://bit.ly/2Fz66lK. For clinicians who may be unfamiliar with measles, there is much more information from the CDC available at: https://bit.ly/2hudTre.