Preventing a measles outbreak: Reflections from an investigation
Focus on three main objectives to prevent measles spread
After reading this article, you will be able to:
- List three prevention measures for measles in the healthcare setting
- Justify the importance of immunizing healthcare workers
- Explain the IP's role during a measles outbreak
In February 2008, a Swiss traveler infected with measles entered a hospital in Tucson, AZ, and initiated a measles outbreak that eventually grew to 14 cases. After the outbreak was quelled, researchers from the CDC took the opportunity to investigate what contributed to the spread of the disease within the hospital to determine important practices to stop future measles outbreaks. Their results were published in the May 15 issue of The Journal of Infectious Diseases.
The researchers' investigation yielded three main keys to preventing a measles outbreak:
- Suspecting measles as a possibility and properly diagnosing patients
- Instituting immediate airborne isolation
- Ensuring easily retrievable measles immunity records for healthcare workers
Based on data acquired from two hospitals in the Tucson area, seven of the 14 patients were confirmed to have healthcare-acquired measles, and of the 11 who had accessed healthcare services while infectious, only one was masked and isolated after rash onset. Additionally, 25% of hospital workers lacked evidence of measles immunity. Combined, the hospitals spent nearly $800,000 responding to and containing the seven healthcare-acquired cases.
The following questions were answered by Preeta Kutty, MD, MPH, a medical epidemiologist at the CDC and a coauthor of the study.
Q What does this study highlight about measles prevention?
A Just to clarify, it wasn't a preplanned study. This came about because there was a measles outbreak in Arizona, and since we hadn't had a report of measles big enough in a hospital setting, we decided that it would be in the interest of medicine and healthcare to find out what was happening.
When we talk about measles prevention, one of the issues that we are facing and have always faced is that measles continues to be endemic in many countries outside of America, and as long as measles is endemic and people travel, whether they are U.S. residents or not, the U.S. population is always going to be exposed to a certain degree of measles. It's already an infectious disease, so it's always one of those diseases that is highly reportable, and hospitals have to immediately report to us within 24 hours.
In this intervention, basically we wanted to know what happens when an outbreak occurs in a healthcare setting. The whole system is important to us because if you have outbreaks like measles, it can disrupt patient care in hospitals and can adversely impact patient health. Also, hospital settings have people who go because they are very sick, and when you have a disease that is very infectious like measles, you end up having higher increased risk for outcomes, especially among immunocompromised patients.
So what we wanted to show was that measles is a very infectious disease and it is possible for it to spread in a healthcare setting. Healthcare professionals like physicians and nurses should suspect measles as a diagnosis, institute immediate airborne isolations, and hospitals should show rapidly retrievable measles immunity records for healthcare personnel, which are paramount to preventing healthcare-associated spread and minimizing hospital outbreaks.
Q How important is it to immunize healthcare workers, and what can hospitals do to increase awareness and bump up their numbers for immunization?
A There is a body called the Advisory Committee for Immunization Practices [ACIP]?, and their recommendation is that healthcare professionals should be fully vaccinated and fully immunized.
ACIP recommendations are that healthcare professionals should be vaccinated for measles. Measles is an infectious disease, and when someone falls ill with measles in a healthcare setting, be it a hospital emergency room or clinic, doctors and nurses have that frontline exposure, and they are the ones that get exposed to the disease, so certainly they should be immunized against measles.
Q Are there things that can be done to increase awareness?
A It's good if the hospitals can talk about measles during the morning rounds. If there are measles in the community, bring that up to increase awareness. Have [continuing medical education] credits for healthcare professionals and check their records to see if the healthcare professionals working in that facility are immunized, and if not, test them to see if they have immunity or vaccinate them.
And then most important of all is educating the healthcare professionals. I know they are already well educated, but they should be provided specific education so that when they see a case they can isolate the case, immediately draw blood, inform the health department, and ensure there are no other exposures around.
Q What were some of the main causes of the outbreak that were uncovered during this investigation?
A Unfortunately, there were multiple causes. One was the lack of adherence to U.S. ACIP recommendations. One was delayed implementation of infection control procedures in the healthcare settings with both patients and personnel. There was delayed implementation of isolation procedures in healthcare settings, and there was also delayed diagnosis of cases by the healthcare personnel because measles was not the first thing that came to their mind. There was also delayed lab confirmation, and that part is not their fault. Measles is a disease that can be negative at times within the first 72 hours of rash onset, so one has to make sure if they have a high suspicion of measles they should test again after 72 hours.
Q What about awareness from healthcare workers? When you're in the midst of an outbreak, are there things you can do to keep them aware of things to look for?
A One of the things they do at the local and state health departments is they have a system where they basically send a fax to all healthcare facilities, clinics, private/urgent care clinics, and hospitals. They send this fax to everyone saying, "There are measles in the community, please look out for someone who has measles-compatible symptoms like rashes," and if they do see it they should inform the health department. So that's one way of going about generating awareness.
The infection control practitioners in the hospital setting play a crucial role, and we worked with some of the best infection control practitioners, so it was really nice. And it was really collaborative to bring this outbreak to a stop.
Q How should the IP be involved with planning and implementing these precautions?
A From my experience working with the IPs, what we ended up doing was actually meeting with people in the hospitals, and they introduced us to the administrators as well as the employee health department and getting all of them on board, along with the infectious disease physicians and pediatricians, and we got them all together and we had a presentation. The IPs actually got the outbreak under control in terms of making sure the employees were well vaccinated and making sure there were signs outside the emergency room saying if they had measleslike symptoms they should call the physician. And they made sure there were isolation rooms available because it's not always easy to find a negative pressure room, which is a requirement to isolate the measles cases.
The IPs played a huge role in controlling the outbreak, and we're truly grateful for that. They do play a major role in isolating the cases and ensuring there are rooms. Since they track the number of cases and the kind of diseases, they are also probably the first few people to find that there are a number of measles cases happening. And they are also coordinating with the labs at the hospital; if there were any measles tests coming back positive, [the labs] would inform the IP, and the IP would inform the local and state health department.
The infectious disease doctors also play a huge role, but like I said, all the data comes to the IPs and they are the ones who are keeping track of the trends, and when they start to see something that isn't normal, that's when they inform the individuals that have to be informed.