Background. Healthcare workers (HCWs) with documented immunity are not always required to wear N95 respirators or are even expected to do so when caring for patients who have the measles. HCWs are at an increased risk for occupational exposures due to the rising frequency of measles outbreaks and the lack of provider experience with the disease. However, there is no consensus on the best ways to respond to healthcare-related exposures for infection prevention. We describe the spread of the measles among HCWs despite prior immunity and discuss the findings of investigations into healthcare-associated exposure during a countywide outbreak.
Methods. Between 30 January 2014 and 21 April 2014, there was a measles outbreak in Orange County, California. Primary and secondary cases, related exposures, and risk factors were discovered. We examined the results of various tactics in response to hospital exposures and subsequent case capturing.
Results. 5 additional cases of the measles among the 22 confirmed cases happened in HCWs. Four of them had contact with measles patients directly; none of them wore N95 respirators. Despite exhibiting symptoms, four HCWs who had previously demonstrated immunity continued to work, leading to 1014 exposures but no transmissions. 13 of the 15 secondary cases overall had direct contact with measles patients, 8 of whom had previously demonstrated immunity.
Conclusions. Despite evidence of prior immunity, HCWs who have unmasked, direct contact with measles patients are at risk of contracting the disease, leading to potentially numerous exposures and necessitating time-consuming investigations. Vaccination may lower infectivity. HCWs should wear N-95 respirators (or an equivalent) when assessing patients who may have the measles, regardless of their level of immunity. Those who have had direct, unprotected exposure should be kept an eye out for symptoms and dismissed as soon as an illness develops.
Ten years after the measles was declared nonendemic, outbreaks increased in the United States, with unvaccinated travelers from other countries being the main importers [1, 2]. Since the disease’s elimination was announced in 2000, there were more measles cases reported nationally in 2014 than ever before [1]. Measles outbreaks have a significant negative impact on healthcare facilities and public health systems, costing an estimated $2. 7 to $5. 3 million in 2011 alone [3, 4].
The potential for exposures in healthcare settings increases as a result of healthcare worker (HCW) inexperience with the measles, which delays recognition and diagnosis. HCWs caring for measles patients frequently interact with one another, which puts them at a high risk of contracting the disease. HCWs may expose numerous patients and employees to their illness if they do so later [5]. The risk of secondary infection is significantly reduced, but not entirely eliminated, by laboratory or historical proof of measles immunity [6, 7]. Despite this, recommendations for N95 respirator use among HCWs who have proof of measles immunity have not always been consistent; when suggested, practitioners have questioned the need for N95 respirator use [8, 9]. Additionally, although the majority of HCWs are required to show proof of measles immunity as a condition of employment, how consistently these rules are enforced varies. While there may be strict occupational health requirements for immunization prior to hire, documentation of immunity in HCWs after hire is less reliable [10]. Despite the low but current risk for measles infection in people with evidence of immunity, infection control and occupational health strategies frequently treat historical documentation of immunity as absolute.
In this study, we describe a measles outbreak in Orange County, California, where 4 secondarily exposed health care workers (HCWs) contracted the disease despite having received vaccinations and having developed immunity in the past. This outbreak necessitated labor-intensive exposure investigations, but no additional cases were found. We discovered that the use of N95 respirators by HCWs, regardless of immunity, and prompt assessment of exposed staff after exposure could significantly lower healthcare-related exposures. We also point out important primary prevention methods used at our facility to reduce exposures related to healthcare.
Local healthcare providers notified the Orange County Health Care Agency (OCHCA) of any primary suspect measles cases; secondary suspect cases were either reported by clinical providers or directly discovered by OCHCA. Testing for measles was arranged for suspected cases who had rash and a fever (temperature, Patients who presented within three days of the onset of the rash underwent oropharyngeal polymerase chain reaction (PCR) testing, along with urine PCR and measles serum immunoglobulin M (IgM) testing whenever practical. Oropharyngeal and urine PCR testing, frequently coupled with measles IgM testing, were performed on patients who presented 4–10 days after the onset of the rash. Measles IgM testing was performed on patients with rash that appeared more than 10 days after exposure, along with urine PCR testing when necessary. According to California Department of Public Health (CDPH) guidelines, exposures were defined as people who were in the same area as a measles patient within 4 days before or after the onset of the rash or within 1 hour of an infectious measles case [11].
