Health Care-Associated Measles Outbreak in the United States After an Importation: Challenges and Economic Impact

Epidemic Intelligence Service, Office of Workforce and Career Development, Centers for Disease Control and Prevention, Atlanta, Georgia.
The Journal of Infectious Diseases (Impact Factor: 6). 06/2011; 203(11):1517-25. DOI: 10.1093/infdis/jir115
Source: PubMed


On 12 February 2008, an infected Swiss traveler visited hospital A in Tucson, Arizona, and initiated a predominantly health care-associated measles outbreak involving 14 cases. We investigated risk factors that might have contributed to health care-associated transmission and assessed outbreak-associated hospital costs.
Epidemiologic data were obtained by case interviews and review of medical records. Health care personnel (HCP) immunization records were reviewed to identify non-measles-immune HCP. Outbreak-associated costs were estimated from 2 hospitals.
Of 14 patients with confirmed cases, 7 (50%) were aged ≥ 18 years, 4 (29%) were hospitalized, 7 (50%) acquired measles in health care settings, and all (100%) were unvaccinated or had unknown vaccination status. Of the 11 patients (79%) who had accessed health care services while infectious, 1 (9%) was masked and isolated promptly after rash onset. HCP measles immunity data from 2 hospitals confirmed that 1776 (25%) of 7195 HCP lacked evidence of measles immunity. Among these HCPs, 139 (9%) of 1583 tested seronegative for measles immunoglobulin G, including 1 person who acquired measles. The 2 hospitals spent US$799,136 responding to and containing 7 cases in these facilities.
Suspecting measles as a diagnosis, instituting immediate airborne isolation, and ensuring rapidly retrievable measles immunity records for HCPs are paramount in preventing health care-associated spread and in minimizing hospital outbreak-response costs.

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    • "Most HCW are immune to measles, but many cannot provide sufficient accessible evidence of documented immunity. If outbreaks occur, these HCW should be temporarily taken off health care work, which may cause severe logistic and financial problems [24,26]. In circumstances in which HCW state they know their history [30,31], undocumented information is clearly not sufficient to justify overriding these problems. "
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    ABSTRACT: Interruption of measles transmission was achieved in Catalonia (Spain) in 2000. Six years later, a measles outbreak occurred between August 2006 and June 2007 with 381 cases, 11 of whom were health care workers (HCW).The objective was to estimate susceptibility to measles in HCW and related demographic and occupational characteristics. A measles seroprevalence study was carried out in 639 HCW from six public tertiary hospitals and five primary healthcare areas. Antibodies were tested using the Vircell Measles ELISA IgG Kit. Data were analyzed according to age, sex, type of HCW, type of centre and vaccination history.The odds ratios (OR) and their 95%CI were calculated to determine the variables associated with antibody prevalence. OR were adjusted using logistic regression.Positive predictive values (PPV) and the 95% confidence intervals (CI) of having two documented doses of a measles containing vaccine (MCV) for the presence of measles antibodies and of reporting a history of measles infection were calculated. The prevalence of measles antibodies in HCW was 98% (95%CI 96.6-98.9), and was lower in HCW born in 1981 or later, after the introduction of systematic paediatric vaccination (94.4%; 95%CI 86.4-98.5) and higher in HCW born between 1965 and 1980 (99.0%; 95%CI 97.0-99.8). Significant differences were found for HCW born in 1965--1980 with respect to those born in 1981 and after (adjusted OR of 5.67; 95%CI: 1.24-25.91)A total of 187 HCW reported being vaccinated: the proportion of vaccinated HCW decreased with age. Of HCW who reported being vaccinated, vaccination was confirmed by the vaccination card in 49%. Vaccination with 2 doses was documented in only 50 HCW, of whom 48 had measles antibodies. 311 HCW reported a history of measles.The PPV of having received two documented doses of MCV was 96% (95%CI 86.3-99.5) and the PPV of reporting a history of measles was 98.7% (95%CI 96.7-99.6) CONCLUSIONS: Screening to detect HCW who lack presumptive evidence of immunity and vaccination with two doses of vaccine should be reinforced, especially in young workers, to minimize the risk of contracting measles and infecting the susceptible patients they care for.
    BMC Infectious Diseases 08/2013; 13(1):391. DOI:10.1186/1471-2334-13-391 · 2.61 Impact Factor
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    • "This is an important issue since health care associated spread is not uncommon. Different outbreak reports have already described how measles spreads in consultation rooms and emergency departments [21-24]. "
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    ABSTRACT: From Mid-February to April 2011 one of the largest measles-outbreak in Flanders, since the start of the 2-dose vaccination scheme in 1995, took place in Ghent, Belgium. The outbreak started in a day care center, infecting children too young to be vaccinated, after which it spread to anthroposophic schools with a low measles, mumps and rubella vaccination coverage. This report describes the outbreak and evaluates the control measures and interventions. Data collection was done through the system of mandatory notification of the public health authority. Vaccination coverage in the schools was assessed by a questionnaire and the electronic immunization database 'Vaccinnet'. A case was defined as anyone with laboratory confirmed measles or with clinical symptoms and an epidemiological link to a laboratory confirmed case. Towards the end of the outbreak we only sought laboratory confirmation for persons with an atypical clinical presentation or without an epidemiological link. In search for an index patient we determined the measles IgG level of infants from the day care center. A total of 65 cases were reported of which 31 were laboratory confirmed. Twenty-five were confirmed by PCR and/or IgM. In 6 infants, too young to be vaccinated, only elevated measles IgG levels were found. Most cases (72%) were young children (0--9 years old). All but two cases were completely unimmunized. In the day care center all the infants who were too young to be vaccinated (N=14) were included as cases. Thirteen of them were laboratory confirmed. Eight of these infants were hospitalized with symptoms suspicious for measles. Vaccination coverage in the affected anthroposophic schools was low, 45-49% of the pupils were unvaccinated. We organized vaccination campaigns in the schools and vaccinated 79 persons (25% of those unvaccinated or incompletely vaccinated). Clustering of unvaccinated persons, in a day care center and in anthroposophic schools, allows for measles outbreaks and is an important obstacle for the elimination of measles. Isolation measures, a vacation period and an immunization campaign limited the spread of measles within the schools but could not prevent further spread among unvaccinated family members. It was necessary to raise clinicians' awareness of measles since it had become a rare, less known disease and went undiagnosed.
    Archives of Public Health 07/2013; 71(1):17. DOI:10.1186/0778-7367-71-17
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    • "Nosocomial outbreaks are costly and highly disruptive [8] [9] [20], and are associated with increased HCP absenteeism and medical leave, and more importantly with transmission to highly vulnerable patients. We believe that it is imperative that all HCP have documented and easily retrievable evidence of measles immunity to ensure case management and rapid outbreak response [6] [9]. To protect the public and the patients we serve, receipt of appropriate measles immunization(s) should be mandatory, absent a valid medical contraindication, for all HCP. "
    Vaccine 06/2012; 30(30):4407-8. DOI:10.1016/j.vaccine.2012.05.015 · 3.62 Impact Factor
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