By Gary Evans, Medical Writer
As a measles outbreak recently reached 70 cases in Clark County, WA, public health officials and infection preventionists were collaborating to identify cases and their contact exposures and to coordinate safe entry into a hospital if care was needed.
“The most important thing we have discovered is the need to really look at our plans for how we partner on the contact investigations. That has been really difficult,” says Dana Nguyen, BSN, RN, CIC, infection prevention practitioner at Clark County Public Health in Vancouver.
Coordinating with infection preventionists in area hospitals has been critical, says Nguyen, president of the Washington state chapter of the Association for Professionals in Infection Control and Epidemiology (APIC).
The contact follow-up often begins when an unvaccinated child contracts measles, exposing other members of his or her family who have also not been immunized. They are placed under local health restriction for the incubation period and advised to call ahead if they need medical care so they can be isolated from other patients.
“We tell them if you need to seek care for any reason, let the EMS or the hospital know in advance that you are under local health restriction for measles,” Nguyen says. “Different hospitals have different processes. Some will greet them in the parking lot and access them before bringing them in with a mask on. Some will have them come to a certain door.”
The contact cases are running in the hundreds, she says, as measles outbreaks tend to be labor-intensive and expensive to contain. Some members of the local community are against vaccinating their children, an increasingly common problem as misinformation and false safety fears are amplified on the internet.
“We have very low vaccination rates in Clark County, which I hate to say was a perfect brewing ground for this,” Nguyen says.
As of March 8, 2019, the outbreak in Washington had reached 70 cases, primarily in the epicenter of Vancouver and surrounding Clark County. Of those cases, 61 were unvaccinated, and two had received one of the recommended two doses of the measles-mumps-rubella (MMR) vaccine. The remainder of cases had unverified vaccine status. Most of the cases — 51 — were children age one year to 10 years old. Two of the measles cases required hospitalization.
Nguyen says there may be a lull in cases but knocked on wood in expressing the hope that the outbreak may be finally ending. “We have been in incident command now for 53 days,” she says.
Four additional cases linked to the outbreak were identified in Oregon, and one case was diagnosed in Georgia. Collaborating with colleagues in Oregon across the Columbia River that borders the states has been a positive aspect of the outbreak, she says.
“Bugs don’t care about rivers or state lines,” Nguyen says. “We have a really strong collaborative community here across the state lines, and I think that has really helped us get our arms around this faster. That part of this has been really powerful.”
By the same token, the outbreak has enabled some face-to-face conversations with community members and patients about the importance of the vaccine for measles and other childhood diseases.
“We’ve had lots of opportunities to educate, to advocate, and to partner,” she says. “Our hospitals and the local APIC chapter have all been working collaboratively to attack this from all directions. It is such a profound concern.”
Indeed, in one of the three proceeding measles outbreaks in Washington over the last decade, an immune-compromised patient died after acquiring measles in a clinic waiting room.
“Sometimes, people become complacent [about vaccine],” Nguyen says. “They listen, but I don’t know that we are in a position to meet them where they are at. When you have 70 cases of measles in your community, how do you ignore that? You kind of can’t.”
In that regard, as this report was filed, state legislators in Washington were trying pass a law that would remove the personal and philosophical exceptions to vaccine requirements. Other states are acting, too, and some are urging federal action to make childhood vaccines mandatory given the current situation. (See related story in this issue.)
Congressional Hearing
“Currently, there are six ongoing but completely preventable measles outbreaks in the U.S., including one in Washington, three in New York, one in Texas, and one in Illinois,” said John Wiesman, DrPH, MPH, of the Washington State Department of Health in Seattle, at a March 5, 2019, hearing of the U.S. Senate Committee on Health, Education, Labor, and Pensions.
Testifying on the resurgence of vaccine-preventable diseases, Wiesman said compared to Washington’s prior measles outbreaks over the last decade, “this one is larger and infecting people faster.”