Exposed county residents were assessed by OCHCA. Healthcare facility patient exposures were co-managed with OCHCA. Staff exposures at the healthcare facility were primarily managed by the facility with assistance from OCHCA. Medical chart reviews and phone/in-person interviews were used to gather clinical data for suspected and confirmed cases; the latter was attempted for all close contacts (household, social, workplace, or other contact with risk for prolonged exposure). For those working in high-risk professions (healthcare/daycare settings), written documentation of two doses of the MMR vaccine or a positive measles serum IgG test were both considered acceptable proof of immunity. Non-high-risk exposures were those with underlying medical conditions, such as pregnancy and immunocompromised status, or high-risk occupations, such as HCW or daycare worker, were defined as those exposed (sharing the same room for any length of time) to an infectious measles patient without close contact.
Staff from the hospital’s infection prevention program and/or OCHCA made an effort to contact each and every contact. The measles symptoms were explained to contacts, who were also asked to report any illnesses to OCHCA. By making recurrent phone calls to high-risk contacts, symptoms were periodically monitored. Figure illustrates the approaches to inpatient exposure investigations used by an academic medical center during this outbreak.
Serology was carried out at OCHCA or the facilities where the patients had presented to check for measles-specific IgM/IgG. OCHCA used the measles virus IgM/IgG antibody test system to confirm all positive samples from community laboratories (MBL Bion, Des Plaines, Illinois; www mblintl. com). At OCHCA, RT-PCR assays with the gene targets nucleoprotein (N3), hemagglutinin (H1), and fusion (F1) were used for all measles viral RNA reverse transcription polymerase chain reaction (RT-PCR) virologic testing. Measles genotype sequencing was carried out by the CDPH Viral and Rickettsial Disease Laboratory [12].
From 16 January 2014 to 21 April 2014, Orange County saw 22 confirmed cases of the outbreak, of which 7 were primary cases (with no known epidemiologic link to a source case) and 15 were secondary cases (Figure). Among 2245 exposures, 1994 (88%) were healthcare associated; 6 secondary cases resulted from exposure in a healthcare setting, 5 of these were HCWs Among secondary cases, 13 (86. 6%) had direct face-to-face contact with measles patients; among these, 8 (61 5%) had evidence of immunity against measles. PCR confirmed measles in 16 cases. Genotyping of PCR-positive samples showed B3 measles virus (linked to strains in outbreaks in the Philippines) in each of the 16 cases. Without PCR testing, four cases that were discovered retrospectively had measles IgM positivity. One patient had a known close contact with a confirmed case and a classic presentation, but they refused testing despite meeting the clinical criteria for measles. Despite being PCR negative (oropharyngeal and urine samples) and serum IgM negative (based on history of descending rash with fever and cough developing after an appropriate incubation period following exposure to a known case), one HCW with two previously documented MMR vaccine doses met criteria for measles based on history. 19 of the 22 cases underwent serologic testing, and 11 of them tested IgM positive.
A 19-year-old woman who had traveled to the Philippines and had been exposed to the measles developed the disease despite receiving three doses of the MMR vaccine, according to records. Six more primary cases were later discovered, but none of them had a history of exposure to the measles or had recently visited a country where the disease is endemic. The outbreak consisted of 2 clusters. Cluster 1 occurred in a wealthy neighborhood and started with an illness in a family who refused vaccinations before spreading to a daycare facility. Cluster 2 was centered on a less affluent Latino adult community in a condensed geographic area over a brief period of time, with exposures that are likely to be common but unrecognized. Most of the affected Latinos’ vaccination histories were unknown or they had already received vaccinations; no one was found to have refused vaccination.
