The United States is currently in the midst of a measles outbreak that has challenged response efforts. From January 1 through July 25, 2019, there have been 1164 cases of measles across 30 states. The US Centers for Disease Control and Prevention (CDC) has reported
that this is the greatest number of cases we’ve seen in since 1992.
Perhaps one of the most challenging aspects of this outbreak from a health care perspective is preparation. Although some may not consider this to be a concern, between 2001-2014, 6% of US measles cases (that were not imported) were transmitted within a health care setting. Sadly, I experienced this firsthand during a 2015 exposure at the health care facility
I worked at, in which a health care worker was exposed to the virus while treating a patient and subsequently became infected. As a result of the health care worker’s infection, 380 individuals were exposed and the response efforts were extensive and significantly disruptive to the daily infection prevention duties. Due to the fact that hospitals can easily act as amplifiers for airborne diseases like measles, the CDC has provided interim infection prevention and control recommendations
for measles in health care settings.
At its core, this guidance focuses on health aspects of both the employee and the patient. For health workers, it is critical to ensure presumptive evidence of immunity to measles and manage exposed/ill health care workers properly. On the patient side, rapid identification and isolation of known or suspected cases and proper isolation maintenance is critical.
The guidelines provide considerable information for health care facilities in their efforts to prepare for and manage patients with suspected or confirmed measles infection, and range from strategies to minimize potential exposures to tips to ensure management of exposures is handled appropriately. To reduce the risk of large-scale exposures, the CDC encourages staff to ensure patients have immediate access to masks in triage and to use a mask as soon as they walk into the facility. If you’re lucky enough to get a heads up (ie, a patient is transferred or calls to let you know), it’s helpful to meet them outside and provide a mask prior to even walking into the building.
Rapid isolation and adherence to the proper precautions is critical. Patients under investigation for measles should wear a mask until they can be placed into a negative pressure room (also known as an airborne infection isolation room) and proper airborne and standard precautions can be used. Health care workers should use a N95 mask or higher respirator when caring for the patient. Those without acceptable presumptive evidence of measles immunity should not be involved in the care of the patient and, therefore, should not enter the room, meaning that even if you’re vaccinated and/or have evidence of immunity, you’re still required to wear a N95 mask when in the patient’s room.
Patients should remain in airborne/standard precautions for 4 days after the onset of the rash, but if the patient is immunocompromised, they should remain in isolation for the duration of illness. Once the patient is discharged, the room should remain vacated for 2 hours to allow for enough air exchanges to occur and for removal of the airborne organisms.
Lastly, if you’re managing an exposure, the CDC notes that for those health care workers with presumptive evidence of immunity, post-exposure prophylaxis is not necessary, nor are work restrictions but daily monitoring should be conducted for 21 days following exposure. If the health care worker does not have evidence of presumptive measles immunity, they should follow the CDC guidance on post-exposure prophylaxis and exclude from work on the 5th day following the first day they were exposed. Also, health care workers “who received the first dose of MMR vaccine prior to exposure may remain at work and should receive the second dose of MMR vaccine, at least 28 days after the first dose.”
The guidance the CDC has provided will help reduce confusion and make response efforts more effective and efficient. Additionally, it’s also important to take the time to talk to frontline staff regarding the signs/symptoms of measles and the importance of keeping the disease in their peripherals. Many providers have not seen cases of measles firsthand, which makes rapid identification challenging. Providing educational images and information on symptoms can also be helpful.
As a lesson learned, be mindful that you may not be seeing the first generation of cases. Our exposure occurred as a result of exposure in Disneyland, but since the patient who visited the health care facility passed the 21-day exposure period and the provider failed to ask if anyone at home was sick, measles was initially ruled out. If you are in a state with active transmission, it’s important to consider exposures at home and at work. Vaccination efforts to reduce staff vulnerability are critical and remain the best form of prevention.