Measles is considered one of the most contagious of the infectious diseases. It is a true airborne pathogen — not just droplet — and can also spread from contaminated surfaces and fomites near the infected patient. Thus, the CDC recommends patient placement in an airborne infection isolation room. If this type of room is unavailable, mask the patient and place him or her in a private room with the door closed, the CDC recommends.
Healthcare workers caring for the patient should be immunized against measles but also wear an N95 respirator due to some reports of vaccine breakthrough. Measles has an incubation period that is generally in the range of 14 days but can be as long as three weeks. That means travelers from one of the many global outbreak areas may become symptomatic and infectious after arrival in the U.S.
“We know that an individual traveled to Washington state from Europe who was already infected — but not yet symptomatic — with a wild strain of the measles virus circulating there,” Wiesman says.
The U.S. may be a victim of its own success, declaring measles eradicated in the nation in 2000 and inadvertently opening a yawning door to public complacency. The full vaccination schedule was and is still recommended, as measles will still circulate in parts of the world. In the U.S., with an effective measles vaccine preventing most cases since the early 1960s, the current resurgence of infections finds even nursing and medical students shocked to learn about conditions before vaccination began, says William Schaffner, MD, a professor of preventive medicine at Vanderbilt University in Nashville, TN.
“When I tell our medical students that before we had vaccine, 400 to 500 people in the U.S. died each year due to measles and its complications, their jaws drop,” he says. “They have no concept of how severe measles can be, and that in the developing world it continues to be a major killer of children.”
Indeed, the World Health Organization offers this grim global snapshot: “Even though a safe and cost-effective vaccine is available, in 2017, there were 110,000 measles deaths globally, mostly among children under the age of five.”1
In the U.S., measles caused more than 500,000 infections prior to vaccine development, Jonathan McCullers, MD, chief pediatrician at Le Bonheur Children’s Hospital in Knoxville, TN, said at the Congressional hearing.
“It is a very dangerous disease — about one in 1,000 infected persons develop encephalitis, an infection of the brain,” he testified. “About one in 1,000 develop severe pneumonia, and about half of those with these severe complications die. There is no specific treatment for measles, so vaccination is the only means of preventing these outcomes.”
In 2018, 372 people contracted measles in 17 different outbreaks in the United States, he said.
Delayed Diagnosis
Outbreaks continue in 2019, but measles is still so rare that many clinicians have never seen a case. They find the infection difficult to diagnose, leading to the subsequent chaos of determining who was exposed and susceptible among other patients and staff.
“There is delayed diagnosis,” Schaffner says. “They see this child who is miserable, has conjunctivitis, a runny nose, cough, and a rash. They have no idea what it is, and they start thinking about all of these other viral diseases simply because they have not seen measles before.”
A single undiagnosed measles case entering a hospital emergency room can set off an outbreak response that includes time-consuming and disruptive contact tracing. “It creates a whole disruption to the system in terms of assessment and follow-up,” says Karen Hoffmann, RN, MS, CIC, FSHEA, FAPIC, president of the national APIC. “That is problematic.”
And expensive. For example, a single imported case of measles ultimately cost two Arizona hospitals some $800,000, with much of the expense related to ensuring the immunity of employees and furloughing exposed workers.2
Hospitals typically require new employees to receive two doses of the MMR vaccine or show proof of immunity. People born before 1957 may be presumed to be immune, according to CDC guidelines — although in the event of an outbreak, the CDC recommends that healthcare workers born before 1957 receive two doses of MMR.
In general, IPs and their partners in public health need to emphasize that there is no scientific controversy, Hoffmann says. “The vaccines are safe — the only controversy is in the lay public,” she says.
REFERENCES
- WHO. Measles. Available at: https://bit.ly/2rN0iyE.
- Chen SY, Anderson S, Kutty PK, et al. Healthcare–associated measles outbreak in the United States after an importation: Challenges and economic impact. J Infect Dis 2011; 203: 1517-1525.
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