Table displays demographic and clinical traits broken down by primary vs. secondary measles cases and vaccination status. In cases where immunization status was known, all five unvaccinated people were older than 12 cases occurred after exposure to 5 unvaccinated measles cases; 1 case acquired the disease after exposure to a primary case with unknown immunity; and two secondary cases occurred after exposure to a single primary case who had received two documented doses of the MMR vaccine.
Measles-like symptoms and signs are present in the clinical presentation (prodromal temperature 101°F [38 10 of 11 cases, who were not known to have had measles exposure when first seen by an HCW, had cough, coryza, and/or conjunctivitis, followed by a descending maculopapular rash. Nevertheless, only 2 of 11 (18%) had measles on initial differential diagnosis The majority of secondary cases and cases in people who had received vaccinations had been exposed to measles and were identified by public health personnel, leading to earlier diagnoses.
Seven patients, including all HCWs, were evaluated by public health workers as soon as rash symptoms appeared, resulting in no healthcare exposures during the course of their medical evaluation. Three cases were discovered retroactively, and no information was available regarding healthcare exposure. Retrospective identification of one patient revealed that they had not sought medical attention. None of the patients experienced encephalitis or pneumonia, and they all recovered completely.
The patients admitted with a primary diagnosis other than measles had the longest median time to airborne isolation, which was twice as long as cases without exposure. As an illustration, of two 3-year-olds who contracted the measles at the same daycare center, one developed Kawasaki disease, and the other had an unidentified febrile illness. Both individuals had the typical measles symptoms, but it took 48 and 24 hours, respectively, before either was put on airborne precautions. Similar to this, 450 exposures occurred after an expectant woman with a “viral exanthem” was placed in airborne precautions 8 hours after arriving. Everyone who was put on airborne precautions had a typical measles presentation and was put on them less than two hours after arriving at a medical facility.
The majority of identified exposures in this outbreak were related to healthcare, and secondary measles among HCWs was a major contributor. Prior to the illness, all HCWs had been informed of their exposure and tested for signs of immunity. HCW-associated facility exposures occurred while working during prodromal symptoms. The clinical and epidemiologic information for the 5 health care professionals who contracted the measles and exposed 1014 people is shown in the table. None wore N95 respirators on initial examination of measles patients. All but 1 had evidence of immunity. It should be noted that 4 out of 5 health care workers (HCWs) had close, direct contact with measles patients; one HCW with serologic proof of immunity worked in the same emergency room but did not recall having any direct contact with the measles case. Only two health care workers (HCWs) who contracted measles had the typical symptoms, and one of them was the HCW with a questionable vaccination history. The majority of exposures were produced by the 3 HCWs who continued working while symptomatic (before the measles was diagnosed), had previously acceptable proof of immunity, and displayed mild prodromal symptoms. No additional cases emerged among the numerous patients and employees that these HCWs exposed.
Figure illustrates two approaches used at an academic medical center for two measles patients. The first case led to 140 inpatient exposures, including those on all hospital floors that circulate air with the emergency room and the medical floor where the patient was housed prior to being placed under airborne precautions. Using strategy I, all inpatients underwent serologic testing. All but four of the 64 patients were measles IgG positive; of these, two were ambiguous and two were negative. Within 72 hours of exposure, all 4 received the measles post-exposure prophylaxis vaccine. Public health serologic testing of exposed individuals who did not meet CDPH criteria for likely immunity revealed similarly high levels of immunity. Even among those in this group, more than 95% had positive measles titers [11] Another instance involved the use of strategy II, which revealed 62 inpatients who had been exposed to the measles, 27 of whom had received post-exposure vaccination. The remaining individuals, many of whom recalled prior MMR vaccinations, declined vaccination. Among 11 requiring serology, all had positive titers. None of the exposed inpatients in either case developed disease.
