Measles stress importance of knowing immune status of hospital employees
Improve recordkeeping, immunize older workers, CDC says
Make sure you know the measles immune status of your employees and have ready access to the information. That is the message to employee health professionals contained in a recent public health advisory from the Centers for Disease Control and Prevention in Atlanta.
The advisory was prompted by an outbreak of measles in Arizona, which led hospitals on a paper chase and vaccination blitz as they sought to ensure the immunity of employees.
Optimally, vaccination information should be contained in an electronic database, not just in paper records, says Jane Seward, MD, MPH, deputy director of CDC's division of viral diseases. "If they don't have records that can be immediately provided when an exposure occurs, it's a huge amount of work to round up that information," she says.
Meanwhile, the CDC may be on the verge of changing its recommendation for people born before 1957. While measles was a ubiquitous childhood disease for that generation, a small proportion remains nonimmune. It would be prudent to conduct serologic testing or to give them one dose of the MMR (measles, mumps, rubella) vaccine, Seward says.
That is what would be recommended in the case of an outbreak. The 1998 recommendation states: "... although birth before 1957 is generally considered acceptable evidence of measles immunity, measles has occurred in some unvaccinated persons born before 1957 who worked in health care facilities. Therefore, health care facilities should consider recommending a dose of MMR vaccine for unvaccinated workers born before 1957 that lack a history of measles disease or laboratory evidence of measles immunity."1
"It is a bit of a double message," Seward notes. "You're considered immune, but if there's an outbreak, you're not. It's better to have the immunity status of everybody, including those born before 1957, with serological testing or physician-documented history of disease."
Testing employees during an outbreak often isn't practical, says Seward, because the employees need to be vaccinated as quickly as possible. A change in the recommendation likely will be proposed when two expert panels convene in June to discuss immunization and health care policy the Advisory Committee on Immunization Practices and the Healthcare Infection Control Practices Advisory Committee, Seward says.
A tourist from Switzerland triggered an outbreak this winter when she came to the emergency department at Northwest Medical Center in Tucson. As of mid-April, 11 exposed people ranging in age from 10 months to 50 years had contracted measles. That included one susceptible health care worker.
Measles is airborne, and anyone in the same room with a measles patient could be infected, says Seward. "It's very, very highly infectious," she says. "It's a serious disease. People who get it typically do end up in health care settings in emergency rooms, in outpatient [clinics] or likely hospitalized. Once that occurs, then there are a number of health care personnel who are exposed."
As many as 1,800 hospital employees were considered potentially exposed, and the hospital ultimately gave about 400 vaccinations, she says.
In another case, a hospital had electronic employee records only for those hired after 1990. They had to determine immune status for hundreds of other employees.
Employees are not the only ones who need verified immunity. Contract workers, volunteers, and any others who come into contact with patients should be vaccinated or have immunity against measles, she says.
It's important to take swift action by isolating patients with known or suspected measles. CDC advises health care providers to suspect measles in anyone with a "generalized maculopapular rash" that lasts three or more days, and who has a fever of 101°F or greater and a cough, nasal congestion or conjunctivitis. The incubation period can range from seven to 18 days, and immunocompromised patients may not exhibit the typical rash, CDC cautions.
Complications of measles can include encephalitis and pneumonia. The World Health Organization reports that an estimated 242,000 people died of complications from measles in 2006.
Although measles is not endemic in the United States, importations continue to occur. Ongoing outbreaks in Switzerland and Israel led to cases in New York, Virginia, Michigan, and California.
"We need to be prepared until there's no measles in the world, and that's not likely to occur," urges Seward. "Health care settings need to be prepared, and they need to remember that measles still exists."
Titering employees to check immune status
By requiring evidence of measles immunity at hire, the Marshfield (WI) Clinic avoids the difficulty of reviewing employee records each time a measles case occurs in Wisconsin, reports Bruce Cunha, RN, MS, COHN-S, manager of employee health and safety.
"We titer all new employees. Any new employee that doesn't have a documentable immunity, we vaccinate again. Then we don't have to go through a hassle every time we have an outbreak," he says.
That is true even for employees who report previous two-dose vaccination or for those born before 1957, who are presumed to have had exposure to measles.
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Preventing measles spread in health care settings This is an excerpt from the CDC Health Advisory related to health care workers: "To prevent transmission of measles in healthcare settings, airborne infection control precautions (available at http://www.cdc.gov/ncidod/dhqp/gl_isolation.html) should be followed stringently. Suspected measles patients (i.e., persons with febrile rash illness) should be removed from emergency department and clinic waiting areas as soon as they are identified, placed in a private room with the door closed, and asked to wear a surgical mask, if tolerated. In hospital settings, patients with suspected measles should be placed immediately in an airborne infection (negative-pressure) isolation room if one is available and, if possible, should not be sent to other parts of the hospital for examination or testing purposes. "All health care personnel should have documented evidence of measles immunity on file at their work location. Having high levels of measles immunity among healthcare personnel and such documentation on file minimizes the work needed in response to measles exposures, which cannot be anticipated. Recent measles exposures in hospital settings in three states necessitated verifying records of measles immunity for hundreds or thousands of hospital staff, drawing blood samples for serologic evidence of immunity when documentation was not on file at the work site, and vaccinating personnel without evidence of immunity." |
After the extra dose of vaccine, fewer than 10% fail to develop immunity, says Cunha. Those employees are considered to be nonresponders.
"We send them a notice that we consider them nonimmune and they have to be careful not to work with patients with measles," he says.
The titering of all employees is not a CDC recommendation, but it is a precautionary measure, says Cunha." Immunization does not equal immunity," he notes.
(Editor's note: A copy of the CDC Health Advisory on measles is available at www2a.cdc.gov/HAN/ArchiveSys/ViewMsgV.asp?AlertNum=00273.)
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 (ACIP). MMWR 1998; 47(RR-8): 1-57.
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