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CDC updates guidelines for measles, rubella vaccines

CDC updates guidelines for measles, rubella vaccines

All people who work in health care facilities should have evidence of measles and rubella immunity, the Centers for Disease Control and Prevention emphasizes in revised guidelines by its Advisory Committee on Immunization Practices.1 Updating 1989 and 1990 guidelines, the CDC also clarified the role of serologic screening to determine measles immunity and revised the criteria for determining acceptable evidence of rubella immunity.

Though measles has been marked by a general decline in incidence in the United States since 1991, 15 of the 75 measles outbreaks reported during 1993-1996 involved nosocomial transmission in a medical facility. A total of 36 measles cases (1.8% of all reported cases) during that period occurred among health care workers, who are at increased risk of acquisition once the virus has been introduced into a community. Although similar surveillance data are not available for rubella, outbreaks have occurred in health care settings, and health care workers have transmitted rubella to patients, the guidelines state.

"Health care workers have a responsibility to avoid transmitting these diseases and thereby causing harm to patients," the CDC emphasized.

Birth before 1957 generally acceptable

Adequate vaccination for health care workers born during or after 1957 consists of two doses of a live measles-containing vaccine and at least one dose of a live rubella-containing vaccine. Health care workers who need a second dose of measles-containing vaccine should be revaccinated one month (at least 28 days) after their first dose. Although birth before 1957 is generally considered acceptable evidence of measles and rubella immunity, health care facilities should consider recommending a dose of measles-mumps-rubella (MMR) vaccine to unvaccinated workers born before 1957 who do not have a history of physician-diagnosed measles or laboratory evidence of measles immunity and laboratory evidence of rubella immunity.

If a measles outbreak occurs within a health-care facility or in the areas served by the facility, all people working at the facility who cannot provide documentation of two doses of measles-containing vaccine (separated by at least 28 days with the first dose administered on or after the first birthday) or who do not have other evidence of measles immunity should receive a dose of MMR vaccine. If indicated, health care workers born during or after 1957 should receive a second dose of MMR vaccine at least 28 days after the previous dose. Some health care workers born before 1957 have acquired measles in health care facilities and have transmitted the disease to patients or coworkers. Therefore, during outbreaks, health care facilities also should strongly consider recommending a dose of MMR vaccine to unvaccinated health care workers born before 1957 who do not have serologic evidence of immunity or a history of measles disease.

"Serologic testing of health care workers before vaccination is not generally recommended during an outbreak because arresting measles transmission requires rapid vaccination of susceptible health care workers," the CDC clarified. "The need to screen, wait for results, and then contact and vaccinate susceptible persons can impede the rapid vaccination needed to curb the outbreak."

Susceptible health care workers exposed to measles should receive a dose of MMR vaccine and should be removed from all patient contact and excluded from the facility from the fifth to the 21st day after the exposure. They may return to work on the 22nd day after exposure. However, susceptible health care workers who are not vaccinated after exposure should be removed from all patient contact and excluded from the facility from the fifth day after their first exposure to the 21st day after the last exposure, even if they receive postexposure immune globulin. Workers who become ill with prodromal symptoms or rash should be removed from all patient contact and immediately excluded from the facility until four days after the onset of their rash.

During rubella outbreaks in health care settings where pregnant women may be exposed, mandatory exclusion and vaccination of health care workers who lack evidence of rubella immunity should be practiced. Exposed health care workers who lack evidence of immunity should be excluded from duty from the seventh day after first exposure through the twenty-first day after their last exposure or until 5 days after the rash appears.

"In addition, because birth before 1957 does not guarantee rubella immunity, health care facilities should strongly consider recommending a dose of MMR vaccine to unvaccinated health-care workers born before 1957 who do not have serologic evidence of immunity," the CDC stated.

Vaccination disrupts work less than infection

Although rubella vaccination during an outbreak has not been associated with substantial personnel absenteeism, vaccination of susceptible people before an outbreak occurs is preferable because vaccination causes far less absenteeism and disruption of routine work activities than does rubella infection.

In addition to measles and rubella, the CDC reminded that sporadic nosocomial cases of mumps have occurred in long-term care facilities housing adolescents and young adults. However, mumps virus is less transmissible than measles and other respiratory viruses, and the low level of mumps transmission in the community results in a low risk for introduction of the disease into health care facilities.

"Because mumps is shed by infected persons before clinical symptoms become evident and because infected persons often remain asymptomatic, an effective routine MMR vaccination program for health care workers is the best approach to prevent nosocomial transmission," the CDC noted.

If exposed to mumps, health care workers who lack acceptable evidence of immunity should be excluded from the health care facility from the 12th day after the first exposure through the 26th day after the last exposure. Workers in whom the disease develops should be excluded from work until nine days after the onset of symptoms.

Reference

1. Centers for Disease Control and Prevention. Measles, mumps, and rubella - vaccine use and strategies for elimination of measles, rubella, and congenital rubella syndrome and control of mumps: Recommendations of the advisory committee on immunization practices. MMWR 1998; 47(No. RR-8):1-57.