For each measles case, we determined the number of known exposures, and we also determined the preventative measures that, if taken, could have avoided these exposures. Immediate triage into airborne isolation of patients presenting with 1%E2%80%933 measles symptoms could have averted 980 (43%) exposures N95 respirator use by HCWs regardless of immunization status could have prevented up to 1014 (100%) of all HCW-associated exposures Once exposed, daily monitoring of HCWs for symptoms and furlough at the first sign of illness could have potentially prevented 922 (91%) identified HCW-related exposures and 41% of all identified exposures
Despite presumed evidence of immunity, this measles outbreak highlights the risk for health care workers to contract the disease while caring for patients with the disease. The false assurance that HCWs with unprotected face-to-face exposures during the outbreak received from their history of immunity caused them to continue working even when prodromal symptoms surfaced. Our results highlight the significance of following the Centers for Disease Control and Prevention’s (CDC) recent recommendation to wear an N95 or equivalent respirator for suspected cases of the measles regardless of immunity status [13, 14]. This poses a problem for primary care facilities because they frequently lack N95 respirators and staff fit-testing procedures. However, compliance with this recommendation varies, even in settings where N95 respirators are available and fit-testing is required [8].
In post-elimination era settings with limited clinical experience with measles, timely N95 respirator use depends on provider suspicion of measles, which may not be realized until after direct contact with infected patients. In our study, 80% of patients required multiple visits before diagnosis This finding emphasizes the need for ongoing, regular education on diseases that have been eradicated in front-line HCWs. The cost of failing to diagnose this highly contagious illness forces triage to take conservative primary prevention measures into account. Following this outbreak, our facility immediately started triaging patients who presented with any rash, using signage to direct patients to enter the facility away from the emergency room waiting area and directly into airborne isolation until further nursing staff evaluation. Therefore, if two suspected measles patients had been promptly triaged in this way (and ultimately tested negative), there would have been no healthcare-associated exposures. In the primary care setting, triaging solely based on rash may not be practical. Importantly, we project that this triaging strategy with the addition of additional symptoms could still significantly reduce the number of exposures. Following refinement, the primary prevention strategies employed at this academic hospital are described in Supplementary Table 4.
The fact that prodromal symptoms in previously immunized HCWs were mild likely contributed to further delayed diagnosis. Identification and furlough at the earliest signs of illness could have prevented 91% of healthcare exposures HCWs who have direct contact with a measles patient and have proof of their immunity are still able to work, but they should be informed that they still run a small risk of getting sick despite their prior immunity. At the first sign of illness, these HCWs should be furloughed and monitored for lingering symptoms.
Despite more than 1000 exposures, the measles vaccination was extremely protective in our county’s outbreak, with only 6 secondary cases in healthcare facilities. Additionally, among the few people who developed breakthrough disease despite vaccination, vaccination appeared to reduce infectivity. Despite 1053 identified exposures, none of the previously immunized individuals (including HCWs) who contracted the measles resulted in further transmission. Meanwhile, 6 secondary cases were caused by 5 unvaccinated people who exposed much fewer people (281) than they did. When exposures occur, as in this outbreak, hospital infection prevention and occupational health program staff’s efforts to maintain concurrent and complete employee vaccination rates are crucial. Mandatory vaccination programs, state immunization requirements, investments in automated systems to support these efforts, and other measures can significantly reduce risks and maximize resource use in response to exposures [15–18].
