Strategies for measles prevention in health care facilities
Click Here to Manage Email Alerts
Despite endemic transmission of measles being deemed eliminated in the United States since 2000, travel-related outbreaks still occur.
As health care workers (HCWs), we have daily encounters with sick patients who could potentially have a contagious illness. Measles is a particular challenge in the health care setting.
Measles is an acute infection caused by the rubeola virus and is highly contagious. The measles virus spreads rapidly, especially in enclosed environments because it can remain contagious in the air and on surfaces for up to 2 hours. Measles typically begins with a mild to moderate fever with cough, coryza and conjunctivitis. Koplik’s spots may appear a few days later, along with fevers and a rash that usually begins on the face and proceeds down the body to the extremities.
Imported cases occur when travelers return to the U.S. after contracting the virus while traveling abroad. Unfortunately, the global threat of measles continues to increase due to unvaccinated children.
In 2022, there were approximately 9 million cases of measles worldwide. This year in the U.S., there have been 151 cases reported as of June 13, most in unvaccinated or undervaccinated patients. Unfortunately, over half of the cases have resulted in hospitalization for management of measles complications.
Measles is preventable through vaccination. Unfortunately, global vaccination programs were highly affected by the COVID-19 pandemic, resulting in a major decline in measles vaccinations, which put approximately 25 million children at risk. Although there was a modest increase in vaccination rates in 2022 in some regions of the world, this trend was not consistent among all countries. This decreased vaccination coverage led to an estimated 18% increase in measles cases and a 43% increase in measles deaths in 2022 compared with 2021.
The goal vaccination rate to induce herd immunity is 95% or greater. Many regions of the world are well below this goal. In the U.S., 90.8% of children are vaccinated by 24 months of age, which is significantly below the goal. As little as a 5% drop in vaccine coverage can increase measles cases threefold.
The pandemic is not the only reason vaccination rates have waned over the years. Vaccine hesitancy or denial has been propagated by unfounded fears that vaccination is related to autism. Although multiple studies have proven that there is no association, this is still used by anti-vaccine activists to recommend against vaccination, which negatively impacts vaccination rates.
Although measles is most common in children, anyone can become infected, including HCWs, who have a two to 19 times higher risk for contracting measles than the general community. Hospital-acquired measles is a real threat, with up to 50% of measles outbreaks occurring in health care facilities. Health care facilities must be vigilant and implement measures to help reduce this risk.
Proof of immunity
To help reduce the risk for outbreaks in health care facilities, WHO recommends all HCWs with direct patient contact be protected against measles either through vaccination or having proof of immunity from a prior measles infection. WHO also states that this should be required for employment. However, in the U.S., the requirements vary by state, with most states not having any requirements regarding measles vaccinations for HCW.
Current recommendations for HCW are to document immunity by one of the following:
- 1. documentation of vaccination with two doses of a live measles-containing vaccine;
- 2. laboratory evidence of immunity;
- 3. laboratory confirmation of disease; or
- 4. born before 1957.
Although it is presumed that people born before 1957 were exposed to measles, it is recommended that they be vaccinated with two doses of a measles vaccine if they do not have laboratory evidence of immunity or laboratory confirmation of disease.
When an HCW is exposed to measles, prompt evaluation of vaccination status is needed. If the HCW is unvaccinated, vaccination should be offered within 72 hours of the exposure, or if vaccination is contraindicated, immunoglobulin should be given. Although this strategy may not prevent measles, it could help reduce the severity of illness and reduce the risk for transmission to others.
It is important to acknowledge that measles immunity does not eliminate the risk for acquiring the disease. The risk is lower, but vaccine failure does occur.
If exposed to measles, a HCW’s immunity status will determine if they must take time off work. For those with presumptive measles immunity, work restrictions are not necessary. They should monitor for signs of disease starting on the 5th day after exposure through day 21 of the last known exposure. HCWs without measles immunity must be excluded from work starting the 5th day after the exposure through day 21 of the last known exposure. If an HCW develops measles, they should be excluded from work for 4 days after the rash onset unless they are immunocompromised, in which case they should stay out of work for the duration of the illness because they can have pronged viral shedding.
Infection prevention measures
Patients presenting for medical care who have signs or symptoms associated with measles should promptly be triaged and immediately isolated to help prevent spread.
Ideally, patients are screened pre-visit by phone, which commonly occurs for clinic visits. In these cases, patients can be directed to alternative entrances to avoid other patients.
However, patients may often present directly to the ED. It is important to increase measles awareness among HCWs to be able to identify measles symptoms and promptly make the diagnosis in all patient populations, including infants, children and adults.
Patients suspected of having measles should immediately be placed in airborne precautions in a single patient room. A room with negative pressure, when feasible, is recommended. To reduce the risk for exposing others to measles, delaying isolation until a definitive diagnosis is made is not recommended.
Patients with confirmed measles should remain in airborne precautions for 4 days after the onset of rash. The exception is that immunocompromised patients with measles should remain in airborne precautions for the duration of their illness.
In addition to airborne precautions, standard precautions should also be followed — including gloves, gowns, eye protection and following hand hygiene practices before and after all patient contact.
To help protect nonimmune employees from exposure, HCWs who lack sufficient immunity against measles should be prevented from caring for patients with measles unless there is not an HCW available who has presumptive evidence of immunity.
When a measles case is identified in your health care facility, you should promptly notify the hospital infection prevention department. Doing so will help identify potential contacts and assist in offering post-exposure prophylaxis to the HCWs who are candidates. In addition, because measles is a nationally notifiable disease, notifying state and local public health departments is required. State and local health departments have the lead in investigating measles cases and outbreaks when they occur.
Significant increases in measles cases and outbreaks around the world are expected to continue due to suboptimal vaccine coverage. Continued education of not only our patients, but our fellow HCWs is essential to overcome the barriers that have impacted vaccination rates. Having a pre-measles exposure plan to ensure that proper patient management, isolation protocols, post-exposure prophylaxis and notification guidelines are in place is important to prepare your staff for when a measles case walks into your facility.
References:
- Botelho-Nevers E, et al. Vaccine. 2012;doi:10.1016/j.vaccine.2012.04.023.
- CDC. Interim infection prevention and control recommendations for measles in health care settings. https://www.cdc.gov/infection-control/hcp/measles/index.html. Published April 12, 2024. Accessed June 25, 2024.
- CDC. Measles cases and outbreaks. https://www.cdc.gov/measles/data-research/. Last updated June 14, 2024. Accessed June 25, 2024.
- CDC. National Center for Health Statistics – Measles, mumps and rubella. https://www.cdc.gov/nchs/fastats/measles.htm. Last reviewed Sept. 27, 2023. Accessed June 25, 2024.
- DeStefano F, Shimabukuro TT. Annu Rev Virol. 2019;doi:10.1146/annurev-virology-092818-015515.
- Limavady A, et al. Infection. 2024;doi:10.1007/s15010-024-02186-0.
- Lo NC, et al. JAMA Pediatr. 2017. doi:10.1001/jamapediatrics.2017.1695.
- Mathis AD, et al. MMWR Morb Mortal Wkly Rep. 2024;10.15585/mmwr.mm7314a1.
- Minta AA, et al. MMWR Morb Mortal Wkly Rep. 2023;doi:10.15585/mmwr.mm7147a1.
For more information:
Jeff Brock, PharmD, MBA, BCIDP, is a Healio | Infectious Disease News Editorial Board Member and infectious disease pharmacy specialist at MercyOne Medical Center in Des Moines, Iowa. He can be reached at jeff.brock@mercyoneiowa.org.