In the post-elimination era, measles exposure investigations are high-cost, high-stress initiatives for regional public health agencies and hospital infection prevention programs, with uncertain financial benefits [4]. The recommended scope and scale of investigation for non-high-risk exposures is less clearly outlined, despite the fact that there is extensive guidance on case definition and high-risk exposure investigation [19]. People who share a space, such as a room or an air pocket, are considered “high priority groups for contact investigation” by the CDC [19]. It is noteworthy that 86. 6% of secondary cases seen in our outbreak had documented face-to-face contact with measles patients Despite a history of previous vaccination or immunity, these direct encounters carried a risk of infection. People who only had airspace exposure to cases (typically, those who shared a waiting room in a clinic or emergency room setting) were unlikely to become ill. While there have been instances of shared airspace transmissions in medical facilities, the majority of these have occurred in regions where measles is endemic, where vaccination rates have not yet led to herd immunity, or where structural engineering standards are less advanced [5]. Additionally, surveying low-risk, nondirect contact exposures required a lot of work and only yielded a small number of nonimmune people. Based on what we learned from this outbreak, OCHCA no longer checks all exposed patients for signs of immunity, instead collaborating with medical facilities to alert low-risk patients to their exposure and provide follow-up advice if symptoms appear. Serologic testing is reserved for high-risk exposures, children, pregnant women, people with compromised immune systems, and people who work in environments like hospitals and daycare centers.
Since the measles was declared eradicated in the US almost 15 years ago [20] The majority of the population has been immunized or has natural immunity, despite the challenges we still face in maintaining high vaccination rates in some communities. Although it is known that people who have had measles before may exhibit unusual symptoms, the clinical presentation or laboratory diagnostic standards in the post-elimination era have not been thoroughly characterized [21–23]. One documented case of measles transmission from a person who had received vaccinations has been reported, and it was observed in our outbreak, but it seems uncommon. According to data from sporadic outbreaks, people who have received the measles vaccination are less contagious [4, 6, 24, 25]. How much less infectious such cases are is unknown. Further definition could substantially streamline exposure investigations. Additionally, our findings raise concerns about the frequency and importance of waning immunity in previously immunized people, particularly HCWs. In the post-elimination era, waning immunity in adults has not been thoroughly investigated.
Our investigation has several limitations. We were unable to locate or get in touch with all measles cases’ local contacts. In the healthcare setting, not all contacts could be reached. Not all patients’ accompanying families could be located or identified. Our findings do not take into account potential HCWs or patients who had the measles but were not diagnosed with it. Even though measles cases must be reported to public health, they are not always found or reported Finally, seroimmunity rates in our county are consistently higher than 98%; communities with lower immunization rates may need to consider response and contact investigation strategies that are different from those suggested here
The high risk of transmission and the protective value of immunization are stressed in current recommendations for measles exposure investigations in healthcare settings; our county’s outbreak experience supported these principles. But we also discovered that direct contact with a measles patient increased the risk of infection significantly, regardless of immunity levels. Nondirect airborne exposures within healthcare facilities in our study did not lead to more cases. For HCWs, disease outbreaks can happen even if they meet the CDC’s requirements for acceptable proof of immunity. Making sure that exposed HCWs are informed about the possibility of a new disease should be the goal of an investigation into measles exposures in healthcare facilities. HCWs should wear N-95 respirators upon entering the room when evaluating suspected measles patients, regardless of their immunity status. Those who had face-to-face unprotected exposure should be closely watched for symptoms and considered for furlough at the first sign of illness.
Supplementary materials are available at http://cid. oxfordjournals. org. The posted materials are the sole responsibility of the author and contain data that the author has provided to the reader. Questions or comments regarding the posted materials should be directed to the author as they have not been copyedited.
Acknowledgments. We acknowledge the efforts of Abiy Tadesse at the California Department of Public Health and Michael Brown from the Orange County Health Care Agency for their work in polymerase chain reaction genotype sequencing and analysis of the measles samples.
Potential conflicts of interest. S. S. H. conducted a clinical trial for which Sage Products and Molnycke donated products to the participating hospitals. All other authors report no potential conflicts. The ICMJE Form for Disclosure of Potential Conflicts of Interest has been submitted by all authors. Conflicts that the editors believe are pertinent to the manuscript’s content have been disclosed
Fundamental Elements to Prevent Measles Transmission
The majority of cases of measles are contracted from members of the household or community, but healthcare facilities can also become a source of infection. [1] Footnote 1.
During 2001-2014, 6% of non-imported measles cases in the United States resulted from transmission in healthcare facilities. Fiebelkorn AP, Redd SB, Kuhar DT. Measles in Healthcare Facilities in the United States During the Postelimination Era, 2001-2014.external icon Clin Infect Dis. 2015 Aug 15;61(4):615-8.
While ensuring community immunization is the most crucial step in preventing measles transmission in all settings, core measles prevention in healthcare settings necessitates a multifaceted strategy that includes:
To stop the spread of any infectious agents among patients, HCPs, and visitors, this interim guidance should be put into practice as part of an all-encompassing infection prevention program.
Healthcare workers (HCP) are any paid or unpaid individuals who work in healthcare facilities and may come into contact with patients or infectious materials, such as bodily fluids, contaminated medical supplies and equipment, contaminated environmental surfaces, or contaminated air. Emergency medical technicians, nurses, nursing assistants, doctors, technicians, therapists, phlebotomists, pharmacists, students, trainees, contractual staff not employed by the healthcare facility, and people not directly involved in patient care but who could be exposed to infectious agents that can be transmitted in the healthcare setting (e. g. , administrative, billing, clerical, dietary, environmental services, laundry, security, engineering, and volunteer personnel)
Acute care facilities, long-term acute care facilities, inpatient rehabilitation facilities, nursing homes and assisted living facilities, home healthcare, and vehicles where healthcare is delivered (e.g., ambulances) are all examples of places that fall under the definition of “healthcare settings.” g. , mobile clinics), as well as outpatient settings like dialysis clinics, doctor’s offices, and others
HCPs who work in healthcare facilities are defined as being exposed to the measles if they spend any time there without protective gear (i e. , not wearing recommended respiratory protection):
* There have been reports of measles surviving in the air for up to two hours. For more information on calculating the time needed for 99 air changes per hour (ACH) in areas with a defined rate, see the list below. 9% removal efficiency of airborne contaminants: Table B1 %E2%80%9CAir changes/hour (ACH) and time required for airborne-contaminant removal by efficiency%E2%80%9D from the 2003 Guidelines for Environmental Infection Control in Health-Care Facilities
Recommendations for Measles in Healthcare Settings
- written proof of two doses of measles virus-containing vaccination, with the second dose administered no earlier than 28 days after the first dose and the first administered at age 12 months or younger; OR
- Laboratory proof of immunity, such as the presence of measles immunoglobulin G (IgG) in serum (ambiguous results are regarded as negative); OR
- Laboratory confirmation of disease; OR
- Birth before 1957.
A. Before arrival to a healthcare setting
- Provide arrival instructions, including which entrance to use and the precautions to take, for people who have measles symptoms or signs. g. , how to follow triage procedures, wear a face mask upon entry, and notify hospital staff)
When transporting a patient with known or suspected measles, instruct Emergency Services to notify the receiving facility/accepting physician in advance.
B. Upon arrival to a healthcare setting
- Before or as soon as possible after entering a facility, individuals with measles symptoms or signs should be identified, given a facemask [2] to wear, and separated from other patients.
Footnote 2 A facemask is a term that applies collectively to items used to cover the nose and mouth and includes both procedure masks and surgical masks.
- Post visual alerts (e. g. at the facility entrance and in common areas (e.g., signs, posters) in the appropriate languages about hand hygiene, cough etiquette, and respiratory hygiene g. , waiting areas, elevators, cafeterias).
- Inform those who exhibit measles symptoms or signs of all pertinent infection control guidelines.
- Make equipment for washing hands available to everyone in the space.
- Provide supplies (e.g., facemasks) near the visual alerts if possible.
Consult the Guideline for Isolation Precautions: Precautions to Prevent Transmission of Infectious Agents for details on standard and airborne precautions.
A. Patient placement
- If the patient is still inside the AIIR, the facemask may be removed.
- Place the masked patient in a private room with the door closed while awaiting transfer. If possible, the patient should wear the mask throughout their stay in the non-AIIR room. The patient should ideally be placed in a room with high-efficiency particulate air (HEPA) filtration where exhaust is circulated. The patient’s room should be left empty after they leave for the required amount of time (up to 2 hours) to allow for 99 9% of airborne-contaminant removal. (See Appendix B, Table B. 1. By efficiency, air changes per hour and the length of time needed to remove airborne contaminants
- delivering a minimum of six (for an existing facility) or twelve (for a new building or renovation) air changes per hour.
- Directing exhaust of air to the outside.
- If an AIIR does not directly exhaust to the outside, if all air is directed through HEPA filters, the air may be returned to the air-handling system or nearby spaces.
Consult the 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings – Glossary for details on AIIR requirements.
B. Healthcare personnel
- HCP should use respiratory protection (i. e. , a respirator) that is at least as protective as a fit-tested, NIOSH-certified disposable N95 filtering facepiece respirator upon entry to the room or care area of a patient with known or suspected measles, regardless of presumptive evidence of immunity
- According to the Occupational Safety and Health Administration’s (OSHA) Respiratory Protection Standard 29 CFR 1910, using a respirator must be part of a comprehensive respiratory protection program. 134external icon.
- If using respirators with snug-fitting facepieces, HCP should have a medical clearance and fit test. g. , a NIOSH-certified disposable N95) and knowledgeable about respirator usage guidelines, safe removal and disposal, and medical conditions that should not be used while wearing a respirator.
C. transporting patients with the measles inside and outside of healthcare facilities
- The patient should wear a facemask if tolerated.
- Use a route and procedure for transportation that involves little interaction with people who are not necessary for the patient’s care.
- Notify the HCP in the receiving area of the patient’s impending arrival and the preventative measures that must be taken.
D. Duration of airborne precautions
Footnote 3
Patients with severe primary immunodeficiency, those who have received a bone marrow transplant, those who have finished all immunosuppressive therapy, those who have developed graft-versus-host disease, those who are receiving treatment for acute lymphocytic leukemia within and until at least 6 months after finishing immunosuppressive chemotherapy, and those with a diagnosis of severe primary immunodeficiency are all considered severely immunocompromised patients. Some experts list HIV-positive people who haven’t recently had their immunologic status confirmed or people who haven’t had measles. Determine whether the patient is immunocompromised by speaking with the exposed person’s treating doctor.
E. Manage visitor access and movement within the facility
F. Implement environmental infection control
The CDC’s website provides comprehensive details on environmental cleaning in healthcare facilities.
A. Management of exposed healthcare personnel
- Postexposure prophylaxis is not necessary.
- Work restrictions are not necessary.
- Implement daily surveillance for measles signs and symptoms for 21 days after the last exposure, and be aware that people who have had the disease before may present with different symptoms.
- Administer postexposure prophylaxis in accordance with CDC and ACIP recommendations.
- Regardless of whether postexposure prophylaxis was taken, you must not go to work from the fifth day after the first exposure until the 21st day after the last exposure.
- HCP who received the first dose of the MMR vaccine before exposure may continue working but needs to get the second dose at least 28 days after the first dose. For 21 days following the last exposure, conduct daily checks for the presence of measles symptoms.
B. Management of healthcare personnel infected with measles
C. Treatment of measles-exposed individuals who lack conclusive evidence of immunity
When a large number of patients are involved in an outbreak or exposure that calls for airborne precautions:
- Air should be released outside, far from people and air intakes.
- Before introducing air to other spaces, force all of it through HEPA filters.
- Alternately, instruct and obtain a medical clearance for HCP to use a different respiratory protection device (e g. , Powered Air-Purifying Respirator (PAPR)) whenever respirators are required.
- OSHA Respiratory Training Videosexternal iconexternal icon.
- Notify public health authorities as soon as possible if a patient has measles that is known or suspected.
- Determine who will be in charge of communicating with public health officials and providing information to HCPs within the facility.
Infection Control and Personal Protective Equipment
If you suspect measles, the following actions are recommended:
- Give the patient a surgical mask right away, preferably before they enter the building.
- Put the disguised patient in a closed-door, private negative pressure room if one is available. 2 hours should pass after a suspected measles patient departs before using this room.
- If one is available, an airborne infection isolation room (AIIR) should be used. For the purpose of using an AIIR, a suspected or confirmed case of the measles should take precedence over a suspected or confirmed COVID-19 case.
- Transfer the patient as soon as you can to a facility with an AIIR if one is not available.
- No matter their presumptive immunity status, healthcare workers entering the patient’s room should wear fit-tested N-95 respirators that are only intended for one use.
- EMS and the receiving hospital should be alerted prior to the arrival of any patients being transported by EMS so the patient can be immediately directed to the proper exam room.
For more information:
Vaccination is the best way to prevent measles. Vaccination provides long-lasting protection against measles.
Measles vaccine is available as part of the MMR or MMRV vaccine combinations, which also include the mumps, rubella, and varicella vaccines. The live-attenuated (weaken) MMR vaccine results in a mild, non-infectious reaction.
When any of the individual components is indicated, the Advisory Committee on Immunization Practices (ACIP) of the CDC suggests using MMR. Single-antigen measles vaccine is not available in the United States.
Infants: If going abroad, infants between the ages of 6 and 11 months should receive one dose of the MMR vaccine prior to flying.
Children should receive the MMR vaccine in two doses, the first at 12 to 15 months and the second at 4 to 6 years of age.
College and other students, health care professionals, and international travelers require two doses that were administered on or after age 1 and at least 28 days apart unless they have proof of measles immunity.
Adults: MMR documentation showing at least one dose or other proof of measles immunity is required for all other adults born in or after 1957.
People receiving postexposure prophylaxis IG: For information on postexposure prophylaxis, see the VDH’s Postexposure Prophylaxis (PEP) Guidance for Measles Exposures. No earlier than 6 months or 8 months after the administration of IGIM or IGIV, respectively, should the MMR vaccine be given. Once the time interval has passed, follow age-appropriate dosing recommendations.
The MMR vaccine shouldn’t be administered to anyone who is seriously immunocompromised for any reason. However, if they do not have severe immunosuppression, HIV-infected people can still receive the MMR vaccine. Children who are HIV-positive may receive the MMR vaccine if their CD4 T-lymphocyte count is e. , CD4 count is 200 cells/µL or greater).
The measles vaccine shouldn’t be given to people who are known to be pregnant. Pregnancy should be avoided for 4 weeks following MMR vaccine.
Individuals taking high doses of corticosteroids daily ( After stopping high dose steroid therapy, postpone getting the MMR vaccine for at least one month.
Administration of blood products and immune globulin require waiting a certain period before administering measles vaccine.
Refer to the most current Vaccine Information Statement for measles.
- Website of the VDH Division of Immunization, Advisory Committee on Immunization Practices (ACIP) MMR Vaccine Recommendations
MMR vaccine is about 93% effective at preventing measles after 1 dose and about 97% effective after 2 doses
Immunoglobulin (IG) should be administered to measles sufferers at high risk of severe illness and/or complications who are unable to receive the vaccine:
For information on PEP for those who have been exposed to the measles virus, please see VDH’s Postexposure Prophylaxis (PEP) Guidance for Measles Exposures.
To obtain IG, healthcare providers can get in touch with their neighborhood health department.
The recommended dose of IMIG is 0. 5 mL/kg of body weight (maximum dose: 15 mL), and 400 mg/kg of IVIG is the suggested dose.
Note: Children
No patient should receive both vaccine and immunoglobulin. Family members should, if at all possible, receive their immunizations or IG treatments as close together as possible to ensure that their quarantine times are the same or comparable.